ARTICLE Intrapulmonary Percussive Ventilation vs Incentive Spirometry for Children With Neuromuscular Disease Christine Campbell Reardon, MD; Demian Christiansen; Elizabeth D. Barnett; Howard J. Cabral, PhD Background: Pulmonary infections can be life threaten- Results: A total of 18 patients were enrolled (9 IPV, ing for children with neuromuscular diseases who have im- 9 IS). Antibiotic use was significantly higher with IS paired ability to clear secretions. Intrapulmonary percussive (24/1000 patient-days) compared with IPV (0/1000 ventilation (IPV) is a pneumatic device that delivers air and patient-days), (incidence rate ratio, 43; 95% confidence aerosol to the lungs at frequencies of 200 to 300 cycles per interval, 6-333). The IS group spent more days hospital- minute at peak pressures from 20 to 40 cm H2O. Anecdotal ized (4.4/1000 patient-days vs 0/1000 patient-days) reports and pilot studies show its safety and effectiveness than the IPV group (incidence rate ratio, 8.5; 95% con- in mobilizing secretions in patients with cystic fibrosis. fidence interval, 1.1-67). The IPV group had 0 episodes of pneumonia or bacterial bronchitis compared with Objective: To test the hypothesis that IPV used in a pul- 3 events in the IS group, although this did not meet sta- monary program for adolescents with neuromuscular dis- tistical significance. ease would reduce the number of days of antibiotic use for pulmonary infection. Conclusion: Intrapulmonary percussive ventilation as part of a preventive pulmonary regimen reduced days of Methods: A randomized, controlled study was con- antibiotic use and hospitalization for respiratory illness ducted to compare efficacy of IPV with incentive in adolescents with neuromuscular disease. spirometry (IS) in reducing number of days of antibiotic use in adolescents with neuromuscular disease. The sec- ondary endpoints were the number of respiratory infections, hospitalizations, and school days missed. Arch Pediatr Adolesc Med. 2005;159:526-531 ULMONARY COMPLICATIONS cussion therapy with handheld percus- are common and can be life sors or vest, mechanical insufflation/ threatening in patients with exsufflation, intermittent positive pressure neuromuscular diseases breathing, and intrapulmonary percus- (NMD).1 Patients with NMD sive ventilation (IPV).4,5 Phave ineffective muscle function, which re- An intrapulmonary percussive ventila- sults in small tidal volumes and reduced tor (Impulsator F00012; Percussionaire cough effectiveness.2,3 They are predis- Corp, Sandpoint, Idaho) is a pneumatic de- posed to atelectasis, retention of airway se- vice that delivers high-flow-rate bursts of cretions, and respiratory infection. Respi- air and aerosol to the lungs at a fre- ratory infections prevent patients from quency of 200 to 300 cycles per minute. attending school, rehabilitative or recre- Pulsatile breaths are delivered at a peak ational programs. Additional conse- pressure of 20 to 40 cm H2O, titrated by Author Affiliations: Pulmonary quences of pulmonary infections include visualizing percussive movement of the in- Center, Boston University exposure to multiple courses of antibiot- tercostal spaces. Breaths are delivered us- School of Medicine, ics with associated risks of acquisition of ing a mouthpiece, and the lungs per- (Dr Reardon), Maxwell Finland antibiotic-resistant microorganisms, an- cussed for 5- to 15-second intervals over Laboratory for Infectious tibiotic-associated colitis, and medical a 15- to 30-minute period.6 Proposed Diseases, Boston Medical complications associated with hospital- mechanisms of action include enhanced Center (Mr Christiansen and ization in an intensive care setting. alveolar recruitment and mucociliary clear- Ms Barnett), Data Coordinating Center (Mr Christiansen) and Treatment options for mobilizing and ance through bronchodilation from a com- Department of Biostatistics clearing secretions and preventing atelec- bination of bronchodilatory medication, 7 (Dr Cabral), Boston University tasis include incentive spirometry (IS), and improved lung inflation. School of Public Health, traditional chest physiotherapy with pos- Prior reports have shown the safety and Boston, Mass. tural drainage, manual cough assist, per- effectiveness of IPV in mobilizing airway (REPRINTED) ARCH PEDIATR ADOLESC MED/ VOL 159, JUNE 2005 WWW.ARCHPEDIATRICS.COM 526 ©2005 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/27/2021 secretions.8-13 A preliminary report examining the effi- cacy and safety of IPV in patients with NMD included 4 Table 1. Clinical Characteristics of Study Subjects* patients (3 with NMD) treated with IPV for pulmonary infiltrates and/or atelectasis.13 Two patients with NMD IS IPV had significant improvement in blood oxygenation and (n=9) (n=9) chest radiographic findings; the third had a slower re- Median age (range), y 17 (14-19) 17 (11-19) sponse and developed transient third degree heart block Male 8 (89) 6 (67) Diagnosis and hypoxemia from mucous plugging following IPV. DMD 5 (56) 5 (56) We became interested in the role of IPV in prevent- SMA 1 (11) 1 (11) ing respiratory illness in patients with NMD after 2 win- SCI 1 (11) 1 (11) ters with high rates of respiratory illness. Between 1998 Mitochondrial 1 (11) 1 (11) and 1999, 24 patients with NMD at a residential reha- OI 1 (11) 1 (11) bilitation facility were prescribed 18 courses of antibi- Days of antibiotic use for prior year† 40 (2) 37 (2) otics for 168 days of antibacterial therapy; 3 were hos- Abbreviations: DMD, Duchenne muscular dystrophy; IPV, intrapulmonary pitalized at acute care facilities for pulmonary infections. percussive ventilation; IS, incentive spirometry; OI, osteogenesis imperfecta; During 1997 through 1998, there were 18 patients with SMA, spinal muscular dystrophy; SCI, spinal cord injury. NMD, 32 courses of antibiotics, 272 days on antibiotics, *Unless otherwise indicated, values are presented as number (percentage). and 10 hospitalizations. Based on published pilot data †For the 1998-1999 school year, the year prior to the study, there were and our institution’s experience with IPV during acute 1890 possible total days for antibiotic prescription. illness, we hypothesized that use of IPV in a preventive regimen would reduce number of days on antibiotics for respiratory infection in patients with pulmonary dys- land, Ohio), which were prepared in blocks of 4. Both groups function caused by NMD, and would be well-tolerated received instruction and practice with their respective treat- by patients and acceptable to caregivers.14 The rationale ment techniques. Patients assigned to IS performed IS (Vol- for using IPV in a preventive program for patients with dyne 2500; Hudson RCI, Temecula, Calif) twice daily for 5 to NMD was to prevent atelectasis and mobilize secretions 10 minutes. Patients randomized to IPV received treatments in patients unable to benefit from traditional techniques twice daily, using 6 mL of normal saline and a percussion fre- quency of 120 cycles per minute. Driving pressure (set at the such as IS because of muscle weakness. It was also im- minimum pressure that induced visible chest oscillations) was portant to determine if IPV could be performed safely in determined individually for each subject and was maintained a population at risk for mucous plugging. consistently during the study. The range of driving pressures We performed a randomized, controlled trial to study used was 20 to 40 cm H2O. the efficacy of IPV in reducing days of antibiotic use and, Treatments took 10 to 15 minutes for complete aerosoliza- secondarily, preventing respiratory infection, days missed tion of saline. Though the manufacturer recommends using al- from school, and hospitalizations in children and young buterol sulfate during IPV treatments, this was not part of this adults with pulmonary compromise caused by NMD. trial because of concern for exacerbating tachycardia, already present in some subjects with muscular dystrophy and dilated cardiomyopathy. Treatments were supervised by a respiratory METHODS therapist or nurse trained in manual cough assist in case mu- cous plugging occurred. PATIENT POPULATION Subjects were evaluated at the beginning and end of the study to assess adequacy of randomization in terms of sever- ity of illness and decline of pulmonary function during the The study site is a 120-bed residential facility providing medi- study, and antibiotic use in the year before the study. Spi- cal, rehabilitative, educational and recreational services to chil- rometry and lung volumes were determined and muscle dren with physical disabilities. Patients with impaired pulmo- strength assessed by measuring maximum voluntary ventila- nary function (defined by restrictive physiology with vital capacity tion, maximum inspiratory pressure, and maximum expira- Ͻ60% predicted, maximum inspiratory pressure Ͻ90 cm H O 2 tory pressure.15 The same respiratory therapist conducted and maximum expiratory pressure less than 100 cm H O) caused 2 pulmonary function testing during the study. Current insti- by NMD were eligible. Of the 23 eligible patients, 18 were en- tutional protocols were used to determine whether patients rolled, 2 patients with tracheostomy tubes were excluded be- required intensification of their pulmonary regimen or ini- cause IPV was part of their standard pulmonary regimen, and tiation of antibiotics. Intensification of regimen occurred 3 declined to participate (Table 1). Consent to participate was when subjects developed