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Highlights from the High Frequency Ventilation Meeting at Snowbird Utah, April 4-7, 2001
HFOV vs SIMV for RDS
Early High Frequency Oscillatory Ventilation (HFOV) vs Synchronized Intermittent Mandatory Ventilation for Very Low Birth Weight (VLBW) Infants. Durand DJ, Asselin JM, Courtney SE, et al. Chldren’s Hospital, Oakland.
This study reported the results of a large, prospective randomized trial designed to determine whether early institution of HFOV, compared to SIMV with continuous tidal volume monitoring, improved the pulmonary outcome of VLBW infants without increasing the incidence of IVH and/or PVL. 500 infants from 26 centers were enrolled. Eligible infants were 601 - 1200 g birth weight, and ventilator-dependent after one dose of Survanta. Infants were randomized and placed on their assigned ventilator as soon as possible after birth (mean time 2.7 hours for switch to HFOV). Patients were treated with ventilator strategies that included permissive hypercapnea, monitoring of lung inflation and tidal volume, aggressive weaning, and standardized extubation criteria. All infants received prophylactic indomethacin. Neuroultrasounds were done at specified times and interpreted by a single masked reviewer. Infants randomized to HFOV had a significantly earlier age at extubation (17 days vs 24 days, p=0.0002), and significantly more babies from the HFOV group were alive without CLD at 36 weeks PMA (57% vs 47%, p=0.036). There were no differences between groups in mortality, or in IVH and/or PVL.
Comment. This study confirmed the findings from smaller studies reported by Dr Clark et al in 1991, and by Dr. Gerstmann er al in 1995. All three studies compared the Sensormedics 3100 HFOV device to conventional ventilation for RDS, and all 3 studies found a significant improvement in survival without CLD in the HFOV group. The present study differs from the earlier studies because of its multi-center design with a large sample size, and because it compared HFOV to newer modes of CMV that included patient-triggered ventilation (SIMV) and tidal volume monitoring. The possibility of an association between HFOV and an increased incidence of IVH has been raised off and on since the HIFI trial was reported in 1989, and surfaced again more recently in a study by Moriette et al (see NeoNotes, Volume 2, Issue 2, 2001 for a review). It should be noted that those studies did not use the Sensormedics HFOV ventilator. None of the randomized, controlled trials that looked at the Sensormedics HFOV for RDS found an increased incidence of IVH or PVL with that device. I feel that this study may conclusively demonstrate advantages in pulmonary outcome using this HFOV device vs SIMV for RDS, without increasing the risk of IVH. I anxiously await the publication of this data, so we can give it closer consideration.