Résumé
La ventilation par oscillations à haute fréquence (HFO) a fait depuis plus de 30 ans l’objet de recherches physiologiques intenses et d’un débat passionné sur son utilité clinique dans le traitement du syndrome de détresse respiratoire aiguë (SDRA). Cette technique potentiellement dangereuse a été promue avec enthousiasme par certaines équipes jusqu’à ce que deux études randomisées contrôlées de grande qualité menées chez l’adulte viennent ruiner ce château de cartes. En effet, les concepts physiologiques (atélectrauma et biotrauma) sur lesquels se fondait l’utilisation de l’HFO dans le SDRA étaient discutables. À l’inverse, le concept de volotrauma ou surdistension télé-inspiratoire responsable des lésions induites par la ventilation (VILI) permettait de prédire une surmortalité au cours de la ventilation du SDRA du fait de volumes inspiratoires trop élevés, ce qui s’est produit au cours d’une des études récentes sur l’HFO. Cet échec retentissant d’une technique complexe et potentiellement dangereuse est à mettre en perspective face à l’amélioration extraordinaire du pronostic du SDRA par des mesures aussi simples que la réduction du volume courant, la curarisation précoce et la mise en décubitus ventral.
Abstract
High frequency oscillatory ventilation (HFO) has been the subject of extensive physiological research for 30 years and even more so of an intense debate on its potential usefulness in the treatment of acute respiratory distress syndrome (ARDS). This potentially harmful technique has been enthusiastically promoted by some teams until two high-quality randomized clinical trials on ARDS in adults caused the ruin of this house of cards. Indeed, physiological concepts such as atelectrauma and biotrauma on which HFO was based during ARDS were highly disputable. On the contrary, the concept of volotrauma i.e., end-inspiratory overdistension as the responsible for ventilator-induced lung injury allowed prediction of excess mortality during mechanical ventilation of ARDS when inspiratory volumes are too high. This is what happened during a recent study on HFO. This resounding failure of a complex and potentially dangerous technique must be put in perspective with the dramatic improvement of ARDS prognosis with very simple interventions such as tidal volume reduction, early pharmacological paralysis and prone positioning.
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Dreyfuss, D., Ricard, JD. & Gaudry, S. Ventilation par oscillations à haute fréquence : rideau ?. Réanimation 24, 4–10 (2015). https://doi.org/10.1007/s13546-015-1034-x
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DOI: https://doi.org/10.1007/s13546-015-1034-x