Title: High Frequency Percussive Ventilation (HFPV) in Severe Bronchopulmonary Dysplasia in Neonates Authors: Kevin Crezee BSRT, RRT-NPS, Shrena Patel MD, Robert DiGeronimo MD RATIONALE: High Frequency Percussive Ventilation (HFPV) has been reported in the literature as a successful mode of mechanical ventilation for some types of patients suffering from HRF and ARDS in burn patients; however, the published experience with the use of HFPV in neonates is minimal. HFPV is a pressure limited, time-cycled, high-frequency mode of ventilation that delivers sub-physiologic tidal volumes at rapid rates using a uniquely designed venturi delivery system. Our aim here is to describe a single center experience with HFPV used for critically ill neonates with Severe Bronchopulmonary Dysplasia (SBPD) failing other established modes of ventilator support. METHODS: A retrospective chart review was done on all neonates admitted to the NICU at Primary Children’s Hospital over a 3-year period (2012-2014). Patients were included in the study if they met SBPD criteria defined as: (1) Need for positive pressure ventilation at 36 weeks postmenstrual age born before 32 weeks gestation OR (2) Need for positive pressure ventilation at 56 days of postnatal age born after 32 weeks gestation. All study patients underwent conversion to HFPV from either conventional or other high frequency modes of ventilation. HFPV with Turbohub Phasitron was provided by the VDR (Percussionaire®, Sandpoint, Idaho). Demographic and clinical data was reviewed to include ventilator settings and blood gas values before and after transitioning to the VDR. RESULTS: During the 3-year study period, there were 13 neonates with SBPD successfully managed on HFPV in our NICU including 5 that underwent multiple trials (total n=20). Patients supported with HFPV had a wide range of birth weight (361 to 3630 gms, mean 1240) and gestational age (24 to 38 weeks, mean 29) with admission diagnoses including BPD, persistent pulmonary hypertension, congenital diaphragmatic hernia and complex congenital heart disease. The majority of patients converted to HFPV from conventional ventilation or high frequency oscillatory ventilation and spent an average of 15 days (range 1-148d) on HFPV with an overall survival to discharge of 69% (9/13). Four of the survivors required tracheostomy placement and were discharged on ventilator support. Following conversion to HFPV, mean airway pressure increased from 14 to 16 cmH20 and Fractional inspired O2 decreased from 79% to 40%, which was coupled with improvements in ventilation (pre- 73 vs. post- 47 PCO2) after 24 hours. CONCLUSION: Based on our clinical experience, HFPV appears to provide a potentially life-saving alternative mode of mechanical ventilation in neonates suffering from SBPD failing other therapies. Future randomized clinical trials should be done to further assess the safety and effectiveness of HFPV in this population of high risk critically ill neonates.

High Frequency Percussive Ventilation (HFPV) in Severe

Bronchopulmonary Dysplasia in Neonates

Kevin Crezeé BS, RRT-NPS, Shrena Patel MD, Robert DiGeronimo MD

Disclosures Respiratory NICU Coordinator – Primary Childrens Hospital

NICU Respiratory Therapist – University of Utah

Clinical Consultant – Ikaria Tech Support

Device in-services

Respiratory Advisory Board

Studies or research conducted with the generous support of the Primary Childrens Hospital Respiratory Care Services Department

Objectives

Review clinical use of HFPV in for Severe BPD in the neonatal population from a single center experience.

Rationale

High Frequency Percussive Ventilation (HFPV) has been reported in the literature as a successful mode of mechanical ventilation for some types of patients suffering from HRF and ARDS in burn patients; however, the published experience with the use of HFPV in neonates is minimal.

HFPV

HFPV is a pressure limited, time-cycled, high-frequency mode of ventilation that delivers sub-physiologic tidal volumes at rapid rates using a uniquely designed venturi delivery system.

WWW.percussionaire.com

Aim

Our aim here is to describe a single center experience with HFPV used for critically ill neonates with Severe Bronchopulmonary Dysplasia (SBPD) failing other established modes of ventilator support.

METHODS:

A retrospective chart review was done on all neonates admitted to the NICU at Primary Children’s Hospital over a 3-year period (2012-2014).

Inclusion criteria

Patients were included in the study if they met SBPD criteria defined as:

1. Need for positive pressure ventilation at 36 weeks postmenstrual age born before 32 weeks gestation

OR

2. Need for positive pressure ventilation at 56 days of postnatal age born after 32 weeks gestation.

Ventilator

HFPV with TurboHub Phasitron was provided by the VDR (Percussionaire®, Sandpoint, Idaho).

Demographic and clinical data was reviewed on all study patients to include ventilator settings and blood gas values before and after transitioning to the VDR.

RESULTS:

During the 3-year study period, there were 13 neonates with severe BPD were successfully managed on HFPV in our NICU including 5 that underwent multiple trials (total n=20).

3 patient under went 2 trials each

2 patients under went 3 trial each

RESULTS: Patients supported with HFPV had a wide range of birth weights

from 361 to 3630 grams (mean 1240)

Gestational Age 24 to 38 weeks (mean 29)

DOL at start of HFPV ranged 38 to 382 (median 78)

Gender 8 Males and 5 Females

Admission diagnoses (including BPD, persistent pulmonary hypertension, congenital diaphragmatic hernia and complex congenital heart disease).

RESULTS:

The majority of patients were converted to HFPV from: HFOV (n=8, Paw Median 19)

CV (n=9)

HFJV (n=3, MAP Median 14)

Average of 15 days on HFPV (range 1-148 days)

Overall survival to discharge of 69% (9/13) Four of the survivors required tracheostomy placement and were

discharged on ventilator support.

RESULTS:

Following conversion to HFPV, Mean Airway Pressure from 14 to 16 cmH20

FiO2 from 79% to 40% after 24 hours.

Ventilation (pre- 73 vs. post- 47 PCO2 ) after 24 hours.

Oxygen & MAP

Ventilation & PH

Additional treatments & Ventilation course

HF Ventilation Course # %

HFOV + HFPV 5 38.5%

HFJV+HFPV 2 15%

HFPV 1 8%

All HFV 5 38.5%

# %

ECMO 1 8%

NO 9 69%

Surfactant 9 69%

Post VDR support

HFOV 2

HFJV 1

CV 14

Support withdrawn on VDR 3

RA at discharge 1 8%O2 at discharge 4 31%

Trachemostomy & CV 4 31%

Discharge

CONCLUSION:

Based on our clinical experience, HFPV appears to provide a potentially life-saving alternative mode of mechanical ventilation in neonates suffering from SBPD failing other therapies.

Future randomized clinical trials should be done to further assess the safety and effectiveness of HFPV in this population of high risk critically ill neonates.