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Discussion
Hansell:
At the American Associa-
tion for Respiratory Care O
PEN
F
ORUM
last year, Jeanette Asselin’s group pre-
sented some preliminary data on the
use of early HFOV, and I believe those
data were very encouraging for early
use of HFOV.
REFERENCE
1. Asselin JW, Durand DJ, Courtney SE. Early
high-frequency oscillatory ventilation
(HFOV) vs synchronized intermittent man-
datory ventilation (SIMV) for very low
birthweight (VLBW) infants (abstract). Re-
spir Care 2001;46(10):1132.
Wiswell:
I was on the steering com-
mittee for the study you refer to. It’s
one of the few HFOV trials that have
shown benefits. They found less mor-
tality and BPD at 36 weeks’ post-con-
ception age with HFOV than with con-
ventional ventilation. The study is
going to be published in the New En-
gland Journal of Medicine.
1
In that
same issue of that journal will appear
what’s known as the “UKOS” trial,
from the United Kingdom Oscillation
Study Group, which found no differ-
ences in outcomes.
2
The problem with
the latter trial, from my perspective, is
that too many centers were involved
and too many different types of de-
vices were used. Three different kinds
of high-frequency oscillator were in-
volved, so I think they were compar-
ing apples to oranges.
REFERENCES
1. Courtney SE, Durand DJ, Asselin JM,
Hudak ML, Aschner JL, Shoemaker CT.
High-frequency oscillatory ventilation ver-
sus conventional mechanical ventilation for
very-low-birthweight infants. N Engl J Med
2002;347(9):643–652.
2. Johnson AH, Peacock JL, Greenough A,
Marlow N, Limb ES, Marston L, Calvert
SA; United Kingdom Oscillation Study
Group. High-frequency oscillatory ventila-
tion for the prevention of chronic lung dis-
ease of prematurity. N Engl J Med 2002;
347(9):633–642.
Rodriguez:
I appreciate that com-
ment. That reinforces the fact that for
each report describing beneficial ef-
fects from HFOV, you can find an-
other one that shows no benefits or
shows potential complications with
HFOV. My personal bias is that there
is very substantial center-to-center
variability. If I’m born in Provo, Utah,
I’d probably like to be on HFOV. But
if I’m born somewhere else, maybe
not. Maybe clinicians just use what
they are used to and feel more com-
fortable with.
I think HFOV has a role in the man-
agement of babies with RDS. At our
center we use it as a rescue modality,
and maybe that’s a little late, since the
lungs have already suffered all the
damage, and probably that’s why we
don’t see significant benefits. I think
there is a subset of patients who may
benefit from early institution of HFOV
and may never need a conventional
ventilator. The Cochrane systematic
review
1
cannot reconcile that HFOV
is better than conventional ventilation.
There are some concerns, and Tom
Wiswell published a very interesting
article in 1996,
2
although he used a
different strategy, which was termed
the “low volume” strategy at that time,
and he raised a very interesting ques-
tion that has also been raised by other
investigators, and that’s central ner-
vous system morbidities—ischemic
lesions in the form of periventricular
leukomalacia and increased incidence
of IVH.
3
Some of the newer trials, in
which an optimal lung volume strat-
egy was used, did not find differences
in those outcomes.
4
There seemed to
be no difference in the incidence of
IVH. However, I’m still a little reluc
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tant to suggest that everybody should
put kids on HFOV right off the bat.
REFERENCES
1. Henderson-Smart DJ, Bhuta T, Cools F,
Offringa M. Elective high frequency oscil-
latory ventilation versus conventional ven-
tilation for acute pulmonary dysfunction
in preterm infants (Cochrane Review). In:
The Cochrane Library, Issue 4 2002. Oxford:
Update Software. Available at http://www.
update-software.com/abstracts/titlelist.htm.
Accessed Jan 16, 2003
2. Wiswell TE, Graziani LJ, Kornhauser MS,
Stanley C, Merton DA, McKee L, Spitzer
AR. Effects of hypocarbia on the develop-
ment of cystic periventricular leukomala-
cia in premature infants treated with high-
frequency jet ventilation. Pediatrics 1996;
98(5):918–924.
3. Clark RH, Dykes FD, Bachman TE, Ashurst
JT. Intraventricular hemorrhage and high-
frequency ventilation: a meta-analysis of
prospective clinical trials. Pediatrics 1996;
98(6 Pt 1):1058–1061.
4. Gerstmann DR, Minton SD, Stoddard RA,
Meredith KS, Monaco F, Bertrand JM, et
al. The Provo multicenter early high-fre-
quency oscillatory ventilation trial: im-
proved pulmonary and clinical outcome in
respiratory distress syndrome. Pediatrics
1996;98(6 Pt 1):1044–1057.
Donn:
Regarding the study by
Courtney et al,
1
I think we should be
careful not to over-interpret the results.
It only compared HFOV to synchro-
nized intermittent mandatory ventila-
tion, and that might not be the best
mode to begin a newborn who has
RDS.
REFERENCE
1. Courtney SE, Durand DJ, Asselin JM,
Hudak ML, Aschner JL, Shoemaker CT.
High-frequency oscillatory ventilation ver-
sus conventional mechanical ventilation for
very-low-birthweight infants. N Engl J Med
2002;347(9):643–652.
Rodriguez:
Absolutely.
Myers:
John Salyer and his col-
leagues recently published a report in
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solized
 agonists, inhaled corticoste-
roids, in the RDS population.
1
The
question is, what’s the efficacy of

agonists, or how do you determine ef-
ficacy in a very small baby, in whom
it is difficult to measure lung compli-
ance and resistance?
REFERENCE
1. Ballard J, Lugo RA, Salyer JW. A survey
of albuterol administration practices in in-
tubated patients in the neonatal intensive
care unit. Respir Care 2002;47(1):31–38.
Rodriguez:
That’s a very good
point. Actually, I’m a little concerned
about the early use of
 agonists in
babies with RDS. I’m not sure whether
there is a role for
 agonists early on
in the course of RDS.
 stimulation
facilitates lung fluid re-absorption, and
some of these babies may have some
retained lung fluid, which from my
point of view is good initially, because
it facilitates surfactant spread and sur-
factant distribution when you’re treat-
ing them. I like to give surfactant when
there is still some lung fluid in place,
because the surfactant will be better
distributed in the lung.
I don’t know of any data that
strongly suggest that the early use of
 agonists makes a substantial differ-
ence in the management of these ba-
bies. Also, there is evidence that sug-
gests that some of the
 agonists that
we use in the neonatal intensive care
unit have an inflammatory effect in
the lung, at least when used chroni-
cally in asthmatic adults.
1
I’m a little
concerned when I see babies who are
3, 4, or 5 days old started on
 ago-
nists, because that may be promoting
more lung inflammation than we
know. Before more data are available
I’m a little reluctant to introduce

agonists into the airway of a baby who
is in the acute phase of RDS.
REFERENCE
1. Swystun VA, Gordon JR, Davis EB, Zhang
X, Cockcroft DW. Mast cell tryptase re-
lease and asthmatic responses to allergen
increase with regular use of salbutamol. J
Allergy Clin Immunol 2000;106(1 Pt 1):
57–64.
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