Re-evaluating early high-frequency oscillatory ventilation in moderate-to-severe pediatric ARDS: evidence from a genetic matching analysis

Background and aims Pediatric acute respiratory distress syndrome (PARDS) carries high mortality in pediatric intensive care units (PICUs). The clinical benefit of early high-frequency oscillatory ventilation (HFOV) for moderate-to-severe PARDS remains controversial. This study aimed to compare clinical outcomes between HFOV and conventional mechanical ventilation (CMV) using a robust genetic matching approach. Methods In this retrospective case–control study, children with moderate-to-severe PARDS admitted to the two PICUs of Chongqing Medical University from January 2012 to June 2024 were analyzed in a pre-specified 7-day landmark cohort (sustained invasive MV ≥ 7 days). Genetic matching in R software was applied to balance baseline characteristics between HFOV and CMV groups. The primary outcome was 28-day mortality; secondary outcomes included ventilator-free days (VFD), PICU-free days (IFD), survival time, and survival rates stratified by pre-intubation PaO 2 /FiO 2 (P/F) ratios. Results After matching, 53 patients were included in each group with well-balanced baseline variables. Sensitivity (Rosenbaum bounds) and robustness (nearest-neighbor matching) analyses confirmed the stability of the matched results. The 28-day mortality was significantly higher in the HFOV group than in the CMV group (49.1% vs. 28.3%, p = 0.04), whereas VFD and IFD did not differ significantly. Logistic regression indicated that HFOV was independently associated with higher 28-day mortality [adjusted OR = 2.47 (95% CI 1.02–5.98), p = 0.04]. In stratified analysis, the 28-day survival rate for moderate PARDS (200 ≥ P/ F > 100) was markedly lower with HFOV than CMV (0.41 vs. 0.82, p = 0.01). Conclusion In this 7-day landmark cohort, early HFOV may not provide extra benefit in moderate-to-severe PARDS and might be associated with higher mortality, whereas CMV was linked with lower observed 28-day mortality. Further prospective studies are warranted.