High-Frequency Percussive Ventilation in Viral Bronchiolitis

Abstract

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. S_pO2 /F_IO2 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.

Keywords: acute bronchiolitis; high-frequency percussive ventilation; mechanical ventilation; pediatric ARDS; pediatric ICU.

Fig. 1.

Box plot of subjects' mean arterial or capillary P_CO2 in the 24 h before and after high-frequency percussive ventilation initiation. HFPV = high-frequency percussive ventilation.

Fig. 2.

Arterial or capillary P_CO2 in the 24 h before and after high-frequency percussive ventilation initiation plotted versus time. Loess curve applied with corresponding shaded 95% CIs. HFPV = high-frequency percussive ventilation.