What can we learn from high-frequency ventilation?

Dipartimento di Medicina Perioperatoria, Terapia Intensiva ed Emergenza

Azienda Sanitaria Universitaria Integrata di Trieste
Università degli Studi di Trieste, Italy

U. Lucangelo MD, PhD

 Historical Overview of High Frequency Ventilation
Oberg and Sjöstrand:

1967 - first experimental application

1972 - first clinical application
High Frequency Positive Pressure Ventilation (HFPPV )

Lunkenheimer:

1972 - High Frequency Oscillation (HFO)

Klain and Smith

1977 – High Frequency Jet Ventilation (HFJV)

The term “High Frequency Ventilation” is used to

describe ventilation at higher than normal

frequencies (above 60 cycles/min = 1 Hz)

with reduced Tidal Volume (Vt) and

Peak Airway Pressure (Ppeak)

Tidal volume versus respiratory rate domain for different
ventilatory strategies
L E
F C
P + CO2
CV
Tidal Volume

P R
V

HFPPV
VD HFJV

HFOV
0 10 100 1000 10000
Respiratory Rate (b/min)
 High Frequency Ventilation
Techniques Overwiew

Heterogeneous group of Techniques

Gas Delivery System Design Frequency

(60 – 2400 cycles/min)
Gas Transport During HFV
“most popular theories”

Bulk gas flow

Diffusion

Taylor dispersion

Asymmetric velocity profiles

Pendelluft

Collateral ventilation

Cardiogenic oscillation
 Gas Transport During HFV

The relative importance of each of

these mechanisms
is not clear !!
These mechanics are not mutually exclusive

All may be operative simultaneously

Effects of lung disease on regional mechanics

High-frequency ventilation was developed in an
effort to avoid many of the complications and
limitations of conventional mechanical ventilation

 Alveolar overdistension

 Use of large tidal volume

Failure to exceed the minimum end-expiratory

lung volume needed to prevent tidal closure of
alveolar units
Froese CMM 1997;25:906
 High Frequency Ventilation

HFPV
HFJV

HFOV
H.F.O.V. is the form of high-frequency ventilation most widely used
in adult critical care.
 HFOV
The oscillatory pressure swings and thus VT are provided by a piston

O2 INLET

CO2 WASH OUT

Pressure
 Static Mean Airway Pressure
∆P
 ∆P
MAP
 Unilevel
 Adjustable %I-time

time
 Pressure transmission in HFOV

The oscillating pressures in the circuit are significantly damped in alveolar regions.
Indeed, the impedance in the endotracheal tube alone significantly reduces the
pressure swings in the trachea to 5-16% of that in the circuit.
 Equation of motion during HFOV

   
Paw(t )  V t  Ers  V t  Rrs  Vt  Irs
 Does High-Frequency Ventilation Offer Benefits Over Conventional
Ventilation in Adult Patients With Acute Respiratory Distress
Syndrome?

Many of the available human data on delivered VT during HFOV are

from studies of neonates.

• Neonates : small and uncuffed endotracheal tubes

higher frequencies (10 – 15 Hz).

• Adults: cuffed endotracheal tubes lower frequency (3 – 6 Hz).

• Very different lung and chest wall mechanics .

Therefore, the very small VT reported in neonates could well be

irrelevant to adult medicine.

Fessler H.E. and Hess D.R. Respiratory Care 2007

Tidal volume delivery during high frequency oscillatory ventilation in
adults with acute respiratory distress syndrome.

• Decreasing endotracheal tube internal diameter from 8 mm to 7 mm and

from 7 mm to 6 mm caused a 15.3% ± 1.7% and 18.9% ± 2.1%
reduction in tidal volume, respectively.

• A 2 Hz increase in frequency (4, 6, 8, 10, 12 Hz) was associated with a 23.1%

± 6.3% decrease in tidal volume.

• A 10 cmH2O increase in pressure amplitude (20, 30, 40 cmH2O ) caused a

21.4% ±3.4% increase in tidal volume.

Tidal volumes are not uniformly small during HFOV (23-225 mL) !!!

Hager DN et al. Crit Care Med 2007

Four methods of measuring tidal volume during
high-frequency oscillatory ventilation.

Measured VT varied with the pressure amplitude and varied

strongly with the frequency.

 At a pressure amplitude of 90 cm H2O and a frequency of only

4 Hz, VT was 200 mL.

 At 10 Hz, the VT fell to about 80 mL, even at the pressure

amplitude of 90 cm H2O.

Hager DN, Fuld M, Kaczka DW, Fessler HE, et al. Crit Care Med 2006
 Determinants of tidal volume during high-frequency oscillation.

In an adult sheep model, was used HFVO management strategies that

were identical to the ones used in early adult clinical trials by Fort and Mehta .

These investigators found that quite large VT (ie, 6 mL/kg)

were being delivered into the proximal airways.

Sedeek KA et al. Crit Care Med 2003

 VT is technically difficult to measure and is not monitored
during HFOV.

 Reliable tidal volume estimates at the airway opening with an infant monitor
during high-frequency oscillatory ventilation.
InPD,
Scalfaro P, Pillow JJ, Sly the clinical
Cotting practice,
J. Crit Care Med 2001.

HFOV
 Four methodsisofnot an intuitive
measuring ventilatory
tidal volume during modality
high-frequency
oscillatory
and ventilation.
the absence of real-time delivered
Hager DN, Fuld M, Kaczka DW, Fessler HE, et al. Crit Care Med 2006
volume monitoring
 Portable instrument for the volume measurement of high-frequency percussive
produces disaffection among the physicians.
ventilators.
Riscica F, Lucangelo U, Accardo A. Biomed Sci Instrum 2010
Comparison of prone positioning and high-frequency oscillatory
ventilation in patients with acute respiratory distress syndrome.

Prospective randomized study that enrolled 39 ARDS patients with a

PaO2/FIO2 < 150 mm Hg at PEEP > 5 cm H2O.

After 12 hours on conventional lung-protective mechanical ventilation

(VT of 6 mL/kg, Pplat ≤ 35 cmH2O, with supine conventional ventilation).

 12 patients received conventional lung protective mechanical ventilation in

prone position.

 13 patients received HFOV in supine position

 12 patients received HFOV in prone position

Papazian L, et al. Crit Care Med 2005

 *
*
PaO2/FiO2

Sup-CV Pro-CV Sup-CV Sup-CV

Papazian L, et al. Crit Care Med 2005

Neutrophil counts in bronchoalveolar lavage fluid

Papazian L, et al. Crit Care Med 2005

 OSCAR/OSCILLATE, Both Imperfect Trials

OSCILLATE OSCAR
(> 72 h excluded) ( up to 7 days)
CMV HFOV CMV HFOV

PaO2/FiO2 113±38 113±37 114±38 121±46

Hospital 35% 47% 41.1% 41.7%

mortality
Apache II 29±7 - 21±6.1 -

VT (ml/kg) 7.1±1.8 - 8.3±3.5 -

PREMATURELY STOPPED
Finally, the epiphenomena of HFOV include the
potential for circulatory depression from
high airway pressure
and the need
for heavy sedation or paralysis
during HFOV.
 Efficacy and adverse events of high-frequency oscillatory ventilation
in adult patients with acute respiratory distress syndrome: a meta-analysis

Huang et al. Critical Care 2014, 18:R102

 Efficacy and adverse events of high-frequency oscillatory ventilation
in adult patients with acute respiratory distress syndrome: a meta-analysis

Huang et al. Critical Care 2014, 18:R102

The effect of HFOV on 30-day or hospital mortality

Huang et al. Critical Care 2014, 18:R102

 The application of HFOV was associated with a trend toward
increased risk of barotrauma and unfavorable hemodynamics.

Huang et al. Critical Care 2014, 18:R102

 The application of HFOV was associated with a trend toward
increased risk of barotrauma and unfavorable hemodynamics.

Huang et al. Critical Care 2014, 18:R102

Current evidence did not support the routine use of HFOV
for ARDS patients in the era of lung-protective ventilation
because of its potential harm.
High Frequency PercussiveVentilation

Delivers high frequency ventilation (200 - 1200

cycles/min) in combination with “low frequency”
breath cycles.

II

E
•Male, 58yrs old, BMI 27,7

•Essential hypertension, paroxystic atrial flutter,

mild mitral and aortic insuffciency
•Bilateral bronchopneumonia

Nasal swab positive for influenza virus A (H1N1)

• pH 7.310
• PaCO2 62.5 mmHg
• PaO2 46.8 mmHg
• HCO3- 26.7 mEq/L
• BE 4.5 and SaO2 77.2 %
• Oxygenation index = 39
• Lung injury score = 3.25
• FiO2= 1
PCV
HFPV
Electrical impedance tomography during VCV
Electrical impedance tomography during HFPV
 The Evidence for New Ventilator
Modes …
It’s not the ventilator mode that makes a difference …

… It’s the skills of the clinician that makes the difference.

Any ventilator mode has the potential to do harm!

Dean Hess 2010

 To ventilate, oscillate, or cannulate?

Given the heterogeneity of acute respiratory distress syndrome,

each of these modalities may play a role in an individual patient.

Future studies comparing LPV, HFOV, and VV ECMO should not only

focus on defining the patients who benefit most from each of these

therapies but also consider long-term functional outcomes.

Shekar K et al. Journal of Critical Care 2013

HFOV should be reserved for patients
failing conventional ventilation
and
applied by clinicians
with considerable experience
with the device.

Respir Care 2016