High-Frequency Oscillatory Ventilation in ARDS

Primary Recommendation

The American Thoracic Society, European Society of Intensive Care Medicine, and Society of Critical Care Medicine issued a strong recommendation against routine use of HFOV in patients with moderate or severe ARDS, based on moderate-high confidence in effect estimates 1, 2, 3

Meta-analysis of three high-quality RCTs (1,371 patients) showed no significant difference in mortality (RR 1.14; 95% CI 0.88-1.48) with HFOV 1, 2
One large multicenter RCT demonstrated significantly higher mortality with HFOV (RR 1.41; 95% CI 1.12-1.79) when compared to lung-protective ventilation with higher PEEP 1, 2
HFOV showed no significant difference in oxygenation at 24 hours (10 mm Hg higher; 95% CI -16 to 27 mm Hg), carbon dioxide tension, or barotrauma rates 1, 2

The American Thoracic Society recommends tidal volumes of 4-8 mL/kg predicted body weight 3
The American Thoracic Society recommends a plateau pressure of ≤30 cm H₂O 3
The American Thoracic Society recommends a PEEP strategy with higher PEEP (average 15.1 ± 3.6 cm H₂O) for moderate-severe ARDS 4
Prone positioning is recommended for >12 hours per day (strong recommendation, moderate-high confidence) for severe ARDS (PaO₂/FiO₂ <150 mmHg) 3, 4

In children, the evidence is insufficient to make firm recommendations for or against HFOV 6
HFOV may be considered if conventional ventilation fails in pediatric patients, using an open lung strategy to maintain optimal lung volume 6

The American Thoracic Society advises against using HFOV as routine first-line therapy for moderate-severe ARDS—the evidence shows no benefit and potential harm 1, 2
The American Thoracic Society advises against delaying proven interventions (prone positioning, lung-protective ventilation) while attempting HFOV 3, 4