USE OF HIGH FREQUENCY PERCUSSIVE VENTILATION FOR ARDS

Abstract

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: High frequency percussive ventilation (HFPV) is a method of ventilation that delivers biphasic percussive microvolumes in a time-cycled, pressure limited fashion. The goal is to increase recruitment of alveoli burdened by secretions or atelectasis to improve gas exchange for those failing conventional ventilation. HFPV has been utilized in the acute inhalation injury population; however, its use has spread to the medical community as a rescue method in acute respiratory distress (ARDS) patients. CASE PRESENTATION: A 24-year-old male with a past medial history of type 2 diabetes, obstructive sleep apnea, and obesity presented to the Emergency Department for worsening epigastric pain, nausea, and vomiting. He was ill appearing with diffuse abdominal pain, guarding, and rebound. Pertinent labs included a lipase of 3,600 U/L and triglycerides of 1,700 mg/dL. Computed tomography (CT) of the abdomen and pelvis revealed severe pancreatic edema with a non-enhancing pancreatic tail concerning for necrosis. He was admitted to the Intensive Care Unit and started on crystalloid infusion and continuous insulin. He developed progressive tachypnea and ultimately required intubation for severe hypoxemia. He further decompensated with worsening fevers and hypotension, requiring initiation of broad-spectrum antibiotics and vasopressors. Despite the insulin infusion, the patient's triglycerides increased to 9,500 mg/dL and he was started on therapeutic plasma exchange. Echocardiogram did not reveal evidence of left ventricular dysfunction. Chest x-ray showed worsening bilateral pulmonary infiltrates suggestive of ARDS. Despite a lung-protective, volume-controlled method of ventilation, the patient continued to exhibit high plateau and driving pressures. Given his significantly distended abdomen and high bladder pressures, he was unable to tolerate prone positioning. PaO2/FiO2 ratio (P/F ratio) was as low as 91. Subsequently he underwent cannulation for veno-venous extracorporeal membrane oxygenation (VV-ECMO). His secretion burden remained high and CT chest revealed dense atelectasis. He was then switched to HFPV for better secretion management and improvement in oxygenation. After 48 hours of HFPV, he had significant improvement in his atelectasis on CT chest and P/F ratio. After eight days, he was decannulated from VV-ECMO and later extubated. DISCUSSION: Our patient experienced known severe complications from hypertriglyceride-induced pancreatitis. His ARDS improved robustly with HFPV with VV-ECMO support. In centers with experience with this type of ventilation, it can be a powerful tool for patients suffering from inhalation injury, high-secretion pneumonias, and ARDS. CONCLUSIONS: Though HFPV does not have a dense volume of data supporting its use in ARDS, in the appropriately selected patient it can provide a safe and efficient way of improving lung recruitment, gas exchange, and potentially outcomes. REFERENCE #1: Godet T, Jabaudon M, Blondonnet R, Tremblay A, Audard J, Rieu B, Pereira B, Garcier JM, Futier E, Constantin JM. High frequency percussive ventilation increases alveolar recruitment in early acute respiratory distress syndrome: an experimental, physiological and CT scan study. Crit Care. 2018 Jan 11;22(1):3. REFERENCE #2: Spapen H, Borremans M, Diltoer M. Van Gorp V, Nguyen D, Honore P. (2014). High-frequency percussive ventilation in severe acute respiratory distress syndrome: A single center experience. Journal of Anesthesiology Clinical Pharmacology. 30(1):65-70. DISCLOSURES: No relevant relationships by Alaynna Kears, source=Web Response No relevant relationships by Christopher Lenivy, source=Web Response No relevant relationships by Kaitlyn Musco, source=Web Response No relevant relationships by Roshun Sangani, source=Web Response No relevant relationships by Daniel Schwed Lustgarten, source=Web Response