Intrapulmonary Percussive Ventilation

Intrapulmonary Percussive Ventilation
theory
Pernet Kurt
22/02/2014
 Florence
Inkendaal Hospital
• Rehabilitation
(neurol. / orthop. / respir.)
– 178 beds : 24/7 hospitalization
– 60 partial : daytime hospitalization
• Acute neurorespiratory unit
(restrictive patients)
–
–
–
–
25 beds
multidisciplinary
Neuromuscular reference center
Center for mechanical ventilation
IPV experience
• Inkendaal
since 1988
– > 100.000 treatments
– 70 patients at home
• Personal
since 2003
– Central neurologic disorders
– Neuromuscular conditions
– Guard duty
What is IPV?
Intrapulmonary Percussive Ventilation
to the airways
high frequency
subtidal volumes
• Developped in 1980’s
• Pneumatic pressure generator
• Phasitron transforms pulses
open circuit
Why IPV?
• Severe pulmonary diseases
• Classic chest physiotherapy fails
Goals :
Mucus retention 
Homogenization of ventilation
Improve blood gasses
Lung recruitment
Phasitron
• Open treatment circuit (open to ambient air)
Mobile venturi
Inspiratory porte
expiratory porte
How does it work?
Schematic
How does it work?
• Pulse
– Venturi open position
– Venturi adjusts pulse flexible to airway properties
How does it work?
Flexible venturi
1:5
venturi
1:4
1:3
1:2
1:1
0
5
10
15
20
25
proximal airway pressure
30
35
40
↑ airway pressure = small volume + higher pressure
↓ airway pressure = large volume + lower pressure
Barotrauma excluded
Adapted to endobronchial resistance
How does it work?
• No pulse
– Expiratory port opens
– Exhalation through expiratory porte
Percussive effects
• Backwash :
– More gas-liquid interactions
• Diffusion :
– More gas mixing
• Fight preferential airway :
– More homogeneous ventilation
• Thixotropic effect :
– Fluidify mucus
Gas- liquid interactions
• Backwash
– Newton’s 3rd Law : action  reaction
– Inward flow  Outward flow
Gas- liquid interactions
• Backwash
– Inward flow  breaks through mucus
– Outward flow  mucus transport
Gas- liquid interactions
• Cephalad airflow bias
– Every pulse the bronchus widens : ↓ inspiratory airflow
– Every pauze the bronchus shrimps : ↑ expiratory airflow
In vitro
Diffusion
• High velocity pulses : ↑ gas mixing
• supply O2 & outwash CO2
CPAP stabilizer
• high frequent pulses
–  airway pressure
–  FRC
– Prevents peripheral airway collapse
Untill equilibrium
CPAP stabilizer
• Stimulates collateral ventilation
– Airflow from  P to  P
CPAP stabilizer
NO CPAP
Collaps between pulses
CPAP
No collaps
Percussive effect
• Fight preferential airway
– Inflammation :  airway resistance
Unevenly distributed
Percussive effect
• Fight preferential airway
– Normal ventilation – Way of ↓ resistance
– Heterogenous ventilation
Percussive effect
• Fight preferential airway
– Percussive ventilation : no preference
– Homogenous ventilation
– No shunt + better clearance
Lung recrutement
Combined effects
 territories recruited
 dynamic compression
 airflow in bronchi
 gas-liquid interactions
Intrapulmonary Percussive Ventilation
litterature
Pernet Kurt
22/02/2014
 Florence
Literature
Research type
1st auteur
Natale
Homnick
Birnkrant
Newhouse
Dalne
Bartsch
Deakins
Varekojis
Bataille
Bougatef
Nguyyen
Degreef
Toussaint
Fraipont
Reardon
Vargas
Antanaglia
Clini
Nava
Tsuruta
Van Ginder.
Lelong-Tissier
Vargas
Dumas
Patient Type
year Cat Diagnose
1994
1995
1996
1998
2000
2001
2002
2003
2003
2003
2003
2003
2003
2004
2005
2005
2006
2006
2006
2006
2008
2009
2009
2010
R
C
O
C
R
R
Re
R
C
R
O
Re
R
R
R
R
R
R
R
O
R
Re
C
R
CF
CF
NM
CF
Intub/Burn
Asthm
Mech Vent
CF
NM
premature
Mech Vent
COPD
NM trach.
card.surgery
NM
COPD
COPD
NM trach.
COPD
Intub/Obesitas
CF
Arthrod. spine
COPD
Neonates
Ped/Ad
Ped
Ped
Ped
Ped
Ad
Ad
Ped
Ped
Ped
Ped
Ad
Ad
Ped
Ad
Ped
Ad
Ad
Ped
Ad
Ad
Ped
Ped
Ad
Ped
Methods and results
n Intervention
9
16
4
18
106
40
ng
24
26
30
42
24
8
40
18
33
40
46
10
10
20
147
25
46
IPV vs CPT
IPV vs CPT
IPV
IPV vs CPT
CPT vs CPT+ IPV
No IPV vs IPV
IPV vs CPT
CPT vs CPT+ IPV
No IPV vs IPV
IPV vs CPT
30 minutes IPV
No IPV vs IPV
CPT vs CPT+ IPV
CPT vs CPT+ IPV
spiro. incitat. vs IPV
No IPV vs IPV
CPT vs CPT+ IPV
CPT vs CPT+ IPV
IPV vs sp. ventilation
IPV + ventilation
CPT vs CPT+ IPV
IPV
IPV post extubation
IPV vs CPAP
Evaluation
RR, quantity mucus
spiro, antibio, hospit
atelectasis score
quantity mucus
incidence pneumonia
ESW
atelectasis score
weight dry mucus
freq, duration, severity infections
incidence retubation
PaO2
incidence infections
weight secretions
atelectasis score
antibiotics, hospititalisations
PaO2, PaCO2
PaCO2, PaO2/FiO2
PaO2/FiO2
work diafragm
PaO2/FiO2
SpO2, FC, Borg, mucus weight
admission to reanimation
expiratory flow, PaO2, PaCO2
evolution tachypnee
Results
IPV = CPT
IPV = CPT
score ↓
IPV = CPT
↓ pneumonia
ESW > met IPV
score ↓
IPV = CPT
↓ in 96% pt
↓ retubation
PaO2↑
↓ infec on periodes
weight↑
score ↓
↓ antibio en hospit
↑ PaO2, ↓PaCO2
↓PaCO2, ↑ PaO2/FiO2
↑ PaO2/FiO2
↓arbeid
↑ PaO2/FiO2
IPV = CPT
0 admissions
↑ EF, ↑ PaO2, ↓ PaCO2
↓ tachypnee time
 14 RCT
 6 observationnel studies
 Favorable results
 671 patients
Riffard G et al. (2012) Indications de l’IPV: revue de la litterature
p
ns
ns
ng
ns
p<0,001
p=0,03
ng
ns
ng
p=0,04
p<0,05
p<0,01
p<0,01
p=0,048
ng
p<0,05
p<0,01
p=0,038
ng
p<0,01
ng
ng
p<0,0
p<0,0001
Agressive
•
15 minutes of IPV at the highest pressures on the scars after
lobectomy = no lesions of the stitches [1].
•
Satisfactory clinical case of IPV use post surgery of a tracheoesophageal fistula [2].
•
Successful IPV use in the treatment of a persistent localized
pneumothorax, 6 months post pulmonary resection [3].
1. Bertin F et al (2004) Risques de l'utilisation de l’UPV en postopératoire de chirurgie pulmonaire. Rev Mal Respir 21:1S53
2. Birnkrant DJ et al (1996) Persistent pulmonary consolidation treated with intrapulmonary percussive ventilation: a
preliminary report. Pediatr Pulmonol 21:246–9
3. Gatani T et al (2010) Management of localized pneumothoraces after pulmonary resection with intrapulmonary
percussive ventilation. Ann Thorac Surg 90:1658–61
Ventilation
•
During a session of mucus clearance, IPV can provide a transitional
ventilatory support in stable chronically mechanically ventilated
patients [1,2,3]
•
In this case, PaO2 and PaCO2 are stable [1,2,3], there are no
hemodynamique changes, patients with a cardial dysfunction
included [4].
1. Dellamonica J et al.(2007) Bench testing of IPV added to a conventional ventilator: pressures and volumes generated.
Intensive Care Med 33:S137
2. Chelha R et al (2001) Intérêt du drainage par IPV au cours du sevrage ventilatoire en réanimation. Rev Mal Respir 18:1S20
3. Toussaint M et al.(2003) Effect of IPV on mucus clearance in duchenne muscular dystrophy patients: a preliminary report.
Respir Care 48:940–7
4. Nguyen ND et al (2003) Does IPV physiotherapy have any influence on hemodynamic? Chest 124:205 S
No collaboration
No synchronisation
•
IPV offers the big advantage of not needing any synchronization, nor
cooperation of the patient [1].
•
IPV can be used in pulmonary obstructed patients presenting an
altered conscience [1].
1. Langenderfer M (1998) Alternatives to percussion and postural drainage: a review of mucus clearance therapies:
percussion and postural drainage, autogenic drainage, positive expiratory pressure, flutter valve, IPV, and high-frequency
chest compression with the therapy vest. J Cardiopulm Rehabil 18:283–9
Decompensation COPD
•
IPV reduces the work of the diaphragm [1].
•
After extubation, IPV improves the expiratory flow and the occlusion
pressure of the airways [2].
•
In case of an exacerbation, 30 minutes of IPV reduces the
respiratory rate and improves blood gases, while reducing the level
of exacerbation [3,4].
1. Nava S et al (2006) Physiological response to IPV in stable COPD patients. Respir Med 100:1526–33
2. Vargas F, Boyer A, Bui HN, et al (2009) Effect of IPV on expiratory flow limitation in chronic obstructive pulmonary disease
patients. J Crit Care 24:212–9
3. Vargas F et al (2005) IPV in acute exacerbations of COPD patients with mild respiratory acidosis: a randomized controlled
trial. Crit Care 9:R382–R9
4. Antonaglia V et al (2006) IPV improves the outcome of patients with acute exacerbation of COPD using helmet. Crit Care
Med 34:2940–5
Pulmonary recrutement
•
In a heterogeneous lung model, IPV allows a better distribution of
insufflated air [1].
•
Post cardiac surgery, IPV reduces the gravity of atelectasis [2].
•
In intubated obese patients with compression atelectasis, IPV in line
with the respirator improves blood gasses and atelectasis [3].
•
IPV helps recruiting pulmonary territories without increasing mean
pressures [1,2,3].
1. Lucangelo U et al. (2010) Gas distribution in a two-compartment model ventilated in IPV and pressure-controlled modes.
Intensive Care Med 36:2125-31
2. Fraipont V et al (2004) Prospective randomized controlled study of use of IPV with chest physiotherapy after cardiac
surgery. Crit Care 8(S1):15
3. Tsuruta R et al (2006) Efficacy and safety of IPV superimposed on conventional ventilation in obese patients with
compression atelectasis. J Crit Care 21:328–32
Incidence of pneumonia
•
In tracheotomized patients, IPV (2Xday) reduces the incidence of
nosocomial pneumonia [1].
•
In tracheotomized burn patients, IPV reduces pneumonia incidence
bij 25% [2] .
1. Clini EM et al. (2006) IPV in tracheostomized patients: a randomized controlled study. Intensive Care Med 32:1994–2001
2. Dalne E et al. (2000) Can IPV be used to improve airway clearance in adult ventilated patients? Intensive Care Med
26:S377
Hospitalization time
•
In COPD patients, the hospital time is shortened. Addition of IPV
also reduces NIV and the number of days in ICU [1].
•
Post cardiac surgery the duration of hospitalization is shortened [2].
•
In the postoperative phase of vertebral arthrodesis, IPV reduces the
intubation time [3].
1. Vargas F et al (2005) IPV in acute exacerbations of COPD patients with mild respiratory acidosis: a randomized controlled
trial. Crit Care 9:R382–R9
2. Fraipont V et al (2004) Prospective randomized controlled study of use of IPV with chest physiotherapy after cardiac
surgery. Crit Care 8(S1):15
3. Lelong-Tissier MC et al (2009) IPV pour la prise en charge postopératoire des scolioses de l’enfant. Arch Pediatr 16:752–4
When other techniques fail…
•
Cardiac surgery
•
Thoracic surgery
•
Traumatology
•
NM-diseases
•
Osteogenesis imperfecta
•
Spinal surgery
1. Birnkrant DJ et al (1996) Persistent pulmonary consolidation treated with IPV: a preliminary report. Pediatr Pulmonol
21:246–9
2. Nino G et al (2009) Use of IPV in the management of pulmonary complications of an infant with osteogenesis imperfecta.
Pediatr Pulmonol 44:1151–4
3. Fraipont V et al (2004) Prospective randomized controlled study of use of IPV with chest physiotherapy after cardiac
surgery. Crit Care 8(S1):15
4. Lelong-Tissier MC et al (2009) Ventilation par IPV pour la prise en charge postopératoire des scolioses de l’enfant. Arch
Pediatr 16:752–4
Adverse effects
•
Few adverse effects have been reported. Rare cases aside, the
good tolerance of IPV has been declared by all auteurs, children
included [1,2,3].
• IPV is often the therapy of choice
of patients [4].
1. Birnkrant DJ et al. (1996) Persistent pulmonary consolidation treated with IPV. Pediatr Pulmonol 21:246–9
2. Homnick DN et al. (1995) Comparison of effects of IPV to standard aerosol and chest physiotherapy in treatment of cystic
fibrosis. Pediatr Pulmonol 2:50–5
3. Toussaint M et al. (2003) Effect of IPV on mucus clearance in Duchenne muscular dystrophy patients. Respir Care
48:940–7
4. Paneroni M et al. (2011) Safety and efficacy of short-term intrapulmonary percussive ventilation in patients with
bronchiectasis. Respir Care 56:984-8
Airway clearance
•
In neuromuscular disease with hypersecretion IPV improved the
expectorated quantity of mucus [1].
•
Good results in a case of cystic fibrosis, in moving large quantities of
mucus, enabling the patient to be better oxygenated [2].
1. Toussaint et al. (2003) Effect of intrapulmonary percussive ventilation on mucus clearance in Duchenne muscular
dystrophy patients: a preliminary report. Respir Care 48:940-7
2. D’mello et al. (2010) High-frequency percussive ventilation for airway clearance in cystic fibrosis: a brief report. Lung
188:511-3.
Airway clearance