Early High-Frequency Oscillatory Ventilation in Pediatric Acute Respiratory Failure. A Propensity Score Analysis.
BACKGROUND
The use of high-frequency oscillatory ventilation (HFOV) for acute respiratory failure in children is prevalent despite the lack of efficacy data.


OBJECTIVE
To compare the outcomes of patients with acute respiratory failure managed with HFOV within 24-48 hours of endotracheal intubation with those receiving conventional mechanical ventilation (CMV) and/or late HFOV.


METHODS
This is a secondary analysis of data from the RESTORE (Randomized Evaluation of Sedation Titration for Respiratory Failure) study, a prospective cluster randomized clinical trial conducted between 2009 and 2013 in 31 U.S. pediatric intensive care units. Propensity score analysis, including degree of hypoxia in the model, compared the duration of mechanical ventilation and mortality of patients treated with early HFOV matched with those treated with CMV/late HFOV.


RESULTS
Among 2,449 subjects enrolled in RESTORE, 353 patients (14%) were ever supported on HFOV, of which 210 (59%) had HFOV initiated within 24-48 hours of intubation. The propensity score model predicting the probability of receiving early HFOV included 1,064 patients (181 early HFOV vs. 883 CMV/late HFOV) with significant hypoxia (oxygenation index ≥ 8). The degree of hypoxia was the most significant contributor to the propensity score model. After adjusting for risk category, early HFOV use was associated with a longer duration of mechanical ventilation (hazard ratio, 0.75; 95% confidence interval, 0.64-0.89; P = 0.001) but not with mortality (odds ratio, 1.28; 95% confidence interval, 0.92-1.79; P = 0.15) compared with CMV/late HFOV.


CONCLUSIONS
In adjusted models including important oxygenation variables, early HFOV was associated with a longer duration of mechanical ventilation. These analyses make supporting the current approach to HFOV less convincing.
1 Department of Pediatrics, University of Massachusetts Medical School, Worcester, Massachusetts.
Scot T
ST
Bateman
2 Department of Pediatrics, University of Alabama, Birmingham, Alabama.
Santiago
S
Borasino
3 Department of Cardiology and.
Lisa A
LA
Asaro
4 Department of Pediatrics, Duke University Medical Center, Durham, North Carolina.
Ira M
IM
Cheifetz
5 Department of Pediatrics, University of California, San Francisco, San Francisco, California.
Shelley
S
Diane
3 Department of Cardiology and.|6 Department of Pediatrics, Harvard Medical School, Boston, Massachusetts.|7 Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts; and.
David
D
Wypij
10 Department of Cardiovascular and Critical Care Services, Boston Children's Hospital, Boston, Massachusetts.|8 Department of Family and Community Health, School of Nursing and.|9 Department of Anesthesia and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
Martha A Q
MA
Curley
D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D005260:Female; D006612:High-Frequency Ventilation / Q000379:methods*; D006801:Humans; D000860:Hypoxia / Q000209:etiology / Q000628:therapy*; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D016017:Odds Ratio; D057216:Propensity Score; D016016:Proportional Hazards Models; D011446:Prospective Studies; D016032:Randomized Controlled Trials as Topic; D012121:Respiration, Artificial / Q000379:methods; D012128:Respiratory Distress Syndrome / Q000150:complications / Q000628:therapy*; D012127:Respiratory Distress Syndrome, Newborn / Q000150:complications / Q000628:therapy*; D012131:Respiratory Insufficiency / Q000150:complications / Q000628:therapy*; D013997:Time Factors
high-frequency oscillatory ventilation; mechanical ventilation; oxygenation index; pediatric acute respiratory distress syndrome