EFFECTS OF INTRAPULMONARY PERCUSSIVE VENTILATION AS COMPLEMENTARY TECHNIQUE IN NONINVASIVE MECHANICAL VENTILATION DURING COPD EXACERBATIONS   Antonio M. Esquinas MD (1), José Manuel Serrano MD (2), Miguel Ángel Folgado MD (3) and G. González Díaz, G (1).  Intensive Care Unit. Hospital Morales Meseguer. Murcia (1) Intensive Care Unit. Hosp Reina Sofia Córdoba (2) Emergency Department. Hospital Virgen de la Concha Zamora (3) and on behalf of Intrapulmonary Percussive-NPPV Working Group

BACKGROUND-1 Intrapulmonary Percussive Ventilation (IPV) is a oscillatory non-invasive airway clearance secretions (ACS) technique that may improve outcome and resolutions of problems associated with ACS (*). There is few studies related best strategies to control ACS during noninvasive mechanical ventilation (NIMV) and avoid early or late failure. Figure Nº1. IPV : Clasical Oscillatory effects during IPV therapy. (*).Hill K, Patman S, Brooks D. Chron Respir Dis. 2010;7(1):9-17. Effect of airway clearance techniques in patients experiencing an acute exacerbation of chronic obstructive pulmonary disease: a systematic review.

BACKGROUND-2 HYPOTHESIS: Late or early failure associated with secretions may have similar objectives with combination of NIMV and IPV We hypothesized that early or intermittent use of IPV could influence control of hypercapnia and/or airway secretions during treatment with in exacerbations of Chronic Obstructive Pulmonary Diseases (COPD). (*) Nava S, Ceriana P. Causes of failure of noninvasive mechanical ventilation. Respir Care. 2004 Mar;49(3):295-303.

AIMS We analyze two strategies of IPV application in selected patients with COPD exacerbations and associated secretions, where NIMV have a relative or absolute contraindications to know ventilatory effects and short outcome with two ACS clearance strategies. We design two strategies in selected high risk COPD exacerbations: (Strategy I): Early NIMV and intermittent application of IPV after control of pH. (Strategy II): Early IPPV application before NIMV application without pH control.

METHODS & PATIENTS-1 1-Population: We enrolled COPD exacerbation patients with secretions and NIPPV in ICU. 2-Inclusion criteria: Criteria of exacerbations of COPD are: a respiratory frequency ≥ 25/min, PaCO2 > 45 mmHg and pH ≤ 7.35. 3-Exclusion criteria: Requirement for emergent intubation. Glasgow coma scale  9. Hemodynamic : systolic arterial pressure < 80 mm hg and ECG instability. Tracheotomy. Facial deformity. Recent oral , esophageal or gastric surgery. Pneumothorax.

METHODS & PATIENTS-2 4-IPV technique: In both groups daily sessions IPV were applied by for 30 minutes/3 day by face mask. 5-NIPPV: BiPAP Ventilator (Respironics, Inc) and face mask with BIPAP mode. 6-MEASUREMENTS: cardiopulmonary monitoring, clinical and arterial blood gases. 7-IPV-THERAPY : clinical and arterial blood gases returned to baseline (Strategy I) or maintain stable (Strategy II). Figure Nº2-A. IPV Device. Figure Nº2-B. Nebulizer and Phasitron.

RESULTS-1 1-Population: 65 patients with COPD exacerbation were admitted in ICU for NIPPV, age 70±12, years, male (90%). 2-Exclusion: n=15 were excluded for severe hypoxemia (PaO2:FiO2≤200) associated with pneumonia (5/15) and cardiac insufficiency (10/15). 3-Inclusion: n=50 patients were enrolled in the study. Figure Nº3. Patient with IPV technique in ICU

RESULTS-2 5-STRATEGY GROUP II 4-STRATEGY GROUP I: (n=25). (n=25). After NIPPV with control of arterial blood gases [pH 7,38/52 mmHg] and IPV treatment showed improved clearance of airway secretions without significant change in Ph/PCO2 [pH 7,39/50 mmHg](p<0.162). 4-STRATEGY GROUP I: (n=25). Thirty minutes of IPV showed a significant decrease in respiratory rate, increase in pH respect pre IPV/pCO2 mmHg from [pH:7,26/76,6 mmHg to pH 7,34/76,6 mmHg] after IPV treatment (p<028; p<043) and improved airway clearance.

RESULTS-3 5-TREATMENT IPV-NIMV: failure (G-I:1/25; GII:0%). 6- UCI STAY: (G-I:3±1; G-II: 4±2) days. 7-HOSPITAL STAY: was significantly shorter in the IPV group than in the control group (6.8 ± 1.0 vs. 7.9 ± 1.3 days, p < 0.05).

CONCLUSIONS & PRESPECTIVES IPV in both strategies, before and after NIMV have positive effects in clinical (ACS) and gas exchange ( PCO2) during NIPPV-COPD exacerbations avoiding early or late failure. IPV is useful as complementary technique during NIMV in selected COPD exacerbation that need ACS. Future clinical studies and guidelines may analyze potential effects and outcome of NIMV and IPV technique.