IPV INTRAPULMONARY PERCUSSIVE VENTILATION IPV 23/03/2013 IPV INTRAPULMONARY PERCUSSIVE VENTILATION

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Meryl Golden
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INTRAPULMONARY PERCUSSIVE VENTILATION INTRAPULMONARY PERCUSSIVE VENTILATION FT Vilma Donizetti Valduce Hospital FT Vilma Donizetti

cycles per minute) mini burst of air ( generally lower the physiologic dead space) on the individual s intrinsic breathing pattern This

M Chatwin PhD International Journal of Respiratory Care, Autumn/Winter 2009 VS VS (intrapulmonary percussive ventilation) Creates a

elastic recoil for passive exhalation HFCWC (high-frequency chest wall compression) Generates a negative transrespiratory pressure by

1 INTRAPULMONARY PERCUSSIVE VENTILATION INTRAPULMONARY PERCUSSIVE VENTILATION FT Vilma Donizetti Valduce Hospital FT Vilma Donizetti Rehabilitation Center Villa Beretta Costa Masnaga, Lecco (I) It s a ventilatory techniques that superimposes high frequency ( cycles per minute) mini burst of air ( generally lower the physiologic dead space) on the individual s intrinsic breathing pattern This creates an internal vibration (percussion) within the lungs and promotes secretion clereance VS Mechanical aids for secretion clereance M Chatwin PhD International Journal of Respiratory Care, Autumn/Winter 2009 VS VS (intrapulmonary percussive ventilation) Creates a positive transrespiratory pressure by injecting short, rapid inspiratory flow pulses into the airway opening and relies on chest wall elastic recoil for passive exhalation HFCWC (high-frequency chest wall compression) Generates a negative transrespiratory pressure by compressing the chest externally to cause short, rapid expiratory flow pulses, and relies on chest wall elastic recoil to return the lungs to FRC 1

VS VS The delivery of a slow deep sustained inspiration by a mechanical device providing controlled positive

mobilization of distal secretions Cough-Assist It is a tecnique useful to remove proximal secretions VS

frequency percussive ventilation) Flow-regulated time-cycled ventilation that creates controlled pressure

breathing cycles ( 10-30 cycles/min) IS IT A TECNIQUE ALSO FOR PEDIATRIC PATIENTS?

clereance in tracheotomized DMD patients -a good alternative (even superior) to other physioterapy

2 VS VS The delivery of a slow deep sustained inspiration by a mechanical device providing controlled positive pressure breath during inspiration It is a tecnique useful to prevent the bronchial obstruction and the mobilization of distal secretions Cough-Assist It is a tecnique useful to remove proximal secretions VS (intrapulmonary percussion ventilation) A pneumatic device for providing chest phisioterapy HFPV (high frequency percussive ventilation) Flow-regulated time-cycled ventilation that creates controlled pressure and delivers a series of high frequency (>300 cycles/min) subtidal volumes in combination with low frequency breathing cycles ( cycles/min) IS IT A TECNIQUE ALSO FOR PEDIATRIC PATIENTS? VDR4 in Neuromuscolar Disease: IN ACUTE 14 Ped/24 Tot - one of the first-choice techniques for mucus clereance in tracheotomized DMD patients -a good alternative (even superior) to other physioterapy techniques - the work of breathing is completely performed by the device - the patient is able to tolerate a treatment of >= 30 min without fatigue or discomfort 2

in Neuromuscolar Disease: IN CHRONIC Safe and effective therapy for selected patients Close observation is essential during and after treatments (>> in patients with difficulty mobilizing or

Toussaint,VPI, revue de la littérature, Elsevier Masson SAS 2012) N days antibiotics using (0 vs 24) N days of hospitalization (0 vs 4,4) N days of school absenteeism 0 episode of pneumonia vs 3 N

) Promote independence and self-care in the patient Useful in patients unable to participate actively (age or fatigue) Atelectasis in pediatric patients 46 patients median age: 3.

3 in Neuromuscolar Disease: IN CHRONIC Safe and effective therapy for selected patients Close observation is essential during and after treatments (>> in patients with difficulty mobilizing or expectoring sputum) Needful a system of aspiration of secretions or a manual or mechanical assistance to cough (M.Toussaint,VPI, revue de la littérature, Elsevier Masson SAS 2012) N days antibiotics using (0 vs 24) N days of hospitalization (0 vs 4,4) N days of school absenteeism 0 episode of pneumonia vs 3 N days of hospitalization in ICU (1 vs 15) N fibroaspirations (2 vs 20) in Cystic Fibrosis in Cystic Fibrosis Promote independence and self-care in the patient Less time spent on therapy (20 vs 30 min.) Promote independence and self-care in the patient Useful in patients unable to participate actively (age or fatigue) Atelectasis in pediatric patients 46 patients median age: 3.1 years Atelectasias score (median) before vs after treatment: CPT 2.0 vs 2.0, 2.0 vs 1.0 Duration of treatment an average : CPT 6.2 vs 2.1 More clinically important improvement in atelectasis than the CPT group is a safe and effective method of alternative airway clearance can be used on patients with artificial airways Six children were hospitalized for respiratory distress with suspicious of atelectasis No side-effect or adverse effect was observed during treatments was safe and effective in atelectasis resolution in ¾ of the cases (CXR improved in 4/5 ptz) 3

45 infants of 42 hours of life (median) Acute

$because of the risk of rib fractures represents a safe$ and effective alternative to airways clereance in infants

PRECAUTIONS Non efficient cough (PCF<180 l/min) Active

Increased ICP Fractured ribs or unstable chest HOW DOES

inspiratory depression generated by the inspiratory

4 45 infants of 42 hours of life (median) Acute bronchiolitis Improvement in the drainage of secretions External chest percussion and vibration were avoided because of the risk of rib fractures represents a safe and effective alternative to airways clereance in infants with OI CONTRA-INDICATION Non-drained pneumothorax SAFETY PRECAUTIONS Non efficient cough (PCF<180 l/min) Active severe hemoptysis Active, untreated tubercolosis Increased ICP Fractured ribs or unstable chest HOW DOES WORK? Subject with spontaneous breathing PPI = PP of inspiratory depression generated by the inspiratory muscles PPE = PP of + pressure of elastic recoil of the lung Subject without spontaneous breathing 4

PRINCIPLES OF ACTION Promoting mobilization of distal secretions Promoting the

PROMOTING MOBILIZATION OF BRONCHIAL SECRETIONS 2.

peaks of pressure causes a vibratory effect internal above the mucosa Spray water

the cohesion and adhesion of the mucus Retrograde flow of the air from the periphery

IMPROVING GAS EXCHANGE Thanks to: - the importance of the flow rates of gas

5 PRINCIPLES OF ACTION Promoting mobilization of distal secretions Promoting the recruitment of the obstructed pulmonary area Improving gas exchange 1. PROMOTING MOBILIZATION OF BRONCHIAL SECRETIONS 2. PROMOTING THE RECRUITMENT OF THE OBSTRUCTED PULMONARY AREA Rapid variation of the peaks of pressure causes a vibratory effect internal above the mucosa Spray water Thanks a more homogeneous distribuition of the air in the bronchial tree Action on the cohesion and adhesion of the mucus Retrograde flow of the air from the periphery toward the mouth + Protective ventilation No Hyperinflation 3. IMPROVING GAS EXCHANGE Thanks to: - the importance of the flow rates of gas delivered to the patient (fino a 40L/min) - the molecolar agitation induced by percussion - PEEP effect Contact between molecules of oxygen and alveolo- capillary membrane 5

6 THE PROTAGONISTS The pneumatic device The nebulizer The Phasitron The Phasitron IN THE HOSPITAL Inspiratory Expiratory Position Did you have compressed air? BERNOULLI-VENTURI EFFECT AT HOME CARE The Phasitron is a pressure-flow converter that transforms high pressure small volumes of gas and low flow into low pressure bigger volumes of gas and high flow. Percussionaire BERNOULLI- VENTURI EFFECT Air accelerates Depression creates by accelerated air Inlet air towards the depression Percussionaire

Autoregulation of the that prevents the overpressure.

comparable lung deposition despite a large difference in particle size Systematically

increase the coalescence of aerosolized particles, increasing their size and promoting

pharmacologic agent must be delivered to the lung Because of high cost of and the

7 Autoregulation of the that prevents the overpressure. When resistance is applied, the Venturi design delivers pressure with decreasing flow entrainment NO BAROTRAUMA!! Circuit is OPEN to room air The aerosol generator The two tecniques showed comparable lung deposition despite a large difference in particle size Systematically an intense spot at the gastric level with (side effects) These turbolence could increase the coalescence of aerosolized particles, increasing their size and promoting their impaction in the upper airway cannot replace a standard nebulizer if a pharmacologic agent must be delivered to the lung Because of high cost of and the large interindividual variability of its IPD, we cannot reccomended this device as a first choice for inhaled drug therapy Saline-water to prevent drying of secretions during session ( especially in invasive way) 7

8 The complete circuit The Phasitron The Phasitron Duo (monopatient, for home) THE INTERFACE ADJUSTMENTS Non invasive Invasive Ratio I/E Proximal pressure Frequency of the percussions Pressure ADJUSTMENTS WHAT IS THE THERAPEUTIC GOAL? Ventilation or Transport of the mucus WHO S THE PATIENT? Obstructive or restrictive With or without breathing autonomy 8

9 Airway clereance TI Expiratory Flow Ventilatory support/ Hyperinflation Frequency, Pressure Percussive Effect Frequency, Pressure, I/E Peep Effect Frequency, Pressure, I/E Frequency PERCUSSION Pressure I/E Ratio I/E time PERCUSSION Frequency Pressure 9

10 TIDAL VOLUME Pressure Frequency Frequency TIDAL VOLUME Pressure I/E time PEEP Frequency Pressure ATTENTION!! In weak patients at risk for developing hypercapnia or cardiac insufficiency 10

11 Ti Te > Inspiratory time E flow > I Flow (B) (A) E/I 1,3/1 Patient in ventilation It only for patient in spontaneous ventilation? Stable Patient Peep < 7 Disconnect the patient from the ventilator Connect the circuit to the patient Instable Patient Peep > 7 Using the cone adapter to connect the respirator and the circuit. Preferably use pressometric modality KNOWLEDGE OF THE TECHNIQUES AND TRAINING OF THE PHYSIOTERAPISTS 11

12 Soon. Corso Arir 2014 Tecniche di clereance delle vie aeree tramite utilizzo di dispositivi oscillatori ad alta frequenza. Una alternativa per la disostruzione bronchiale e la riespansione polmonare 12

The objectives of this presentation are to

1 The objectives of this presentation are to 1. Review the mechanics of airway clearance 2. Understand the difference between secretion mobilization and secretion clearance 3. Identify conditions that