Prospective, randomized comparison of high-frequency oscillatory ventilation and conventional mechanical ventilation in pediatric respiratory failure

Objective: To compare the effectiveness of high-frequency oscillatory ventilation with conventional mechanical ventilation in pediatric patients with respiratory failure. Setting: Five tertiary care pediatric intensive care units. Design: A prospective, randomized, clinical study with crossover. Patients: Seventy patients with either diffuse alveolar disease and/or airleak syndrome were randomized to receive high-frequency oscillatory ventilation or conventional mechanical ventilation. Interventions: Patients randomized to receive high-frequency oscillatory ventilation were managed, using a strategy that consisted of aggressive increases in mean airway pressure to attain the "ideal" lung volume and to achieve an arterial oxygen saturation of ≥90%, with an Fio2 of ≤0.6. Patients who were randomized to receive conventional mechanical ventilation were treated with a strategy that utilized increases in end-expiratory pressure and inspiratory time to increase mean airway pressure and to limit increases in peak inspiratory pressure. Target blood gas values were the same for both groups. Crossover to the alternate ventilator was required if the patient met defined criteria for treatment failure. Measurements and Main Results: Physiologic data and ventilatory parameters were collected prospectively at predetermined intervals after randomization. Airleak Scores were derived daily, based on the chest radiograph and the patient's clinical condition. In the high-frequency oscillatory ventilation group, the Pao2/Pao2 ratio increased significantly and the oxygenation index (mean airway pressure × Fio2 × 100/Pao2) decreased significantly over time. There were no differences between the groups in duration of mechanical ventilation, frequency of airleak, Airleak Scores, or 30-day survival rates. Significantly fewer patients treated with high-frequency oscillatory ventilation required supplemental oxygenation at 30 days compared with patients managed with conventional ventilation. When ventilatory subgroups were compared, the patients managed with high-frequency oscillation only had significantly better ranked outcomes than patients managed with conventional ventilation only. Conclusions: Our results indicate that high-frequency oscillatory ventilation, utilizing an aggressive volume recruitment strategy, results in significant improvement in oxygenation compared with a conventional ventilatory strategy designed to limit increases in peak airway pressures. Furthermore, despite the use of higher mean airway pressures, the optimal lung volume strategy used in this study was associated with a lower frequency of barotrauma, as indicated by requirement for supplemental oxygen at 30 days, and improved outcome compared with conventional mechanical ventilation. (Crit Care Med 1994; 22:1530–1539)