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 does not practice medicine or provide medical services or advice. 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 an emergency department setting.

Introduction
Pediatric respiratory emergencies are among the most frequent causes of hospital admission^1,3. 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 Vapotherm high velocity therapy, 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 therapy 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 high velocity therapy. 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 high velocity therapy 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 high velocity therapy. 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 high velocity therapy. 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 high velocity therapy in the management of acute bronchiolitis in a small child. The rapid application of high velocity therapy 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.