High-Frequency Oscillation vs Mechanical Ventilation for Neonatal Acute Respiratory Distress Syndrome: A Randomized Clinical Trial.

Summary

In a single-center RCT of 386 preterm infants with NARDS, elective HFOV reduced bronchopulmonary dysplasia compared with continued CMV under two accepted BPD definitions, without increasing mortality or major neonatal complications. Findings support HFOV as a preventive strategy for BPD in high-risk preterm NARDS.

Key Findings

• HFOV reduced BPD versus CMV: 34.3% vs 44.9% (NICHD 2001 definition; RR 0.92, 95% CI 0.86-0.99).
• HFOV reduced BPD under 2019 definition: 17.1% vs 25.4% (RR 0.68, 95% CI 0.45-1.00).
• No significant differences in mortality, severe ROP, NEC ≥ stage 2, IVH ≥ grade 3, air leak, or hsPDA.
• Sensitivity analysis excluding 44 crossovers yielded consistent estimates.

Clinical Implications

For preterm infants with NARDS stabilized on CMV, early transition to elective HFOV may reduce BPD risk. Implementation should consider center expertise and await multicenter confirmation before broad guideline changes.

Limitations

• Single-center design may limit generalizability.
• Potential lack of blinding and treatment crossovers could introduce bias.
• BPD definition heterogeneity complicates cross-study comparisons.

Future Directions

Multicenter RCTs comparing HFOV-first strategies with standardized protocols and long-term neurodevelopmental follow-up are needed to confirm generalizability and inform guidelines.