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High-frequency oscillatory ventilation (HFOV) in bronchiolitis patients

Respiratory syncytial virus (RSV) is nowadays the leading cause of bronchiolitis and viral pneumonia in children. Although the course is often benign, some children need prolonged hospitalisation and mechanical ventilation or even ECMO if conventional mechanical ventilation (CMV) fails.

HFOV is currently considered to be contraindicated in obstructive airway disease with prolonged time constants due to the risk of dynanmic airtrapping. This could give rise to circulatory and ventilatory compromise and barotrauma. Nevertheless, bronchiolitis patients are sometimes put on HFOV after deterioration on CMV.

We report 9 patients with RSV bronchiolitis and pulmonary overdistention (small airway disease) successfully treated with HFOV after deterioration on CMV. Although marked hyperinflation was present in all our patients prior to transition, no airleaks developed during HFOV. In one patient the oxygenation index (OI) increased after start of HFOV. Nitric oxide was added and oxygenation improved immediately. All patients survived without residual lung disease.

In distinct to current opinion, we showed that small airway disease can safely and successfully be managed with HFOV. Ventilatory strategy should be directed to open up the small airways and keep them open with sufficiently high mean airway pressures (`the open airway strategy' similar to the `open lung strategy' in diffuse alveolar disease). Permissive hypercapnia may be used to reduce pressure swings as much as possible, leading to less shear stress on lung tissue, without influencing airway recruitment. Further dynamic airtrapping can be prevented with the use of longer expiratory than inspiratory times and with prevention of spontaneous breathing. An increasing OI at 48 h may be an indicator of failure of HFOV and alternative treatments should be considered. NO might be such an option to avoid ECMO.


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Duval, E., van Vught, A., Leroy, P. et al. High-frequency oscillatory ventilation (HFOV) in bronchiolitis patients. Crit Care 3 (Suppl 1), P034 (2000).

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