de Jager Pauline, Kamp Tamara, Dijkstra Sandra K, Burgerhof Johannes G M, Markhorst Dick G, Curley Martha A Q, Cheifetz Ira M, Kneyber Martin C J
Department of Paediatrics, Division of Paediatric Critical Care Medicine, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Huispost CA 80, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands.
Department of Epidemiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
Ann Intensive Care. 2019 Jan 18;9(1):9. doi: 10.1186/s13613-019-0492-0.
High-frequency oscillatory ventilation (HFOV) is a common but unproven management strategy in paediatric critical care. Oscillator settings have been traditionally guided by patient age and/or weight rather than by lung mechanics, thereby potentially negating any beneficial effects. We have adopted an open-lung HFOV strategy based on a corner frequency approach using an initial incremental-decremental mean airway pressure titration manoeuvre, a high frequency (8-15 Hz), and high power to initially target a proximal pressure amplitude (∆P) of 70-90 cm HO, irrespective of age or weight.
We reviewed prospectively collected data on patients < 18 years of age who were managed with HFOV for acute respiratory failure. We measured metrics for oxygenation, ventilation, and haemodynamics as well as the use of sedative-analgesic medications and neuromuscular blocking agents.
Data from 115 non-cardiac patients were analysed, of whom 53 had moderate-to-severe paediatric acute respiratory distress syndrome (PARDS). Sixteen patients (13.9%) died. Frequencies≥ 8 Hz and high ∆P were achieved in all patients irrespective of age or PARDS severity. Patients with severe PARDS showed the greatest improvement in oxygenation. pH and PaCO normalized in all patients. Haemodynamic parameters, cumulative amount of fluid challenges, and daily fluid balance did not deteriorate after transitioning to HFOV in any age or PARDS severity group. We observed a transient increase neuromuscular blocking agent use after switching to HFOV, but there was no increase in the daily cumulative amount of continuous midazolam or morphine in any age or PARDS severity group. No patients experienced clinically apparent barotrauma.
This is the first study reporting the feasibility of an alternative, individualized, physiology-based open-lung HFOV strategy targeting high F and high ∆P. No adverse effects were observed with this strategy. Our findings warrant further systematic evaluation.
高频振荡通气（HFOV）是儿科重症监护中一种常见但未经证实的管理策略。传统上，振荡器设置是根据患者年龄和/或体重而非肺力学来指导的，从而可能抵消任何有益效果。我们采用了一种基于角频率方法的肺开放HFOV策略，使用初始递增-递减平均气道压滴定操作、高频（8-15Hz）和高功率，最初目标是近端压力振幅（∆P）为70-90cmH₂O，而不考虑年龄或体重。
我们回顾了前瞻性收集的18岁以下因急性呼吸衰竭接受HFOV治疗患者的数据。我们测量了氧合、通气和血流动力学指标，以及镇静镇痛药物和神经肌肉阻滞剂的使用情况。
分析了115例非心脏患者的数据，其中53例患有中重度儿科急性呼吸窘迫综合征（PARDS）。16例患者（13.9%）死亡。所有患者无论年龄或PARDS严重程度如何，均达到了≥8Hz的频率和高∆P。重度PARDS患者的氧合改善最大。所有患者的pH值和PaCO₂均恢复正常。在任何年龄或PARDS严重程度组中，转换为HFOV后血流动力学参数、液体冲击累积量和每日液体平衡均未恶化。我们观察到转换为HFOV后神经肌肉阻滞剂的使用有短暂增加，但在任何年龄或PARDS严重程度组中，咪达唑仑或吗啡的每日累积量均未增加。没有患者发生临床明显的气压伤。
这是第一项报告以高频率和高∆P为目标的另一种基于生理学的个体化肺开放HFOV策略可行性的研究。该策略未观察到不良反应。我们的研究结果值得进一步系统评估。
