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Research

High frequency oscillation in patients with acute lung injury and acute respiratory distress syndrome (ARDS): systematic review and meta-analysis

BMJ 2010; 340 doi: https://doi.org/10.1136/bmj.c2327 (Published 18 May 2010) Cite this as: BMJ 2010;340:c2327
  1. Sachin Sud, fellow1,
  2. Maneesh Sud, medical student2,
  3. Jan O Friedrich, assistant professor3,
  4. Maureen O Meade, associate professor4,
  5. Niall D Ferguson, assistant professor5,
  6. Hannah Wunsch, assistant professor6,
  7. Neill K J Adhikari, lecturer7
  1. 1Critical Care Medicine Program, Interdepartmental Division of Critical Care, University of Toronto, Toronto General Hospital, 585 University Ave, Toronto, ON, Canada, M5G 2N2
  2. 2Undergraduate Medicine Office, Faculty of Medicine 260 Brodie Centre, 727 McDermot Avenue, University of Manitoba, Winnipeg, MB, Canada, R3E 3P5
  3. 3Interdepartmental Division of Critical Care, University of Toronto, and Critical Care and Medicine Departments and the Keenan Research Centre in the Li Ka Shing Knowledge Institute, St Michael’s Hospital, 30 Bond Street, 4-015 Bond Wing, Toronto, ON, Canada, M5B 1W8
  4. 4Departments of Medicine and Clinical Epidemiology and Biostatistics, McMaster University Medical Centre, 1200 Main Street W, Hamilton, Ontario, Canada L8N 3Z5
  5. 5Interdepartmental Division of Critical Care, University of Toronto, and Department of Medicine, Division of Respirology, University Health Network and Mount Sinai Hospital, 600 University Avenue, Suite 18-206, Toronto, ON, Canada M5G 1X5
  6. 6Department of Anesthesiology, Columbia University, 622 W 168th St, PH5-527D, New York, NY10032, USA
  7. 7Interdepartmental Division of Critical Care, University of Toronto, and Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue Room D1.08, Toronto, ON, Canada M4N 3M5
  1. Correspondence to: J O Friedrich j.friedrich{at}utoronto.ca
  • Accepted 7 April 2010

Abstract

Objective To determine clinical and physiological effects of high frequency oscillation compared with conventional ventilation in patients with acute lung injury/acute respiratory distress syndrome (ARDS).

Design Systematic review and meta-analysis.

Data sources Electronic databases to March 2010, conference proceedings, bibliographies, and primary investigators.

Study selection Randomised controlled trials of high frequency oscillation compared with conventional ventilation in adults or children with acute lung injury/ARDS.

Data selection Three authors independently extracted data on clinical, physiological, and safety outcomes according to a predefined protocol. We contacted investigators of all included studies to clarify methods and obtain additional data. Analyses used random effects models.

Results Eight randomised controlled trials (n=419 patients) were included; almost all patients had ARDS. Methodological quality was good. The ratio of partial pressure of oxygen to inspired fraction of oxygen at 24, 48, and 72 hours was 16-24% higher in patients receiving high frequency oscillation. There were no significant differences in oxygenation index because mean airway pressure rose by 22-33% in patients receiving high frequency oscillation (P≤0.01). In patients randomised to high frequency oscillation, mortality was significantly reduced (risk ratio 0.77, 95% confidence interval 0.61 to 0.98, P=0.03; six trials, 365 patients, 160 deaths), and treatment failure (refractory hypoxaemia, hypercapnoea, hypotension, or barotrauma) resulting in discontinuation of assigned therapy was less likely (0.67, 0.46 to 0.99, P=0.04; five trials, 337 patients, 73 events). Other risks were similar. There was substantial heterogeneity between trials for physiological (I2=21-95%) but not clinical (I2=0%) outcomes. Pooled results were based on few events for most clinical outcomes.

Conclusion High frequency oscillation might improve survival and is unlikely to cause harm. As ongoing large multicentre trials will not be completed for several years, these data help clinicians who currently use or are considering this technique for patients with ARDS.

Footnotes

  • We thank all primary investigators who provided additional data for this review: Steven Derdak and Tom Bachman; Casper Bollen; Spyros Mentzelopoulos; Rujipat Samransamruajkit; and Sanjoy Shah. Preliminary results from this study were presented at the Society of Critical Care Medicine 2008 annual congress.72

  • Contributors: All authors contributed to study concept and design, revised the manuscript for important intellectual content, and approved the final version. SS conceived the study, acquired data, analysed and interpreted data, and drafted the manuscript. MS, JOF, and NKJA acquired, analysed, and interpreted data. MOM, NDF, and HW interpreted data. NKJA and JOF contributed equally to this study. SS, JOF, and NKJA are guarantors.

  • Funding: The study received no specific funding. JOF is supported by a Clinician-Scientist award from the Canadian Institutes of Health Research (CIHR). NDF is supported by a CIHR New Investigator Award. CIHR had no involvement in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript.

  • Competing interests: All authors have completed the Unified Competing Interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare that all authors had: (1) No financial support for the submitted work from anyone other than their employer; (2) No financial relationships with commercial entities that might have an interest in the submitted work; (3) No spouses, partners, or children with relationships with commercial entities that might have an interest in the submitted work; (4) The following non-financial interests relevant to the submitted work: MOM and NDF are primary investigators and JOF and NKJA are co-investigators for the ongoing Canadian Institutes of Health Research (CIHR) funded OSCILLATE study. CareFusion (formerly SensorMedics) is providing study oscillators to some of the hospitals involved in the OSCILLATE study for the duration of the study.

  • Ethical approval: Not required.

  • Data sharing: The protocol for the systematic review and dataset (RevMan 5.0 format) are available by request to the corresponding author.

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See: http://creativecommons.org/licenses/by-nc/2.0/ and http://creativecommons.org/licenses/by-nc/2.0/legalcode.

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