A Multi-Center Study of HFOV in Immunocompromised

and Immunocompetent Children

Poster #681

Claire Stewart MD1, Nadir Yehya MD2, Lin Fei PhD3, Ranjit S. Chima MD1
1Division

of Critical Care Medicine, 3Division of Biostatistics and Epidemiology, Cincinnati Childrens Hospital Medical Center, Cincinnati, OH
2Division of Critical Care Medicine, Childrens Hospital of Philadelphia, Philadelphia, PA

Introduction
High Frequency Oscillatory Ventilation (HFOV) is a form
of nonconventional ventilatory support employed for
respiratory failure. Recent, propensity-matched analysis
of a large national database demonstrated worse
outcomes for children needing HFOV support when
compared to those supported on a conventional
ventilator1.

Results

Results

Table 2. Comparison of Survivors and Non- Survivors

Over five year period, 134 patients met inclusion criteria at these
2 centers.

Total
(n= 134)

Patient characteristics at the time of HFOV initiation are

presented below (Table. 1).

Table 1. Baseline Patient Characteristics (N=134)

Published outcomes for children needing HFOV for

respiratory failure are variable. Recently published
studies have shown 55-66% survival for children needing
HFOV support with immunocompromised state having a
significant impact on outcome2,3.

Table 3. Multivariate Analysis for Mortality

Survivors
(n=78)

Non-Survivors
(n=56)

P-value

Age (mos)

6.9 [2.4,24]

13.5 [6, 43.5]

0.027

PRISM III

14 [8,21]

18 [10,24]

0.12

Immunocompromised

23 (34%)

45 (66%)

<.001

Stem cell transplant

6 (17%)

29 83%)

<.001

Before HFOV
Age (months)

8.7 [3,32]

Male

80 (60%)

PRISM III Score at 24h

Markers of oxygenation may be able to discriminate

survivors from non-survivors. Some groups have looked
at oxygenation index (OI) prior to HFOV while others have
examined the ratio of OI at 24 hours to the OI prior to
HFOV4-6.

21 [19,24]

22 [20,25]

0.13

PF Ratio

71 [60,95]

70 [54,86.5]

0.13

28.2 [21.6,35.4]

33.3 [23.8,40.8]

0.14

27.5 [25,30]

32 [28,35]

<.001

145 [105,250]

76.5 [60.7,132]

<.001

18.4 [10.3,26.7]

37.8 [23.8,51.3]

<.001

OI

15 [8.23]

Length of Conventional Ventilation

prior to HFOV initiation (days)

Mean Airway Pressure

At 24 hr of HFOV
Mean Airway Pressure

1 [0,4]

PF Ratio
PaO2//FiO2 prior to HFOV initiation

Objectives
Determine survival and variables associated with poor
outcome for patients requiring HFOV support.

OI

70 [58,95]

Mean Airway Pressure prior to

HFOV initiation (cm H2O)

22 [19,24]

Oxygenation Index prior to HFOV

initiation

28 [22,40]

Con$nuous data are presented as median and IQR, categorical data are presented as %age, medians are
compared using a Wilcoxon rank-sum test for paired data. Categorical variables are compared using a Fisher
exact test.

Figure 2. Comparison of OI pre-HFOV and at 24 hours of HFOV

Con$nuous data presented as median values with IQR (25th and 75th),
categorical data presented as a percentage

Variable

Odds Ratio

95% CI

P-value

Not immunocompromised

Reference

Immunocompromised, No
SCT

4.9

1.7-14

0.003

Immunocompromised, SCT

15.7

4.8-51.1

<0.001

1.05

1.02-1.08

0.001

Immunocompromised Status

OI at 24 hrs of HFOV

For the entire cohort of patients using OI at 24 hours of HFOV as

a predictor of mortality, the AUC was 0.78 (0.7, 0.9) (Figure 3.).
The best cutoff value to predict mortality for OI at 24 hours of
HFOV was 30 with a Sensitivity of 0.70, Specificity of 0.78, PPV
of 0.69 and NPV of 0.78.

Figure 3. ROC Curve for OI at 24 hrs of HFOV

#"

To test the performance of the oxygenation index at 24

hours in predicting outcome.
Half (51%, 68/134) of the patients in our cohort were
immunocompromised with half of those patients having
undergone SCT (51%, 35/68).

Multi-Center Retrospective Review following IRB

approval
Inclusion Criteria:
Patients aged 1 month to 21 years of age
HFOV support for greater than 24 hours
January 2010 to December 2014 in the Pediatric
Intensive Care Unit (PICU)
Exclusion Criteria
Less than 1 month or greater than 21 years of age
HFOV support for less than 24 hours
Data collected included, but was not limited to, patient
demographics, PRISM III score, immunocompromised
status (defined as having malignancy, primary
immunodeficiency, stem cell or solid organ
transplant), ventilatory support before HFOV, ventilatory
support at 24 hours of HFOV, days of HFOV, arterial blood
gas data, vasoactive support, use of extracorporeal
membrane oxygenation, and PICU mortality.
Immunocompromised patients were split into those
receiving stem cell transplant (SCT) and others (non-SCT).
Statistical analyses were completed using SAS 9.3 (Cary,
North Carolina) and GraphPad Prism Version 5 (LaJolla,
California).

Survival to PICU discharge for the entire cohort was 58%

(78/134) with a significant difference in survival amongst
immunocompromised and non-immunocompromised patients
(34% vs. 83%, p<0.001).

*"

Amongst immunocompromised patients, SCT recipients had

significantly lower survival when compared to non-SCT patients
with (17% vs. 73%, p <0.001) (Fig. 1).

80"

Non/Survivor"

Survivor"

83%
Survival
*p<0.05 when compared OI pre in survivors; # p<0.05 when compared to OI 24h in survivors

70"
11"

60"
Number of Pa@ents

Methods

50"

17%
Survival

Conclusions

52%
Survival

In this cohort of patients needing HFOV PICU survival was nearly 60%.

40"
30"
20"
10"
0"

29"

16"

55"

In keeping with published data the presence of an immunocompromised state had the strongest impact on outcome with SCT recipients having the worst
outcome.
Survivors had a statistically significant improvement in OI at 24h when compared to non-survivors. Notably OI at 24h was a significant predictor of mortality.

6"
SCT

17"
References
Non-SCT

Non-Immunocompromised

Figure 1. Survival Stratified by Underlying Condition

(N=134)

1.
2.
3.
4.
5.
6.

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