Application of

High Frequency
Oscillatory
Ventilation
in NICU

Lily Rundjan
Neonatology Division
Medical Faculty
University of Indonesia –
Cipto Mangunkusumo Hospital
Hesitancy for using HFOV in NICU
The use of HFOV
 Mostly used as the last rescue 
success rate ?
 Initial setting as primary or secondary
mode ?
 Homogenous vs heterogenous lung
disease
 Close monitoring
 Weaning strategy
 The main goal (to reduce VILI) may not
be achieved  need to understand
lung protective principle
Good understanding will lead to
the optimal result
Clinical use of HFOV
• Late rescue
• Infants failing conventional ventilation
• Widely accepted
• High morbidity and mortality

• Early rescue
• Infants at high risk of complications
• Generally accepted

• First-line treatment / Primary mode

• Promising, physiologically attractive
• Still controversial
 Lung protective effect of HFOV

100
Death or CLD at 30 d (%)

80

60

40

20

0
CV HFOV/CV HFOV

Clark et al Pediatrics 1992

 High-frequency ventilation
Meta-analysis

There is no clear evidence that elective HFOV

offers important advantages over CV
when used as the initial ventilation strategy
to treat preterm infants with acute pulmonary
dysfunction. There may be a small reduction in
the rate of CLD with HFOV use, but the evidence
is weakened by the inconsistency of this effect
across trials and the overall borderline significance.

Cools et al. The Cochrane Library 2010

 Primary HFOV vs Secondary HFOV
• Minimize lung injury • Not all patients will
from the start benefit
• HFOV will not fix a • Limited number of HF-
lung that is already ventilators
destroyed by
conventional • Limited number of
ventilation medical and nursing
staff with
• More exposure and training/experience
thus more experience HFOV
medical and nursing
staff
HFOV vs CMV

Gerstman et al
 HFOV vs CMV
Fundamental differences
CMV HFOV
Rate 0-150 180-900
Tidal volume 4-20ml/kg 0.1-3ml/kg
Alveolar 0->50cm H2O 0.1-5 cmH2O
pressure
EELV Low Normal
Gas flow Low High
HFOV vs CMV
 High frequency ventilation:
gas exchange

• Slutsky et al. NEJM 2002

 Lung protective ventilation
• Recruit collapsed alveoli
• Stabilize
alveoli during in-and
expiration
• Prevent end-inspiratory overdistention
• Usethe lowest possible pressure
amplitude in order to reduce tidal
volume
• Reduce oxygen concentration

Optimal lung volume or open lung ventilation

Principle of lung protective
ventilation strategy

Injury
Zone of
Overdistention

“Safe”
Window

Zone of
Derecruitment
Volume and Atelectasis
Injury

Pressure
 HFOV

CPAP system
+ Small Vt
with high frequency

Oxygenation Ventilation / CO2 removal

CNN Rocourt 
Determinants of gas exchange
CMV vs HFOV
 High frequency ventilation

Oxygenation Ventilation
(CO2 clearance)
• FiO2 • Decreasing CO2:
 Monitor of optimal • Increase the amplitude
oxygenation : SpO2 or • Decrease the frequency
pO2 • Change I:E ratio from 1:2 to 1:1
• MAP
• Increasing CO2:
 Increase MAP for
• Decrease the amplitude
underinflated lung to
improve oxygenation • Increase the frequency

 Chest X Ray : optimal • Change I:E ratio from 1:1 to 1:2

chest expansion Th8-9
ribs
 Application of HFOV

• High Volume Strategy (high volume and low

oxygen)
 ↑ MAP, alveolar recruitment, atelectasis
elimination  improvement in oxygenation
 Used in uniform / homogenous lung disease
(RDS)
 MAP > 2-3 cmH2O from CMV setting

• Low Volume Strategy (low volume and high

oxygen)
 Used in heterogeneous lung disease (e.g.
MAS, PPHN without lung disease)
 Prevent overdistension of alveoli
Initial setting
MAP
• Primary
• Start MAP from 6-8  increase stepwise

• Secondary
• HVLS: 2-3 cmH2O higher than MAP at CMV
• LVLS: similar MAP to CMV

Amplitude: based on chest wiggle

Frequency
HFOV Application in lung diseases:
1. Homogenous lung disease (RDS)
• If possible use primary HFOV in nRDS!
• If resources are limited, use primary HFOV in
preterms < 28 wk with nRDS
• Open lung strategy / lung recruitment
• Target : achieve FiO2 < 25% with stepwise
increment of MAP
• Surfactant therapy if Opening MAP x FiO2 ≥ 3
Primary HFOV
Lung recruitment in neonates
Oxygenation to monitor
lung volumes
 CT 1 CT 2
CT 3

Paw = CDP CDP= FRC

Continuous
Distending
Pressure
 Recruit first the lung and then keep open the
lung at the lowest pressure necessary!

Some bedside rules:

1. Lower FiO2 before CDP
(=MAP)
2. Always try to define lung
closing pressure to assure
that you will use lowest
pressures required
3. Try to work always the
highest frequency possible
– increase the amplitude
in a first step to correct for
high pCO2
4. If you are “lost”  always
decrease CDP first
Adapted from Suzuki H
Acta Pediatr Japan 1992; 34:494-500
Initiating HFOV
Preterm Infant
Surfactant
therapy
HFOV Application in lung diseases:
2. Heterogeneous lung disease
(Partially recruited)
HFOV in MAS HFOV in pneumonia

• Recruit the atelectatic •Unable to recruit

areas without alveoli due to ongoing
overdistending the inflammation
emphysematous areas •Good choice of
• Treat hypotension before antibiotics
recruiting lung •Accept higher FiO2
• Surfactant replacement / until pneumonia
surfactant lavage ? resolved
HFOV Application in lung diseases:
3. Non-recruitable lung diseases
Congenital diaphragmatic hernia (CDH)
OUTLINE OF PRINCIPLES OF MANAGEMENT
Resuscitation
ET tube placement with minimal bag mask/ ventilation
Vascular access
Gut decompression by nasogastric tube
Ventilation objectives: preductal SaO2 > 85% and pH > 7.3 with PIP 25 cm H2O
Cardiopulmonary management
Ventilation
Conventional ventilation
Objective: preductal SaO2 > 85%, pH > 7.3
PIP < 25 cm H2O
HFOV
Objective: preductal SaO2 > 85%
MAP < 16 cm H2O
Pulmonary vascular management
Cardiac echo
Exclude CHD
Assess RV function
Estimate PA pressure
Identify the ductus and assess shunting
Trial of inhaled nitric oxide for patients with increased RV pressure

Bohn AJRCCM 2002

 HFOV Application in lung diseases:
3. Non-recruitable lung diseases
Pulmonary hypoplasia
• Small but often biochemically mature lung
• Structurally immaturity, high susceptibility to barotrauma
• High pulmonary vascular resistance

APPROACH:
Low pressure strategy:
• Initial Paw 10 – 15 cm H2O
• Paw 10 – 15 cm H2O
• Wait for an effect
• Gentle stepwise recruitment only if oxygenation remains poor and lung
parenchyma is opacified
Initially allow minimal or no spontaneous respiration
• Sedation and muscle relaxation
Treat co-existing PPHN
Inhaled nitric oxide
• Worth trying in those failing to oxygenate on HFOV
High frequency ventilation:
monitoring
• Oxygenation
• Pulse oximetry (SpO2)
• Transcutaneous PaO2
• Blood gas

• Ventilation
• Transcutaneous PaO2
• Blood gas
• Tidal volume or DCO2 (add-on)

• Chest radiography
• Optimization of lung volume (unreliable)
• Tube position
• Detecting overdistention

• Blood pressure
• Hypotension clear sign of overdistention!
Transcutaneous monitor
Florian Respiratory Monitoring

TVhf
DCO2 =
TVhf2 x freq
 Weaning to extubation

Options: Preterm Term

Wean to low Paw and extubate directly V V
from HFOV

Wean to low Paw brief period of low rate V

SIMV (or ETCPAP), then extubate

When lung disease improved transfer to V

synchronized IMV and extubate when
able
At what HFOV setting can we extubate ?

Preterm van Velzen A et al PCCM 2009

• FiO2 < 0.3 • 214 preterm infants (29.5 + 2.5

wk, BW 1300 + 480 g)
• Paw 6-8 cm H2O
• Early OLV HFOV
• ∆ 10-15 cm H2O
• Extubation from HFOV
• WOB satisfactory attempted at a median age of
62 hrs
• pH > 7.25
• Successful in 193 (90%) of the
infants
• Paw at the time of extubation 6.8
+ 1.6 cmH2O
At what HFOV setting can we extubate ?

Preterm Term
• FiO2 < 0.3 • FiO2 < 0.3
• Paw 6-8 cm H2O • Paw 6-10 cm H2O
• ∆ 10-15 cm H2O • ∆ 15-20 cm H2O
• WOB satisfactory • WOB satisfactory
• pH > 7.25 • pH > 7.25
Key points
• Spontaneous breathing is better
• Aim for good chest wiggle  absent /
decreased chest wiggle : splinting,
obstruction from mucous plug or ETT
position / kinking, deterioration of lung
disease
• For oxygenation : aim for the lowest FiO2
and optimal MAP
• For ventilation : permissive hypercapnia for
preterm infants
Troubleshooting
• Low pO2 / SpO2
• DOPE 
• D = displaced tube
• O = obstructed tube
• P = pneumothorax
• E = equipment failure

• Suboptimal lung recruitment  CXR

• Overinflation  evaluate: blood pressure,

decrease the MAP, evaluate CXR

Increase MAP and / or FiO2

 ...Troubleshooting
• High CO2
• Check DOPE
• Alveolar ventilation insufficiency  increase the
amplitude, evaluate if there is chest wiggle or not
• Increased airway resistance in diseases (e.g MAP,
BPD) or other non-homogenous lung disease  is
HFO suitable?

• Under-inflated lungs  evaluate CXR

• Over-inflated lungs  evaluate CXR,  MAP

Increase the amplitude

Decrease the oscillator frequency
 ...Troubleshooting

• Low CO2
• Observed the chest wiggle: is it too
much?
• Signs of lung recovery

Decrease the amplitude

Increase the oscillator frequency
Shift to conventional ventilator
Conclusion

• Understand lung physiology!

• Understand lung disease!
• Understand lung recruitment!
• Understand your ventilator!
• Secure adequate monitoring

Improve
competence and
confidence
Good luck with
your patients