1)Kumagaya General Hospital, 2)Saimtama Medical University Hospital 89L /143 The effect of biphasic extrathoracic cuirass ventilation for acute respiratory failure in children Yutaka　Ueda1) Kuniyuki　Okada2) 1)Kumagaya General Hospital, 2)Saimtama Medical University Hospital

Introduction There are many reports that noninvasive positive pressure ventilation via mask(NIPPV) is effective intervention in patients with acute respiratory failure(ARF). We treat with the Biphasic Cuirass Ventilation (BCV) as a first-line intervention in children’s ARF. We usually treat by BCV using continuous negative pressure mode and secretion clearance mode. We’ll show you what is BCV and the study for ARF in children treated by BCV in our hospital. ●

What is BCV? BCV applies a negative or positive inspiration expiration diaphragm diaphragm BCV applies a negative or positive pressure within the cuirass, and supports a patient’s spontaneous breathing. 左がRTXの写真です。 キュイラスと呼ばれる胸当てを胸腹壁に密着させ、キュイラス内に陰圧と陽圧をかけることにより胸壁と横隔膜の動きをコントロールし換気の補助を行います。 これは強制換気ではないため自発呼吸がある症例が大前提となります。 Cuirass

Modes Continuous negative pressure Secretion clearance Control mode This mode applies only a negative pressure within the cuirass. The patient can breathe easily because their lung was expanded. Secretion clearance This mode applies a negative and a positive pressure within the cuirass alternately to vibrate the patient’s chest wall. This mode can thin secretions like a physical therapy. Control mode This mode applies a negative and a positive pressure within the cuirass alternately. This mode provides full control over the patient’s respiration without synchronization. Respiratory triggered This mode provides full control the patient’s respiration synchronized with their inspiration only. Respiratory synchronized This mode provides full control over the patient’s respiration (inspiration and expiration) with synchronization. ● モードの種類です。 Continuous negative mode（以下CNと略します）：キュイラス内を陰圧にすることにより横隔膜を下げ、胸郭を広げ、呼吸の補助を行うモードです。 Secretion clearance mode（以下CLと略します）：キュイラス内に短時間に陽圧と陰圧を交互にかけ、胸壁に振動を与えることにより気道分泌物の排出を促進する、言わば肺理学療法を行うモードです。 このほかControl mode、Trigger modeとありますが当科で使用しているのは上の2つのモードのみです。

Benefit Fault Simple and easy to set on or off, Support the patient’s breathe physiologically, Increase patient’s tidal volume（improve oxygenation）, Increase venous return（decrease CVP, increase urine output）, The pressure applied within the cuirass acts uniformly over the thorax. The lung expansion is also uniform ventilating all areas of the lungs. Maintain the quality of life（eat, feed, speak), Secretion Clearance mode make expectorations. In positive pressure ventilation’s complications (ex. barotrauma, volutrauma, pnuemothorax and ventilator associated pneumonia) are of no relevance with BCV. Fault Skin damage arises due to an excess of pressure. Air leakage (it does not fit) makes temperature decrease. It is necessary for small children not to remove cuirass. RTXの利点です まず簡単であること 陽圧換気のような強制的な換気ではなく、生理的な換気であることが挙げられます 胸郭を広げることによる換気量の増加 胸郭内を陰圧にすることによる静脈環流量の増加。これによりCVP減少、尿量増加の効果があります 肺全体に均一に圧がかけられると、換気の不均等分布を起こしにくくなります。 経口摂取が可能 などが挙げられます

How to use in our Hospital Continuous negative mode Inspiratory：-10cmH2O Secretion clearance mode Vibration mode： Inspiratory -10cmH2O, Expiratory +10cmH2O, Frequency 600cpm, 2 minute Cough mode： Inspiratory −10cmH2O, Expiratory +5cmH2O, Respiratory Rate 20/min, I:Eratio=5:1, 1 minute Each secretion clearance session is doing both modes represents 4 cycles, and 3-4 times a day.

A case of severe ARF due to RS Virus infection 1 month, Male History Cough and rhinorrhea appears 6days, apnea and poor feeding appears 3days before admission. He visited a primary doctor and carried our hospital because of respiratory distress (SpO2 was 80%). He was born at 37 weeks with 2578g and is delivery was normal. He has no cardiac diseases. Physical findings SpO2 was 92%（Oxygen 3L/min） He had cyanosis and groaned. Breath sound was poor, and heard rale. Labo data WBC 9100/μL, RBC 290x104/μL, Hb 9.0mg/dL, PLT 38.5x104/μL Na 119mEq/L, K 5.3mEq/L、CRP 1.58mg/dL Blood Gas(vein)：pH 7.175, pCO2 88.5mmHg, pO2 85.3mmHg RS Virus Antigen on nasal discharge (+)

Continuous Negative Pressure Clinical course Secretion Clearance BCV Continuous Negative Pressure discharge 10L/min 5L/min 1L/min 0.5L/min O2 (mmHg) (%) PCO2 SpO2 SpO2 PCO2 RSVにRTXを使用した代表的な症例の経過です。 pCO2　88.5と高炭酸ガス血症を認めましたがＣＮ持続陰圧モードで行いpCO2は速やかに改善しました。また同時に経腸栄養を開始することができました。 このようにRTXがRSウイルス感染症に有効であることがおわかり頂けたと思います。 次に全体像をお示しします。 PCO2 was improved in 3 hours. The duration of hospital stay (day)

Aim To evaluated the effect of BCV in ARF, we compared BCV with conventional positive pressure ventilation. Method We had a retrospective study to analyze the clinical data of patients with ARF admitted in Saitama Medical University Hospital from April 2006 until March 2010. 52 patients were enrolled in this study. Patients were categorized 3 groups according to the mechanical ventilation method: conventional mechanical ventilation (CMV) noninvasive positive pressure ventilation via mask (NIPPV) biphasic cuirass ventilation with continuous negative pressure (BCV). Multiple comparisons were performed by a Fisher PLSD test by Stat view®.

Demographic data（n=52） Sex, M：F Age, year Height, cm Weight, kg CMV：n＝6 NIPPV：n=6 BCV：n=40 Sex, M：F 5：1 1：5 21：19 Age, year 2.41±1.3 （0.82） 0.12±0.023 （0.13） 0.84±0.34 （0.16） Height, cm 76.4±9.5 ※1 （72.0）　 51.7±1.7 （51.0） 62.0±3.0 （57.0） Weight, kg 9.6±2.3 （8.3） 3.5±0.37 （3.3） 7.02±0.86 （5.4） Birth week, weeks 36.8±2.4 （39.1） 37.3±0.80 （37.5） 38.1±0.38 （38.0） Birth weight, kg 2.72±0.51 （2.82） 2.43±0.15 ※2 （2.57）　 3.02±0.093 （3.02） ● （）is median. ※1 Height: CMV vs. NIPPV P-value 0.036 ※2 Birth weight：BCV vs. NIPPV P-value 0.014

The details of acute respiratory failure （n=52） The number of lower respiratory tract infection was 48(92%), especially RSV infection was 41(79%).

The comparison of the effect pre and post treatment PCO2 RR SpO2 (mmHg) (/min) (%) 24hr 24hr hr prePCO2：BCV vs. CMV P-value=0.006, CMV vs. NIPPV P-value 0.048 preSpO2：CMV vs. NIPPV P-value=0.047 ● NIPPVとBCVは同等の効果あり。 BCV and NIPPV were similar effect on improvement. PrePCO2 of CMV was significant higher than BCV and NIPPV. PreSpO2 of CMV was significant lower than NIPPV. It means the patients with extremely severe ARF was treated by CMV.

The comparison of treatment period in 3 groups Mechanical ventilation time Duration of hospital stay （hour） （day） P=0.004 P<0.001 P<0.001 P=0.001 BCV and NIPPV Mechanical ventilation and duration of hospital stay were more shorter than CMV.

The number of cases using 3types of mechanical ventilation（n=52） 2006年よりRTX、NIPPV導入し挿管数減少 CMV decreased after 2006.

PCO2, RR and SpO2 when ventilator started （mmHg） （/min） （%） P=0.021 P=0.029 Ventilation was started milder case of ARF than 2005(CMV only).

BCV prevented to intubate. ＝93.0％ NIPPV can avoid CMV reports. Authors Year Patients(n) Success reference Benhamou　et al. 1992 30 60% Chest 1992;102:912-917 Meduri et al. 1996 132 65% Chest 1996;109:179-193 Guilherme et al. 2008 458 62.6% Crit Care Med 2008;36(2):441-447 雑誌の名前を入れた方がよい。 BCV prevented to intubate more than NIPPV.

Result BCV is simple and easy to start and stop, when you want to use. Continuous negative pressure mode is suitable for the infant. Because it is not necessary to synchronize infant’s spontaneous respiration. The treatment period of BCV is shortened, and the medical expense can be reduced. It has the possibility to make it prevent serious illness-ization by early treatment of BCV. ●

Conclusion BCV is beneficial as a first-line intervention for children with ARF because it is easy and effective.