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primary indication for use of HFOV. HFOV is an efficacious rescue treatment in lung diseases characterised by low distending lung volume and is a feasible alternative to ECMO under these conditions, providing that appropriate volume recruitment strategies are applied. The goal of rescue HFOV is to optimise the distending lung volume and in so doing. Achieving this goal will improve gas exchange through the highly efficient gas mixing that occurs during gas exchange whilst protecting the lung from the barotrauma that would result to achieve the same gas exchange at conventional breathing frequencies. There is no clear evidence to guide clinicians when to commence rescue treatment with HFOV. Such guidelines need to consider the potential recruitable lung volume which is influenced by disease (eg hyaline membrane disease versus pulmonary hypoplasia) and also gestation (less mature infants have absent/underdeveloped Table 3: Suggested conventional ventilation settings to consider commencement of HFOV as a rescue treatment. Tidal volume (mL/kg) Peak inspiratory pressure (cmH2 O) Breathing frequency (breaths/min.) 4.5 – 5.0 5.0 – 6.0 6.0 – 7.0 22 – 25 24 – 27 25 – 30 70 – 80 60 – 70 50 – 60 Extreme Preterm Very Preterm Term Indications for HFOV rescue treatment 50 I 11 Indications for HFOV I I 51 Lung volume and mean airway pressure alveoli and may become over distended at lower total lung capacities and tidal volumes relative to their weight). Rather than using absolute limits for peak pressure as the indication for switching to rescue HFOV, in clinical settings where HFOV is used primarily for rescue, clinicians should consider the nature of the disease being treated, the stage in the natural history of the lung disease, the susceptibility/ resilience of that infant to iatrogenic injury and departure from gestation appropriate healthy breathing patterns when deciding when to initiate rescue HFOV.
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