Acute Respiratory Failure In Children Research Articles

Acute Respiratory Failure in Children: A Clinical Update on Diagnosis.

Acute respiratory failure (ARF) is a sudden failure of the respiratory system to ensure adequate gas exchanges. Numerous clinical conditions may cause ARF, including pneumonia, obstructive lung diseases (e.g., asthma), restrictive diseases such as neuromuscular diseases (e.g., spinal muscular atrophy and muscular dystrophy), and albeit rarely, interstitial lung diseases. Children, especially infants, may be more vulnerable to ARF than adults due to anatomical and physiological features of the respiratory system. Assessing respiratory impairment in the pediatric population is particularly challenging as children frequently present difficulties in reporting symptoms and due to compliance and cooperation in diagnostic tests. The evaluation of clinical and anamnestic aspects represents the cornerstone of ARF diagnosis: first level exams (e.g., arterial blood gas analysis) confirm and evaluate the severity of the ARF and second level exams help to uncover the underlying cause. Prompt management is critical, with supplemental oxygen, mechanical ventilation, and the treatment of the underlying problem. The aim of this review is to provide a comprehensive summary of the current state of the art in diagnosing pediatric ARF, with a focus on pathophysiology, novel imaging applications, and new perspectives, such as biomarkers and artificial intelligence.

Inflammatory and coagulant responses after acute respiratory failure in children of different body habitus

BackgroundEndothelial injury and systemic inflammation are key determinants of acute respiratory failure (ARF) outcome. We sought to determine if childhood obesity alters the degree of injury and inflammation in (ARF) patients with and without sepsis.MethodsPlasma markers of endothelial injury (thrombomodulin), thrombosis (plasminogen activator inhibitor, PAI-1), and inflammation (IL-8 and IL-1ra) were measured over 3 days in children with ARF. Weight classification (healthy, overweight, and obesity) was determined by body mass index or weight‐for‐height z scores. Daily biomarker concentration and concentration change over time were compared among weight groups. Secondarily, we stratified by sepsis versus non-sepsis ARF.ResultsTwenty-six percent of the 229 children had obesity. Obesity was associated with longer duration of mechanical ventilation (median of 12 days compared to 7 days in the healthy weight, p = 0.006) and ICU stay (median of 18 days compared to 10 days in the healthy weight, p = 0.01 and compared to 11 days in the overweight, p = 0.02). Thrombomodulin levels were significantly higher in the obesity group on study days 1 and 2. In those with sepsis-associated ARF, thrombomodulin change over time increased most significantly in the obesity group (p = 0.015 for the interaction term of weight group and day on thrombomodulin concentration). There were no weight-based differences for IL-8, IL-1ra, or PAI-1.ConclusionsObesity was associated with elevated thrombomodulin, most notably in children with sepsis-associated ARF. This may denote worse endothelial injury in children with obesity and ARF. We found no difference in biomarkers of systemic inflammation among the weight groups.

Association of surfactant protein A2 with acute respiratory failure in children.

Interactions among single nucleotide polymorphisms (SNPs) of surfactant protein (SP) are associated with acute respiratory failure (ARF) and its short-term outcome, pulmonary dysfunction at discharge (PDAD) in children. However, genetic association studies using individual SNPs have not been conducted before. We hypothesize that SP genetic variants are associated with pediatric ARF and its short-term complications by themselves. We used available genotype and clinical data in the Floros biobank consisting of 248 children aged ≤24 months with ARF; 86 developed PDAD. A logistic regression analysis was performed for each of the 14 selected SNPs, SP-A1 and SP-A2 genotypes. A p-value less than the Bonferroni correction threshold was considered significant. A likelihood ratio test was done to compare two models (one with demographic data and another with genetic variants). Before Bonferroni correction, female sex is associated with a decreased risk of ARF. Black race and the rs721917 of the SFTPD are associated with increased risk of ARF. After Bonferroni correction, the 1A0 1A1 genotype of SFTPA2 was associated with decreased risk of ARF. The likelihood ratio test showed that the model of the genotype information with demographic data was a better fit to predict ARF risk. None of the SP SNPs and SP-A1, SP-A2 genotypes were associated with PDAD. Our results indicate that SNPs and genotypes of SPs involved in innate immunity and host defense play an important role in ARF and, in the future, may be used as biomarkers.

Risk factors for recurrent respiratory tract infections and acute respiratory failure in children with spinal muscular atrophy.

Assessment of and intervention for sleep-disordered breathing and malnutrition are related to the prevention of recurrent respiratory tract infections (RRTIs) and acute respiratory failure (ARF) in children with spinal muscular atrophy (SMA). However, specific standards for sleep-disordered breathing and malnutrition in the prevention of RRTIs and ARF have not been clarified. The study aimed to identify the risk factors and predictive indices for RRTIs and/or ARF in children with SMA. In this retrospective study, the differences in clinical characteristics between patients with and without RRTIs and ARF were compared, and binary logistic regression analysis was carried out. The optimal cutoff points for positive predictors were obtained. SMA type 1 (odds ratio (OR) = 5.21, 95% confidence interval (CI) 1.50-18.17, p = 0.010) and the apnea-hypopnea index (AHI) (OR = 1.12, 95% CI 1.01-1.24, p = 0.026) were risk factors, while the body mass index z score (BMIz) (OR = 0.65, 95% CI 0.46-0.91, p = 0.013) and mean pulse oxygen saturation (MSpO2 ) (OR = 0.72, 95% CI 0.52-1.00, p = 0.049) were protective factors. A standard consisting of (i) MSpO2 < 96% and (ii) AHI > 10 events/h and/or BMIz < -1 predicted the occurrence of RRTIs and/or ARF in the next year with a sensitivity of 0.513 and a specificity of 0.957. SMA type 1, BMIz, AHI and MSpO2 should be used to estimate the risk of RRTI and/or ARF in children with SMA. MSpO2 < 96% combined with AHI > 10 events/h or BMIz < -1 should be used as the intervention standard.

Paediatric dengue shock syndrome and acute respiratory failure: a single-centre retrospective study

ObjectiveDengue shock syndrome (DSS) is a serious health condition leading to paediatric intensive care unit (PICU) admissions and deaths in tropical countries. Acute respiratory failure (ARF) is associated with DSS...

Science, Medicine, and the Anesthesiologist

Science, Medicine, and the Anesthesiologist

EFFECT OF NONINVASIVE VENTILATION ON OUTCOME OF PEDIATRIC PATIENTS WHO DEVELOP ACUTE RESPIRATORY FAILURE

TOPIC: Critical Care TYPE: Original Investigations PURPOSE: The utilization of noninvasive ventilation (NIV) has become popular as a supportive therapy in the treatment of acute respiratory failure in children. It has been proven to be effective in selected patients, and has decreased the incidence of endotracheal intubation, and the risk of acquiring ventilator-associated pneumonia, barotrauma, laryngeal swelling, and post-extubation vocal cord dysfunction. In the local setting, there is paucity of literature regarding the use of non -invasive ventilation in pediatrics, hence this study aims to determine its outcome and predictors of success, to fill gap in knowledge. METHODS: The study is a retrospective cross-sectional study that examined the outcomes and predictors of success of use of non- invasive ventilation in pediatric patients with acute respiratory failure. RESULTS: There were a total of 75 patients included in the study. Seventy three percent (n= 55) of patients had NIV success as an outcome while twenty seven percent (n= 20) of patient has NIV failure as an outcome. The average age of the participants 0.33 or 3.9 months. Seventy six percent (n= 57) were male, while twenty four percent (n=18) were female. Most of the patient had a normal nutritional status with an incidence of 50.6% (n= 38). The most common cardiac diagnosis of patients who were instituted with NIV are dextro transposition of the great arteries (46%) and ventricular septal defect (40.91%). The most common cause of respiratory failure of patients who were instituted with non- invasive ventilation are post extubation failure (64%); pulmonary congestion (54%) and pneumonia (53%).On multivariate analysis, the following factors namely 1) Presence of Pneumonia (p = 0.008); 2.) Presence of sepsis (p= 0.10); 3.) Having a severe respiratory distress prior to NIV ( p = 0.044) 4.) and using CPAP as the NIV mode (p= 0.003) were found to be significantly associated with NIV outcome. Specifically, it was found that patients with pneumonia were 97.72% less likely to have successful NIV and patients with presence of sepsis were 94.95% less likely to have successful NIV. In addition, patients with severe level of distress prior to NIV were 99.97% less likely to have successful NIV. Lastly, patients with CPAP NIV mode were 63.5 times more likely to have successful NIV compared to patients with BIPAP NIV mode. CONCLUSIONS: The use of non- invasive ventilation in patients with acute respiratory failure can be effective and can ultimately decrease the need for endotracheal intubation. However, caution with its use should be applied in patients with pneumonia, sepsis and severe level of respiratory distress, Knowledge regarding the efficacy and possible predictors of outcome of NIV use, can help in the prevention of pulmonary morbidity as well as in the improvement of management approach to children presenting with respiratory distress. CLINICAL IMPLICATIONS: This study evaluated the clinical indication, predictors and outcomes of non -invasive ventilation. The information gathered in this study will contribute to the existing pool of knowledge and will help the pediatricians to decide whether to initiate NIV or not. This study will also serve as a stepping stone to the pursuit of further studies about non- invasive ventilation. DISCLOSURES: No relevant relationships by JENNEYFER REZZA RUCKENBROD, source=Web Response

Efficacy of Noninvasive Ventilator in the Treatment of Severe Pneumonia Complicated with Acute Respiratory Failure in Children

Efficacy of Noninvasive Ventilator in the Treatment of Severe Pneumonia Complicated with Acute Respiratory Failure in Children

Invasive and noninvasive ventilation strategies for acute respiratory failure in children with coronavirus disease 2019.

Severe Acute Respiratory Syndrome Coronavirus 2 presents as symptomatic coronavirus disease 2019 (COVID-19) disease in susceptible patients. Severe pediatric COVID-19 disease is rare, limiting potential data accumulation on associated respiratory failure in children. Pediatric intensivists and pulmonologists managing COVID-19 patients look to adult guidelines and pediatric-specific consensus statements to guide management. The purpose of this article is to review the current literature and recommended strategies for the escalation of noninvasive and invasive respiratory support for acute respiratory failure associated with COVID-19 disease in children. There are no prospective studies comparing COVID-19 treatment strategies in children. Adult and pediatric ventilation management interim guidance is based on evidence-based guidelines in non-COVID acute respiratory distress syndrome, with considerations of (1) noninvasive positive pressure ventilation versus high-flow nasal cannula and (2) high versus lower positive end expiratory pressure strategies related to lung compliance and potential lung recruitability. Management of acute respiratory failure from COVID-19 requires individualized titration of noninvasive and invasive ventilation modalities with consideration of preserved or compromised pulmonary compliance. Research regarding best practices in the management of pediatric severe COVID-19 with respiratory failure is lacking and is acutely needed as the pandemic surges and vaccination of the pediatric population will be delayed compared to adults.

Noninvasive Ventilation and Mechanical Insufflator-Exsufflator for Acute Respiratory Failure in Children With Neuromuscular Disorders.

Children with neuromuscular disorder (NMD) usually have pulmonary involvement characterized by weakened respiratory muscles, insufficient coughing, and inability to clear airway secretions. When suffering from community-acquired pneumonia, these patients are more likely to develop acute respiratory failure (ARF). Therefore, recurrent pneumonias leading to acute on chronic respiratory failure accounts for a common cause of mortality in children with NMD. For many years, noninvasive ventilation (NIV) has been regarded as a life-prolonging tool and has been used as the preferred intervention for treating chronic hypoventilation in patients with advanced NMD. However, an increasing number of studies have proposed the utility of NIV as first-line management for acute on chronic respiratory failure in NMD patients. The benefits of NIV support in acute settings include avoiding invasive mechanical ventilation, shorter intensive care unit or hospital stays, facilitation of extubation, and improved overall survival. As the difficulty in clearing respiratory secretions is considered a significant risk factor attributing to NIV failure, combined coughing assistance of mechanical insufflator-exsufflator (MI-E) with NIV has been recommended the treatment of acute neuromuscular respiratory failure. Several recent studies have demonstrated the feasibility and effectiveness of combined NIV and MI-E in treating ARF of children with NMD in acute care settings. However, to date, only one randomized controlled study has investigated the efficacy of NIV in childhood ARF, but subjects with underlying NMD were excluded. It reflects the need for more studies to elaborate evidence-based practice, especially the combined NIV and MI-E use in children with acute neuromuscular respiratory failure. In this article, we will review the feasibility, effectiveness, predictors of outcome, and perspectives of novel applications of combined NIV and MI-E in the treatment of ARF in NMD children.

Оцінювання нутрітивного статусу у дітей з гострою дихальною недостатністю: проспективне обсерваційне когортне дослідження

Оцінювання нутрітивного статусу у дітей з гострою дихальною недостатністю: проспективне обсерваційне когортне дослідження

Ventilator-induced lung injury in children: a reality?

Mechanical ventilation (MV) is inextricably linked to the care of critically ill patients admitted to the paediatric intensive care unit (PICU). Even today, little evidence supports best MV practices for life-threatening acute respiratory failure in children. However, careful attention must be paid because this life-saving technique induces pulmonary inflammation that aggravates pre-existing lung injury, a concept that is known as ventilator-induced lung injury (VILI). The delivery of too large tidal volumes (Vt) (i.e., volutrauma) and repetitive opening and closure of alveoli (i.e., atelectrauma) are two key mechanisms underlying VILI. Despite the knowledge of these mechanisms, the clinical relevance of VILI in critically ill children is poorly understood as almost all of our knowledge has been obtained from studies in adults or experimental studies mimicking the adult critical care situation. This leaves the question if VILI is relevant in the paediatric context. In fact, limited paediatric experimental data showed that the use of large, supraphysiologic Vt resulted in less inflammation and injury in paediatric animal models compared to adult models. Furthermore, the association between large Vt and adverse outcome has not been confirmed and the issue of setting positive end-expiratory pressure (PEEP) to prevent atelectrauma has hardly been studied in paediatric clinical studies. Hence, even today, the question whether or not there VILI is relevant in pediatric critical remains to be answered. Consequently, how MV is used remains thus based on institutional preferences, personal beliefs and clinical data extrapolated from adults. This signifies the need for clinical and experimental studies in order to better understand the use and effects of MV in paediatric patients with or without lung injury.

Initiation of Noninvasive Ventilation for Acute Respiratory Failure in a Pediatric Intermediate Care Unit.

Noninvasive ventilation (NIV) is increasingly used to manage acute respiratory failure in children, decreasing the need for mechanical ventilation. Safely managing these patients outside of the ICU improves ICU resource use. We measured the impact of a guideline permitting initiation of NIV in an intermediate care unit (IMCU) on ICU bed use. A guideline for an NIV trial for acute respiratory failure was implemented in a 10-bed IMCU. The guideline stipulated criteria for initiation and maintenance of NIV. There were 4.5 years of intervention data collected. Baseline data were gathered for patients with acute respiratory failure who were transferred from the IMCU to the ICU for NIV initiation in the 3.25 years before guideline implementation. Three hundred eight patients were included: 101 in the baseline group and 207 in the intervention group. In the intervention group, 143 patients (69%) remained in the IMCU after NIV initiation, and 64 (31%) transferred to the ICU. A total of 656.4 ICU bed-days were saved in the intervention period (3.3 days per patient initiated on NIV in the IMCU). There was a significant decrease in the rate of intubation in the IMCU for patients awaiting ICU transfer (3 patients in the baseline group versus 0 patients in the intervention group; P = .035). The initiation of NIV in the IMCU for pediatric patients with acute respiratory failure saved ICU bed-days without increasing intubation in the IMCU for patients awaiting transfer. Close monitoring of these critically ill patients is a key component of their safe care.

Revisión sistemática de los efectos del uso de la cánula nasal de alto flujo en población neonatal y pediátrica

La cánula nasal de alto flujo es una modalidad de aporte adicional de oxígeno cuyo uso se ha incrementado en los últimos tiempos debido a que ofrece unos alcances positivos como alternativa a la ventilación mecánica no invasiva para la falla respiratoria en niños y en adultos (López &amp; Morteruel, E., 2013). El presente artículo tiene como objetivo revisar los efectos del uso de la cánula nasal de alto flujo en la población pediátrica. Metodología de revisión: Se consultaron las bases de datos Pubmed, Library, Cochrane y EBSCO Host, con un período de publicación de enero del 2005 hasta noviembre de 2014, usando términos MesH tanto en inglés como en español.Resultados: Se encontraron 275 artículos de los cuales se seleccionaron los que cumplían con los criterios de inclusión para este estudio, quedando un total de 50 artículos a los cuales se les analizó su contribución frente al tema; dichos aportes se clasificaron en: efectos respiratorios, efectos cardiovasculares y efectos adversos con relación a la utilización de la cánula nasal de alto flujo en la población pediátrica y algunas variables emergentes como indicaciones, usos y recomendaciones entre otras. Conclusión: La oxigenoterapia de alto flujo mediante el sistema de cánula nasales una conducta fisioterapéutica eficaz, útil, segura y sencilla de utilizar en la población pediátrica que permite disminuir el uso de dispositivos invasivos en la unidad de cuidados intensivos, permite suministrar un apoyo respiratorio eficiente a distintos grupos de pacientes con diferentes enfermedades, con miras a disminuir la necesidad de ventilación mecánica invasiva, con el consiguiente ahorro de estancias hospitalarias.

ĐẶC ĐIỂM LÂM SÀNG, NGUYÊN NHÂN, PHÂN LOẠI SUY HÔ HẤP CẤP Ở TRẺ EM THEO KHÍ MÁU

SUMMARY&#x0D; THE CLINICAL FEATURE, CAUSES AND CLASSIFICATION OF PEDIATRIC ACUTE RESPIRATORY FAILURE THROUGH ARTERIAL BLOOD GAS&#x0D; Pham Thi Que, Pham Van Thang&#x0D; Ha Noi Medical University&#x0D; &#x0D; Objectives: The study to describe clinical feature, causes and classification of acute respiratory failure in children through arterial blood gas in the Intensive Care Unit of Vietnam National Children's Hospital.&#x0D; Subjects and Methods: Aprospective descriptive study on 96 patients with acute respiratory failure in the Intensive Care Unit in Vietnam of National Children's Hospital from 10/2016 to 10/2017.&#x0D; Results: Type 2 acute respiratory failure was 55,2%, followed by type 1 with 25% and type 3 with 19,8%. Total patients with type 1 respiratory failure had tachypnea, cyanosis and SpO2 ˂ 90% and bilateral parenchymal lung injury. Type 2 acute respiratory failure can have symptoms like brachypnea, acynosis, SpO2 ≥ 90%. Wheezing is most common; emphysema and atelectasis with 37,2%. Bronchopneumonia is the most common cause of acute respiratory failure, including 61,1% type 2 acute respiratory failure.&#x0D; Conclusion: Based on the clinical feature of acute respiratory failure as a basis for assessing severe condition and appropriate treatment interventions.&#x0D; Key words: classification of acute respiratory failure, arterial blood gas.&#x0D;

Randomized Study of Early Continuous Positive Airways Pressure in Acute Respiratory Failure in Children With Impaired Immunity (SCARF) ISRCTN82853500.

Previous trials in adults with impaired immunity and respiratory failure suggest that early noninvasive ventilation avoids endotracheal intubation and improves survival. No randomized clinical trials have addressed this question in children. We undertook an open, parallel-group randomized trial in three pediatric hospitals. Children with impaired immunity and acute respiratory failure defined as tachypnoea (> 90th centile); a new requirement for supplemental oxygen; and new chest radiograph infiltrates. Children were randomly assigned to early PICU admission for continuous positive airways pressure (early continuous positive airways pressure) or to standard care. The primary outcome was endotracheal intubation by 30 days. One-hundred fourteen children met inclusion criteria of whom 42 were randomized between January 2013 and January 2016. There was no significant difference in endotracheal intubation by 30 days with early continuous positive airways pressure (10/21; 48%) compared with standard care (5/21; 24%), odds ratio 2.9 (0.8-10.9), p value equals to 0.11. However, 30-day mortality was significantly higher with early continuous positive airways pressure (7/21; 33%) compared with standard care (1/21; 5%), odds ratio 10.0 (1.1-90.6), p value equals to 0.041. Mortality at 90 days was early continuous positive airways pressure (11/21; 52%) versus standard care (4/21; 19%), odds ratio 4.7 (1.2-18.6), p value equals to 0.029, whereas mortality at 1 year was similar early continuous positive airways pressure (13/21; 61.9%) versus standard care (9/21; 42.7%), odds ratio 2.2 (0.6-7.4), p value equals to 0.22. There were two serious adverse events: early continuous positive airways pressure (pneumothorax) and standard care (hemothorax). This study provided no evidence to support early PICU admission for continuous positive airways pressure in children with acute respiratory failure and impaired immunity. There was a trend toward increased endotracheal intubation and a higher early mortality in the early continuous positive airways pressure group.

Acute Respiratory Failure in Children.

This article reviews the definition, pathophysiology, etiology, assessment, and management of acute respiratory failure in children. Acute respiratory failure is the inability of the respiratory system to maintain oxygenation or eliminate carbon dioxide. Acute respiratory failure is a common cause for admission to a pediatric intensive care unit. Most causes of acute respiratory failure can be grouped into one of three categories: lung parenchymal disease, airway obstruction, or neuromuscular dysfunction. Many patients with acute respiratory failure are managed successfully with noninvasive respiratory support; however, in severe cases, patients may require intubation and mechanical ventilation. [Pediatr Ann. 2018;47(7):e268-e273.].

Noninvasive ventilation in pediatric acute respiratory failure

ZusammenfassungAkutes Atemversagen kann auch im Kindesalter mit nichtinvasiver Beatmung (NIV) behandelt werden. In den letzten Jahren wurden die technischen Voraussetzungen der NIV-Beatmungsgeräte für das Kindesalter verbessert, zudem steht heutzutage eine größere Auswahl an konfektionierten nasalen und Full-face-Masken für Kinder ab dem Säuglingsalter als Interface zur Verfügung. Vor allem Kinder mit hyperkapnischem Atemversagen profitieren von der NIV. Evidenz für Vorteile der NIV besteht für die Bronchiolitis, Asthma sowie für das „Acute-on-chronic“-Atemversagen, d. h. ein Atemversagen bedingt durch eine akute Infektion bei einer zugrunde liegenden neuromuskulären Erkrankung, Zerebralparese oder einer chronischen Lungenerkrankung wie der zystischen Fibrose. Nichtinvasive Beatmung ist bei prolongiertem Weaning von invasiver Beatmung und bei Fehlbildungen des oberen Atemwegs hilfreich. Alveoläre Erkrankungen mit vorwiegend hypoxämischem Atemversagen wie ambulant erworbene Pneumonien oder das „acute respiratory distress syndrome“ (ARDS) stellen keine Indikationen für die NIV dar. Aufgrund relevanter möglicher Nebenwirkungen und der Möglichkeit der schnellen Verschlechterung des Gasaustauschs bei NIV-Versagen sollte die NIV auf der pädiatrischen Intensivstation mit der Möglichkeit zu einem raschen Wechsel auf einen invasiven Beatmungszugang stattfinden.

Clinical Epidemiological Profile of Children with Acute Respiratory Insuficiency in a Pediatric Intensive Care Unit

Objective: to know the epidemiological clinical profile of children admitted for acute respiratory failure (ARF) in the Pediatric Intensive Care Unit (ICU) of the Teresina Emergency Hospital (TEH), from 2010 to 2015.&#x0D; Method: a quantitative approach, with a sample of 451 medical records obtained in the electronic system of hospitalization of the patients who were admitted to the Pediatric ICU of the Hospital. After approval by the Ethics Committee of Estácio Ceut Faculty, the study was started.&#x0D; Results: Of the 721 hospitalizations due to ARF in children, 451 (62.6%) required clinical interventions in the ICU. Of these, 59.4% were male, in the age range of one to six years (61.9%), with a diagnosis in the ICD 10 by J96.0. In 99.7% of the cases, hospitalized for a period of more than ten days (72.4%), originating in the interior of Piauí (63.4%), whose discharge occurred by administrative closure (75.6%), followed by deaths, which were 19,3%.&#x0D; Conclusion: Acute Respiratory Insufficiency is a serious problem of global, national and local public health, because it is a morbidity that requires advanced technology for health treatment, with relative mortality. It is reasonable for therapeutic measures to prevent respiratory diseases to be systematically stimulated and implemented by health services to prevent them.&#x0D; KEYWORDS: Infant Mortality; Respiratory Insufficiency; Epidemiology.

Early High-Frequency Oscillatory Ventilation in Pediatric Acute Respiratory Failure. A Propensity Score Analysis.

The use of high-frequency oscillatory ventilation (HFOV) for acute respiratory failure in children is prevalent despite the lack of efficacy data. To compare the outcomes of patients with acute respiratory failure managed with HFOV within 24-48 hours of endotracheal intubation with those receiving conventional mechanical ventilation (CMV) and/or late HFOV. This is a secondary analysis of data from the RESTORE (Randomized Evaluation of Sedation Titration for Respiratory Failure) study, a prospective cluster randomized clinical trial conducted between 2009 and 2013 in 31 U.S. pediatric intensive care units. Propensity score analysis, including degree of hypoxia in the model, compared the duration of mechanical ventilation and mortality of patients treated with early HFOV matched with those treated with CMV/late HFOV. Among 2,449 subjects enrolled in RESTORE, 353 patients (14%) were ever supported on HFOV, of which 210 (59%) had HFOV initiated within 24-48 hours of intubation. The propensity score model predicting the probability of receiving early HFOV included 1,064 patients (181 early HFOV vs. 883 CMV/late HFOV) with significant hypoxia (oxygenation index ≥ 8). The degree of hypoxia was the most significant contributor to the propensity score model. After adjusting for risk category, early HFOV use was associated with a longer duration of mechanical ventilation (hazard ratio, 0.75; 95% confidence interval, 0.64-0.89; P = 0.001) but not with mortality (odds ratio, 1.28; 95% confidence interval, 0.92-1.79; P = 0.15) compared with CMV/late HFOV. In adjusted models including important oxygenation variables, early HFOV was associated with a longer duration of mechanical ventilation. These analyses make supporting the current approach to HFOV less convincing.