Current Role of High Frequency Oscillatory Ventilation and Airway Pressure Release Ventilation in Acute Lung Injury and Acute Respiratory Distress Syndrome

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Lung protective ventilatory strategies using conventional ventilators have resulted in decreased mortality in adult patients who have acute lung injury and acute respiratory distress syndrome. Conceptually, high frequency oscillatory ventilation and airway pressure release ventilation appear not only able to fulfill the goals of lung protection, but also to offer some additional advantages over conventional ventilation. Although early data for each of these modes in adults have been encouraging, their widespread use—particularly outside of a rescue situation—cannot be recommended without further evidence.

Section snippets

High frequency oscillatory ventilation: overview and physiologic effects

The majority of clinical trials on HFOV have been performed in the neonatal population [18]. Over the past few years, coupled with better understanding of the injurious effects of mechanical ventilation, there have been renewed interest and advances in the application of HFOV in adult patients with ALI and ARDS.

HFOV is characterized by rapid oscillations of a diaphragm (in adults at frequencies of 3 Hz–10 Hz, or 180–600 breaths per minute) driven by a piston pump (Fig. 1). The forward and

High frequency oscillatory ventilation: clinical studies in ALI and ARDS

Current published clinical studies on the application of HFOV in adults have mainly been case series in “rescue” situations, where conventional ventilation has arguably failed. There have only been two published randomized, controlled trials where HFOV has been compared with conventional mechanical ventilation in adult ALI and ARDS. Table 1 summarizes the clinical trials on HFOV in adult ALI and ARDS subjects.

Derdak and colleagues [28] set out to compare equivalency between HFOV and

High frequency oscillatory ventilation: potential limitations and pitfalls

The higher applied mPaws have invariably led to concerns of barotrauma and hemodynamic compromise. Mehta and colleagues [32] reported the incidence of pneumothorax to be 21.8%. Of 156 subjects, 26% needed to have HFOV discontinued because of problems with oxygenation and ventilation or hemodynamics. In contrast, the incidences of pneumothorax and hemodynamic instability were found to be similar in the two trials [28], [35], which compared HFOV to CV. Furthermore, in 25 subjects on HFOV with an

Airway pressure release ventilation: overview and physiologic effects

APRV is a mode of ventilation designed to allow patients to breathe spontaneously while receiving high continuous positive airway pressure with an intermittent pressure release phase.

First described in 1987 [42], a continuous airway pressure (Phigh) maintains adequate lung volumes and recruits alveoli. This, together with FiO2, achieves the oxygenation targets. The timing and duration of the pressure release (Plow) would, correspondingly, affect ventilation. The delivered VT is, therefore,

Airway pressure release ventilation: clinical studies in ALI and ARDS

There are few large clinical studies on the use of APRV in adult ALI and ARDS patients. Table 2 presents the summary of APRV trials on subjects with ALI and ARDS.

In a single center observational study on the trends in ICU mortality [56], the use of APRV was associated with a reduction in the incidence of multiorgan failure and mortality in trauma subjects with ARDS over a 2-year period, as compared with historical controls (21.4% versus 29.3%, P<0–05). Other modifications in therapy, such as

Airway pressure release ventilation: potential limitations and pitfalls

There are theoretic risks of VILI during APRV. It is important to note that the set Phigh is not necessarily the maximal stretching pressure to which the lungs are subjected. Spontaneous breathing during Phigh generates negative pleural pressures that add to the stretch.. This has to be considered when evaluating the maximal stretch to which the lungs are exposed. Neumann and colleagues [43] demonstrated aggregate tidal volumes approaching 1 L in airway pressure, flow, and volume tracings. In

Discussion

HFOV and APRV are unique “open lung” ventilatory strategies which may offer improved gas exchange and lung protection. Their favorable physiologic effects, however, have not been translated into demonstrable survival benefits in clinical trials. It is important to note that improved physiology (for instance improved oxygenation) does not necessarily translate into improved outcome. For example, patients ventilated in the small tidal volume arm of the ARDSNet [16] protocol had an early worsening

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    Mailing address for Chuin Siau as of July 1, 2008: Department of Medicine, Changi General Hospital, 2 Simei Street 3, S(529889), Singapore.

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