High frequency percussive ventilation in pediatric acute respiratory failure

Abstract

Objective: High frequency percussive ventilation (HFPV) is used in acute respiratory failure, but is poorly described in pediatrics. We aimed to describe the clinical characteristics, ventilator settings, and outcomes of a large pediatric cohort, and to determine predictors of who would benefit from HFPV. Hypothesis: Gas exchange 2 h after HFPV initiation predicts success. Design: Single center retrospective cohort study testing association between gas exchange 2 h after HFPV initiation with success, defined a priori. Patients: Intubated children on HFPV for ≥2 h from 2012 to 2018. Methods: We described indications, ventilator settings, and gas exchange immediately before, 2 h after, and at termination of HFPV. Univariate and multivariate regression tested association of oxygenation and ventilation after HFPV initiation with success. Areas under the receiver operating characteristic (AUROC) curve and adjusted odds ratios (aORs) were computed. Results: We performed 237 courses of HFPV in 193 children (22% non-survivors), of which 162 (68%) were successful. In univariate analysis, pH (AUROC, 0.65) and PCO 2 (AUROC, 0.66) 2 h after HFPV predicted success. In multivariate analysis, pH (aOR: 1.67 per 1 SD; 95% confidence interval [CI]: 1.19-2.35), PCO 2 (aOR: 0.49 per 1 SD; 95% CI: 0.31-0.79), and oxygenation index (aOR: 0.66 per 1 SD; 95% CI: 0.44-0.97) 2 h after HFPV initiation were associated with success. Conclusion: We describe the largest cohort of HFPV to date, with detailed description of indications and settings. Gas exchange after 2 h of HFPV was independently associated with success.

High-Frequency Percussive Ventilation in Viral Bronchiolitis

“…HFPV has been in use for over 30 years, and though its use has not been adopted widely, it has been shown to improve gas exchange in a variety of adult and pediatric populations ranging from those with respiratory failure postcardiac surgery to inhalation injury. 3,4,6,7,[16][17][18] Our data suggest HFPV has efficacy in ventilating patients with bronchiolitis, with a mean drop in P CO 2 of 14 mm Hg in the 24 h post-HFPV initiation. Studies by Rizkalla, 3 respiratory failure and also illustrated improved ventilation, with P CO 2 analyzed in their studies at 24, 6, and 2 h post-HFPV, respectively.…”

“…15 Though our data suggest a potentially decreased risk of barotrauma from HFPV including no cases of air leak secondary to HFPV, other studies confirm that HFPV can be associated with those findings. Butler et al 7 reported an 8% (18/237) incidence of air leak post-HFPV, and Rizkalla 3 and Tawfik 6 each reported one case in their cohorts (3% and 4%, respectively). Our finding that HFPV does not produce hemodynamic instability in bronchiolitis is supported by similar findings in studies by Oribabor et al 25 in adult cardiac subjects and by Rizkalla et al 3 and Butler et al 7 in children with acute respiratory failure.…”

“…10,[19][20][21] Improvements in oxygenation from HFPV have been demonstrated in both adults and children in other studies. 17,22,23 In the general pediatric population, Rizkalla et al 3 found a significant OSI reduction of 39% 24 h post-HFPV initiation; and Tawfik et al 6 found a significant increase in S pO 2 /F IO 2 at 6 h post initiation, whereas Butler et al 7 did not find any significant change when measuring oxygenation index at 2 h post-HFPV. An important caveat to our gas exchange findings is the parallel observation that initiation of neuromuscular blockade concurrent with HFPV is a standard practice at our institution, with 94% of subjects experiencing an infusion of 12 h or greater.…”

“…High-frequency percussive ventilation (HFPV) is a ventilatory mode that has shown success in treating adult and pediatric subjects with oxygenation and/or ventilation derangements refractory to conventional invasive mechanical ventilation but that has not been rigorously evaluated in the bronchiolitis population. [3][4][5][6][7] HFPV uses a pneumatically driven system to create a hybrid of conventional and highfrequency ventilation that was first shown to have efficacy in patients with burn-associated inhalation injury, demonstrating enhanced secretion removal, lung recruitment, and gas exchange among both adult and pediatric subjects. [8][9][10] HFPV's application in bronchiolitis may be similarly advantageous given the similar physiology of high secretion burden and mucous plugging.…”

Update on ventilation management in the Pediatric Intensive Care Unit

“…In the setting of acute hypoxic respiratory failure, HFOV has not been shown to reduce mortality in adult or pediatric patients. Currently, there are insufficient data to recommend other forms of alternative ventilation like high-frequency HFPV, HFJV, or APRV [13][14][15]. The PEMVECC consensus recommendations did caution use of HFJV in patients with obstructive airway disease secondary to the risk of dynamic hyperinflation.…”