High-Frequency Jet Ventilation Improves Gas Exchange in Extremely Immature Infants with Evolving Chronic Lung Disease

ABSTRACT

Extremely preterm infants often develop chronic lung disease (CLD) characterized by heterogeneous aeration; poorly supported, floppy airways; and air trapping. High-frequency jet ventilation (HFJV) with high end-expiratory pressure (optimal lung volume strategy [OLVS]) may improve airway patency, lead to better gas distribution, improve gas exchange, and facilitate extubation. In a pilot trial, this study sought to explore the effect of HFJV on oxygenation, ventilation, and ease of extubation in preterm infants with evolving CLD and refractory respiratory failure (RRF). From September 2002 to October 2004, 12 episodes of RRF developed in 10 ventilated extremely immature infants with evolving CLD (10 on conventional and two on high-frequency oscillation). Chorioamnionitis was confirmed in all infants, patent ductus arteriosus was ligated in five patients, and Ureaplasma urealyticum was cultured from trachea in four patients. HFJV with OLVS was initiated when oxygenation index (OI) > 10 or exhaled tidal volume (Vte) ≥ 7 mL/kg were required to maintain partial pressure of carbon dioxide, arterial (Paco ₂) < 60 mm Hg. Inspiratory time (0.02/s) and frequency (310 to 420/min) were set initially with adjustment of pressure amplitude to keep Paco ₂ between 45 and 55 mm Hg. Ventilatory stabilization and weaning from mechanical ventilation with extubation to nasal continuous positive airway pressure (CPAP) were the goals of this approach. Gas exchange data were analyzed by Analysis of variance for repeated measures. Ten patients on 11 occasions of RRF were extubated to nasal CPAP successfully in a median of 15.5 days. Nine of 10 patients survived (one died of pentalogy of Cantrell), all required supplemental O₂ at 36 weeks. Paco ₂ decreased within 1 hour after the initiation of HFJV, and OI decreased by 24 hours. Both remained significantly lower until successful extubation (p < 0.02). Compared with conventional ventilation or high-frequency oscillatory ventilation, HFJV used with OLVS appears to improve gas exchange and may facilitate weaning from mechanical ventilation (MV) in extremely immature infants with evolving CLD. These encouraging pilot data need to be confirmed in a larger clinical trial.

KEYWORDS

Chronic lung disease - high-frequency jet ventilation - gas exchange

REFERENCES

• 1 Coalson J J, Winter V, deLemos R A. Decreased alveolarization in baboon survivors with bronchopulmonary dysplasia.  Am J Respir Crit Care Med. 1995;  152 640-646
• 2 Coalson J J, Winter V T, Siler K T, Yoder B A. Neonatal chronic lung disease in extremely immature baboons.  Am J Respir Crit Care Med. 1999;  160 1333-1346
• 3 Rimensberger P C. Neonatal respiratory failure.  Curr Opin Pediatr. 2002;  14 315-321
• 4 Muscedere J G, Mullen J BM, Gan K, Slutsky A S. Tidal volume at low airway pressures can augment lung injury.  Am J Respir Crit Care Med. 1994;  149 1327-1334
• 5 Ito Y, Manwell S EE, Kerr C L et al.. Effects of ventilation strategies on the efficacy of exogeneous surfactant therapy in a rabbit model of acute lung injury.  Am J Respir Crit Care Med. 1998;  157 149-155
• 6 Gerstmann D R, Minton S D, Stoddart R A et al.. The Provo multicenter early high frequency oscillatory ventilation trial: improved pulmonary and clinical outcome in respiratory distress syndrome.  Pediatrics. 1996;  98 1044-1052
• 7 Plavka R, Kopecky P, Sebron V, Svihovec P, Zlatohlavkova B, Janus V. A prospective randomized comparison of conventional mechanical ventilation and very early high frequency oscillatory ventilation in extremely premature newborns with respiratory distress syndrome.  Intensive Care Med. 1999;  25 68-75
• 8 Courtney S E, Durand D J, Asselin J M et al.. High frequency oscillatory ventilation versus conventional mechanical ventilation for very low birth weight infants.  N Engl J Med. 2002;  347 643-652
• 9 Solway J, Rossing T H, Saari A F, Drazen J M. Expiratory flow limitation and dynamic pulmonary hyperinflation during high frequency ventilation.  J Appl Physiol. 1986;  60 2071-2078
• 10 Pillow J J, Neil H, Wilkinson M H, Ramsden C A. Effect of I/E ratio on mean alveolar pressure during high frequency oscillatory ventilation.  J Appl Physiol. 1999;  87 407-441
• 11 Bunnell J B. General concepts of high frequency ventilation. In: Donn SM, Sinha SK A Manual of Neonatal Respiratory Care. New York; Futura Publishing Co 2000: 226-234
• 12 Friedlich P, Subramanian N, Sebald M, Noori S, Seri I. Use of high-frequency jet ventilation in neonates with hypoxemia refractory to high-frequency oscillatory ventilation.  J Matern Fetal Neonatal Med. 2003;  13 398-402
• 13 Clark R H, Gerstmann D R, Jobe A H, Moffitt S T, Slutsky A S, Yoder B A. Lung injury in neonates: causes, strategies for prevention, and long-term consequences.  J Pediatr. 2001;  139 478-486
• 14 van Kaam A H, Haitsma J J, De Jaegere A, van Aalderen W M, Kok J H, Lachmann B. Open lung ventilation improves gas exchange and attenuates secondary lung injury in a piglet model of meconium aspiration.  Crit Care Med. 2004;  32 443-449
• 15 Dos Santos C C, Slutsky A S. Overview of high-frequency ventilation modes, clinical rationale, and gas transport mechanisms.  Respir Care Clin N Am. 2001;  7 549-575