High-Frequency Oscillatory Ventilation Use and Severe Pediatric ARDS in the Pediatric Hematopoietic Cell Transplant Recipient

Courtney M Rowan, Ashley Loomis, Jennifer McArthur, Lincoln S Smith, Shira J Gertz, Julie C Fitzgerald, Mara E Nitu, Elizabeth AS Moser, Deyin D Hsing, Christine N Duncan, Kris M Mahadeo, Jerelyn Moffet, Mark W Hall, Emily L Pinos, Robert F Tamburro, Ira M Cheifetz, the Investigators of the Pediatric Acute Lung Injury and Sepsis Network

The effectiveness of high-frequency oscillatory ventilation (HFOV) in the pediatric hematopoietic cell transplant patient has not been established. We sought to identify current practice patterns of HFOV, investigate parameters during HFOV and their association with mortality, and compare the use of HFOV to conventional mechanical ventilation in severe pediatric ARDS. This is a retrospective analysis of a multi-center database of pediatric and young adult allogeneic hematopoietic cell transplant patients requiring invasive mechanical ventilation for critical illness from 2009 through 2014. Twelve United States pediatric centers contributed data. Continuous variables were compared using a Wilcoxon rank-sum test or a Kruskal-Wallis analysis. For categorical variables, univariate analysis with logistic regression was performed. The database contains 222 subjects, of which 85 patients were managed with HFOV. Of this HFOV cohort, the overall pediatric ICU survival was 23.5% (n = 20). HFOV survivors were transitioned to HFOV at a lower oxygenation index than nonsurvivors (25.6, interquartile range 21.1-36.8, vs 37.2, interquartile range 26.5-52.2, P = .046). Survivors were transitioned to HFOV earlier in the course of mechanical ventilation, (day 0 vs day 2, P = .002). No patient survived who was transitioned to HFOV after 1 week of invasive mechanical ventilation. We compared patients with severe pediatric ARDS treated only with conventional mechanical ventilation versus early HFOV (within 2 d of invasive mechanical ventilation) versus late HFOV. There was a trend toward difference in survival (conventional mechanical ventilation 24%, early HFOV 30%, and late HFOV 9%, P = .08). In this large database of pediatric allogeneic hematopoietic cell transplant patients who had acute respiratory failure requiring invasive mechanical ventilation for critical illness with severe pediatric ARDS, early use of HFOV was associated with improved survival compared to late implementation of HFOV, and the patients had outcomes similar to those treated only with conventional mechanical ventilation.