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Original Investigation |

Comparison of High-Frequency Oscillatory Ventilation and Conventional Mechanical Ventilation in Pediatric Respiratory Failure

Punkaj Gupta, MBBS1,2; Jerril W. Green, MD1; Xinyu Tang, PhD3; Christine M. Gall, DrPHc4; Jeffrey M. Gossett, MS3; Tom B. Rice, MD4,5; Robert M. Kacmarek, PhD, RRT6,7; Randall C. Wetzel, MBBS4,8,9
[+] Author Affiliations
1Division of Pediatric Critical Care, Department of Pediatrics, University of Arkansas Medical Center, Little Rock
2Division of Pediatric Cardiology, Department of Pediatrics, University of Arkansas Medical Center, Little Rock
3Division of Biostatistics, Department of Pediatrics, University of Arkansas Medical Center, Little Rock
4Virtual PICU Systems LLC, Los Angeles, California
5Division of Pediatric Critical Care, Department of Pediatrics, Medical College of Wisconsin, Milwaukee
6Department of Anesthesia, Massachusetts General Hospital, Harvard Medical School, Boston
7Department of Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston
8Department of Anesthesiology, Keck School of Medicine, University of Southern California, Los Angeles
9Division of Pediatric Critical Care, Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles
JAMA Pediatr. 2014;168(3):243-249. doi:10.1001/jamapediatrics.2013.4463.
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Importance  Outcomes associated with use of high-frequency oscillatory ventilation (HFOV) in children with acute respiratory failure have not been established.

Objective  To compare the outcomes of HFOV with those of conventional mechanical ventilation (CMV) in children with acute respiratory failure.

Design, Setting, and Participants  We performed a retrospective, observational study using deidentified data obtained from all consecutive patients receiving mechanical ventilation aged 1 month to 18 years in the Virtual PICU System database from January 1, 2009, through December 31, 2011. The study population was divided into 2 groups: HFOV and CMV. The HFOV group was further divided into early and late HFOV. Propensity score matching was performed as a 1-to-1 match of HFOV and CMV patients. A similar matching process was performed for early HFOV and CMV patients.

Exposure  High-frequency oscillatory ventilation.

Main Outcomes and Measures  Length of mechanical ventilation, intensive care unit (ICU) length of stay, ICU mortality, and standardized mortality ratio (SMR).

Results  A total of 9177 patients from 98 hospitals qualified for inclusion. Of these, 902 (9.8%) received HFOV, whereas 8275 (90.2%) received CMV. A total of 1764 patients were matched to compare HFOV and CMV, whereas 942 patients were matched to compare early HFOV and CMV. Length of mechanical ventilation (CMV vs HFOV: 14.6 vs 20.3 days, P < .001; CMV vs early HFOV: 14.6 vs 15.9 days, P < .001), ICU length of stay (19.1 vs 24.9 days, P < .001; 19.3 vs 19.5 days, P = .03), and mortality (8.4% vs 17.3%, P < .001; 8.3% vs 18.1%, P < .001) were significantly higher in HFOV and early HFOV patients compared with CMV patients. The SMR in the HFOV group was 2.00 (95% CI, 1.71-2.35) compared with an SMR in the CMV group of 0.85 (95% CI, 0.68-1.07). The SMR in the early HFOV group was 1.62 (95% CI, 1.31-2.01) compared with an SMR in the CMV group of 0.76 (95% CI, 0.62-1.16).

Conclusions and Relevance  Application of HFOV and early HFOV compared with CMV in children with acute respiratory failure is associated with worse outcomes. The results of our study are similar to recently published studies in adults comparing these 2 modalities of ventilation for acute respiratory distress syndrome.

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Figure 1.
Study Design and Outcomes

CMV indicates conventional mechanical ventilation; HFOV, high-frequency oscillatory ventilation.

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Figure 2.
Kaplan-Meier Curves for Intensive Care Unit (ICU) Length of Stay (LOS) and Duration of Mechanical Ventilation

A, ICU LOS for conventional mechanical ventilation (CMV) and high-frequency oscillatory ventilation (HFOV) patients (death times are marked in the plot). The median ICU LOS was estimated to be 14.6 days (95% CI, 13.8-15.2 days) for CMV patients and 21.9 days (95% CI, 20.9-23.4 days) for HFOV patients. A significant difference was seen in the ICU LOS between CMV and HFOV patients based on the frailty model (P < .001). B, Duration of mechanical ventilation for CMV and HFOV patients (death times are marked in the plot). The median duration of mechanical ventilation was estimated to be 10.3 days (95% CI, 9.5-10.9 days) for CMV patients and 16.8 days (95% CI, 15.7-18.1 days) for HFOV patients. A significant difference was seen in the duration of mechanical ventilation between CMV and HFOV patients based on the frailty model (P < .001).

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