Ventilation
High-frequency oscillatory ventilation in patients with acute exacerbation of chronic obstructive pulmonary disease

https://doi.org/10.1016/j.jcrc.2011.04.008Get rights and content

Abstract

Purpose

High-frequency oscillatory ventilation (HFOV) is usually considered not indicated for treatment of patients with chronic obstructive pulmonary disease (COPD) because of the theoretical risk of air trapping and hyperinflation. The aim of our study was to establish whether HFOV can be safely applied in patients with acute exacerbation of COPD and hypercapnic respiratory failure.

Methods

Ten patients (age, 63-83 years) requiring intensive care treatment who failed on noninvasive ventilation were studied. After initial conventional mechanical ventilation (CMV) of less than 72 hours, all patients were transferred to HFOV for 24 hours and then back to CMV. Arterial blood gases, spirometry, and hemodynamic parameters were repeatedly obtained in all phases of CMV and HFOV at different settings. Regional lung aeration and ventilation were assessed by electrical impedance tomography.

Results

High-frequency oscillatory ventilation was tolerated well; no adverse effects or severe hyperinflation and hemodynamic compromise were observed. Effective CO2 elimination and oxygenation were achieved. Ventilation was more homogeneously distributed during HFOV than during initial CMV. Higher respiratory system compliance and tidal volume were found during CMV after 24 hours of HFOV.

Conclusions

Our study indicates that short-term HFOV, using lower mean airway pressures than recommended for acute respiratory distress syndrome, appears safe in patients with COPD while securing adequate pulmonary gas exchange.

Introduction

High-frequency oscillatory ventilation (HFOV) is frequently used in neonatal patients, especially in preterm infants with respiratory distress syndrome [1], [2], [3], [4]. It is less often applied in adult patients in whom its use is mainly motivated by its potential protective effect on lung tissue—the minimal oscillatory airway pressure swings and lower peak alveolar pressures are expected to minimize ventilator-associated lung injury [5], [6]. In this specific indication, HFOV has been used in adult patients with acute lung injury or acute respiratory distress syndrome (ARDS) [7], [8], [9], [10].

High-frequency oscillatory ventilation is usually considered not indicated and even contraindicated in patients with airway obstruction. This is recommended in textbooks on mechanical ventilation (eg, Tobin [11] and Oczenski [12]) and in the recent protocol for HFOV use in adults [13]. However, this recommendation is mainly based on theoretical considerations because very little experience on the use of HFOV in patients with airway obstruction exists. High-frequency oscillatory ventilation has been avoided in this group of patients because of the postulated risk of air trapping and hyperinflation with subsequent hemodynamic impairment. It has only been reported as a rescue therapy in 1 pediatric patient with status asthmaticus and in 5 children with bronchiolitis [14], [15].

According to our knowledge, HFOV has never been applied in adult patients with known severe airway obstruction like in chronic obstructive pulmonary disease (COPD). We hypothesize that HFOV need not be contraindicated in these patients when invasive mechanical ventilation is necessary for treating respiratory failure during the acute exacerbation of the disease. If clinical expertise is available, even patients with COPD might be ventilated by HFOV without increasing the risk of air trapping and hemodynamic adverse effects. However, the ventilator settings should be properly titrated so that the airways are stented open by the applied continuous distending pressure (CDP) both during inspiration and expiration. Under these circumstances, the patients with COPD may benefit from the protective nature of HFOV, and because COPD is known to be associated with spatially heterogeneous lung tissue damage with regionally dissimilar lung mechanics [16], the ventilation distribution may become more homogeneous.

Therefore, we initiated a study on the use of HFOV in patients with acute exacerbated COPD, using a lower mean airway pressure strategy than is recommended for ARDS, with the aim of checking the applicability, effectiveness, and safety of this ventilation mode. We used multiple examination tools to analyze pulmonary gas exchange, hemodynamics, global and regional lung ventilation, and the side effects of HFOV. We report here the results of this study.

Section snippets

Patients and study protocol

The study was approved by the ethics committee of the Christian Albrechts University in Kiel, Germany, and performed in compliance with the Helsinki Declaration. Written informed consent was obtained from the patients or legal representatives.

Ten patients admitted to the intensive care unit because of respiratory failure due to an acute exacerbation of COPD who failed on noninvasive ventilation were studied. None of the patients had bacterial pneumonia or congestive heart failure. The timeline

Results

The patients were transferred to HFOV after a period of CMV ranging from 23 hours and 32 minutes to 71 hours and 49 minutes. After transition to HFOV, CDP was set to 19.3 ± 2.2 cm H2O (mean ± SD), and by the end of the 24-hour period of HFOV, CDP was 24.5 ± 5.3 cm H2O. A constant maintenance CDP for the duration of at least 2 hours was achieved after 2 hours and 30 minutes to 4 hours and 45 minutes after initiation of HFOV. Six patients were oscillated at a rate of 360 oscillations·min−1, 4 at

Discussion

The results of our study indicate that patients with a known history of COPD can be ventilated by HFOV when an acute exacerbation of the disease accompanied by a severe hypercapnic respiratory failure necessitates the use of invasive mechanical ventilation. All patients could be safely ventilated by HFOV for the whole 24-hour study period using a lower mean airway pressure strategy than is recommended in ARDS patients [13]. Adequate gas exchange comparable with CMV was achieved; Paco2 tended to

Conclusions

Our study on the use of HFOV in patients with acute exacerbation of COPD showed that HFOV, applied with a lower mean airway pressure strategy than is recommended for ARDS, was safe and provided adequate pulmonary gas transport. No serious adverse effects were detected. More homogeneous ventilation distribution was found during HFOV, and improved respiratory system mechanics was detected after the application of HFOV. The possible clinical advantages or disadvantages of HFOV in patients with

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    Competing interests: Viasys Healthcare reimbursed the fee and the travel costs of I.F. to the congresses of the European Society of Intensive Care Medicine and of the American Thoracic Society. N.W. received an unrestricted research grant from CareFusion. M.Q. gave scientific talks for CareFusion and Novalung and received speaking fees from both companies. The other authors declare that they have no competing interests.

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