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Randomized comparison of high-frequency ventilation with high-rate intermittent positive pressure ventilation in
U Thome1, H Kössel, G Lipowsky
1Sektion Neonatologie und pädiatrische Intensivmedizin, Kinderklinik, Universität Ulm, Ulm, Germany.
Insights
High-frequency ventilation (HFV) did not reduce lung injury in preterm infants compared to intermittent positive pressure ventilation (IPPV). Both ventilation methods showed similar rates of treatment failure and mortality.
Area of Science:
- Neonatalogy
- Pediatric Critical Care
- Respiratory Medicine
Background:
- Mechanical ventilation is crucial for preterm infants but carries risks of lung injury.
- High-frequency ventilation (HFV) and intermittent positive pressure ventilation (IPPV) are common modes, each with different strategies.
- Optimizing ventilation to minimize lung injury in vulnerable preterm neonates remains a critical challenge.
Purpose of the Study:
- To test if HFV with a high lung volume strategy reduces treatment failures compared to IPPV in preterm infants.
- To evaluate the efficacy of different mechanical ventilation strategies in preventing lung injury.
- To compare the incidence of air leaks, chronic lung disease, and intracranial hemorrhage between HFV and IPPV.
Main Methods:
- A randomized, controlled, multicenter trial involving 284 preterm infants (gestational age 24-30 weeks) requiring mechanical ventilation shortly after birth.
- Infants were assigned to either IPPV or HFV until 240 hours post-randomization, extubation, or meeting treatment failure criteria.
- Treatment failure was defined by air leaks, high oxygenation index, death, or chronic lung disease; secondary outcomes included intracranial hemorrhage.
Main Results:
- The trial was terminated early after interim analysis; no significant difference in treatment failure rates was observed between IPPV (46%) and HFV (54%) groups (P =.15).
- Air leaks were more frequent in the HFV group (42%) compared to the IPPV group (31%) (P =.042).
- Incidence of chronic lung disease, severe intracranial hemorrhage, and mortality before discharge were similar between the two ventilation strategies.
Conclusions:
- HFV with a high lung volume strategy did not demonstrate a benefit in reducing lung injury or treatment failures in preterm infants compared to IPPV.
- The findings suggest that IPPV with high rates and low peak inspiratory pressures may be as effective as HFV in this population.
- Further research may be needed to refine ventilation strategies for optimizing outcomes in extremely preterm neonates.
Objective:
In a randomized, controlled, multicenter trial, we tested the hypothesis that high-frequency ventilation (HFV) with a high lung volume strategy results in fewer treatment failures than intermittent positive pressure ventilation (IPPV) with high rates and low peak inspiratory pressures.
Study Design:
Infants with a gestational age between >/=24 weeks and <30 weeks, requiring mechanical ventilation within 6 hours of birth, were randomly assigned to receive either IPPV or HFV until 240 hours after randomization, extubation, or meeting treatment failure criteria. Treatment failure, the primary end point, was determined when air leaks, an oxygenation index >35 to 45 (depending on gestational age), death, or chronic lung disease occurred. Chronic lung disease was defined as persistent requirement of mechanical ventilation, continuous positive airway pressure, or supplemental oxygen at a postmenstrual age of 36 weeks. Secondary end points included the incidence of intracranial hemorrhage.
Results:
The third scheduled interim analysis led to termination of the trial after recruitment of 284 infants. Treatment failure criteria were met by 46% of infants receiving IPPV and 54% of infants receiving HFV (1-tailed primary hypothesis, P =.92; 2-tailed chi2 test, P =.15). Air leaks occurred in 31% and 42% (P =.042), CLD in 23% and 25%, and grade 3-4 intracranial hemorrhage in 13% and 14% of IPPV-treated and HFV-treated patients, respectively. The mortality rate before discharge was 10% in both groups.
Conclusion:
HFV with a high lung volume strategy did not cause less lung injury in preterm infants than IPPV with a high rate and low peak inspiratory pressures.