The Use of High Velocity Therapy with Inline Nebulization in Avoiding Intubation and PICU admission in Status Asthmaticus complicated by a COVID-19 Infection (ILD)
By Dr. John Misdary
Vapotherm’s high velocity therapy is a tool for treating respiratory distress. Although individual results may vary, Vapotherm believes this case study is an example of the clinical benefit Vapotherm’s high velocity therapy can have in the PICU. Practitioners should refer to the full indications for use and operating instructions of any products referenced herein before prescribing them.
Asthma is the most common chronic disease in childhood. Acute asthma exacerbations are one of the most common reasons for presentation to the Emergency Department (ED) and for hospitalization in the pediatric age. In the United States, among asthmatic children nearly 60% have one or more acute exacerbations each year and up to 20% require ED visits annually. Moreover, asthmatic patients treated in the ED are at higher risk for future exacerbations and any single severe acute episode may progress to life-threatening respiratory failure. Severe asthma exacerbations can be triggered by viral infections.
Patient History and Presentation
A 4 year-old male presented to a Pediatric Emergency Department in West Florida via private vehicle with a chief complaint of wheezing. He has a history of severe asthma and with frequent exacerbations, numerous admissions including a pediatric intensive care unit (PICU) admission that required intubation in the last six months. The family was from out of town and may have been exposed to a family member who was COVID-19 positive at a reunion a few days prior. He is on Singulair, Flovent, and Zyrtec daily and uses albuterol per his asthma action plan. He presented with his mother in acute respiratory distress, tachypneic, occasional wheezes with severe retractions, and cold and clammy with a capillary refill of 3-4 seconds. He had been coughing more frequently in the past few days but got worse in the 24 hours prior to arrival. He had been compliant with his daily medications and family had used his albuterol MDI with spacer six times in the last 24 hours without any improvement. On arrival, the patient had an initial pulse oxygen saturation (SpO2) of 76% on room air. The patient was anxious and fighting during vital signs and initial assessment. He was found to have an oral temperature of 38.3°C, respiratory rate of 58 breaths per minute(bpm) and heart rate of 143 beats per minute. An accurate blood pressure was not able to be obtained in triage. He had a weight of 20 kilograms(kg). The patient was agitated and had a weak cry.
Treatment and Response
The child was taken immediately back from triage to a resuscitation room and the attending physician and respiratory therapist were immediately called to the room to meet the patient. The patient was in acute respiratory distress and met criteria for a sepsis alert. He was placed on the cardiac monitor and pulse oximeter. He was given 300mg of rectal acetaminophen for the fever and a peripheral IV was placed and secured. The decision was made to place the child on Vapotherm’s high velocity therapy with the nasal cannula that provided inline nebulization as it was unlikely that the child would tolerate a facemask for treatment due to his agitation. After the nasal cannula was secured, high velocity therapy was started at a flow of 40 liters per minute (L/min) and 70% fraction of inspired oxygen (FiO2). The patient was started on 15mg of albuterol with 1mg of Atrovent as an hour long continuous in-line nebulizer treatment to maintain uninterrupted delivery of high velocity therapy. He was given Magnesium Sulfate 400mg IV over 30 min, Decadron 12mg IV, and a 400ml Lactated Ringer’s (LR) bolus due to concerns for COVID-19. He had a complete blood count (CBC), comprehensive metabolic panel (CMP), arterial blood gas (ABG), Respiratory viral panel, Lactate, Blood Cultures, C-reactive protein (CRP) and portable chest x-ray (PCXR) performed per sepsis protocol.
Within 30 minutes of the initiation of therapy, the patient was calm and laying in his mother’s lap watching cartoons. He was asking for a drink of water, his color had improved, and SpO2 readings were between 92-93%. His respiratory rate dropped to 42 bpm and the high velocity therapy settings were reduced to 50% FiO2 and a flow of 35 L/min. His PCXR showed increase perihilar markings consistent with a viral infection and his initial ABG showed a pH of 7.29, partial pressure of carbon dioxide (PaCO2) of 42, partial pressure of oxygen (PaO2) of 71 and bicarbonate (HCO3) of 20 consistent with primary respiratory acidosis. CBC showed a white blood cell count (WBC) of 3.2 but otherwise it was normal as was CMP with exception of HCO3 which was 16. One hour later, which was 30 min after completion of his nebulizer treatment, his respiratory rate was 43 bpm and SpO2 was 95%. The high velocity therapy settings were weaned to 25 L/min and 35% FiO2. His viral panel came back positive for COVID-19 and Rhinovirus. His CRP was 1.6 and Lactate was 2.9. He was given an additional treatment of albuterol 5mg while receiving high velocity therapy and continuously monitored.
Another ABG was drawn after two hours after initiation of high velocity therapy, resulting with pH of 7.37, PaCO2 of 36, PaO2 of 111, and Lactate of 1.9. The patient was more comfortable at this time with only mild retractions and a respiratory rate of 32 bpm and heart rate of 113 beats per minute. He had normal speech, good color, brisk capillary refill, and mild diffuse wheezes. Rather than being placed on NiPPV or intubated and being admitted to the PICU for his respiratory distress, he was admitted to the pediatric floor on high velocity therapy on Albuterol 5mg every 2-4 hours. Over the course of the next 24 hours the high velocity therapy was weaned and discontinued. He was placed back on his home meds and transitioned to oral steroids. His fever resolved, he was on Albuterol 5mg every 4 hours, and eating normally. Blood Cultures were negative after 48 hours and a repeat PCXR was normal. He was discharged home on day 3 with follow up arranged with his home pediatric pulmonologist 48 hours after discharge.
Management of status asthmaticus with a concomitant COVID-19 infection in a septic pediatric patient poses challenges. With an irritable pediatric patient, less is always more. Getting the child calm while attempting evaluation and treatment is essential in this patient. This case report describes the successful intervention of high velocity therapy in the management of pediatric status asthmatics with sepsis secondary to a COVID-19 infection. The child presented with substantial hypoxia, work of breathing and agitation. High velocity therapy aided in the ability to provide management for this critically ill patient, that is as invasive as a nasal cannula, and provides both respiratory support and nebulized treatments with no additional equipment. A recent study of administration of continuous nebulized albuterol via high flow nasal cannula led to a greater than fourfold increase in drug delivery compared to a nebulizer with a face mask1. The early implementation of high velocity therapy helped provide adequate ventilatory support for this septic COVID-19 patient in respiratory distress and permitted management of the patient on the floor avoiding the use of PICU bed and avoiding the escalation of care.
Learn more about high velocity therapy use in pediatric patients.
 Moody GB & Ari A. Quantifying continuous nebulization via high flow nasal cannula and large volume nebulizer in a pediatric model. Pediatric Pulmonology. 2020;55:2596–2602. DOI: 10.1002/ppul.24967