Skip to main content
Erschienen in: Annals of Intensive Care 1/2020

Open Access 01.12.2020 | Letter to the Editor Response

Response to the authors

verfasst von: Pauline de Jager, Martin C. J. Kneyber

Erschienen in: Annals of Intensive Care | Ausgabe 1/2020

download
DOWNLOAD
print
DRUCKEN
insite
SUCHEN
Hinweise

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
We like to thank the authors for their interest in our manuscript and their positive feedback. High-frequency oscillatory ventilation (HFOV) is used in our unit for any type of PARDS when the patient meets specific criteria as outlined in our manuscript (in summary, peak inspiratory pressure [PIP] > 28–32 cm H2O, PEEP > 8 cm H2O, FiO2 > 0.60, and oxygenation index [OI] increases on three consecutive 1-h measurements despite increasing PEEP) [1]. We understand the author’s perspective that HFOV might be more effective in certain types of PARDS, but we advocate that HFOV should not only be considered in case of refractory hypoxaemia, but also when the bedside team wants to prevent ventilator settings becoming toxic. An individualised lung volume optimisation manoeuvre (such as the staircase incremental–decremental titration of the continuous distending pressure (CDP) helps in identifying patients who have potential for lung recruitability since the response is highly heterogeneous among PARDS [2]. As our data showed, such an individualised manoeuvre can be tolerated well in terms of haemodynamic effects with a minimal risk of barotrauma (in fact, we observed no barotraumas following the manoeuvre in our cohort).
The authors raise an important point: what is the “optimal” frequency in relation to PARDS severity? Although the concept of the corner frequency is quite clear, it is difficult to detect at the bedside how the “optimal” frequency can be identified in heterogenous PARDS [3]. Basically, the lower the lung compliance, the higher the frequency probably should be. For simplicity, when we implemented the HFOV clinical algorithm in our unit, the advice was to start with 12 Hz in all patients, irrespective of age or PARDS severity and titrate immediately after the lung volume optimisation manoeuvre using the PCO2 to give direction (e.g. frequency up or down). Our data confirmed that it was possible to do this in all patients, irrespective of age (Fig. 1).
We agree that in a subgroup of patients in our cohort, especially those with mild-to-moderate PARDS optimisation of conventional mechanical ventilation settings might have been attempted. The median OI of 38 as pointed out by the reviewer is the OI after the lung volume optimisation manoeuvre, hence the high CDP we use as part of the open-lung concept confounds the OI. It is true that in general in the paediatric intensive care unit there is a relatively low use of positive end-expiratory pressure (PEEP) and tolerance of high FiO2 instead. However, the best strategy to optimise CMV in children with severe PARDS remains uncertain [4]. To date, there is no specific PEEP strategy shown to be beneficial nor are there outcome data demonstrating that higher PEEP is better than lower PEEP in PARDS, although there are some suggestions that lower PEEP in PARDS may be associated with increased mortality [5]. We also do not know what the optimal Vt is in (severe) PARDS [6]. Hence, we advocate that HFOV should also be considered if the bedside team wants to prevent ventilator settings becoming toxic.
We eagerly await the results of a 2-by-2 factorial randomised controlled trial comparing the effects of ventilation strategy (CMV vs HFOV) with or without prone positioning (http://​www.​prospect-network.​org) on patient outcome [7].

Acknowledgements

Not applicable.
Not applicable.
Not applicable.

Competing interests

Dr. Kneyber received unrestricted technical support and lecture fees from Vyaire. Dr. de Jager disclosed that she does not have any potential conflicts of interest.
Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://​creativecommons.​org/​licenses/​by/​4.​0/​.

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Literatur
1.
Zurück zum Zitat de Jager P, Kamp T, Dijkstra SK, Burgerhof JGM, Markhorst DG, Curley MAQ, et al. Feasibility of an alternative, physiologic, individualized open-lung approach to high-frequency oscillatory ventilation in children. Ann Intensive Care. 2019;9(1):9.CrossRef de Jager P, Kamp T, Dijkstra SK, Burgerhof JGM, Markhorst DG, Curley MAQ, et al. Feasibility of an alternative, physiologic, individualized open-lung approach to high-frequency oscillatory ventilation in children. Ann Intensive Care. 2019;9(1):9.CrossRef
2.
Zurück zum Zitat de Jager P, Burgerhof JGM, Koopman AA, Markhorst DG, Kneyber MCJ. Lung volume optimization maneuver responses in pediatric high frequency oscillatory ventilation. Am J Respir Crit Care Med. 2019;199:1034–6.CrossRef de Jager P, Burgerhof JGM, Koopman AA, Markhorst DG, Kneyber MCJ. Lung volume optimization maneuver responses in pediatric high frequency oscillatory ventilation. Am J Respir Crit Care Med. 2019;199:1034–6.CrossRef
3.
Zurück zum Zitat Venegas JG, Fredberg JJ. Understanding the pressure cost of ventilation: why does high-frequency ventilation work? Crit Care Med. 1994;22(9 Suppl):S49–57.CrossRef Venegas JG, Fredberg JJ. Understanding the pressure cost of ventilation: why does high-frequency ventilation work? Crit Care Med. 1994;22(9 Suppl):S49–57.CrossRef
4.
Zurück zum Zitat Kneyber MCJ, de Luca D, Calderini E, Jarreau PH, Javouhey E, Lopez-Herce J, et al. Recommendations for mechanical ventilation of critically ill children from the Paediatric Mechanical Ventilation Consensus Conference (PEMVECC). Intensive Care Med. 2017;43(12):1764–80.CrossRef Kneyber MCJ, de Luca D, Calderini E, Jarreau PH, Javouhey E, Lopez-Herce J, et al. Recommendations for mechanical ventilation of critically ill children from the Paediatric Mechanical Ventilation Consensus Conference (PEMVECC). Intensive Care Med. 2017;43(12):1764–80.CrossRef
5.
Zurück zum Zitat Khemani RG, Parvathaneni K, Yehya N, Bhalla AK, Thomas NJ, Newth CJL. PEEP lower than the ARDS network protocol is associated with higher pediatric ARDS mortality. Am J Respir Crit Care Med. 2018;198:77–89.CrossRef Khemani RG, Parvathaneni K, Yehya N, Bhalla AK, Thomas NJ, Newth CJL. PEEP lower than the ARDS network protocol is associated with higher pediatric ARDS mortality. Am J Respir Crit Care Med. 2018;198:77–89.CrossRef
6.
Zurück zum Zitat de Jager P, Burgerhof JG, van Heerde M, Albers MJ, Markhorst DG, Kneyber MC. Tidal volume and mortality in mechanically ventilated children: a systematic review and meta-analysis of observational studies*. Crit Care Med. 2014;42(12):2461–72.CrossRef de Jager P, Burgerhof JG, van Heerde M, Albers MJ, Markhorst DG, Kneyber MC. Tidal volume and mortality in mechanically ventilated children: a systematic review and meta-analysis of observational studies*. Crit Care Med. 2014;42(12):2461–72.CrossRef
7.
Zurück zum Zitat Kneyber MCJ, Cheifetz IM, Curley MAQ. High-frequency oscillatory ventilation for PARDS: awaiting PROSPect. Crit Care. 2020;24(1):118.CrossRef Kneyber MCJ, Cheifetz IM, Curley MAQ. High-frequency oscillatory ventilation for PARDS: awaiting PROSPect. Crit Care. 2020;24(1):118.CrossRef
Metadaten
Titel
Response to the authors
verfasst von
Pauline de Jager
Martin C. J. Kneyber
Publikationsdatum
01.12.2020
Verlag
Springer International Publishing
Erschienen in
Annals of Intensive Care / Ausgabe 1/2020
Elektronische ISSN: 2110-5820
DOI
https://doi.org/10.1186/s13613-020-00694-4

Weitere Artikel der Ausgabe 1/2020

Annals of Intensive Care 1/2020 Zur Ausgabe

Update AINS

Bestellen Sie unseren Fach-Newsletter und bleiben Sie gut informiert.