Effect of intrapulmonary percussive ventilation on expiratory flow limitation in chronic obstructive pulmonary disease patients

Clinical application of intrapulmonary percussive ventilation: A scoping review

Impaired respiratory function secondary to acute or chronic respiratory disease poses a significant clinical and healthcare burden. Intrapulmonary percussive ventilation (IPV) is used in various clinical settings to treat excessive airway secretions, pulmonary atelectasis, and impaired gas exchange. Despite IPV's wide use, there is a lack of clinical guidance on IPV application which may lead to inconsistency in clinical practice. This scoping review aimed to summarise the clinical application methods and dosage of IPV used by clinicians and researchers to provide guidance. A two-staged systematic search was conducted to retrieve studies that used IPV in inpatient and outpatient settings. MEDLINE, EMBASE, CINAHL, Scopus, and Google scholar were searched from January 1979 till 2022. Studies with patients aged ≥16 years and published in any language were included. Two reviewers independently screened the title and abstract, reviewed full text articles, and extracted data. Search yielded 514 studies. After removing duplicates and irrelevant studies, 25 studies with 905 participants met the inclusion criteria. This is the first scoping review to summarise IPV application methods and dosages from the available studies in intensive care unit (ICU), acute inpatient (non-ICU), and outpatient settings. Some variations in clinical applications and prescribed dosages of IPV were noted. Despite variations, common trends in clinical application and prescription of IPV dosages were observed and summarised to assist clinicians with IPV intervention. Although an evidence-based clinical guideline could not be provided, this review provides detailed information on IPV application and dosages in order to provide clinical guidance and lays a foundation towards developing a clinical practice guideline in the future.

Effect of intrapulmonary percussive ventilation on intensive care unit length of stay, the incidence of pneumonia and gas exchange in critically ill patients: A systematic review

Background

Pulmonary complications such as pneumonia, pulmonary atelectasis, and subsequent respiratory failure leading to ventilatory support are a common occurrence in critically ill patients. Intrapulmonary percussive ventilation (IPV) is used to improve gas exchange and promote airway clearance in these patients. The current evidence regarding the effectiveness of intrapulmonary percussive ventilation in critical care settings remains unclear. This systematic review aims to summarise the evidence of the effectiveness of intrapulmonary percussive ventilation on intensive care unit length of stay (ICU-LOS) and respiratory outcomes in critically ill patients.

Research question

In critically ill patients, is intrapulmonary percussive ventilation effective in improving respiratory outcomes and reducing intensive care unit length of stay.

Methods

A systematic search of intrapulmonary percussive ventilation in intensive care unit (ICU) was performed on five databases from 1979 to 2021. Studies were considered for inclusion if they evaluated the effectiveness of IPV in patients aged ≥16 years receiving invasive or non-invasive ventilation or breathing spontaneously in critical care or high dependency units. Study titles and abstracts were screened, followed by data extraction by a full-text review. Due to a small number of studies and observed heterogeneities in the study methodology and patient population, a meta-analysis could not be included in this review. Outcomes of interest were summarised narratively.

Results

Out of 306 identified abstracts, seven studies (630 patients) met the eligibility criteria. Results of the included studies provide weak evidence to support the effectiveness of intrapulmonary percussive ventilation in reducing ICU-LOS, improving gas exchange, and reducing respiratory rate.

Interpretation

Based on the findings of this review, the evidence to support the role of IPV in reducing ICU-LOS, improving gas exchange, and reducing respiratory rate is weak. The therapeutic value of IPV in airway clearance, preventing pneumonia, and treating pulmonary atelectasis requires further investigation.

Intermittent High-Frequency Percussive Ventilation Therapy in 3 Patients with Severe COVID-19 Pneumonia

BACKGROUND High-frequency percussive ventilation (HFPV) is a method that combines mechanical ventilation with high-frequency oscillatory ventilation. This report describes 3 cases of patients with severe COVID-19 pneumonia who received intermittent adjunctive treatment with HFPV at a single center without requiring admission to the Intensive Care Unit (ICU). CASE REPORT Case 1 was a 60-year-old woman admitted to the hospital 14 days after the onset of SARS-CoV-2 infection symptoms, and cases 2 and 3 were men aged 65 and 72 years who were admitted to the hospital 10 days after the onset of SARS-CoV-2 infection symptoms. All 3 patients presented with clinical deterioration accompanied by worsening lung lesions on computed tomography (CT) scans after 21 days from the onset of symptoms. SARS-CoV-2 infection was confirmed in all patients by real-time reverse transcription-polymerase chain reaction (RT-PCR) assay from nasal swabs. All 3 patients had impending respiratory failure when non-invasive intermittent HFPV therapy was initiated. After therapy, the patients had significant clinical improvement and visibly decreased lung lesions on followup CT scans performed 4-6 days later. CONCLUSIONS The 3 cases described in this report showed that the use of intermittent adjunctive treatment with HFPV in patients with severe pneumonia due to infection with SARS-CoV-2 improved lung function and may have prevented clinical deterioration. However, recommendations on the use of intermittent HFPV as an adjunctive treatment in COVID-19 pneumonia requires large-scale controlled clinical studies. In the pandemic context, with a shortage of ICU beds, avoiding ICU admission by using adjunctive therapies on the ward is a useful option.

Feasibility and safety of intrapulmonary percussive ventilation in spontaneously breathing, non-ventilated patients in critical care: A retrospective pilot study

Background

Intrapulmonary percussive ventilation is used in various clinical settings to promote secretion clearance, reverse or treat atelectasis and improve gas exchange. Despite a few studies reporting the use of intrapulmonary percussive ventilation in critical care, the available data remain insufficient, contributing to weaker evidence toward its effectiveness. Also, there is a paucity of studies evaluating the safety and feasibility of intrapulmonary percussive ventilation application in critical care. This retrospective pilot study has evaluated the safety and feasibility of intrapulmonary percussive ventilation intervention in non-intubated patients admitted to an intensive care unit.

Methods

The medical records of 35 subjects were reviewed, including 22 subjects who received intrapulmonary percussive ventilation intervention and 13 subjects matched for age, sex, and primary diagnosis who received chest physiotherapy. The records were audited for feasibility, safety, changes in oxygen saturation, chest X-ray changes, and intensive care unit length of stay.

Results

A total of 104 treatment sessions (IPV 65 and CPT 39) were delivered to subjects admitted with a range of respiratory conditions in critical care. Subjects completed 97% of IPV sessions. No major adverse events were reported with intrapulmonary percussive ventilation intervention. Intensive care unit length of stay in the intrapulmonary percussive ventilation group was 9.6 ± 6 days, and in the CPT group, it was 11 ± 9 days (p = 0.59). Peripheral oxygen saturation pre to post intervention was 92% ± 4 to 96% ± 4 in IPV group and 95% ± 4 to 95% ± 3 in the CPT group.

Conclusion

Application of intrapulmonary percussive ventilation intervention was feasible and safe in non-ventilated adult patients in critical care.

Efficacy of Oscillation and Lung Expansion in Reducing Postoperative Pulmonary Complication

BACKGROUND

Postoperative pulmonary complications (PPCs) cause high morbidity and mortality. Targeted treatment for patients at risk for PPCs can improve outcomes. This multicenter prospective trial examined the impact of oscillation and lung expansion (OLE) therapy, using continuous high-frequency oscillation and continuous positive expiratory pressure on PPCs in high-risk patients.

METHODS

In stage I, CPT and ICD codes were queried for patients (n = 210) undergoing thoracic, upper abdominal, or aortic open procedures at 3 institutions from December 2014 to April 2016. Patients were selected randomly. Age, comorbidities, American Society of Anesthesiologists physical status classification scores, and PPC rates were determined. In stage II, 209 subjects were enrolled prospectively from October 2016 to July 2017 using the same criteria. Stage II subjects received OLE treatment and standard respiratory care. The PPCs rate (prolonged ventilation, high-level respiratory support, pneumonia, ICU readmission) were compared. We also compared ICU length of stay (LOS), hospital LOS, and mortality using t-tests and analysis of covariance. Data are mean ± SD.

RESULTS

There were 419 subjects. Stage II patients were older (61.1 ± 13.7 years vs 57.4 ± 15.5 years; p < 0.05) and had higher American Society of Anesthesiologists scores. Treatment with OLE decreased PPCs from 22.9% (stage I) to 15.8% (stage II) (p < 0.01 adjusted for age, American Society of Anesthesiologists score, and operation time). Similarly, OLE treatment reduced ventilator time (23.7 ± 107.5 hours to 8.5 ± 27.5 hours; p < 0.05) and hospital LOS (8.4 ± 7.9 days to 6.8 ± 5.0 days; p < 0.05). No differences in ICU LOS, pneumonia, or mortality were observed.

CONCLUSIONS

Aggressive treatment with OLE reduces PPCs and resource use in high-risk surgical patients.

Safety and effectiveness of the high-frequency chest wall oscillation vs intrapulmonary percussive ventilation in patients with severe COPD

Purpose

Chest physiotherapy is an important tool in the treatment of COPD. Intrapulmonary percussive ventilation (IPV) and high-frequency chest wall oscillation (HFCWO) are techniques designed to create a global percussion of the lung which removes secretions and probably clears the peripheral bronchial tree. We tested the hypothesis that adding IPV or HFCWO to the best pharmacological therapy (PT) may provide additional clinical benefit over chest physiotherapy in patients with severe COPD.

Methods

Sixty patients were randomized into three groups (20 patients in each group): IPV group (treated with PT and IPV), PT group with (treated with PT and HFCWO), and control group (treated with PT alone). Primary outcome measures included results on the dyspnea scale (modified Medical Research Council) and Breathlessness, Cough, and Sputum scale (BCSS), as well as an evaluation of daily life activity (COPD Assessment Test [CAT]). Secondary outcome measures were pulmonary function testing, arterial blood gas analysis, and hematological examinations. Moreover, sputum cell counts were performed at the beginning and at the end of the study.

Results

Patients in both the IPV group and the HFCWO group showed a significant improvement in the tests of dyspnea and daily life activity evaluations (modified Medical Research Council scale, BCSS, and CAT) compared to the control group, as well as in pulmonary function tests (forced vital capacity, forced expiratory volume in 1 second, forced expiratory volume in 1 second/forced vital capacity%, total lung capacity, residual volume, diffusing lung capacity monoxide, maximal inspiratory pressure, maximal expiratory pressure) and arterial blood gas values. However, in the group comparison analysis for the same variables between IPV group and HFCWO group, we observed a significant improvement in the IPV group maximal inspiratory pressure, maximal expiratory pressure, BCSS, and CAT. Similar results were observed in changes of sputum cytology with reduction of inflammatory cells (neutrophils and macrophages).

Conclusion

The two techniques improved daily life activities and lung function in patients with severe COPD. IPV demonstrated a significantly greater effectiveness in improving some pulmonary function tests linked to the small bronchial airways obstruction and respiratory muscle strength and scores on health status assessment scales (BCSS and CAT) as well as a reduction of sputum inflammatory cells compared with HFCWO.

Effects of intrapulmonary percussive ventilation on airway mucus clearance: A bench model

AIM

To determine the ability of intrapulmonary percussive ventilation (IPV) to promote airway clearance in spontaneously breathing patients and those on mechanical ventilation.

METHODS

An artificial lung was used to simulate a spontaneously breathing patient (Group 1), and was then connected to a mechanical ventilator to simulate a patient on mechanical ventilation (Group 2). An 8.5 mm endotracheal tube (ETT) connected to the test lung, simulated the patient airway. Artificial mucus was instilled into the mid-portion of the ETT. A filter was attached at both ends of the ETT to collect the mucus displaced proximally (mouth-piece filter) and distally (lung filter). The IPV machine was attached to the proximal end of the ETT and was applied for 10-min each to Group 1 and 2. After each experiment, the weight of the various circuit components were determined and compared to their dry weights to calculate the weight of the displaced mucus.

RESULTS

In Group 1 (spontaneously breathing model), 26.8% ± 3.1% of the simulated mucus was displaced proximally, compared to 0% in Group 2 (the mechanically ventilated model) with a P-value of < 0.01. In fact, 17% ± 1.5% of the mucus in Group 2 remained in the mid-portion of the ETT where it was initially instilled and 80% ± 4.2% was displaced distally back towards the lung (P < 0.01). There was an overall statistically significant amount of mucus movement proximally towards the mouth-piece in the spontaneously breathing (SB) patient. There was also an overall statistically significant amount of mucus movement distally back towards the lung in the mechanically ventilated (MV) model. In the mechanically ventilated model, no mucus was observed to move towards the proximal/mouth piece section of the ETT.

CONCLUSION

This bench model suggests that IPV is associated with displacement of mucus towards the proximal mouthpiece in the SB patient, and distally in the MV model.

Intrapulmonary Percussive Ventilation as a Lung Recruitment Strategy in Brain-Dead Organ Donors

OBJECTIVE

To determine the strength of the evidence evaluating the effectiveness of intrapulmonary percussive ventilation (IPV) as a safe alternative or adjunctive therapy to traditional chest physiotherapy (CPT) among potential organ donors.

DATA SOURCES

Literature search conducted from February 2015 to November 2015 using PubMed, Cumulative Index of Nursing and Allied Health Literature, Scopus, and bibliographies of pertinent articles. Search Terms: Intrapulmonary percussive ventilation, chest physiotherapy, chest wall oscillation, organ donors, and ventilation.

STUDY SELECTION

Articles in English from 1994 to present directly compared IPV to CPT or conventional (no) therapy.

DATA EXTRACTION

Association of Critical-Care Nurses Levels of Evidence was used to determine the strength of evidence. Level B and level C articles were reviewed.

DATA SYNTHESIS

No studies were found using IPV in the donor population. Results from studies using IPV in other populations indicated IPV had no adverse effects, improved sputum clearance and oxygenation, and reduced atelectasis and pneumonia in patients with artificial airways.

CONCLUSION

Intrapulmonary percussive ventilation may be a safe and effective alternative or adjunctive to CPT therapy and improve the number of lungs available for transplantation. Clinical research is essential to determine the effectiveness of this therapy for lung recruitment in the donor population.

Physiotherapy in critically ill patients

Prolonged stay in Intensive Care Unit (ICU) can cause muscle weakness, physical deconditioning, recurrent symptoms, mood alterations and poor quality of life. Physiotherapy is probably the only treatment likely to increase in the short- and long-term care of the patients admitted to these units. Recovery of physical and respiratory functions, coming off mechanical ventilation, prevention of the effects of bed-rest and improvement in the health status are the clinical objectives of a physiotherapy program in medical and surgical areas. To manage these patients, integrated programs dealing with both whole-body physical therapy and pulmonary care are needed. There is still limited scientific evidence to support such a comprehensive approach to all critically ill patients; therefore we need randomised studies with solid clinical short- and long-term outcome measures.

Nasal high frequency percussive ventilation versus nasal continuous positive airway pressure in transient tachypnea of the newborn: a pilot randomized controlled trial (NCT00556738)

OBJECTIVE

To determine whether nasal high frequency percussive ventilation (NHFPV) would decrease duration of transient tachypnea of the newborn (TTN) compared to nasal continuous positive airway pressure (NCPAP) in newborn infants.

METHODS

A prospective, unmasked, randomized, controlled clinical trial was conducted in 46 eligible newborn infants who were hospitalized for TTN in the University Hospital of Bordeaux (France) between 2007 and 2009. Infants born by cesarian section ≥37 GA, ≥2,000 g with diagnosis of TTN and with a transcutaneous saturation <90% at 20 min after birth were eligible. Infants were randomized to either NHFPV or NCPAP. The primary endpoint was a reduction of the duration of TTN. Secondary endpoints were the duration of oxygen therapy and the minimal level required to obtain a saturation between 90% and 96% integrated into an index which included a time factor: [(FiO2 -21)/time of O2 therapy].

RESULTS

In the NHFPV group the duration of TTN was half the time of NCPAP group (105 min ± 20 and 377 min ± 150, respectively; P < 0.0001). There was a significant decrease in duration of oxygen supplementation in the NHFPV group (6.3 min ± 3.3) compared to the NCPAP group (19.1 min ± 8.1; P < 0.001), and a significant decrease in level of oxygen supplementation [(FiO2 -0.21)/time of O2 therapy] in the NHFPV group (0.29 min(-1)  ± 0.16) compared to the NCPAP group (0.46 min(-1)  ± 0.50; P < 0.001). There was no complication and NHFPV was as well tolerated as NCPAP.

CONCLUSION

NHFPV is well tolerated and more effective than NCPAP in treatment of TTN. NHFPV might be a novel and safe tool to manage TTN. Pediatr Pulmonol.