High-frequency ventilation☆,☆☆,★

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TYPES OF HIGH-FREQUENCY VENTILATION AND HOW THEY ARE ADJUSTED

There are several types of HFV: high-frequency oscillatory ventilation, high-frequency jet ventilation, high-frequency flow interruption, high-frequency positive-pressure ventilation, and hybrids. Each type of high-frequency ventilator and the specific strategies suggested for its safe use are unique; published results on the use of one type of HFV cannot be generally applied. Most of the data on the use of HFV in the United States has involved one of five high-frequency devices or one of its

Oxygenation

Strategies used to improve oxygenation during HFV are similar to those used during conventional ventilation. For optimal oxygen delivery, assisted ventilation should be used with a strategy that maximizes ventilation-perfusion matching without impairing cardiac output. During HFV, lung volume is held relatively constant and the cycle of inflation and deflation associated with conventional ventilation is reduced. Conceptually, HFV allows the use of high end-expiratory pressures without requiring

Prevention of lung injury

Most investigators believe that the use of HFV in the management of neonates with respiratory failure reduces ventilator-induced lung injury. Results of animal experiments comparing HFV with the continued use of conventional ventilation strongly support this belief. In the premature baboon model of HMD, the use of HFOV reduces the occurrence of air leak, prevents the development of HMD, promotes uniform lung inflation, and improves gas exchange and lung mechanics.12, 27 In rhesus monkeys with

Hyaline membrane disease

Clinical trials comparing the use of HFV and conventional ventilation in neonates with HMD are not as encouraging as animal data (Table). The National Institutes of Health sponsored the largest (n = 673) study to date.34 The HIFI study group reported that HFOV was not effective in improving survival or reducing the incidence of bronchopulmonary dysplasia. In comparison with conventional ventilation, HFOV was associated with a small but significant increase in the occurrence of grades 3 and 4

COMPLICATIONS

Complications reported to be associated with HFV include hypotension, intraventricular hemorrhage, and necrotizing tracheobronchitis. The interaction of airway pressure with cardiac output is related to lung compliance and lung volume. The use of high airway pressure can cause overinflation of the lungs, reduce venous return, increase pulmonary vascular resistance, and reduce cardiac output.59 Animal and human studies show that, when used with a strategy that avoids lung hyperinflation, HFV

CONCLUSION

High-frequency ventilation often improves gas exchange in critically ill neonates in whom conventional ventilation has failed. However, its role in improving outcome has not been determined. In premature babies, it may reduce the occurrence of air leak syndromes and chronic lung disease; in term infants, it may reduce the need for ECMO. Research is needed to define the following: (1) disease-specific strategies that promote lung recovery and minimize lung injury, (2) the effect of HFV on

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    ☆

    From the Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia

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    Reprint requests: Reese H. Clark, MD, Department of Pediatrics, 2040 Ridgewood Dr., Atlanta, GA 30322.

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