What are the guidelines for using high frequency ventilation (HFV) in newborns with severe respiratory failure?

Guidelines for High Frequency Ventilation in Newborns with Severe Respiratory Failure

High frequency oscillatory ventilation (HFOV) should be considered as a rescue therapy for term and near-term newborns with severe respiratory failure when conventional ventilation fails, particularly in cases of pulmonary interstitial emphysema (PIE). 1, 2

Indications for HFOV in Newborns

Primary Indications

• Rescue therapy for infants failing conventional mechanical ventilation 1
• Pulmonary interstitial emphysema (PIE) in extreme preterm infants 2
• Severe respiratory failure with an oxygenation index (OI) exceeding 25 1
• Diffuse alveolar disease requiring lung recruitment 3

Specific Clinical Scenarios

• HFOV is particularly beneficial in newborns with:
  • Persistent pulmonary hypertension of the newborn (PPHN) refractory to conventional ventilation 1
  • Air leak syndromes (pneumothorax, pulmonary interstitial emphysema) 4
  • Severe hypoxemic respiratory failure 5

Implementation Strategy

HFOV Parameters

• Use low oscillatory frequencies (5-6 Hz) for extreme preterm infants 2
• Apply a high lung volume strategy to achieve optimal alveolar recruitment 3
• Initial target for delivered tidal volumes in infants with CDH: 3.5 to 5 mL/kg 1
• Limit plateau pressure ≤28 cmH2O in most cases 1
• Consider higher plateau pressures (≤29-32 cmH2O) only if chest wall elastance is increased 1

Monitoring Parameters

• Assess oxygenation index (OI) before and after initiation of HFOV
  • OI values >20.5 pre-HFOV and >21.5 at 2 hours, >23.5 at 6 hours, and >34 at 12 hours post-HFOV initiation are associated with increased mortality risk 5
• Monitor for signs of dynamic hyperinflation, especially in obstructive airway disease 1
• Evaluate cardiovascular status closely, particularly in infants with cardiac dysfunction 1

Contraindications and Cautions

Absolute Contraindications

• HFOV should not be used in obstructive airway disease due to risk of dynamic hyperinflation 1, 2

Relative Contraindications/Cautions

• Use with extreme caution in infants with:
  • Cardiac dysfunction 1, 2
  • Passive pulmonary blood flow 1
  • Right ventricular dysfunction 1
• Congenital diaphragmatic hernia (CDH): Surfactant treatment in CDH does not improve clinical outcomes 1

Adjunctive Therapies

Surfactant Administration

• Consider surfactant replacement in conjunction with HFOV for:
  • Preterm infants with RDS 1, 6
  • Meconium aspiration syndrome 1, 6
  • Sepsis/pneumonia with secondary surfactant deficiency 1

Inhaled Nitric Oxide (iNO)

• iNO is indicated for term and near-term infants with PPHN or hypoxemic respiratory failure with OI >25 1
• Lung recruitment strategies with HFOV can improve efficacy of iNO therapy 1

Escalation of Care

ECMO Consideration

• ECMO support is indicated for term and near-term neonates with severe PH or hypoxemia refractory to iNO and optimization of respiratory function 1
• Consider ECMO if conventional ventilation and HFOV fail in reversible diseases 1
• Early consultation with an ECMO center is recommended if ECMO is not available on-site 1

Special Considerations

Congenital Diaphragmatic Hernia (CDH)

• HFOV can be used as rescue therapy for infants with CDH failing conventional ventilation 1
• Be aware that iNO treatment in CDH patients has shown no effect on combined endpoint of death and ECMO use 1
• Caution with pulmonary vasodilators in CDH due to potential LV dysfunction 1

Preterm Infants

• iNO can be beneficial for preterm infants with severe hypoxemia primarily due to PPHN 1
• HFOV with low frequencies (5-6 Hz) is specifically recommended for PIE in extreme preterm infants 2

By following these guidelines, clinicians can appropriately implement high frequency ventilation strategies for newborns with severe respiratory failure, potentially reducing mortality and the need for more invasive interventions such as ECMO.