Intermittent recruitment with high-frequency oscillation/tracheal gas insufflation in acute respiratory distress syndrome

Abstract

In acute respiratory distress syndrome (ARDS), recruitment sessions of highfrequency oscillation (HFO) and tracheal gas insufflation (TGI) with short-lasting recruitment manoeuvres (RMs) may improve oxygenation and enable reduction of subsequent conventional mechanical ventilation (CMV) pressures. We determined the effect of adding HFO-TGI sessions to lung-protective CMV on early/severe ARDS outcome.We conducted a prospective clinical trial, subdivided into a first single-centre period and a second two-centre period. We enrolled 125 (first period, n554) patients with arterial oxygen tension (Pa,O 2 )/inspiratory oxygen fraction (FI,O 2 ) of ,150 mmHg for .12 consecutive hours at an end-expiratory pressure of o8 cmH 2 O. Patients were randomly assigned to an HFO-TGI group (receiving HFO-TGI sessions with RMs, interspersed with lung-protective CMV; n561) or CMV group (receiving lung-protective CMV and RMs; n564). The primary outcome was survival to hospital discharge.Pre-enrolment ventilation duration was variable. During days 1-10 post-randomisation, Pa,O 2 / FI,O 2 , oxygenation index, plateau pressure and respiratory compliance were improved in the HFO-TGI group versus the CMV group (p,0.001 for group6time). Within days 1-60, the HFO-TGI group had more ventilator-free days versus the CMV group (median (interquartile range) 31.0 (0.0-42.0) versus 0.0 (0.0-23.0) days; p,0.001), and more days without respiratory, circulatory, renal, coagulation and liver failure (pf0.003). Survival to hospital discharge was higher in the HFO-TGI group versus the CMV group (38 (62.3%) out of 61 versus 23 (35.9%) out of 64 subjects; p50.004).Intermittent recruitment with HFO-TGI and RMs may improve survival in early/severe ARDS.

Insuflação de gás traqueal como recurso terapêutico em ventilação mecânica invasiva: revisão sistemática

“…Além disso, verificou-se que a HFO associada à TGI apresentou mais dias livres da VM, com melhora clínica da função renal e resultados satisfatórios nos exames de coagulação e insuficiência hepática. Portanto, propiciou um maior índice de sobrevivência à alta hospitalar, com uma diferença de 26,4% na comparação com o grupo que utilizou somente VMI 22 . Já no estudo de Vrettou et al 23 , a TGI foi aplicada em pacientes diagnosticados com traumatismo cranioencefálico (TCE) complicados por SDRA, que apresentavam PaO 2 /FiO 2 < 100 mmHg e ≥ 10 de pressão cmH 2 O no final da expiração.…”

“Low-” versus “high”-frequency oscillation and right ventricular function in ARDS. A randomized crossover study

“…Notably, prior two-center data on moderate-to-severe ARDS suggested a survival benefit from the intermittent use of “low-frequency” (i.e., approximately 4 Hz) HFO with tracheal tube cuff leak and tracheal gas insufflation (TGI) [14]. “Low”-HFO frequency, cuff leak, and TGI augment CO 2 elimination [14, 15], with potential benefit on RV function.…”

“…“Low”-HFO frequency, cuff leak, and TGI augment CO 2 elimination [14, 15], with potential benefit on RV function.…”

“…In sharp contrast, recently proposed and tested HFO strategies [7, 8] were based just on pilot clinical data and expert consensus [8]; furthermore, these HFO strategies were focused at preventing lung injury, without concurrently protecting the RV [7–12, 18]. Therefore, discrepant prior data [6, 14] and recent RCT results [7, 8] might partly reflect differences in protocol-employed HFO ventilator settings and their impact on RV function and patient outcomes.…”

“…In the present physiological study, we used transesophageal echocardiography (TEE) and tested the hypothesis that “short-term” “low-frequency” HFO with cuff leak and with or without TGI,—i.e., HFO strategies aimed at preventing hypercapnia [14, 15]—might result in (1) improved RV function as compared with a “high-frequency” HFO strategy without cuff leak or TGI, which may promote hypercapnia [7, 8], and (2) similar RV function relative to lung protective CV. Avoiding excessive hypercapnia might prevent or attenuate RV dysfunction/failure during the application of high-HFO mean airway pressure (mPaw) aimed at augmenting lung recruitment [9–13].…”