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IS HFOV STILL RELEVANT IN 2015?

Is HFOV still relevant in the era of NIV?  

David Tingay

Neonatal Research, Murdoch Childrens Research Institute Neonatology, Royal Children’s Hospital Dept of Paediatrics, University of Melbourne, Melbourne, Australia

Butler et al. Anesth Analg 1980

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Assisted  ven*la*on  in  Australia  and  New  Zealand  1996-­‐2006  

Year1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

Num

ber o

f inf

ants

0

2000

4000

6000

8000

HFV

use

(per

cent

age

of in

fant

s gi

ven

IPPV

)

0

2

4

6

8

10

12

14

16nCPAP aloneIPPVHFV HFV %

5.9% 7.3% 10%

11.7% 11.3% 12.6% 10.2% 12.3%

13.1% 14% 13.9%

p<0.001

Tingay et al JPCH 2007

Assisted  ven*la*on  in  Australia  and  New  Zealand  1996-­‐2006  

ANZNN Report 2012

199619

9719

9819

9920

0020

0120

0220

0320

0420

0520

0620

0720

0820

0920

1020

1120

120

5

10

15

20

HFV

Use

(% in

fant

s gi

ven

IPP

V)

p<0.001

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HFOV  use  by  gesta*onal  age    1996  –  2003  

Num

ber o

f inf

ants

H

FV use (percentage of all ventilated infants)

Gestational age (weeks) 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42

0

1000

2000

0

5

10

15

20

4.2%

3.6%

38.1%

32.7%

25.2%

19.2% 12.6%

4.4% 5.1%

8.1%

8.7%

8.9%

8.1%

8.5%

7.4% 5.9%

5.6%

5.1%

4.0%

9.7%

3000

4000

25

30

35

40 HFV CMV nCPAP HFV %

2012 = 55%

Trends  in  HFV  use  by  disease  type  1996-­‐2006  

All disease p<0.05

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

HMD PPHN MAS Pneumonia CDH Congenital Others

HFO

V u

se (%

of a

ll In

fant

s rec

eivi

ng IP

PV)

Disease Type

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

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Indicators  of  illness  severity  Highest  appropriate  FIO2  in  the  first  12  hours  of  life  •  Significantly  greater  in  the  HFV  group  

–  Median  FIO2  0.8  (HFV)  vs.  0.5  (CMV);  p<0.0001  

•  HFV  group  more  likely  to  require  FIO2  >0.95  –  37.2%  (HFV)  vs.  22%  (CMV);  p<0.0001  

•  FIO2  >0.95  related  to  GA  <26  weeks  –  RR  0.95  (95%  CI  0.93,  0.97)  

•  HFV  less  likely  to  be  in  air  early  –  2.6%  (HFV)  vs.  12.3%  (CMV)  

Days  of  assisted  respiratory  support  •  HFV   group   required   more   days   of   assisted   respiratory  

support  –  Median  days  21  (IQR  4,  54)  vs.  7  (IQR  2,  32);  p<0.0001  

Adverse  Outcomes  

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HFOV  use  by  gesta*onal  age  at  RCH  1994  to  present  

0

10

20

30

40

50

60

70

23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42

Gestational age (weeks)

Num

ber

of In

fant

s (R

CH

)

0

50

100

150

200

250

300

350

400

450

Num

ber

of In

fant

s (A

NZ

NN

)

Number of Infants (RCH)Number of Infants (ANZNN)

Broader  experiences  PreVILIG  CollaboraSve  Group  •  IPA  of  available   trials   comparing  first   intenSon  HFOV  vs  CMV   in  

preterm  infants  –  18  trials  (n=3652)  

•  Sub-­‐group   3-­‐way   interacSon:   prematurity   +   iniSal   lung   disease  severity  –  Infants  born  <26/40  seemed   to  do  worse  on  HFOV   if   they  had  mild   lung  

disease  •  Risk  of  death  or  BPD  74%  vs  67%  

–  But,  they  did  beber  if  they  had  severe  lung  disease:  •  Risk  of  death  or  BPD  71%  vs  87%  

   Neither  reached  significance  

Unpublished data courtesy of F Cools

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Broader  Experiences  –  Intriguing  Ques*ons  

•  319/592 surviving adolescent ex-prems •  UKOS RCT (n=797, NEJM 2002)

•  HFOV = Superior Pulmonary function tests •  No differences in functional outcomes except better

teacher rated ‘quality of life’ scores

Conclusions  

•  HFV   is  a  well  established  as  a  mode  of  venSlaSon   for  neonatal  respiratory  failure  

•  The  use  of  HFV  is  stable  in  Aust  and  NZ  •  HFV  is  used  in  a  relaSvely  high  proporSon  of  infants  ≤  25  weeks  

gestaSon  •  HFV  is  increasingly  being  used  for  diseases  of  term  infants  •  The  use  of  HFV  is  associated  with  those  infants  at  greatest  risk  of  

adverse  outcome  •  We  speculate   that  HFV   is  applied  as  a  “late   rescue”   treatment,  

when   convenSonal   modes   of   venSlaSon   have   failed   and   the  infant  is  dying