Journal of Applied Physiology AJP: Renal Physiology
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J Appl Physiol 104: 1234-1235, 2008; doi:10.1152/japplphysiol.01226.2007c
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POINT-COUNTERPOINT

Rebuttal from Dr. Kacmarek

Ferguson and Slutsky first assume that only with HFO can lung protection with small tidal volumes and high PEEP levels be achieved. This is not supported by data from both animals and patients. As I noted, lung protection has been proven very effective during CMV. The optimal use of HFO is based on lung recruitment (5). Lung recruitment maneuvers can very easily be applied to patients after stabilization during conventional mechanical ventilation (3, 8). Selection of optimal PEEP (CV) or mean airway pressure (HFO) post lung recruitment is the key to sustaining the benefits of lung recruitment. Once optimal PEEP is established, tidal stretch can be minimized by tidal volume limitation. As has been clearly demonstrated small tidal volumes (≤6 ml/kg) and rapid rates with low plateau pressures (<30 ml/kg) has resulted in markedly decreased mortality in ALI/ARDS (7, 10).

Second, they state that HFO has been proven to be more effective than CMV in animal studies. This is only true when CMV is not applied with a lung protective strategy. Recent data indicate the equivalence of CMV to HFO (6, 9).

Third, they imply that clinically HFO is more effective that CMV. The current data do not indicate this. Meta-analysis of the neonatal/pediatric data indicates equivalence between the two approaches when both are preformed in a lung protective manner (1). Remember, regardless of age group HFO has never shown a mortality benefit even when CMV was applied inappropriately.

In adults, the two randomized controlled trials (2, 4) were negative, one showing a beneficial trend for HFO (survival 63% HFO vs. 48% CMV) and the other, contrary to the statement of Ferguson and Slutsky, showing a beneficial trend for CMV (survival 77% CMV vs. 67% HFO). In addition, in the Derdak et al. study (4) the application of CMV was not protective; tidal volume 10 ml/kg PBW and plateau pressure 37 cmH2O. No benefit to either approach can be claimed!

Ferguson and Slutsky go on to remind us that the purpose of this debate is not to demonstrate that HFO is better clinically, but rather that it represents "the optimal physiological approach" to mechanical ventilation. I agree, but how can it be the optimal physiological approach without being better clinically! I must question if a technique that frequently maintains mean airway pressures in adults above 30 cmH2O and that frequently requires sedation to apnea can ever be considered the optimal physiological approach.

REFERENCES

  1. Bollen CW, Uiterwaal CAPM, van Vaught AJ. Cumulative metaanalysis of high-frequency versus conventional ventilation in premature neonates. Am J Respir Crit Care Med 168: 1150–1155, 2003.[Free Full Text]
  2. Bollen CW, van Well Th JG, Sherry T, Beale RJ, Shah S, Findlay G, Monchi M, Chiche JD, Weiler N, Uiterwaal C, van Vught AJ. High frequency oscillatory ventilation compared with conventional mechanical ventilation in adult respiratory distress syndrome: a randomized controlled trial. Crit Care 9: R430–R439, 2005.[CrossRef][Web of Science][Medline]
  3. Borges JB, Okamoto VN, Matos GF, Caramez MP, Arantes PR, Barros F, Souza CE, Victorino JA, Kacmarek RM, Barbas CS, Carvalho CR, Amato MB. Reversibility of lung collapse and hypoxemia in early acute respiratory distress syndrome. Am J Respir Crit Care Med 174: 268–278, 2006.[Abstract/Free Full Text]
  4. Derdak S, Mehta S, Stewart TE, Smith T, Rogers M, Buchman TG, Carlin B, Lowson S, Granton J. High frequency oscillatory ventilation for acute respiratory distress syndrome in adults. Am J Respir Crit Care Med 166: 801–808, 2002.[Abstract/Free Full Text]
  5. Fessler HE, Derdak S, Ferguson ND, Hager DN, Kacmarek RM, Thompson BT, Brower R. A protocol for high-frequency oscillatory ventilation in adults: results from a roundtable discussion. Crit Care Med 35: 1649–1654, 2007.[CrossRef][Web of Science][Medline]
  6. Sedeek KA, Takeuchi M, Suchodolski K, Vargas SO, Shimaoka M, Schnitzer JJ, Kacmarek RM. Open lung protective ventilation with PCV, HFO, and ITPV results in similar gas exchange, hemodynamics and lung mechanics. Anesthesiology 99: 1102–1111, 2003.[CrossRef][Web of Science][Medline]
  7. The Acute Respiratory Distress Syndrome Network. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med 342: 1301–1308, 2000.[Abstract/Free Full Text]
  8. Tugrul S, Akinci O, Ozcan PE, Ince S, Esen F, Telci L, Akpir K, Cakar N. Effects of sustained inflation and postinflation positive end-expiratory pressure in acute respiratory distress syndrome: focusing on pulmonary and extrapulmonary forms. Crit Care Med 31: 738–744, 2003.[CrossRef][Web of Science][Medline]
  9. Vazquez de Anda GF, Hartog A, Verbrugge SJC, Gommers D, Lachmann B. The open lung concept: pressure controlled ventilation is as effective as high frequency oscillatory ventilation in improving gas exchange and lung mechanics is surfactant deficient animals. Intens Care Med 25: 990–998, 1999.[CrossRef][Web of Science][Medline]
  10. Villar J, Kacmarek RM, Perez-Mendez L, Aguirre-Jaime A. A high positive end-expiratory pressure, low tidal volume ventilatory strategy improves outcome in persistent acute respiratory distress syndrome: a randomized, controlled trial. Crit Care Med 34: 1311–1318, 2006.[CrossRef][Web of Science][Medline]




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