Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore.
Saw Swee Hock School of Public Health, National University Health System, NUS Graduate School for Integrative Science and Engineering, National University of Singapore, 12 Science Drive 2, Singapore, 117549, Singapore.
Crit Care. 2020 Jan 31;24(1):31. doi: 10.1186/s13054-020-2741-x.
High-frequency oscillatory ventilation (HFOV) use was associated with greater mortality in adult acute respiratory distress syndrome (ARDS). Nevertheless, HFOV is still frequently used as rescue therapy in paediatric acute respiratory distress syndrome (PARDS). In view of the limited evidence for HFOV in PARDS and evidence demonstrating harm in adult patients with ARDS, we hypothesized that HFOV use compared to other modes of mechanical ventilation is associated with increased mortality in PARDS.
Patients with PARDS from 10 paediatric intensive care units across Asia from 2009 to 2015 were identified. Data on epidemiology and clinical outcomes were collected. Patients on HFOV were compared to patients on other modes of ventilation. The primary outcome was 28-day mortality and secondary outcomes were 28-day ventilator- (VFD) and intensive care unit- (IFD) free days. Genetic matching (GM) method was used to analyse the association between HFOV treatment with the primary outcome. Additionally, we performed a sensitivity analysis, including propensity score (PS) matching, inverse probability of treatment weighting (IPTW) and marginal structural modelling (MSM) to estimate the treatment effect.
A total of 328 patients were included. In the first 7 days of PARDS, 122/328 (37.2%) patients were supported with HFOV. There were significant differences in baseline oxygenation index (OI) between the HFOV and non-HFOV groups (18.8 [12.0, 30.2] vs. 7.7 [5.1, 13.1] respectively; p < 0.001). A total of 118 pairs were matched in the GM method which found a significant association between HFOV with 28-day mortality in PARDS [odds ratio 2.3, 95% confidence interval (CI) 1.3, 4.4, p value 0.01]. VFD was indifferent between the HFOV and non-HFOV group [mean difference - 1.3 (95%CI - 3.4, 0.9); p = 0.29] but IFD was significantly lower in the HFOV group [- 2.5 (95%CI - 4.9, - 0.5); p = 0.03]. From the sensitivity analysis, PS matching, IPTW and MSM all showed consistent direction of HFOV treatment effect in PARDS.
The use of HFOV was associated with increased 28-day mortality in PARDS. This study suggests caution but does not eliminate equivocality and a randomized controlled trial is justified to examine the true association.
高频振荡通气（HFOV）在成人急性呼吸窘迫综合征（ARDS）中的应用与死亡率增加有关。然而，HFOV 仍然经常被用作儿科急性呼吸窘迫综合征（PARDS）的抢救治疗。鉴于 HFOV 在 PARDS 中的证据有限，以及在成人 ARDS 患者中证明存在危害的证据，我们假设与其他机械通气模式相比，HFOV 的使用与 PARDS 患者的死亡率增加有关。
从 2009 年至 2015 年，在亚洲的 10 个儿科重症监护病房中确定了患有 PARDS 的患者。收集了流行病学和临床结果的数据。将接受 HFOV 的患者与接受其他通气模式的患者进行比较。主要结局为 28 天死亡率，次要结局为 28 天呼吸机（VFD）和重症监护病房（IFD）无天数。采用遗传匹配（GM）方法分析 HFOV 治疗与主要结局之间的关联。此外，我们进行了敏感性分析，包括倾向评分（PS）匹配、逆概率处理加权（IPTW）和边缘结构模型（MSM），以估计治疗效果。
共纳入 328 例患者。在 PARDS 的前 7 天，122/328（37.2%）例患者接受 HFOV 支持。HFOV 组和非 HFOV 组的基线氧合指数（OI）差异有统计学意义（分别为 18.8[12.0，30.2]和 7.7[5.1，13.1]；p<0.001）。GM 方法共匹配了 118 对，发现 HFOV 与 PARDS 28 天死亡率之间存在显著关联[比值比 2.3，95%置信区间（CI）1.3，4.4，p 值 0.01]。HFOV 组和非 HFOV 组的 VFD 无差异[平均差异-1.3（95%CI-3.4，0.9）；p=0.29]，但 HFOV 组的 IFD 明显较低[-2.5（95%CI-4.9，-0.5）；p=0.03]。从敏感性分析来看，PS 匹配、IPTW 和 MSM 均显示出 HFOV 治疗 PARDS 的一致方向。
HFOV 的使用与 PARDS 患者的 28 天死亡率增加有关。本研究表明需要谨慎，但不能消除模棱两可，需要进行随机对照试验来检查真实的关联。
