Rescue high frequency jet ventilation versus conventional ventilation for severe pulmonary dysfunction in preterm infants

Joshi VH, Bhuta T

Published Online:

January 21, 2009

In very low birth weight infants who require support on breathing machines (ventilators), ventilator associated lung injury and the toxic effects of oxygen may be important factors in creating a chronic disturbance in lung function. Compared to routine conventional ventilators, high frequency jet ventilators (breathing machines that introduce short duration pulses of gas under pressure into the airway at a very fast rate) may reduce the severity of lung injury associated with mechanical ventilation. However, there is little evidence to support the use of rescue high frequency jet ventilation in the treatment of preterm infants with severe pulmonary problems. Only one trial is included in this review. This trial did not demonstrate any difference in infants who received high frequency jet ventilation. However, the trial had a small number of patients and did not report on long-term outcomes, therefore, it is difficult to interpret these findings.

Abstract (click to read)

Background:

Chronic pulmonary disease is a major cause of mortality and morbidity in very low birth weight infants despite increased use of antenatal steroids and surfactant therapy. Ventilator injury and oxygen toxicity are thought to be important factors in the pathogenesis of chronic pulmonary disease. There is evidence in animal studies and adult human studies that high frequency jet ventilation may reduce the severity of lung injury associated with mechanical ventilation.

Objectives:

In preterm infants with severe pulmonary dysfunction, does the use of high frequency jet ventilation (HFJV) compared to conventional ventilation (CV) reduce mortality and morbidity without an increase in adverse effects?

Search strategy:

We searched MEDLINE (1966 - August 2005), Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 3, 2005), and EMBASE (1988 - August 2005). Information was also obtained from experts in the field and cross references were checked.

Selection criteria:

Randomized and quasi-randomized controlled trials of rescue high frequency jet ventilation versus conventional ventilation in preterm infants born at less than 35 weeks of gestation or with a birth weight less than 2000 grams with respiratory distress were included in the systematic review.

Data collection and analysis:

The standard methods of the Cochrane Neonatal Review Group were used, including independent trial assessment and data extraction. Data were analysed using relative risk (RR) and risk difference (RD).

Main results:

Two randomized trials were identified. One trial (Engle 1997) was excluded as the study was restricted to term and near-term infants. The included trial (Keszler 1991) randomized 166 preterm infants and reported data on 144 infants. Cross-over to the alternate treatment was permitted if the initial treatment failed. There was no statistically significant difference in the overall mortality (including survival after cross-over) between the two groups [RR 1.07, (95% CI 0.67, 1.72)]. The survival by original assignment was identical. In a secondary analysis, the study demonstrated rescue treatment with HFJV, up until the time of cross-over, was associated with lower mortality, [RR 0.66 (95% CI 0.45,0.97)]. No significant differences were found in the incidence of CLD in survivors at 28 days of age, IVH, new air leaks, airway obstruction and necrotizing tracheobronchitis.

Authors' conclusions:

There was no significant difference in the overall mortality between rescue high frequency jet ventilation and conventional groups. In a secondary analysis, rescue treatment with HFJV, up until the time of cross-over, was associated with lower mortality. There was no significant increase in adverse effects like intraventricular hemorrhage, new air leaks, airway obstruction and necrotizing tracheobronchitis with rescue high frequency jet ventilation. The included study was done before the introduction of surfactant and widespread use of antenatal steroids. The number of infants included was small and there were high numbers of post randomization exclusions. Due to the crossover design and small numbers of infants in the included study, there is insufficient information to assess the effectiveness of rescue HFJV in preterm infants. Studies that target the most at-risk population and have appropriate power to assess some of the important outcomes are needed. These trials would also need to incorporate long term pulmonary and neurodevelopmental outcomes.

This record should be cited as:

Joshi VH, Bhuta T. Rescue high frequency jet ventilation versus conventional ventilation for severe pulmonary dysfunction in preterm infants. Cochrane Database of Systematic Reviews 2006, Issue 1. Art. No.: CD000437. DOI: 10.1002/14651858.CD000437.pub2

Assessed as up to date:

August 31, 2005

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Primary Review Group:

Neonatal Group

Health topics:

Neonatal care > Mechanical ventilation

Cochrane Summaries^beta

Independent high-quality evidence for health care decision making

Rescue high frequency jet ventilation versus conventional ventilation for severe pulmonary dysfunction in preterm infants

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