A Case Report: Application Of Non-Invasive High Frequency Percussive Ventilation Via The Volumetric Diffusive Respirator For Secretion Clearance And Lung Recruitment

Abstract

Introduction: Management of airway secretion clearance and atelectasis during acute respiratory infections presents unique challenges for children with congenital myopathies. We describe a child with myotubular myopathy and pneumonitis in which non-invasive High Frequency Percussive Ventilation (HFPV) was used for lung recruitment and secretion mobilization, alleviating need for reintubation. Case Report: An 11 month-old male with congenital myotubular myopathy, and chronic non-invasive positive pressure ventilation (NIPPV) support was admitted to our pediatric ICU with respiratory failure secondary to rhinovirus pneumonitis. He was intubated on admission and supported with conventional ventilation for three weeks. His OI peaked at 8 on hospital day 1 with a P/F ratio of 192. Radiographs revealed clearing airspace disease. He was extubated to BiPAP: IPAP 24, EPAP 12, rate of 25. Two days after extubation, he developed complete opacification of his left hemithorax and associated hypoxemia from mucus plugging and atelectasis. He was managed with aggressive Chest physiotherapy, alternating intermittent percussive ventilation (IPV) treatments and cough-assist treatments with bronchodilators and hypertonic saline every 2 hours However, his respiratory distress and complete left lung atelectasis did not improve. He was then managed with non-invasive HFPV via a NIPPV interface and the VDR to improve secretion mobilization and airway clearance. Initial VDR settings were: Pulsatile Flowrate 20cmH20, Demand Peep 2cmH2O, Oscillatory Peep 10H2O, Convective rate 30bpm, Percussive rate 600, I:E 1:1, FiO2 0.4. Within 12 hours of HFPV initiation, chest radiography revealed fully expanded left lung (Figures 1-2). He had resolution of his hypoxemia and respiratory distress and was transitioned to conventional BiPAP, and weaned towards his home BiPAP regimen without further requirement for invasive mechanical ventilation. Discussion: HFPV is an advanced mode of ventilation that