1. INTERNATIONAL STUDY: USE OF HIGH FREQUENCY CHEST WALL OSCILLATION (HFCWO) IN SECRETION MANAGEMENT IN MECHANICALLY VENTILATED PATIENT.
Antonio Esquinas, MD, PhD (1), Mantellini Ennio MD(2), Francisco Leon Benitez MD (4); Jesus Cortes N (4), Javier Miralles N (4); G. González Díaz MD (1).
Perrero L MD (3), Gatta A PT (3), Decorato N. PT (2), Scarpa S (2)
and Brian Becker, MEd, RRT (5).
(1) Intensive Care Unit, Hospital Morales Meseguer, Murcia (Spain)
(2) Respiratory and Cardiac Rehabilitation Department of Rehabilitation, Alessandria Hospital (Italy); (3) Neurologic Rehabilitation Department of Rehabilitation, Alessandria Hospital ( Italy); (4); Intensive Care Unit. Hospital Comarcal de Melilla (Spain) and (5) Hill-Rom Inc., St. Paul, Minnesota, USA.
HFCWO- Working Group in Critically
Partial funding support in the form of devices was provided by Hill-Rom Inc.

2. BACKGROUND
Frequently mechanically ventilated patients may show clinical conditions associated with bronchial secretions. Adequate airway clearance is key therapeutic factor to facilitate gas exchange and prevent complications (endotracheal occlusion tube, atelectasia, ventilator associated pneumonia (VAP), difficult weaning, etc) (1).
High-Frequency Chest Wall Oscillation (HFCWO) is a “noninvasive mechanical method” for airway secretions (2) that improve bronchial clearance by high external oscillatory compression in pediatric and some adults respiratory diseases.
However, there is scarce information related application in adults mechanically ventilated patients.
(1). Jelic S, Clinical review: airway hygiene in the intensive care unit. Crit Care. 2008;12(2):209.
(2). Gosselink R, et al. Physiotherapy for adult patients with critical illness: recommendations of the
European Respiratory Society and European Society of Intensive Care Medicine Task
Force on Physiotherapy for Critically Ill Patients. Intensive Care Med Jul;34(7):

3. AIMS & DESIGN 1-OBJECTIVES:
To Analyze: 1) Effects of early and aggressive airway clearance
secretions, 2) tolerance and 3) complications during
different options of mechanical ventilation (invasive or
noninvasive) with application of HFWCO.
2-DESIGN:
International multicenter prospective observational study in
three European hospitals (Spanish (n=2) and Italian (n=1)
with experience in HFCWO.
3-SETTING:
Polyvalent Intensive Care Units (n=2).
Respiratory and Cardiac Rehabilitation Department (n=1).
Neurologic Department of Rehabilitation (n=1).   

4. METHODS & PATIENTS
HFCWO: Patients were treated with high-frequency chest wall oscillation (HFCWO) to control bronchial secretions.
HFCWO protocol:
Device Vest- Hill Rom-Model 104; Hz (5, 10, 15) guided by PEF/PIF ratios follow twice per day for 15 minutes per session.Cardiopulmonary monitoring and gas exchange.
Figure Nº1. Patient mechanically ventilated with HFCWO

5. RESULTS & PATIENTS-2
HFCWO protocol- Fig Nº2,3,4,5,

6. RESULTS & PATIENTS-1
Over a two years period (March ). 1-POPULATION: We enrolled 127 patients with clinical conditions associated with ARF respiratory failure requiring mechanical ventilation by noninvasive mechanical ventilation (NIV), invasive mechanical ventilation ( IMV) by endotracheal tube or tracheostomy. 2-DEMOGRAPHY DATES: Age = years; female = 32 (25.19%). APACHE II score = SAPS II score = Days mechanical ventilation = days.

7. RESULTS & PATIENTS-2 3- TYPE VENTILATORY SUPPORT:
Fig Nº6
3- TYPE VENTILATORY SUPPORT:
Tracheostomizated = 24 (18.89%).
Noninvasive mechanical ventilation (NIV) = 14 (11.02%).
Invasive mechanical ventilation: 89 (70.07%).

8. RESULTS& PATIENTS -3
Type ARF in the mechanically ventilated patients associated with bronchial secretions:
GROUP A = ARF-medical lung diseases n=29
Infections n=20
Non infections diseases n=18
Skin disease n= 1
Urologic n= 1
Urinary n= 3
Neuromuscular diseases n= 13
GROUP B = ARF-Postoperative abdominal surgery n=54
GROUP C = ARF-Difficult weaning n= 24
GROUP D = ARF-Atelectasis n = 20
Total n=127

9. RESULTS & PATIENTS-4 1- AIRWAY CLEARANCE.
Effective, based on amount of secretions cleared and improvement in oxygenation index, was achieved in
126 patients (99.2%).
2- GAS EXCHANGE (pre- vs post-HFCWO).
pH: ± .05 vs 7,37 ± .05 (p=.029)(*)
PaO2: ± 16   vs ± 28 (p= .004) (*)
PCO2: ± .17  vs ± .23 (p= .101) (NS)
SaO2: ± .3.1 vs 96,56 ± 2.82.
FiO2 : 49±.17 vs 46±.23.

10. RESULTS & PATIENTS-5 3- VENTILATOR ASSOCIATED PNEUMONIA (VAP).
7% (9 of 127 patients) (pre-study-15% (year 2006) and 20% ( year-2007).
4- ATELECTASIS.
Resolution in 16 of 20 subjects (80%) ( Slide Nº 11).
5- WEANING.
107 mechanical ventilated patients (84.25%) were successfully weaned in days.
6- ICU-MORTALITY.
n= 33 (25.9%).

11. Figure Nº7. Case of ATELECTASIS-HFCWO.
2-After HFCWO
1-Before- HFCWO
Left atelectasia with total lung colapse.

12. CONCLUSIONS & PRESPECTIVES
HFCWO is an effective “noninvasive” therapeutic method for common complications related with airway secretions during differents forms of mechanical ventilation ( invasive or noninvasive options).
Early application in selected patients following a specific protocol knowing interaction among HFCWO-ventilator –patient is crucial.
Future clinical trials are necessary to establish and define more specific recommendations in mechanically ventilated patients.
Partial funding support in the form of devices was provided by Hill-Rom Inc.