title: A protocol for high-frequency oscillatory ventilation in adults: results from a roundtable discussion.
abstract: OBJECTIVE
  Ventilator settings typically used for high-frequency oscillatory ventilation (HFO) in adults provide acceptable gas exchange but may not take best advantage of its lung-protective aspects. We provide guidelines for HFO in adults with acute respiratory distress syndrome that should optimize the lung-protective characteristics of this ventilation mode.
  
  
  METHODS
  Roundtable discussions, iterative revisions, and consensus.
  
  
  METHODS
  Five academic medical centers.
  
  
  METHODS
  Not applicable.
  
  
  METHODS
  Participants addressed how to best maintain ventilation through combinations of oscillation pressure amplitude, frequency, and the use of an endotracheal tube cuff leak, and to maintain oxygenation through combinations of recruitment maneuvers, mean airway pressure, and oxygen concentration. The guiding principles were to provide lung protective ventilation by minimizing the size of tidal volumes, and balance the risks and benefits of lung recruitment and distension.
  
  
  RESULTS
  HFO may provide smaller tidal volumes and more complete lung recruitment than conventional modes. To optimize these features, we recommend use of the maximum pressure-oscillation amplitude coupled with the highest tolerated frequency, targeting a pH of only 7.25-7.35. This will yield a smaller tidal volume than typical HFO settings where frequency is limited to 6 Hz or less and pressure amplitude is submaximal. Lung recruitment can be achieved with the use of recruitment maneuvers, especially during the first several days of HFO. Recruitment may be augmented or sustained with generous mean airway pressures. These may either be chosen from a table of recommended mean airway pressure and oxygen concentration combinations, or individually titrated based on the oxygenation response of each patient.
  
  
  CONCLUSIONS
  Modification of the goals and tactics of HFO use may better protect against ventilator-associated lung injury. Further clinical trials are needed to compare the effects on patient outcome of the best use of HFO compared to the most protective use of conventional modes in adult acute respiratory distress syndrome.
authors.affiliation: Division of Pulmonary and Critical Care Medicine, Johns Hopkins Medical Institutions, Baltimore, USA. hfessler@jhmi.edu
authors.forename: Henry E
authors.initials: HE
authors.lastname: Fessler
authors.forename: Stephen
authors.initials: S
authors.lastname: Derdak
authors.forename: Niall D
authors.initials: ND
authors.lastname: Ferguson
authors.forename: David N
authors.initials: DN
authors.lastname: Hager
authors.forename: Robert M
authors.initials: RM
authors.lastname: Kacmarek
authors.forename: B Taylor
authors.initials: BT
authors.lastname: Thompson
authors.forename: Roy G
authors.initials: RG
authors.lastname: Brower
mesh_terms: D000328:Adult; D002985:Clinical Protocols; D006612:High-Frequency Ventilation / Q000009:adverse effects / Q000379:methods*; D006801:Humans; D012128:Respiratory Distress Syndrome / Q000209:etiology / Q000628:therapy*