Examination of High-Frequency Percussive Ventilation Initiation Protocols

Abstract

Background:

High-frequency percussive ventilation (HFPV) has been used in patients ranging from neonates to adults. There is little evidence to support protocol development for HFPV. This study aims to describe how practitioners initiate HFPV based on hospital protocols.

Methods:

Protocols were identified in published literature, and voluntarily submitted after an email was sent via a list-serve and posted on AARConnect. Settings were categorized based on the VDR-4 manual, recommendations from Forrest Bird,⁸ and feedback from subject matter experts (SME). Categories were developed with SME interviews to establish low, moderate, high, and variable/match conventional settings. The category table was reviewed by SMEs for feedback based on clinical experiences. Demand and oscillatory PEEP categories were off, low (1-3 cm H₂O), moderate (4-6 cm H₂O), high (≥ 7 cm H₂O), and match conventional. Pulsatile flow categories were low (20-30 cm H₂O), moderate (31-40 cm H₂O), high (≥ 40 cm H₂O), and match conventional/variable.

Results:

Eighteen protocols were identified. The low and moderate categories for demand PEEP each had 5 (28%) protocols, and 2 (11%) protocols were variable. Moderate oscillatory PEEP had 4 (22%) protocols, high had 7 (39%), and variable had 5 (28%) protocols. Pulsatile flow had 10 (56%) protocols in the low category and 5 (28%) were variable.

Conclusions:

Setting variation among protocols indicates little agreement between hospitals on the appropriate initiation strategy for HFPV. Future studies are needed to develop evidence-based protocols and determine a systematic approach for HFPV settings in specific patient populations.

Initiation Setting Categories

Initial Settings	0	Low (1)	Moderate (2)	High (3)	Match Conventional/Variable (4)
Demand PEEP (cmH2O)	Off	1-3	4-6	≥ 7	 
Percussive Rate (bpm)	 	300-400	400-500	> 500	 
I time/E time (sec)	 	1	1.5	2	> 2 sec
Convective Pressure Rise (cmH2O)	Off	1-3	4-6	≥ 7	 
Pulsatile Flow (cmH2O)	 	20-30	31-40	> 40	 
Oscillatory PEEP (cmH2O)	 	1-3	4-6	≥ 7	 
Convective Rate (bpm)	 	10-14	15-19	≥ 20	 
Airway Cuff Leak	No	Yes	 	 	 

Category Percentage Table

Setting	Not Addressed	0	Low (1)	Moderate (2)	High (3)	Match Conventional/Variable (4)
Percussive Rate n(%)	0 (0%)	--	1 (6%)	14 (78%)	3 (17%)	0 (0%)
Convective Rate n(%)	0 (0%)	0 (0%)	3 (17%)	13 (72%)	1 (6%)	1 (6%)
I time/E time n(%)	1 (6%)	--	0 (0%)	1 (6%)	12 (67%)	4 (22%)
Pulsatile Flow n(%)	0 (0%)	--	10 (56%)	3 (17%)	0(0%)	5 (28%)
Convective Pressure Rise n(%)	11 (61%)	2 (11%)	0 (0%)	2 (11%)	2 (11%)	1 (6%)
Demand PEEP n(%)	2 (11%)	3 (17%)	5 (28%)	5 (28%)	1 (6%)	2 (11%)
Oscillatory PEEP n(%)	2 (11%)	0 (0%)	0 (0%)	4 (22%)	7 (39%)	5 (28%)
Airway Cuff Leak n(%)	6 (33%)	0 (0%)	12 (67%)	--	--	--