Summary: Two Papers Published Online in the NEJM, OSCILLATE and OSCAR, have failed to demonstrate that HFOV benefits patients with ARDS. In the OSCILLATE study there was an 11% increase in 28 day mortality (NNH 9). HFOV should not be used in routine management of patients with ARDS.
For the past two decades many intensivists have used an “open lung” approach to managing hypoxaemia in ARDS. This approach involves using high levels of PEEP, inverse ratio ventilation (IRV), airway pressure release ventilation (APRV) or high frequency oscillation ventilation (HFOV) – to keep severely injured lungs in a state of inflation during most of the respiratory cycle. “Open Lung” can be achieved by using high PEEP and small tidal volumes, or moderate levels of PEEP and long inspiratory times. In either case mean airway pressure increases. The most sophisticated method of using PEEP involves the construction of pressure volume curves and setting the PEEP above the lower inflection point. To date, the high PEEP approach has neither been proven to be better or worse than the incremental PEEP approach based on fiO2. However a 2010 meta-analysis has suggested that high PEEP may be beneficial in ARDS. With long inspiratory times oxygenation occurs principally during inspiration rather than expiration; functionally ventilation occurs on the expiratory limb of the volume-pressure curve.
There is good physiologic reasoning behind the open lung approach. Severe ARDs is characterized by massive atelectasis, increased lung water and pleural effusions; functional residual capacity is obliterated. As most gas exchange occurs in expiration, and end expiratory lung volumes are lost, open lung approaches use the inspiratory reserve volume. Further, it is widely believed that phasic opening and closing of injured lung units and uninjured adjacent units results in ventilator induced lung injury (atelectrauma). Open lung approaches prevent atelectrauma. The majority of ICUs utilize conventional ventilator strategies such as pressure support, pressure control (or bilevel) or volume assist-control in early ARDs. However, in patients with severe and refractory hypoxic respiratory failure, units differ between using high PEEP and so called “advanced” modes to maintain oxygenation. Despite the conceptual attractiveness of IRV, APRV and HFOV there has always been an evidence gap in support of these modes: nobody knows how much the lung stretches. There is no easy way to measure end inspiratory lung volumes and hence to evaluate the risk of volutrauma. Proponents of “advanced” modes will argue that absence of evidence does not mean absence of efficacy: clearly open lung modes of ventilation improve oxygenation – so this must be good. However, we have decades of data suggesting that prone positioning improves oxygenation, but not outcomes.
Background and Methods: This was a multi center trial of 38 hospitals in Canada, the United States, Saudi Arabia, Chile, and India from July 2009 thru August 2012. Patients were eligible for inclusion if they had had an onset of pulmonary symptoms within the previous 2 weeks (i.e. this was an acute illness), had been intubated, had hypoxemia defined as a PaO2/FiO2 (PF) ratio of ≤200, with an FiO2 of ≥0.5), and had bilateral infiltrates on CXR. These criteria must have been met within the previous 72 hours. The authors were careful – patients who met criteria were put on pressure control ventilation, TV 600ml, FiO2 0.6 and PEEP 10cmH2O. If, after 30 minutes, the PF ratio was still below 200, the patients were enrolled in the trial. Patients were randomized to HFOV or conventional ventilation (CV). The patients were remarkably well balanced at baseline – and very sick – with mean Apache II scores in both groups of 29.
Technique: a recruitment maneuver was performed initially (40cmH2O for 40 seconds) then HFOV was commenced at a mean airway pressure of 30 cmH2O, adjusted to keep the PaO2 between 55 to 80 mm Hg (7.3 to 10.5 kPa). The frequency was adjusted to keep the pH above 7.2. Once mean airway pressure (mPaw) dipped below 24 cmH2O conversion to CV was considered; if mPaw went below 20cmH2O – conversion was mandatory. The CV group received a recruitment maneuver, then pressure controlled ventilation with TV 6ml/Kg and PEEP adjusted according to protocol. Initial PEEP was 20cmH2O. Patients could also receive volume assist control or pressure support ventilation. For patients with good compliance and gas exchange (presumably during the weaning phase), the investigators did not set limits for tidal volumes. A weaning protocol governed both limbs.
Results: the primary outcome was in-hospital mortality. The study was stopped early because of increased risk in the study group. At the time of termination, 571 patients had been enrolled, of whom 548 had undergone randomization: 275 to the HFOV group and 273 to the control-ventilation group. A total of 129 patients (47%) in the HFOV group, as compared with 96 patients (35%) in the control group, died in the hospital (relative risk of death with HFOV, 1.33; 95% confidence interval, 1.09 to 1.64; P=0.005) – an absolute risk INCREASE of 12%! This was independent of any other risk factor other than HFOV and was consistent at 28 days. Indeed 28 day mortality was 40% in HFOV group (which is not particularly bad) versus 29% (which is really excellent) in the conventional ventilation group – absolute risk increase 11% – number needed to injure 9. The duration of hospital stay for survivors was, on average, 5 days fewer in the CV group (although statistical significance is not reported) 25 versus 30 days.
Did HFOV have a physiological effect? Yes – patients almost immediately needed more vasopressors, more sedation and more neuromuscular blockade. There were fewer cases of refractory hypoxaemia but this had no statistically significant impact on outcomes.
So, what to make of this study? Firstly, let us be clear – this was an excellent study (that we were all aware of) performed by experts in the field of mechanical ventilation, who have a long track record of publication and interest in HFOV. They were not expecting the published results. This is a significant setback to our understanding of ARDS and interventions to rescue patients from severe hypoxaemia. Among my critical care colleagues, there are those of us who are proponents of ARPV and those of us who use HFOV. The published results ask as many questions about APRV as they do about oscillation. Can the worse outcomes be explained by increased doses of vasopressors and more sedation? No, I don’t believe it to be so: it is inconceivable that increased drug utilization could explain an 11% risk increase at 28 days. It is more likely that HFOV exacerbates ventilator induced lung injury (VILI).
The OSCAR study took place in the UK and included nearly 800 patients that had PF ratio <200 and were randomized to HFOV or CV. There was no significant between-group difference in the primary outcome, death at 28 days, which occurred in 166 of 398 patients (41.7%) in the HFOV group and 163 of 397 patients (41.1%) in the conventional-ventilation group (P=0.85). In other words – HFOV did not benefit these patients. Patients enrolled in this study had an average Apache II of 21 – lower than Oscillate – but had equally bad gas exchange when recruited. Although there was an increase in the use of muscle relaxants, there was no evidence of increased vasopressor requirements.
Of interest, patients in OSCAR had similar (although worse) 28 day mortality rates to those in the HFOV arm of the OSCILLATE study. It is worth looking at the LOV and EXPRESS trials for comparison. The EXPRESS trial had slightly older patients (60y both groups) with better gas exchange – PF ratio 143 and 144. Twenty eight day mortality was 31.2% and 27.8% (lower in high PEEP approach but not significant). The LOV study had patients in the same age range as both of these studies, but the PF ratios were significantly higher (144 in both groups); Apache II scores were 24 and 25 (patients were sicker than OSCAR). Mortality rates for all cause in hospital were 36.4% and 40.4% (again not significant). The lower end outcome is similar to the conventional group (and indeed had similar vent strategy to that group) in OSCILLATE. This suggests that the better outcomes in the conventional group in OSCILLATE accurately reflect true outcomes, and that the 28 day mortality in the LOV trial over-estimates outcomes at hospital discharge. But, can the difference in gas exchange really explain why the outcomes in OSCAR, in the conventional group at least, were 10% worse than EXPRESS? I don’t know – but comparing OSCILLATE to OSCAR – a 29% 28 day mortality (similar to LOV) is substantially lower than the 41% in the UK trial. These data suggest that the conventional group in that study did worse than expected. And, if this were the case, then HFOV was harmful in the OSCAR study too: the mortality rate for HFOV was essentially the same in both studies. Ok that might be conjecture – but take my point: a 41% mortality rate for ARDS is very high in the setting of a randomized controlled trial. For example, in the original ARMA trial the mortality rate in the control group (high TV) was 39.8% versus 31%; PF ratios 138 and 134. In the ALVEOLI trial the mortality rates were 24.9% (high PEEP) and 27.5%; PF ratios were 165 and 154. I have long argued that many of the patients in the NIH studies probably didn’t have ARDS – but the outcomes in OSCAR are the worst published in a multi center trial since the control group in Aries. Whatever way you look at it – this is all BAD NEWS for HFOV.
HFOV – is it safe?
One striking thing about these studies is how much the conflict with a previous meta-analysis of previously published papers. In that paper eight randomized controlled trials (n=419 patients) were included; the majority of patients had ARDS. Patients on HFOV had better oxygenation and reduced mortality (risk ratio 0.77, 95% confidence interval 0.61 to 0.98, P=0.03; six trials, 365 patients, 160 deaths). These results conflict directly with the outcomes of OSCILLATE and OSCAR: it is scary how meta-analysis of small studies (publication bias) can be misleading.
So, is it time to wrap up your oscillator and consign it to the ventilator graveyard? For ARDS – for routine practice – I think so.
For rescue therapy or as a bridge to ECMO – HFOV may still have a role. Oscillation remains a useful therapy for broncho-pleural fistula and perhaps for severe lung contusion. But in other settings – I believe – use with extreme care. Is it time for a complete re-evaluation of open lung approaches in ARDS? Perhaps so – certainly before we put patients on extreme IRV modes (such as APRV) or HFO we should ask – “have I maxed out my options with conventional ventilation?”
One Step Forward – Two Steps Back.