High-frequency oscillatory ventilation after cardiac surgery: a treatment for all ages

a recent issue of Critical Care, Bojan and colleagues [1] reported their experience with early initiation of high-frequency oscillatory ventilation (HFOV) in pediatric cardiac surgery that demonstrated shorter mechanical ventilation times and intensive care stays. Acute lung injury is common in adult patients undergoing surgery, yet there is scant reporting of the intraoperative utility of HFOV [2]. We initiated HFOV in a 49-year-old morbidly obese (body mass index of 69 kg/m 2) man who had aortic stenosis, pulmonary hypertension, and decompensated congestive heart failure and who was undergoing aortic valve replacement. Separation from cardiopulmonary bypass (CPB) with inverse-ratio pressure-control ventilation – fraction of inspired oxygen (FiO 2) of 1.0 and positive end-expiratory pressure (PEEP) of 18 cm H 2 O – failed because of hypoxia, defi ned as an arterial partial pressure of oxygen (PaO 2) of 64 mm Hg. HFOV was initiated (mean pressure airway of 33 cm H 2 O and FiO 2 of 1.0), yielding a PaO 2 of 74 mm Hg and allowing CPB separation. Th e patient was transitioned to conventional ventilation on postoperative day 3 and was extubated on postoperative day 5. Th is adult patient benefi ted from HFOV, as did the pediatric population of Bojan and colleagues. Continuous positive intrathoracic pressure is a concern as it may impede venous return and thereby limit cardiac output (CO) [3]. However, the transition from ventilation with PEEP to HFOV usually results in signifi cant changes in oxygenation/ventilation but not in CO [4]. In patients with pulmonary hypertension, HFOV has been demonstrated to increase CO and decrease pulmonary vascular resistance [5]. For our patient, HFOV allowed improved oxygenation without aff ecting hemodynamics. HFOV may be a safe and eff ective therapy to improve oxygenation/ventilation in patients undergoing cardiac surgery and possibly is underused because of unfounded hemodynamic concerns. HFOV needs exploration as a rescue tool after CPB for patients with hypoxia. Competing interests The authors declare that they have no competing interests. High-frequency oscillatory ventilation and short-term outcome in neonates and infants undergoing cardiac surgery: a propensity score analysis. Anesthesia and intraoperative high-frequency oscillatory ventilation during burn surgery. B: High-frequency oscillatory ventilation (HFOV) and airway pressure release ventilation (APRV): a practical guide. Cardiovascular responses to high-frequency oscillatory ventilation during acute lung injury in sheep.