High Frequency Oscillation (HFO): Physiological Basis for a Potentially ‘Optimal’ Protective Ventilatory Strategy

  • A. Rossi
  • T. E. Stewart
  • V. M. Ranieri


Acute respiratory distress syndrome (ARDS) is a primary cause of death in ICUs with a reported mortality ranging between 30–60% [1, 2]. Intrapulmonary shunt, increased dead space, and reduced lung compliance are the main pulmonary patho-physiological alterations leading to multiple organ failure (MOF) and ultimately death. Conventional mechanical ventilation is effective in delivering oxygen and providing adequate carbon dioxide clearance, both in volume-cycled and pressure-limited modes. However experimental and clinical data show that conventional ventilation may stress the alveolar wall resulting in further pulmonary injury (ventilator induced lung injury [VILI]) [3, 4]. Tidal volume (VT), positive end-expiratory pressure (PEEP), and inspiratory oxygen fraction (FiO2) are the three key ventilator settings during conventional ventilation. Strong evidence suggests that reducing VT and optimizing PEEP prevents VILI, providing a lung protective strategy [5, 6]. However, ‘conventional’ protective ventilatory strategies are usually accompanied by side effects such as use of high respiratory rate, hypercapnia, hemodynamic impairment, etc. [7].


Acute Lung Injury Acute Respiratory Distress Syndrome Dead Space Respir Crit Conventional Mechanical Ventilation 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Sloane PJ, Gee MH, Gottlieb JE, et al (1992) A multicenter registry of patients with acute respiratory distress syndrome. Physiology and outcome. Am Rev Respir Dis 146: 419–426Google Scholar
  2. 2.
    Zilberberg MD, Epstein SK (1998) Acute lung injury in the medical ICU: comorbid conditions, age, etiology, and hospital outcome. Am J Respir Crit Care Med 157: 1159–1164PubMedCrossRefGoogle Scholar
  3. 3.
    Slutsky AS, Tremblay LN (1998) Multiple system organ failure. Is mechanical ventilation a contributing factor? Am J Respir Crit Care Med 157: 1721–1725PubMedCrossRefGoogle Scholar
  4. 4.
    Slutsky AS (1999) Lung injury caused by mechanical ventilation. Chest 116: 9S - 15SPubMedCrossRefGoogle Scholar
  5. 5.
    Slutsky AS (1993) Mechanical ventilation. American College of Chest Physicians’ Consensus Conference. Chest 104: 1833–1859PubMedCrossRefGoogle Scholar
  6. 6.
    Ferguson ND, Stewart TE (2001) The use of high-frequency oscillatory ventilation in adults with acute lung injury. Respir Care Clin N Am 7: 647–661PubMedCrossRefGoogle Scholar
  7. 7.
    Brower RG, Ware LB, Berthiaume Y, Matthay MA (2001) Treatment of ARDS. Chest 120: 1347–1367PubMedCrossRefGoogle Scholar
  8. 8.
    Tremblay LN, Slutsky AS (1998) Ventilator-induced injury: from barotrauma to biotrauma. Proc Assoc Am Physicians 110: 482–488PubMedGoogle Scholar
  9. 9.
    Ranieri VM, Giunta F, Suter PM, Slutsky AS (2000) Mechanical ventilation as a mediator of multisystem organ failure in acute respiratory distress syndrome. JAMA 284: 43–44PubMedCrossRefGoogle Scholar
  10. 10.
    Tremblay LN, Miatto D, Hamid Q, Govindarajan A, Slutsky AS (2002) Injurious ventilation induces widespread pulmonary epithelial expression of tumor necrosis factor-alpha and interleukin-6 messenger RNA. Crit Care Med 30: 1693–1700PubMedCrossRefGoogle Scholar
  11. 11.
    Boussarsar M, Thierry G, Jaber S, Roudot-Thoraval F, Lemaire F, Brochard L (2002) Relationship between ventilatory settings and barotrauma in the acute respiratory distress syndrome. Intensive Care Med 28: 406–413PubMedCrossRefGoogle Scholar
  12. 12.
    Dreyfuss D, Soler P, Basset G, Saumon G (1988) High inflation pressure pulmonary edema. Respective effects of high airway pressure, high tidal volume, and positive end-expiratory pressure. Am Rev Respir Dis 137: 1159–1164Google Scholar
  13. 13.
    Chiumello D, Pristine G, Slutsky AS (1999) Mechanical ventilation affects local and systemic cytokines in an animal model of acute respiratory distress syndrome. Am J Respir Crit Care Med 160: 109–116PubMedCrossRefGoogle Scholar
  14. 14.
    Tremblay L, Valenza F, Ribeiro SP, Li J, Slutsky AS (1997) Injurious ventilatory strategies increase cytokines and c-fos m-RNA expression in an isolated rat lung model. J Clin Invest 99: 944–952PubMedCrossRefGoogle Scholar
  15. 15.
    Slutsky AS, Drazen FM, Ingram RH Jr, et al (1980) Effective pulmonary ventilation with small-volume oscillations at high frequency. Science 209: 609–671PubMedCrossRefGoogle Scholar
  16. 16.
    Slutsky AS, Brown R, Lehr J, Rossing T, Drazen JM (1981) High-frequency ventilation: a promising new approach to mechanical ventilation. Med Instrum 15: 229–233PubMedGoogle Scholar
  17. 17.
    Rimensberger PC, Pristine G, Mullen BM, Cox PN, Slutsky AS (1999) Lung recruitment during small tidal volume ventilation allows minimal positive end-expiratory pressure without augmenting lung injury. Grit Care Med 27: 1940–1945CrossRefGoogle Scholar
  18. 18.
    The Acute Respiratory Distress Syndrome Network (2000) Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med 342: 1301–1308Google Scholar
  19. 19.
    Stewart TE, Meade MO, Cook DJ, et al (1998) Evaluation of a ventilation strategy to prevent barotrauma in patients at high risk for acute respiratory distress syndrome. Pressure-and Volume-Limited Ventilation Strategy Group. N Engl J Med 338: 355–361Google Scholar
  20. 20.
    Brochard L, Roudot-Thoraval F, Roupie E, et al (1998) Tidal volume reduction for prevention of ventilator-induced lung injury in acute respiratory distress syndrome. The Multicenter Trail Group on Tidal Volume reduction in ARDS. Am J Respir Crit Care Med 158: 1831–1838Google Scholar
  21. 21.
    Amato MB, Barbas CS, Medeiros CM, et al (1998) Effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome. N Engl J Med 338: 347–354PubMedCrossRefGoogle Scholar
  22. 22.
    Ranieri VM, Suter PM, Tortorella C, et al (1999) Effect of mechanical ventilation on inflammatory mediators in patients with acute respiratory distress syndrome: a randomized controlled trial. JAMA 282: 54–61PubMedCrossRefGoogle Scholar
  23. 23.
    Hubmayr RD (2002) Perspective on lung injury and recruitment: a skeptical look at the opening and collapse story. Am J Respir Crit Care Med 165: 1647–1653PubMedCrossRefGoogle Scholar
  24. 24.
    dos Santos CC, Slutsky AS (2001) Overview of high-frequency ventilation modes, clinical rationale, and gas transport mechanisms. Respir Care Clin N Am 7: 549–575PubMedCrossRefGoogle Scholar
  25. 25.
    Oberg PA, Sjostrand U (1969) Studies of blood-pressure regulation. I. Common-carotidartery clamping in studies of the carotid-sinus baroreceptor control of the systemic blood pressure. Acta Physiol Scand 75: 276–286Google Scholar
  26. 26.
    Stewart TE, Slutsky AS (1995) Mechanical ventilation: A shifting philosophy. Curr Opin Crit Care 1: 49–56Google Scholar
  27. 27.
    HIFI Study Group (1989) High frequency oscillatory ventilation compared with conventional mechanical ventilation in the treatment of respiratory failure in preterm infants. N Engl J Med 320: 88–93CrossRefGoogle Scholar
  28. 28.
    Arnold JH, Hanson JH, Toro-Figuero LO, Gutierrez J, Berens RJ, Anglin DL (1994) Prospective, randomized comparison of high-frequency oscillatory ventilation and conventional mechanical ventilation in pediatric respiratory failure. Crit Care Med 22: 1530–1539PubMedGoogle Scholar
  29. 29.
    Gerstmann DR, Minton SD, Stoddard RA, et al (1996) The Provo multicenter high-frequency oscillatory ventilation trial improved pulmonary and clinical outcome in respiratory distress syndrome. Pediatrics 98: 1044–1057PubMedGoogle Scholar
  30. 30.
    Fort P, Farmer C, Westerman J, et al (1997) High-frequency oscillatory ventilation for adult respiratory distress syndrome-a pilot study. Grit Care Med 25: 937–947CrossRefGoogle Scholar
  31. 31.
    Mehta S, Lapinsky SE, Hallett DC, et al (2001) A prospective trial of high frequency oscillatory ventilation in adults with acute respiratory distress syndrome. Crit Care Med 29: 1360–1369PubMedCrossRefGoogle Scholar
  32. 32.
    Derdak S, Mehta S, Stewart TE, et al (2002) High-frequency oscillatory ventilation for acute respiratory distress syndrome in adults: a randomized, controlled trial. Am J Respir Grit Care Med 166: 801–808CrossRefGoogle Scholar
  33. 33.
    MacDonald R, Stewart TE, Lapinsky S, Aubin M, Hallett D, Mehta S (2000) Oxygenation response to inhaled nitric oxide (INO) when combined with high frequency oscillatory ventilation (HFOV). Am J Respir Crit Care Med 161: A47 (abst)Google Scholar
  34. 34.
    Varkul MD, Stewart TE, Lapinsky SE, Ferguson ND, Mehta S (2001) Successful use of combined high-frequency oscillatory ventilation, inhaled nitric oxide, and prone positioning in the acute respiratory distress syndrome. Anesthesiology 95: 797–799PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2003

Authors and Affiliations

  • A. Rossi
  • T. E. Stewart
  • V. M. Ranieri

There are no affiliations available

Personalised recommendations