intrapulmonary percussive ventilatio IPV

A review of evidence.Efficacy of intrapulmonary percussive ventilation (IPV) or Percussionaire : 

A review of evidence.Efficacy of intrapulmonary percussive ventilation (IPV) or Percussionaire Kola akinlabi MSc student University College London.

Aim of review : 

Aim of review To find out if IPV is superior to other chest clearance techniques To find out if IPV improve Peak expiratory flow rate required to mobilize secretions. To find out the effects of IPV on respiratory mechanics. To find out if IPV can help patients with hyper-secretions e.g. SCI Does it cause any harm?

A recap: Hypersecretion in spinal cord injury : 

A recap: Hypersecretion in spinal cord injury Hypersecretion – 1 hour after injury in tetraplegia (Lanig IS 2000). In 40% of acute tetraplegia (Bhaskar KR et al 1991). Hypersecretion caused by loss of sympathetic control and unopposed vagal activity (Bhaskar KR et al 1991). Loss of sympathetic stimuli causes (reduced influence by adrenergic innervations) reduction in rate of cilia beating ( Slack RS 1994).

Why do we need to Rx secretion : 

Why do we need to Rx secretion Increased secretions coupled with an ineffective cough and bronchospasm leads to mucous plugs and consequent collapse.

IPV : 

IPV Very common in the US Used in acute spinal unit For aggressive management of atelectasis and secretions- shown to have decrease the risk of pneumonia and the need for bronchoscopy ( Berlly 2007),.

What is IPV : 

What is IPV It’s a therapeutic modality designed to clear and maintain pulmonary airways. Delivers high frequency, low- volume, positive- pressure breath in the range of 100-300 cycles/min . Peak pressure 20-40cm H20 (Kathleen et al 2002) It helps to mobilize and clear retained secretions assist in resolution of atelectasis Deliver aerosolized medications to hydrate viscous mucous plugs (Belly et al 2007)

Principles of actions : 

Principles of actions Mobilization of secretion Combination of Increased airway distending pressure and delivery of bronchodilator nebulizer solution Two – phase gas liquid flow – causes bronchodilation and mobilization of secretion from the peripheral to the central.( Natale, 1993) Resolution of atelectasis Direct, high –frequency osscillatory ventilation like effect and breath of 200-300 cycle/min (Salim, 2005). Hydration of mucus plug Deliver aerosolized medications (Belly et al, 2007)

Questions are? : 

Questions are? What are the evidence of IPV Could we accept this (IPV) as a routine practice if there is enough evidence? If yes, then could we standardized parameters based on evidence?

The evidence for IPV : 

The evidence for IPV

IPV- in tracheostomised patients : 

IPV- in tracheostomised patients Aim was to investigate if IPV + usual chest physiotherapy improves gas exchange and lung mechanics in tracheostomised pts weaned from mechanical ventilator 46 trachy pts Randomly assigned to two Rx groups 1.Chest PT (control), 2. Chest PT + IPV 10 mins Rx twice/day for 15 days, breathing frequency was 250cycle/min. Outcome measures were ABG, Pa02/FI02 ratio and Maximum expiratory Pressure (MEP). Result showed significant increase in Pa02/FI02 ratio by 21.65 mean difference, -11.75 to 55.05 CI at p=0.038 and MEP by 9.26 mean diff at p=0.014 Conclusion: the addition of IPV to the usual chest PT regimen in tracheostomised patients improves gas exchange and expiratory muscle performance. (Clini et al, intensive Care medicine 2006)

Comparison of IPV and Chest PT in Cystic Fibrosis : 

Comparison of IPV and Chest PT in Cystic Fibrosis Aim was to find out acute changes in pulmonary functions and sputum physical properties 9 non hospitalised CF patients Randomised cross over trial 3 Rx applied; (1).2.5mg albuterol via IPV,(2) 2.5mg albuterol via IPV + percussion and PD, (3) 2.5mg albuterol via nebulizer + Percussion and PD. 5 days Rx, and result taken 1 hr, 4hr and 20 hr after Rx. Outcome measures were Pulmonary Function Tests (25-75 mean FEF, FeV1, FVC) and sputum volume and viscoellastic xteristics. Results showed that among the 3 Rx there was no significant improvement in Pulmonary function test at 1hr or 4hr after Rx nor in the volume of sputum expectorated in the 4hr or in the subsequent 20hr. Among patients receiving IPV, more serious disease had greater improvement in FEF25-751 hr after treatment but these difference disappeared by 4hr. There was no difference in viscoellastic xteristics of sputum expectorated after each Rx. Conclusion: IPV was as effective as standard nebulizing and percussion &PD in improving short –term PFT results and enhancing sputum expectoration. (Natale et al, Chest 1994).

Efficacy and safety of IPV superimposed on convectional ventilation in obese patients with compression atelectasis : 

Efficacy and safety of IPV superimposed on convectional ventilation in obese patients with compression atelectasis Purpose was to investigate efficacy and safety of IPV in obese patients with respiratory failure due to compression atelectasis, who had not improved with conventional ventilator. 10 obese patients with compression atelectasis were included continuous Rx for more than 24 hrs Outcome measures were Pa02/Fi02 ratio, pulmonary compliance, CT Haemmodynamic parameters, ventilator settings and were monitored and recorded every 1hr, ABG analyzed every 3hrs and ICP for safety checks. Results showed that before IPV Pa02Fi02 ratio which has remained low significantly increased from 189 to 243 mmHg at 3hrs from initiation of IPV. At 24 hrs it increased to 280mmHg. Also there was significant increase in dynamic compliance from 30ml/cm at 0HR to 35 ml/cm at 12 hours and 38ml/cm at 24 HRs HR and MAP were not significantly changed during IPV. CT scan showed improvement in the area of atelectasis. Conclusion: These result demonstrated that IPV was effective and safe in compression atelectasis in improving compression atelectasis. (Tsuruta et al, J of critical care 2006)

IPV vs incentive spirometer (IS) for children with NMD : 

IPV vs incentive spirometer (IS) for children with NMD To test the hypothesis that IPV will reduce number of days of antibiotics use for pulmonary fibrosis. A RCT- compare efficacy of IPV and IS 18 patients were enrolled; 9 IPV and 9 IS Primary Outcome measure was number of days on antibiotics for respiratory illness. Secondary were no of school day missed due to respiratory illness, and days of hospitalization. Rx period was oct 1999 to april 2000. twice daily 5-10 mins Rx. Neither grp received chest physio or PD Both group were on BiPAP t/o the study via FM Result showed that patients in IPV did not receive any antibiotics during study period. Patients in the IS group received 44 days of antibiotics. IS grp were 1 pt was hospitalised for respi illness for 8 days, 3 pts had 3 courses abx. IPV grp zero days Conclusion: IPV as part of a preventive pulmonary regimen reduced days of Abx use and respiratory illness in children with NMD Reardon et al, Arch of paedtr Adlesc 2005

So what do we think Use or discard? : 

So what do we think Use or discard?

references : 

references