- Email: [email protected]
Management of Localized Pneumothoraces After Pulmonary Resection With Intrapulmonary Percussive Ventilation
Management of Localized Pneumothoraces After Pulmonary Resection With Intrapulmonary Percussive Ventilation Tindaro Gatani, MD, Nicola Martucci, MD, Antonello La Rocca, MD, Carmine La Manna, MD, Francesco Scognamiglio, MD, Rosario Salvi, MD, and Gaetano Rocco, MD, FRCSEd GENERAL THORACIC
Department of Thoracic Surgery and Oncology, Division of Thoracic Surgery and Service of Pulmonology, National Cancer Institute, Pascale Foundation, Naples, Italy
Background. Intrapulmonary percussive ventilation (IPV) aims at clearing retained secretions through oscillary vibrations generated by high frequency bursts of gas delivered into the airways at rates between 200 and 300 breaths per minute and at a delivery pressure of 10 to 20 cm water. In addition, IPV can improve recruitment of alveolar units and deliver aerosolized medications. The use of IPV to resolve challenging postlobectomy localized pneumothoraces is hereafter described. Methods. Between January 2005 and March 2009, four patients with long-term complicated postresectional residual air spaces persisting 6 months (mean, 187 days) after primary surgery were treated by IPV. The type of operation was upper lobectomy and lower lobectomywedge resection in 1 and 3 patients, respectively. Mean preoperative and immediate postsurgical forced expiratory volume in the first second of expiration were 2.31 L
and 1.49 L, respectively. Mean preoperative and immediate postsurgical forced vital capacity were 3.13 L and 2.1 L, respectively. Patients were subjected to 12-minutelong IPV sessions up to a total of 8 to 12 sessions administered every other day in an outpatient setting. Results. Complete resolution of the spaces within a mean of 22 days of beginning of treatment was noted. The post-IPV forced expiratory volume in the first second of expiration and forced vital capacity were 1.72 and 2.4 liters, respectively. No treatment-related morbidity was observed. Conclusions. Intrapulmonary percussive ventilation can be expected to decisively contribute to resolving long-term localized pneumothoraces after subtotal pulmonary resections in an outpatient setting. (Ann Thorac Surg 2010;90:1658 – 61) © 2010 by The Society of Thoracic Surgeons
S
Material and Methods
elf-limiting residual spaces after subtotal pulmonary resections usually undergo watchful observation. In rare circumstances, these localized pneumothoraces persist despite long-term drainage and may complicate with an empyema and the attendant need for additional surgical treatment along with prolonged hospitalization. Intrapulmonary percussive ventilation (IPV) is used to improve clearance of bronchial secretions in patients with severe chronic obstructive pulmonary disease, infants, and advanced neuromuscular disease [1]. Successful application of IPV results in increased alveolar recruitment and relief of atelectasis and pulmonary consolidation [1]. We hereafter report our experience with the management through IPV of persistent and complicated spaces after subtotal pulmonary resections in an outpatient setting.
Accepted for publication June 22, 2010. Address correspondence to Dr Rocco, Department of Thoracic Surgery and Oncology, Division of Thoracic Surgery, National Cancer Institute, Pascale Foundation, via Semmola 81, Naples, 80131, Italy; e-mail: [email protected].
© 2010 by The Society of Thoracic Surgeons Published by Elsevier Inc
Between January 2005 and March 2009, four patients with persistent localized pneumothoraces after pulmonary resection (mean, 187 days) were treated with IPV after failing medical treatment and physiotherapy (Table 1). There were 3 males and one female with a mean age of 64 years; two patients were current and two were former smokers. Mean preoperative and immediate postsurgical forced expiratory volume in the first second of expiration (FEV1) were 2.31 L and 1.49 L, respectively. Mean preoperative and immediate postsurgical forced vital capacity (FVC) were 3.13 L and 2.1 L, respectively. Moreover, mean preoperative Dlco (diffusion lung capacity for carbon monoxide) percentage of predicted value was 69.1%. Mean postsurgical and post-IPV treatment arterial oxygen saturation was 95% and 97.2%, respectively. All patients were asymptomatic at rest but complaining of some exertional dyspnea (category 3, according to the 0 to 10 Borg scale [2]). In all instances, IPV treatment was administered in an out-patient setting. The patients received individual 12 minute sessions every other day up to a total of 8 to 12 sessions. The IPV sessions were administered by a specialized nurse under the supervision of a dedicated 0003-4975/$36.00 doi:10.1016/j.athoracsur.2010.06.092
Ann Thorac Surg 2010;90:1658 – 61
GATANI ET AL IPV FOR LOCALIZED PNEUMOTHORACES
1659
Patient
Comorbid
Operation
BPF/OWT
Pre
Post
IPV
FEV1 3.1 (98.0%) FVC 3.87 (91.6%) FEV1 1.5 (76.1%) FVC 2.05 (85.9%) FEV1 2.24 (71.2%) FVC 3.36 (85.1%) FEV1 2.5 (80.8%) FVC 3.25 (84.5%)
FEV1 1.21 (45.1%) FVC 1.95 (56.5%) FEV1 1.16 (58.6%) FVC 1.66 (69.5%) FEV1 1.59(51.2%) FVC 2.19 (56.4%) FEV1 2.03 (65.5%) FVC 2.6 (67.4%)
FEV1 1.42 (52.7%) FVC 2.27 (65.8%) FEV1 1.36 (69.8%) FVC 1.96 (82.8%) FEV1 1.86 (60.2%) FVC 2.45 (63%) FEV1 2.26 (72.5%) FVC 2.95 (76.6%)
1
COPD
LUL
No
2
Asthma
wRLL
No
3
Renal carcinoma
LLL
Yes
4
PTCA
RLL
No
Continued
Table 1. Continued Sat 02% Pre-IPV
Sat 02% Post-IPV
Dlco mL/mm Hg/min Pre-IPV
Dlco mL/mm Hg/min Post-IPV
Duration of Space (Months)
Percussionaire 12-Minute Applications
Resolution of Space After Beginning of IPV
96%
97%
20.4 (72.8%)
25.12 (89.6%)
6
12 on alternate days
23 days
96%
97%
11.27 (67.1%)
12.44 (75.3%)
10
12 on alternate days
22 days
94%
97%
18.38 (61.8%)
19.77 (73.3%)
12 on alternate days
25 days
94%
98%
19.87 (74.7%)
25.71 (96.7%)
8 on alternate days
21 days
3 (after OWT closure) 6
FEV1 and FVC values expressed in liters. BPF ⫽ bronchopleural fistula; Comorbid ⫽ comorbidities; COPD ⫽ chronic obstructive pulmonary disease; Dlco ⫽ diffusing capacity of lung for carbon monoxide; FEV1 ⫽ forced expiratory volume in the first second of expiration; FVC ⫽ forced vital capacity; IPV ⫽ intrapulmonary percussive ventilation (posttreatment spirometry); LLL ⫽ left lower lobectomy; LUL⫽ left upper lobectomy; OWT ⫽ open window thoracostomy; Pre ⫽ preoperative spirometry; Post ⫽ postsurgical spirometry; PTCA ⫽ percutaneous transluminal coronary angioplasty; RLL ⫽ right lower lobectomy; Sat ⫽ saturation; wRLL ⫽ wedge right lower lobe.
physician. Continuous monitoring of heart rate, blood pressure, respiratory rate, and arterial oxygen saturation was applied. The necessary training to achieve the plateau of the learning curve was calculated to be 10 cycles of 10 sessions per cycle. Oscillatory pulsations were generated by a ventilator (Percussionaire; Percussionaire Corporation, Sandpoint, ID) which was able to deliver high frequency minibursts (100 to 300 cycles per minute) at a pressure of 10 to 20 cm water delivered at the patient’s mouth. The device working pressure settings varied according to the individual tolerability offered by the single patient (between pressures of 0.3 mbar at the beginning of the first session to 1.0 mbar at the end of the last session, with gradual 0.1 mbar stepwise increases). During IPV sessions, aerosolized mucolytics and bronchodilators were routinely added to the delivered mist to relieve bronchospasm and to enhance airway clearance. These were aerosolized formulations duplicating the same standard treatment regimens the patients already had been receiving in the postoperative period; typically 1 mL vial of oxitropium bromide (1.5 mg/mL), 2 mL vial of ambroxol (15 mg), and 2 mL vial of fluticasone (500 mg). During IPV treatment, under no circumstances were attempts made at evacuating air from the residual
spaces nor was external chest physiotherapy administered. Our Institutional Review Board approved this retrospective study and waived patient consent as long as patients were not identifiable. Compliance with the declaration of Helsinki was ensured for the entire duration of the study.
Results Complete lung reexpansion was obtained in all patients (Fig 1) within three weeks of beginning of treatment (mean, 22 days). Mean immediate postsurgical FEV1 and FVC were 1.49 L and 2.1 L, respectively. Mean FEV1 and FVC measured after IPV increased by 8.7% and 9.6% compared with immediate postsurgical FEV1 and FVC, respectively. Total loss of mean FEV1 and FVC compared with preoperative values was 17.7% and 14.7%, respectively. Moreover, Dlco measured at the end of IPV treatment was 83.7%; mean Dlco improvement after IPV was as high as 14.6%. In addition, mean post-IPV treatment arterial oxygen saturation was 97.2% with a mean 2.2% improvement compared with the immediate postsurgical measurement. No treatment-related complications were observed.
GENERAL THORACIC
Table 1. Patients’ Clinical Features
1660
GATANI ET AL IPV FOR LOCALIZED PNEUMOTHORACES
Ann Thorac Surg 2010;90:1658 – 61
Fig 1. Example of postsurgical outcome (A) and (B) after right lower lobectomy demonstrating persistent localized pneumothoraces (patient no. 4). After failing medical treatment and physiotherapy, the patient was subjected to intrapulmonary percussive ventilation with satisfactory results (C) and (D).
GENERAL THORACIC
Comment Intrapulmonary percussive ventilation, a term coined by Bird in the 1980s [1], belongs to the modalities of noninvasive ventilation aimed at clearing secretions and enhancing oxygenation, especially in pediatric patients with cystic fibrosis [3, 4]. Reportedly, IPV facilitates airway clearance and expansion through “radial displacement” of the bronchial wall and by generating pulsatile expiratory flows of greater magnitude than the inspiratory ones at each respiratory cycle [5]. From a clinical standpoint, the use of IPV primarily translates into increased sputum production and resolution of atelectatic parenchymal areas demonstrated by radiologic criteria [5]. Improved gas exchange and spirometry tests as well as distribution of aerosolized medications have also been observed, although no conclusive evidence is available [5]. In fact, IPV has been successfully used in acute exacerbations of chronic obstructive pulmonary disease due to the potential to improve depth of breathing and oxygen delivery to the alveoli by balancing the gas exchange and enhancing carbon dioxide washout [1, 6]. In an outpatient setting, IPV can be administered through a volume-oriented ventilator with the addition of a pneumatic powered device capable of delivering mini bursts of high flows of air at a high rate per minute. This front of high velocity percussive flow recruits distal alveolar lung units by mobilizing secretions; at the same time, aerosolized mixtures can be distributed to facilitate relief of acute inflammation and bronchial spasm. The percussive cycle is physician or patient assisted in as much as, while spontaneously breathing through the nozzle, the patient can trigger the intrapulmonary per-
cussion cycle. The IPV has been successfully administered to complement chest physiotherapy in the immediate postoperative period after cardiac surgery or in tracheotomized patients after pulmonary resections [7, 8]. Moreover, the IPV treatment proved effective in reducing persisting pulmonary consolidations [9, 10]. Recently, Lucangelo and colleagues [11] reported that IPV was effective in significantly reducing hospitalization by improving the perioperative course of patients undergoing pulmonary resections. To the best of our knowledge, the concept of managing persisting air spaces by improving reexpansion of the residual lung to lobar or sublobar resections after all conventional measures have failed by IPV is new. As a rule, postoperative incomplete reexpansion is observed when it is not associated to increasing dyspnea or signs of impaired oxygenation. The latter usually mandates air evacuation through a chest drain with the attendant prolonged length of hospital stay. Likewise, a thoracostomy tube is inserted in the asymptomatic patient if a longstanding, significant lung collapse is associated to visible thickening of the parietal pleura or the residual space is at risk for infection. Our limited experience indicates the possibility to manage such patients conservatively in an outpatient setting by subjecting them to well-tolerated IPV regimens which may lead to complete reexpansion of the residual lung. Although we cannot provide conclusive evidence of the superiority of IPV over watchful observation or the administration of inhaled mucolytics and bronchodilators by an experienced physiotherapist, we believe IPV may be a useful adjunct to the management protocols of resected patients, particularly in the noninvasive man-
agement of residual localized pneumothoraces in an ambulatory setting [12]. Nevertheless, larger series are warranted to confirm this initial experience.
References 1. Lucangelo U, Fontanesi L, Antonaglia V, et al. High frequency percussive ventilation (HFPV). Principles and technique. Minerva Anestesiol 2003;69:841– 8. 2. Borg GA. Psychophysical bases of perceived exertion. Med Sci Sports Exerc 1982;14:377– 81 [Article in English, Italian]. 3. Organized jointly by the American Thoracic Society, the European Respiratory Society, the European Society of Intensive Care Medicine, and the Société de Réanimation de Langue Française, and approved by ATS Board of Directors, December 2000. International Consensus Conferences in Intensive Care Medicine: noninvasive positive pressure ventilation in acute respiratory failure. Am J Respir Crit Care Med 2001;163:283–91. 4. Varekojis SM, Douce FH, Flucke RL, et al. A comparison of the therapeutic effectiveness of and preference for postural drainage and percussion, intrapulmonary percussive ventilation, and high-frequency chest wall compression in hospitalized cystic fibrosis patients. Respir Care 2003;48: 24 – 8. 5. Chatburn RL. High-frequency assisted airway clearance. Respir Care 2007;52:1224 –35.
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6. Antonaglia V, Lucangelo U, Zin WA, et al. Intrapulmonary percussive ventilation improves the outcome of patients with acute exacerbation of chronic obstructive pulmonary disease using a helmet. Crit Care Med 2006;34:2940 –5. 7. Shinozaki T, Deane RS, Perkins FM, et al. Comparison of high-frequency lung ventilation with conventional mechanical lung ventilation. Prospective trial in patients who have undergone cardiac operations. J Thorac Cardiovasc Surg 1985;89:268 –74. 8. Clini EM, Antoni FD, Vitacca M, et al. Intrapulmonary percussive ventilation in tracheostomized patients: a randomized controlled trial. Intensive Care Med 2006;32:1994 –2001. 9. Birnkrant D, Pope J, Lewarsky J, Stegmaier J, Besunder J. Persistent pulmonary consolidation treated with intrapulmonary percussive ventilation: a preliminary report. Pediatr Pulmonol 1996;21:246 –9. 10. Yen Ha TK, Bui TD, Tran AT, Badin P, Toussaint M, Nguyen AT. Atelectatic children treated with intrapulmonary percussive ventilation via a face mask: clinical trial and literature overview. Pediatr Int 2007;49:502–7. 11. Lucangelo U, Antonaglia V, Zin WA, et al. High-frequency percussive ventilation improves perioperatively clinical evolution in pulmonary resection. Crit Care Med 2009;37: 1663–9. 12. Blanch L, Villar J, López-Aguilar J. High-frequency percussive ventilation: an old mode with a great future. Crit Care Med 2009;37:1810 –1.
INVITED COMMENTARY The article by Gatani and colleagues [1] describes the use of intrapulmonary percussive ventilation (IPV) to manage residual postoperative air spaces in a series of 4 patients who were asymptomatic at rest but reported dyspnea on exertion. As a form of chest physiotherapy, IPV vibrates the airways internally for secretion management and recruitment of atelectatic lung parenchyma. This is in contrast to manual percussion, which vibrates the airways externally. The results of this study are interesting and encouraging. This small case series demonstrates the resolution of postoperative air spaces, and more importantly the overall improvement of pulmonary function as measured by forced expiratory volume in 1 second, forced vital capacity, and Dlco. The main advantage of IPV in comparison with the traditional method for evacuation of air space (eg, thoracostomy tube) is that IPV is noninvasive and it can be administered in the outpatient setting. The efficacy of IPV in comparison with traditional chest physiotherapy (with or without bronchodilators) is unclear, because there is no control present. A persistent pleural space after lung resection should be the exception rather than the norm, especially for wedge resection or lower lobectomy. Although the cause of the residual air spaces in this series of patients is unclear (except for the 1 patient with the bronchopleural fistula and open pleural window), the importance of chest tube management with
© 2010 by The Society of Thoracic Surgeons Published by Elsevier Inc
good pulmonary toilet to optimize lung expansion in the perioperative period can not be overemphasized. Nonetheless, the authors [1] demonstrate that IPV is a useful noninvasive technique for managing the difficult, yet unusual, problem of long-term residual air space after pulmonary resection. Although pulmonary function was improved with the application of IPV, the incremental increases are modest and may not necessarily translate to improved symptoms. Further study is necessary to determine whether the time and expense of this technology can be justified for such an infrequent problem in which patients are often relatively asymptomatic. Betty C. Tong, MD, MHS Department of Surgery Duke University Box 3531 Duke University Medical Center Durham, NC 27710 e-mail: [email protected]
Reference 1. Gatani T, Martucci N, La Rocca A, et al. Management of localized pneumothoraces after pulmonary resection with intrapulmonary percussive ventilation. Ann Thorac Surg 2010;90:1658 – 61.
0003-4975/$36.00 doi:10.1016/j.athoracsur.2010.07.027
GENERAL THORACIC
Ann Thorac Surg 2010;90:1658 – 61
Department of Thoracic Surgery and Oncology, Division of Thoracic Surgery and Service of Pulmonology, National Cancer Institute, Pascale Foundation, Naples, Italy
Background. Intrapulmonary percussive ventilation (IPV) aims at clearing retained secretions through oscillary vibrations generated by high frequency bursts of gas delivered into the airways at rates between 200 and 300 breaths per minute and at a delivery pressure of 10 to 20 cm water. In addition, IPV can improve recruitment of alveolar units and deliver aerosolized medications. The use of IPV to resolve challenging postlobectomy localized pneumothoraces is hereafter described. Methods. Between January 2005 and March 2009, four patients with long-term complicated postresectional residual air spaces persisting 6 months (mean, 187 days) after primary surgery were treated by IPV. The type of operation was upper lobectomy and lower lobectomywedge resection in 1 and 3 patients, respectively. Mean preoperative and immediate postsurgical forced expiratory volume in the first second of expiration were 2.31 L
and 1.49 L, respectively. Mean preoperative and immediate postsurgical forced vital capacity were 3.13 L and 2.1 L, respectively. Patients were subjected to 12-minutelong IPV sessions up to a total of 8 to 12 sessions administered every other day in an outpatient setting. Results. Complete resolution of the spaces within a mean of 22 days of beginning of treatment was noted. The post-IPV forced expiratory volume in the first second of expiration and forced vital capacity were 1.72 and 2.4 liters, respectively. No treatment-related morbidity was observed. Conclusions. Intrapulmonary percussive ventilation can be expected to decisively contribute to resolving long-term localized pneumothoraces after subtotal pulmonary resections in an outpatient setting. (Ann Thorac Surg 2010;90:1658 – 61) © 2010 by The Society of Thoracic Surgeons
S
Material and Methods
elf-limiting residual spaces after subtotal pulmonary resections usually undergo watchful observation. In rare circumstances, these localized pneumothoraces persist despite long-term drainage and may complicate with an empyema and the attendant need for additional surgical treatment along with prolonged hospitalization. Intrapulmonary percussive ventilation (IPV) is used to improve clearance of bronchial secretions in patients with severe chronic obstructive pulmonary disease, infants, and advanced neuromuscular disease [1]. Successful application of IPV results in increased alveolar recruitment and relief of atelectasis and pulmonary consolidation [1]. We hereafter report our experience with the management through IPV of persistent and complicated spaces after subtotal pulmonary resections in an outpatient setting.
Accepted for publication June 22, 2010. Address correspondence to Dr Rocco, Department of Thoracic Surgery and Oncology, Division of Thoracic Surgery, National Cancer Institute, Pascale Foundation, via Semmola 81, Naples, 80131, Italy; e-mail: [email protected].
© 2010 by The Society of Thoracic Surgeons Published by Elsevier Inc
Between January 2005 and March 2009, four patients with persistent localized pneumothoraces after pulmonary resection (mean, 187 days) were treated with IPV after failing medical treatment and physiotherapy (Table 1). There were 3 males and one female with a mean age of 64 years; two patients were current and two were former smokers. Mean preoperative and immediate postsurgical forced expiratory volume in the first second of expiration (FEV1) were 2.31 L and 1.49 L, respectively. Mean preoperative and immediate postsurgical forced vital capacity (FVC) were 3.13 L and 2.1 L, respectively. Moreover, mean preoperative Dlco (diffusion lung capacity for carbon monoxide) percentage of predicted value was 69.1%. Mean postsurgical and post-IPV treatment arterial oxygen saturation was 95% and 97.2%, respectively. All patients were asymptomatic at rest but complaining of some exertional dyspnea (category 3, according to the 0 to 10 Borg scale [2]). In all instances, IPV treatment was administered in an out-patient setting. The patients received individual 12 minute sessions every other day up to a total of 8 to 12 sessions. The IPV sessions were administered by a specialized nurse under the supervision of a dedicated 0003-4975/$36.00 doi:10.1016/j.athoracsur.2010.06.092
Ann Thorac Surg 2010;90:1658 – 61
GATANI ET AL IPV FOR LOCALIZED PNEUMOTHORACES
1659
Patient
Comorbid
Operation
BPF/OWT
Pre
Post
IPV
FEV1 3.1 (98.0%) FVC 3.87 (91.6%) FEV1 1.5 (76.1%) FVC 2.05 (85.9%) FEV1 2.24 (71.2%) FVC 3.36 (85.1%) FEV1 2.5 (80.8%) FVC 3.25 (84.5%)
FEV1 1.21 (45.1%) FVC 1.95 (56.5%) FEV1 1.16 (58.6%) FVC 1.66 (69.5%) FEV1 1.59(51.2%) FVC 2.19 (56.4%) FEV1 2.03 (65.5%) FVC 2.6 (67.4%)
FEV1 1.42 (52.7%) FVC 2.27 (65.8%) FEV1 1.36 (69.8%) FVC 1.96 (82.8%) FEV1 1.86 (60.2%) FVC 2.45 (63%) FEV1 2.26 (72.5%) FVC 2.95 (76.6%)
1
COPD
LUL
No
2
Asthma
wRLL
No
3
Renal carcinoma
LLL
Yes
4
PTCA
RLL
No
Continued
Table 1. Continued Sat 02% Pre-IPV
Sat 02% Post-IPV
Dlco mL/mm Hg/min Pre-IPV
Dlco mL/mm Hg/min Post-IPV
Duration of Space (Months)
Percussionaire 12-Minute Applications
Resolution of Space After Beginning of IPV
96%
97%
20.4 (72.8%)
25.12 (89.6%)
6
12 on alternate days
23 days
96%
97%
11.27 (67.1%)
12.44 (75.3%)
10
12 on alternate days
22 days
94%
97%
18.38 (61.8%)
19.77 (73.3%)
12 on alternate days
25 days
94%
98%
19.87 (74.7%)
25.71 (96.7%)
8 on alternate days
21 days
3 (after OWT closure) 6
FEV1 and FVC values expressed in liters. BPF ⫽ bronchopleural fistula; Comorbid ⫽ comorbidities; COPD ⫽ chronic obstructive pulmonary disease; Dlco ⫽ diffusing capacity of lung for carbon monoxide; FEV1 ⫽ forced expiratory volume in the first second of expiration; FVC ⫽ forced vital capacity; IPV ⫽ intrapulmonary percussive ventilation (posttreatment spirometry); LLL ⫽ left lower lobectomy; LUL⫽ left upper lobectomy; OWT ⫽ open window thoracostomy; Pre ⫽ preoperative spirometry; Post ⫽ postsurgical spirometry; PTCA ⫽ percutaneous transluminal coronary angioplasty; RLL ⫽ right lower lobectomy; Sat ⫽ saturation; wRLL ⫽ wedge right lower lobe.
physician. Continuous monitoring of heart rate, blood pressure, respiratory rate, and arterial oxygen saturation was applied. The necessary training to achieve the plateau of the learning curve was calculated to be 10 cycles of 10 sessions per cycle. Oscillatory pulsations were generated by a ventilator (Percussionaire; Percussionaire Corporation, Sandpoint, ID) which was able to deliver high frequency minibursts (100 to 300 cycles per minute) at a pressure of 10 to 20 cm water delivered at the patient’s mouth. The device working pressure settings varied according to the individual tolerability offered by the single patient (between pressures of 0.3 mbar at the beginning of the first session to 1.0 mbar at the end of the last session, with gradual 0.1 mbar stepwise increases). During IPV sessions, aerosolized mucolytics and bronchodilators were routinely added to the delivered mist to relieve bronchospasm and to enhance airway clearance. These were aerosolized formulations duplicating the same standard treatment regimens the patients already had been receiving in the postoperative period; typically 1 mL vial of oxitropium bromide (1.5 mg/mL), 2 mL vial of ambroxol (15 mg), and 2 mL vial of fluticasone (500 mg). During IPV treatment, under no circumstances were attempts made at evacuating air from the residual
spaces nor was external chest physiotherapy administered. Our Institutional Review Board approved this retrospective study and waived patient consent as long as patients were not identifiable. Compliance with the declaration of Helsinki was ensured for the entire duration of the study.
Results Complete lung reexpansion was obtained in all patients (Fig 1) within three weeks of beginning of treatment (mean, 22 days). Mean immediate postsurgical FEV1 and FVC were 1.49 L and 2.1 L, respectively. Mean FEV1 and FVC measured after IPV increased by 8.7% and 9.6% compared with immediate postsurgical FEV1 and FVC, respectively. Total loss of mean FEV1 and FVC compared with preoperative values was 17.7% and 14.7%, respectively. Moreover, Dlco measured at the end of IPV treatment was 83.7%; mean Dlco improvement after IPV was as high as 14.6%. In addition, mean post-IPV treatment arterial oxygen saturation was 97.2% with a mean 2.2% improvement compared with the immediate postsurgical measurement. No treatment-related complications were observed.
GENERAL THORACIC
Table 1. Patients’ Clinical Features
1660
GATANI ET AL IPV FOR LOCALIZED PNEUMOTHORACES
Ann Thorac Surg 2010;90:1658 – 61
Fig 1. Example of postsurgical outcome (A) and (B) after right lower lobectomy demonstrating persistent localized pneumothoraces (patient no. 4). After failing medical treatment and physiotherapy, the patient was subjected to intrapulmonary percussive ventilation with satisfactory results (C) and (D).
GENERAL THORACIC
Comment Intrapulmonary percussive ventilation, a term coined by Bird in the 1980s [1], belongs to the modalities of noninvasive ventilation aimed at clearing secretions and enhancing oxygenation, especially in pediatric patients with cystic fibrosis [3, 4]. Reportedly, IPV facilitates airway clearance and expansion through “radial displacement” of the bronchial wall and by generating pulsatile expiratory flows of greater magnitude than the inspiratory ones at each respiratory cycle [5]. From a clinical standpoint, the use of IPV primarily translates into increased sputum production and resolution of atelectatic parenchymal areas demonstrated by radiologic criteria [5]. Improved gas exchange and spirometry tests as well as distribution of aerosolized medications have also been observed, although no conclusive evidence is available [5]. In fact, IPV has been successfully used in acute exacerbations of chronic obstructive pulmonary disease due to the potential to improve depth of breathing and oxygen delivery to the alveoli by balancing the gas exchange and enhancing carbon dioxide washout [1, 6]. In an outpatient setting, IPV can be administered through a volume-oriented ventilator with the addition of a pneumatic powered device capable of delivering mini bursts of high flows of air at a high rate per minute. This front of high velocity percussive flow recruits distal alveolar lung units by mobilizing secretions; at the same time, aerosolized mixtures can be distributed to facilitate relief of acute inflammation and bronchial spasm. The percussive cycle is physician or patient assisted in as much as, while spontaneously breathing through the nozzle, the patient can trigger the intrapulmonary per-
cussion cycle. The IPV has been successfully administered to complement chest physiotherapy in the immediate postoperative period after cardiac surgery or in tracheotomized patients after pulmonary resections [7, 8]. Moreover, the IPV treatment proved effective in reducing persisting pulmonary consolidations [9, 10]. Recently, Lucangelo and colleagues [11] reported that IPV was effective in significantly reducing hospitalization by improving the perioperative course of patients undergoing pulmonary resections. To the best of our knowledge, the concept of managing persisting air spaces by improving reexpansion of the residual lung to lobar or sublobar resections after all conventional measures have failed by IPV is new. As a rule, postoperative incomplete reexpansion is observed when it is not associated to increasing dyspnea or signs of impaired oxygenation. The latter usually mandates air evacuation through a chest drain with the attendant prolonged length of hospital stay. Likewise, a thoracostomy tube is inserted in the asymptomatic patient if a longstanding, significant lung collapse is associated to visible thickening of the parietal pleura or the residual space is at risk for infection. Our limited experience indicates the possibility to manage such patients conservatively in an outpatient setting by subjecting them to well-tolerated IPV regimens which may lead to complete reexpansion of the residual lung. Although we cannot provide conclusive evidence of the superiority of IPV over watchful observation or the administration of inhaled mucolytics and bronchodilators by an experienced physiotherapist, we believe IPV may be a useful adjunct to the management protocols of resected patients, particularly in the noninvasive man-
agement of residual localized pneumothoraces in an ambulatory setting [12]. Nevertheless, larger series are warranted to confirm this initial experience.
References 1. Lucangelo U, Fontanesi L, Antonaglia V, et al. High frequency percussive ventilation (HFPV). Principles and technique. Minerva Anestesiol 2003;69:841– 8. 2. Borg GA. Psychophysical bases of perceived exertion. Med Sci Sports Exerc 1982;14:377– 81 [Article in English, Italian]. 3. Organized jointly by the American Thoracic Society, the European Respiratory Society, the European Society of Intensive Care Medicine, and the Société de Réanimation de Langue Française, and approved by ATS Board of Directors, December 2000. International Consensus Conferences in Intensive Care Medicine: noninvasive positive pressure ventilation in acute respiratory failure. Am J Respir Crit Care Med 2001;163:283–91. 4. Varekojis SM, Douce FH, Flucke RL, et al. A comparison of the therapeutic effectiveness of and preference for postural drainage and percussion, intrapulmonary percussive ventilation, and high-frequency chest wall compression in hospitalized cystic fibrosis patients. Respir Care 2003;48: 24 – 8. 5. Chatburn RL. High-frequency assisted airway clearance. Respir Care 2007;52:1224 –35.
GATANI ET AL IPV FOR LOCALIZED PNEUMOTHORACES
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6. Antonaglia V, Lucangelo U, Zin WA, et al. Intrapulmonary percussive ventilation improves the outcome of patients with acute exacerbation of chronic obstructive pulmonary disease using a helmet. Crit Care Med 2006;34:2940 –5. 7. Shinozaki T, Deane RS, Perkins FM, et al. Comparison of high-frequency lung ventilation with conventional mechanical lung ventilation. Prospective trial in patients who have undergone cardiac operations. J Thorac Cardiovasc Surg 1985;89:268 –74. 8. Clini EM, Antoni FD, Vitacca M, et al. Intrapulmonary percussive ventilation in tracheostomized patients: a randomized controlled trial. Intensive Care Med 2006;32:1994 –2001. 9. Birnkrant D, Pope J, Lewarsky J, Stegmaier J, Besunder J. Persistent pulmonary consolidation treated with intrapulmonary percussive ventilation: a preliminary report. Pediatr Pulmonol 1996;21:246 –9. 10. Yen Ha TK, Bui TD, Tran AT, Badin P, Toussaint M, Nguyen AT. Atelectatic children treated with intrapulmonary percussive ventilation via a face mask: clinical trial and literature overview. Pediatr Int 2007;49:502–7. 11. Lucangelo U, Antonaglia V, Zin WA, et al. High-frequency percussive ventilation improves perioperatively clinical evolution in pulmonary resection. Crit Care Med 2009;37: 1663–9. 12. Blanch L, Villar J, López-Aguilar J. High-frequency percussive ventilation: an old mode with a great future. Crit Care Med 2009;37:1810 –1.
INVITED COMMENTARY The article by Gatani and colleagues [1] describes the use of intrapulmonary percussive ventilation (IPV) to manage residual postoperative air spaces in a series of 4 patients who were asymptomatic at rest but reported dyspnea on exertion. As a form of chest physiotherapy, IPV vibrates the airways internally for secretion management and recruitment of atelectatic lung parenchyma. This is in contrast to manual percussion, which vibrates the airways externally. The results of this study are interesting and encouraging. This small case series demonstrates the resolution of postoperative air spaces, and more importantly the overall improvement of pulmonary function as measured by forced expiratory volume in 1 second, forced vital capacity, and Dlco. The main advantage of IPV in comparison with the traditional method for evacuation of air space (eg, thoracostomy tube) is that IPV is noninvasive and it can be administered in the outpatient setting. The efficacy of IPV in comparison with traditional chest physiotherapy (with or without bronchodilators) is unclear, because there is no control present. A persistent pleural space after lung resection should be the exception rather than the norm, especially for wedge resection or lower lobectomy. Although the cause of the residual air spaces in this series of patients is unclear (except for the 1 patient with the bronchopleural fistula and open pleural window), the importance of chest tube management with
© 2010 by The Society of Thoracic Surgeons Published by Elsevier Inc
good pulmonary toilet to optimize lung expansion in the perioperative period can not be overemphasized. Nonetheless, the authors [1] demonstrate that IPV is a useful noninvasive technique for managing the difficult, yet unusual, problem of long-term residual air space after pulmonary resection. Although pulmonary function was improved with the application of IPV, the incremental increases are modest and may not necessarily translate to improved symptoms. Further study is necessary to determine whether the time and expense of this technology can be justified for such an infrequent problem in which patients are often relatively asymptomatic. Betty C. Tong, MD, MHS Department of Surgery Duke University Box 3531 Duke University Medical Center Durham, NC 27710 e-mail: [email protected]
Reference 1. Gatani T, Martucci N, La Rocca A, et al. Management of localized pneumothoraces after pulmonary resection with intrapulmonary percussive ventilation. Ann Thorac Surg 2010;90:1658 – 61.
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Ann Thorac Surg 2010;90:1658 – 61