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Review
. 2016 Apr 4;4(4):CD004085.
doi: 10.1002/14651858.CD004085.pub4.

High-frequency oscillatory ventilation versus conventional ventilation for acute respiratory distress syndrome

Sachin Sud  1 , Maneesh Sud, Jan O Friedrich, Hannah Wunsch, Maureen O Meade, Niall D Ferguson, Neill K J Adhikari
Affiliations
Review

High-frequency oscillatory ventilation versus conventional ventilation for acute respiratory distress syndrome

Sachin Sud et al. Cochrane Database Syst Rev. .

Abstract

Background: High-frequency oscillation (HFO) is an alternative to conventional mechanical ventilation that is sometimes used to treat people with acute respiratory distress syndrome, but effects on oxygenation, mortality and adverse clinical outcomes are uncertain. This review was originally published in 2004 and was updated in 2013 and again in 2015.

Objectives: To determine the effects of HFO compared to conventional mechanical ventilation on physiological outcomes, clinical outcomes, and mortality when used for the treatment of acute respiratory distress syndrome (ARDS).

Search methods: We electronically searched the Cochrane Central Register of Controlled Trials (CENTRAL) (Ovid), MEDLINE (Ovid), EMBASE (Ovid), and ISI, from inception to December 2015. We conducted the original search in 2002. We manually searched reference lists from included studies and review articles; searched conference proceedings of the American Thoracic Society (1994 to 2015), Society of Critical Care Medicine (1994 to 2015), European Society of Intensive Care Medicine (1994 to 2015), and American College of Chest Physicians (1994 to 2015); contacted clinical experts in the field; and searched for unpublished and ongoing trials in clinicaltrials.gov and controlled-trials.com.

Selection criteria: Randomized controlled trials (RCTs) comparing treatment using HFO with conventional mechanical ventilation for children and adults diagnosed with ARDS.

Data collection and analysis: Three review authors independently extracted data on clinical, physiological, and safety outcomes according to a predefined protocol. We contacted investigators of all included studies to clarify methods and obtain additional data. We used random-effects models in the analyses.

Main results: We include 10 RCTs (n = 1850); almost all participants had moderate or severe ARDS. For the primary analysis, the risk of bias was low in three studies and unclear in five studies; the overall quality of evidence was very low due to imprecision, inconsistency, indirectness and methodologic limitations. In participants randomized to HFO, there was no significant difference in hospital or 30-day mortality (risk ratio (RR) 0.92, 95% confidence interval (CI) 0.72 to 1.16; P = 0.46, I² = 66%; 8 trials, 1779 participants, 807 deaths) compared with conventional ventilation. One large multicentre RCT was terminated early because of increased mortality in participants randomized to HFO compared to mechanical ventilation with low tidal volume and high positive end expiratory pressure, with HFO reserved only as a rescue therapy. We found substantial between-trial statistical heterogeneity (I² = 0% to 66%) for clinical outcomes, including mortality.

Authors' conclusions: The findings of this systematic review suggest that HFO does not reduce hospital and 30-day mortality due to ARDS; the quality of evidence was very low. Our findings do not support the use of HFO as a first-line strategy in people undergoing mechanical ventilation for ARDS.

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Conflict of interest statement

All authors have completed the Cochrane online conflicts of interest form and declare the following:

Sachin Sud: nothing to declare. Maneesh Sud: nothing to declare. Jan O Friedrich: no financial interests to declare; Dr. Friedrich is a co‐investigators for the Canadian Institutes of Health Research (CIHR) funded OSCILLATE study, which was included in this review (Ferguson 2013). CareFusion (formerly SensorMedics) is providing study oscillators to some of the hospitals involved in the OSCILLATE study for the duration of the study. Hannah Wunsch: nothing to declare. Maureen O Meade:no financial interests to declare; Dr. Meade is a primary investigator for the Canadian Institutes of Health Research (CIHR) funded OSCILLATE study, which was included in this review (Ferguson 2013). CareFusion (formerly SensorMedics) is providing study oscillators to some of the hospitals involved in the OSCILLATE study for the duration of the study. Niall D Ferguson:no financial interests to declare; Dr. Ferguson is a primary investigator for the Canadian Institutes of Health Research (CIHR) funded OSCILLATE study, which was included in this review (Ferguson 2013). CareFusion (formerly SensorMedics) is providing study oscillators to some of the hospitals involved in the OSCILLATE study for the duration of the study. Neill KJ Adhikari: no financial interests to declare; Dr. Adhikari is a co‐investigators for the Canadian Institutes of Health Research (CIHR) funded OSCILLATE study, which was included in this review (Ferguson 2013). CareFusion (formerly SensorMedics) is providing study oscillators to some of the hospitals involved in the OSCILLATE study for the duration of the study.

Four of the seven authors (JOF, NKJA, NDF, MOM) co‐authored one of the included studies Ferguson 2013 and were not involved in the acquisition and interpretation of data, or the assessment of risk of bias for this study (which was performed by SS and MS). JOF verified the calculation of ratio of means (which was first performed independently by SS and MS), for physiologic outcomes for all studies, including Ferguson 2013.

Figures

1
1
Study flow diagram for the updated literature search (from 2011 to Dec 2015, see also Results of the search)
2
2
Methodological quality summary: review authors' judgements about each methodological quality item for each included study.
3
3
Methodological quality graph: review authors' judgements about each methodological quality item presented as percentages across all included studies.
4
4
Forest plot of comparison: 1 Mortality, outcome: 1.1 Hospital or 30‐day mortality. (HFO = high frequency oscillation, CMV = conventional mechanical ventilation)
5
5
Forest plot of comparison: 2 Adverse events, outcome: 2.1 Treatment failure (intractable hypoxia, hypotension, acidosis, hypercapnoea requiring discontinuation of study intervention). (HFO = high frequency oscillation, CMV = conventional mechanical ventilation)
1.1
1.1. Analysis
Comparison 1 Mortality, Outcome 1 Hospital or 30‐day mortality.
1.2
1.2. Analysis
Comparison 1 Mortality, Outcome 2 Hospital or 30‐day mortality (Bollen 2005 and Mentzelopoulos 2012 participants lost to follow‐up censored).
1.3
1.3. Analysis
Comparison 1 Mortality, Outcome 3 Hospital or 30‐day mortality (Shah 2004 post‐randomization withdrawals included).
1.4
1.4. Analysis
Comparison 1 Mortality, Outcome 4 Hospital or 30‐day mortality: adult versus paediatric trials.
1.5
1.5. Analysis
Comparison 1 Mortality, Outcome 5 Hospital or 30‐day mortality: lung‐protective ventilation mandatory vs non‐mandatory.
1.6
1.6. Analysis
Comparison 1 Mortality, Outcome 6 Hospital or 30‐day mortality (trials with low risk of bias).
2.1
2.1. Analysis
Comparison 2 Ventilator dependency, Outcome 1 Duration of mechanical ventilation.
2.2
2.2. Analysis
Comparison 2 Ventilator dependency, Outcome 2 Ventilator‐free days.
3.1
3.1. Analysis
Comparison 3 Adverse events, Outcome 1 Treatment failure (intractable hypoxia, hypotension, acidosis, hypercapnoea requiring discontinuation of study intervention).
3.2
3.2. Analysis
Comparison 3 Adverse events, Outcome 2 Barotrauma.
3.3
3.3. Analysis
Comparison 3 Adverse events, Outcome 3 Hypotension.
3.4
3.4. Analysis
Comparison 3 Adverse events, Outcome 4 Hypotension (Shah included).
3.5
3.5. Analysis
Comparison 3 Adverse events, Outcome 5 ETT obstruction.
4.1
4.1. Analysis
Comparison 4 Physiological endpoints (ratio of means), Outcome 1 PaO₂/FiO₂ (ratio of means).
4.2
4.2. Analysis
Comparison 4 Physiological endpoints (ratio of means), Outcome 2 Oxygenation index (ratio of means).
4.3
4.3. Analysis
Comparison 4 Physiological endpoints (ratio of means), Outcome 3 PaCO₂ (ratio of means).
4.4
4.4. Analysis
Comparison 4 Physiological endpoints (ratio of means), Outcome 4 Mean airway pressure (ratio of means).
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References

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