With Respiratory Distress Syndrome Ventilation and Conventional Ventilation in Preterm Infants of Less Than 30 Prospective Randomized Multicenter Comparison of High-Frequency Oscillatory

Background. Early use of high-frequency ventilation and exogenous surfactant is proposed as the optimal mode of ventilatory support in infants with respiratory distress syndrome. In very premature infants, we tested the hypothesis that high-frequency versus conventional ventilation could decrease exogenous surfactant requirements and improve pulmonary outcome, without altering the complication rate, including that of severe intraventricular hemorrhage. Methods. Preterm infants with a postmenstrual age of 24 to 29 weeks, presenting with respiratory distress syndrome were randomly assigned to high-frequency oscillatory ventilation (lung volume recruitment strategy) or conventional ventilation. Results. Two hundred seventy-three infants were enrolled. One hundred fifty-three had a postmenstrual age of 24 to 27 weeks, and 143 had a birth weight <1000 g. One hundred thirty-four infants were randomized at 142 minutes of life (median) to receive conventional ventilation (mean postmenstrual age at birth: 27. 6 6 1.5 weeks; mean birth weight: 997 6 245 g); and 139 infants were randomized at 145 minutes of life to receive high-frequency ventilation (mean postmenstrual age at birth: 27.5 6 1.4 weeks; mean birth weight: 976 6 219 g). High-frequency ventilation, compared with conventional ventilation, was associated with a twofold reduction in the requirement for >2 instillations of exogenous surfactant (30% vs 62%; odds ratio: .27; 95% confidence interval: .16–.44) and no difference in pulmonary outcome. The incidence of severe intraventricular hemorrhage was 24% in the high-frequency group and 14% in the conventional ventilation group (adjusted odds ratio: 1.50; 95% confidence interval: .68–3.30). Conclusion. Early use of high-frequency oscillatory ventilation in very premature infants decreases exogenous surfactant requirements, does not improve the pulmonary outcome, and may be associated with an increased incidence of severe intraventricular hemorrhage. Pediatrics 2001;107:363–372; prematurity, high-frequency ventilation, chronic lung disease, multicenter trial, intraventricular hemorrhage. ABBREVIATIONS. Po2, partial pressure of oxygen; Fio2, fraction of inspired oxygen; Pco2, partial pressure of carbon dioxide; OR, odds ratio; CI, confidence interval; SD, standard deviation. Increasing survival rates of very premature infants are associated with a high incidence of chronic lung disease, in which volutrauma is believed to play an important role. The objective of the various high-frequency ventilation techniques is to reduce acute lung injury. In animals, the pulmonary benefits of high-frequency ventilation versus conventional ventilation have been demonstrated without exogenous surfactant1 and in combination with this treatment in some,2–5 but not all experiments. In infants, the message from neonatal trials remains unclear,6–12 resulting in an ongoing debate concerning the best ventilation mode for the management of respiratory distress syndrome. Because of the wider use of antenatal steroids and exogenous surfactant over recent years, new studies are required. We tested the hypothesis that, in infants born before 30 weeks, early use of high-frequency oscillatory ventilation with a lung volume recruitment strategy can decrease the exogenous surfactant requirements and improve pulmonary outcome, without altering the incidence of severe intraventricular hemorrhage.