High-frequency percussive ventilation in severe acute respiratory distress syndrome: A single center experience

Optimizing Management of Acute Respiratory Distress Syndrome in Critically Ill Surgical Patients: A Systematic Review

INTRODUCTION

This systematic review aims to evaluate the optimal management of acute respiratory distress syndrome (ARDS) in critically ill surgical patients, specifically focusing on positioning, extracorporeal membrane oxygenation (ECMO) use, ventilation, fluid resuscitation, and pharmacological treatments.

METHODS

A systematic review was conducted utilizing four databases including PubMed, Google Scholar, EMBASE, and ProQuest. This study followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and was registered with The International Prospective Register of Systematic Reviews. Studies published until May 20, 2024, that assessed the management of ARDS in critically ill surgical adult populations were included in our review. The primary outcome of interest was mortality, with secondary outcomes like intensive care unit (ICU) length of stay (LOS), ventilator days, and oxygenation also being considered.

RESULTS

A total of fifteen studies met inclusion criteria; four studies assessed positional interventions, four assessed treatments with ECMO, three assessed mechanical ventilation settings, and four assessed fluid resuscitation and medications. Prone position was found to decrease mortality, ICU LOS, ventilator days, and increased oxygenation (P < 0.001). ECMO utilization decreased the overall mortality rate when compared to patients without ECMO (36.4% versus 43.9%, P < 0.001). Maintaining a tidal volume ≤8 mL/kg body weight and plateau pressure ≤35 cm H2O on mechanical ventilation also decreased patient mortality (P < 0.001). Finally, conservative fluid management decreased ICU LOS, whereas methylprednisolone use demonstrated decreased mortality.

CONCLUSIONS

Prone positioning, ECMO utilization, lung protective ventilation settings, and methylprednisolone reduced mortality among surgical patients with ARDS. In addition, prone positioning and conservative fluid management were associated with decreased ICU LOS, ventilator days, and improved oxygenation status.

High-frequency percussive ventilation in acute respiratory failure

Introduction

High-frequency percussive ventilation (HFPV) is a ventilation mode characterised by high-frequency breaths. This study investigated the impact of HFPV on gas exchange and clinical outcomes in acute respiratory failure (ARF) patients during spontaneous breathing, noninvasive ventilation (NIV) and invasive mechanical ventilation (iMV).

Methods

This systematic review included randomised and nonrandomised studies up to August 2023. Inclusion criteria focused on adult ARF patients, HFPV application, comparisons with other ventilation modes, and outcomes related to oxygenation and clinical parameters. A pooled data analysis was performed comparing HFPV with iMV concerning gas exchange, pulmonary infection and mortality.

Results

Of the 51 identified records, 29 met the inclusion criteria. HFPV was safely and effectively applied to ARF patients during spontaneous breathing or NIV, improving oxygenation. For patients who underwent iMV, HFPV significantly enhanced oxygenation and the arterial partial pressure of carbon dioxide, reduced pulmonary infection occurrence and improved survival. Barotrauma rates were not elevated with HFPV, and haemodynamic stability remained unaffected. HFPV was also utilised in patients undergoing extracorporeal membrane oxygenation, resulting in improved lung recruitment and oxygenation.

Conclusion

HFPV had favourable effects on physiological and certain clinical outcomes in ARF patients. However, the overall evidence quality remains weak, necessitating large-scale randomised controlled trials for definitive conclusions.

Impact of opioid free Anaesthesia versus opioid Anaesthesia on the immediate postoperative oxygenation after bariatric surgery: a prospective observational study

Introduction: Opioid induced respiratory depression (OIRD) is a preventable aetiology of postoperative respiratory depression with 85% of the episodes taking place in the first 24 postoperative hours. Due to altered respiratory functional metrics and frequently coexisting comorbidities, obese patients are at a particularly higher risk for such complications. The present study aimed to assess if an opioid-free anesthesia (OFA) was associated with a reduced immediate postoperative OIRD when compared to Opiod-based anesthesia (OA). Methods: Obese patients presenting for bariatric surgery were consecutively included in a non-randomized fashion. Lung protective ventilation strategies applied in both groups. In the OA group, Sufentanil was used for intraoperative analgesia in a liberal fashion. In the OFA group, patients received a pre-induction dexmedetomidine loading, followed by a lidocaine, ketamine and dexmedetomidine bolus immediately before induction, further maintained throughout the intraoperative period. Plethysmographic saturations were obtained before induction as well as after extubation and in the Post-anesthesia care unit (PACU). Opioid requirement and Postoperative Nausea and Vomiting incidence were similarly registered. Results: Thirty-four patients were included in the OFA group, and 30 in the OA group. No significant anthropometric and comorbidity differences were found between both groups. OFA patients had significantly lower pre-induction saturations after dexmedetomidine loading. No difference was found for post-extubation saturations as well as well as pre-PACU discharge. The need for supplemental oxygen at the PACU was higher in the OA group. Opioid requirement and cumulative consumption (MEDs) were significantly higher with OA. Conclusion: OFA was not associated with significant postoperative saturation changes but led to a lower need of postoperative supplemental oxygen therapy. OA led to higher opioid rescue need. No fatal respiratory complications were registered in both groups in the immediate postoperative period.

High-Frequency Percussive Ventilation in Viral Bronchiolitis

BACKGROUND

High-frequency percussive ventilation (HFPV) is an alternative mode of mechanical ventilation that has been shown to improve gas exchange in subjects with severe respiratory failure. We hypothesized that HFPV use would improve ventilation and oxygenation in intubated children with acute bronchiolitis.

METHODS

In this single-center prospective cohort study we included mechanically ventilated children in the pediatric ICU with bronchiolitis 1-24 months old who were transitioned to HFPV from conventional invasive mechanical ventilation from November 2018-April 2020. Patients with congenital heart disease, on extracorporeal membrane oxygenation (ECMO), and with HFPV duration < 12 h were excluded. Subject gas exchange metrics and ventilator parameters were compared before and after HFPV initiation.

RESULTS

Forty-one of 192 (21%) patients intubated with bronchiolitis underwent HFPV, and 35 met inclusion criteria. Median age of cohort was 4 months, and 60% were previously healthy. All subjects with available oxygenation saturation index (OSI) measurements pre-HFPV met pediatric ARDS criteria (31/35, 89%). Mean CO2 decreased from 65.4 in the 24 h pre-HFPV to 51 (P < .001) in the 24 h post initiation. SpO2 /FIO2 was significantly improved at 24 h post-HFPV (153.3 to 209.7, P = .001), whereas the decrease in mean OSI at 24 h did not meet statistical significance (11.9 to 10.2, P = .15). The mean peak inspiratory pressure (PIP) decreased post-HFPV from 29.7 to 25.0 at 24 h (P < .001). No subjects developed an air leak or hemodynamic instability secondary to HFPV. Two subjects required ECMO, and of these, one subject died.

CONCLUSIONS

HFPV was associated with significant improvement in ventilation and decreased exposure to high PIPs for mechanically ventilated children with bronchiolitis in our cohort and had a potential association with improved oxygenation. Our study shows that HFPV may be an effective alternative mode of ventilation in patients with bronchiolitis who have poor gas exchange on conventional invasive mechanical ventilation.

High frequency percussive ventilation for respiratory immobilization in radiotherapy

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HFPV maybe a tool for immobilizing thoracic targets in radiotherapy.

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The procedure itself was well tolerated and well complied.

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Chest wall motion was significantly reduced by greater than 60%.

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HFPV can be greatly advantageous, particularly for SBRT and PBS proton therapy.

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Duty cycle under HFPV was significantly higher than conventional methods.

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The appropriate interface can lead to extensive HFPV prolonged times.

High frequency percussive ventilation (HFPV) employs high frequency low tidal volumes (100–400 bursts/min) to provide respiration in awake patients while simultaneously reducing respiratory motion. The purpose of this study is to evaluate HFPV as a technique for respiratory motion immobilization in radiotherapy. In this study fifteen healthy volunteers (age 30–75 y) underwent HFPV using three different oral interfaces. We evaluated each HFPV oral interface device for compliance, ease of use, comfort, geometric interference, minimal chest wall motion, duty cycle and prolonged percussive time. Their chest wall motion was monitored using an external respiratory motion laser system. The percussive ventilations were delivered via an air driven pneumatic system. All volunteers were monitored for PO₂ and tc-CO₂ with a pulse oximeter and CO₂ Monitoring System. A total of N = 62 percussive sessions were analyzed from the external respiratory motion laser system. Chest-wall motion was well tolerated and drastically reduced using HFPV in each volunteer evaluated. As a result, we believe HFPV may provide thoracic immobilization during radiotherapy, particularly for SBRT and pencil beam scanning proton therapy.

Use of High-Frequency Percussive Ventilation to Expand Organ Donor Pool

A 34-year-old woman was brought in to the emergency department after a motor vehicle accident. She had signs of traumatic head injury with Glasgow Coma Scale score of 3, and her neurological examination was consistent with brain death. She was persistently hypoxic on conventional mechanical ventilation and high-frequency percussive ventilation was initiated. The patient’s oxygenation improved and was sustained long enough to provide time for organ procurement. This is the first case portraying high-frequency percussive ventilation as a bridge for donors failing on conventional mechanical ventilation.