Use of High Velocity Nasal Insufflation (HVNI) in Reversal of Multifactorial Acute Respiratory Failure and Prevention of Tracheal Intubation in a Pediatric Patient in the Emergency Department

Dennis Perusso • Patrícia Vieira Gorgonio • Fernanda Alves Ferrante • Jefferson Kiyoshi Segalla Mizutani • Karen Florio Mediotti • Leonardo Emerson Duque Salas • Patrícia Coimbra Silva • Patrícia da Silva Oliveira

Vapotherm’s Hi-VNI® Technology is a tool for treating the signs and symptoms of respiratory distress. The enclosed materials describe certain outcomes in relation to the use of Vapotherm’s Hi-VNI Technology, but individual results may vary. Practitioners should refer to the full indications for use and operating instructions of any products referenced herein before prescribing them.

 

Introduction
Pediatric respiratory emergencies are among the most frequent causes of hospital admission1,3. This is why early recognition and immediate treatment are essential in preventing cardiorespiratory arrest.

Case Presentation
On an afternoon in April of 2017, a couple brought their 10-month-old daughter to the emergency room of a 638-bed hospital in São Paulo, Brazil. They reported that the child was experiencing respiratory distress and had been diagnosed with bronchiolitis at a different medical facility two days prior. Based on the parents’ report, the child had experienced an onset of symptoms four days prior, indicating that the patient might be experiencing severe bronchiolitis symptoms.

The patient was agitated and tearful, with clear and visible signs of acute respiratory failure such as sweating, tachypnea, use of accessory musculature, paradoxical breathing with intense use of abdominal musculature, retractions, nasal flaring and hypoxemia with a cutaneous pallor. Her vital signs upon admission to the emergency department (ED) showed distress, with a respiratory rate of 85bpm, pulse oxygen saturation at 72% in ambient air (FiO2 21%), heart rate at 192bpm, blood pressure 105×72 mmHg, a body temperature of 38.3°C, and capillary filling time greater than 3 seconds showing lacy skin, indicating a poor perfusion.

Treatment and Response
After five minutes of assessing the patient and establishing the seriousness of the case, the medical team suggested intubation rather than NIV or CPAP. However, the physiotherapy team suggested placing the patient on Hi-VNI Technology, trying to avoid the intubation as well as a possible respiratory arrest and consequent cardiac arrest.

After approximately six minutes in the ED, the physiotherapy team initiated High Velocity Nasal Insufflation (HVNI) via (Precision Flow®; Vapotherm® pediatric cannula).

We calculated the flow needed to be between 10 and 20 L/min, based on the patient’s weight and work of breathing. We started with a flow of 10L/min and after five minutes of acclimation, we gradually raised it to 15 L/min. We started with a FiO2 of 100% and reduced it by 40% within approximately 40 minutes. The device was set at 36°C the entire time. The patient experienced improvement in the signs of acute respiratory distress within the first ten minutes of being placed on HVNI. The respiratory rate fell by approximately 50% and the patient showed a reduction of dyspnea, improvement of oxygen saturation (97% with FiO2=45%), improvement of cyanosis signs and hypoxemia. The patient reached a full reversal of acute respiratory distress within one hour of her arrival in ED. After one hour and 30 minutes the patient was already stabilized, calm and wanting to feed. Based on the patient’s stable condition, feeding was authorized, but the patient was maintained on HVNI during feeding.  Her score number of 1 in the emergency severity index—which was considered severe enough for ICU admission—became a 4 after two hours on HVNI. She was admitted to a pediatric ward and hospitalized for approximately 4 days. This duration encompassed the whole symptomatic cycle of bronchiolitis so that we could ensure that she did not decompensate upon discharge.

Interpretation
We believe that the key to this patient’s success as well as similar results we’ve seen in our ED, is due not only to a highly trained team, but to HVNI. As determined by MILLER & COLS in 2016, the technology enables respiratory muscle relief and reduces work of breathing, while the rapid flushing of CO2 from the extrathoracic dead space results in improved physiologic ventilation outcomes.

The ventilatory support along with the oxygenation that the technology provided through humidified and comfortable gas delivery contributed to the positive outcomes in this case.

Conclusion
This case report describes the effective use of HVNI in the management of acute bronchiolitis in a small child. The rapid application of HVNI appeared to effectively manage the acute respiratory distress demonstrated by the patient, who would likely otherwise been intubated and placed on mechanical ventilation. This case report is consistent with other experience within this hospital, in management of acute respiratory distress among such pediatric patients, suggesting a safe and effective alternative management tool.

We believe that this technology may prevent the use of invasive mechanical ventilation and ICU admission. It is important to note that we have experienced similar results repeatedly, not only in this case, but in all similar cases so far.

 

References

1. McDermott KW, Stocks C, Freeman W. Overview of Pediatric Emergency Department Visits, 2015. HCUP Statistical Brief #242. August 2018. Agency for Healthcare Research and Quality, Rockville MD. https://www.hcup-us.ahrq.gov/reports/statbriefs/sb242-Pediatric-ED-Visits-2015.pdf.
2. Miller TL, Saberi B, Saberi S. Computational fluid dynamics modeling of extrathoracic airway flush: evaluation of high flow nasal cannula design elements. J Pulmon Respir Med. 2016;6:376.
3. Rotta A, Wiryawan B. Respiratory Emergencies in Children. Respiratory Care. 2003;48:3.
2019-03-25T08:57:15-04:00Mar 19|Patient Case Studies|