High-Frequency Oscillatory Ventilation (HFOV) Updates

Introduction And Pathophysiological Rationale

High-Frequency Oscillatory Ventilation (HFOV) is a lung-protective ventilation strategy that delivers extremely small tidal volumes (1 to 3 mL/kg) at highly elevated frequencies (3 to 15 Hz) utilizing active exhalation.
It achieves effective gas exchange through bulk flow, pendelluft, and asymmetric velocity profiles while employing sub-dead-space tidal volumes.
This modality minimizes ventilator-induced lung injury (VILI), volutrauma, and atelectrauma while sustaining a constant mean airway pressure (MAP) to ensure optimal alveolar recruitment.
In India, pediatric acute respiratory distress syndrome (PARDS) and neonatal acute respiratory distress syndrome (NARDS) carry substantial morbidity, making HFOV a critical rescue option where extracorporeal membrane oxygenation (ECMO) remains unavailable.

A 2026 randomized controlled trial (RCT) demonstrated that elective HFOV significantly reduces bronchopulmonary dysplasia (BPD) incidence (34.3% versus 44.9%) and lowers the risk of severe BPD by 32% in preterm infants.
A 2025 RCT established that non-invasive HFOV (NHFOV) utilized as primary respiratory support significantly diminishes the requirement for invasive mechanical ventilation within 72 hours compared to nasal CPAP in extremely preterm neonates.
Volume-guarantee HFOV (HFOV-VG) demonstrates emerging clinical feasibility for controlling tidal volumes, successfully mitigating amplitude variability in neonates.
The ongoing PROSpect trial protocol evaluates the efficacy of HFOV combined with prone positioning versus conventional mechanical ventilation (CMV) in moderate-to-severe PARDS.
Real-world cohorts from resource-limited settings confirm that HFOV improves oxygenation as a rescue therapy, though it provides no routine mortality benefit over CMV.

Governing Society	Specific Clinical Recommendations
PALICC-2 (2023, 2025 Reviews)	Does not recommend routine HFOV use over CMV in PARDS; reserves HFOV strictly as rescue therapy when lung-protective CMV fails (plateau pressure >28 cmH2O).
Surviving Sepsis Campaign (SSC) 2026	Suggests conditional use of HFOV as a rescue strategy for refractory hypoxemia in sepsis and PARDS, with no routine preference over CMV.
ESPNIC And UK Guidelines (2025)	Supports the elective use of HFOV in preterm NARDS specifically for BPD prevention and recommends NHFOV as primary support in extremely preterm infants.
IAP Critical Care Modules (2025-2026)	Aligns with PALICC-2 algorithms, recommending HFOV exclusively as rescue therapy in Indian PICUs when CMV proves inadequate.

For neonates, clinicians must initiate HFOV at frequencies of 10 to 15 Hz with a MAP set 2 to 5 cmH2O above previous CMV settings.
For older children, the recommended frequency is 5 to 10 Hz requiring relatively higher MAP titrations.
Optimization of lung volume requires a stepwise MAP increase or decrease while meticulously monitoring oxygenation, carbon dioxide response, and systemic hemodynamics.
The MoHFW and ICMR Standard Treatment Workflows have officially incorporated HFOV as a rescue ventilation modality in severe PARDS and NARDS PICU protocols.
Implementation challenges include substantial operator dependence, significant heterogeneity in clinical trials, and limited availability of specialized equipment in resource-limited settings.