Respiratory Medicine Case Reports 22 (2017) 232e234

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Respiratory Medicine Case Reports

journal homepage: www.elsevier.com/locate/rmcr

Case report

Innovative chest physiotherapy techniques (the MetaNeb® System) in

the intubated child with extensive burns
Alexandra Ferguson*, Sarah Wright
Children's Health Queensland Hospital and Health Service, Brisbane, Australia

a r t i c l e i n f o a b s t r a c t

Article history: Introduction: The Metaneb® is a new generation Intrapulmonary Percussive Ventilation device utilised
Received 27 June 2017 by the physiotherapist to assist airway clearance by providing calibrated oscillations during inspiration
Received in revised form up to 3.8Hz. Predominantly used in the adult chronic respiratory patient, with anecdotal evidence in
22 August 2017
intubated patients, it was also proven to be safe in a paediatric lung model lab study. This case report
Accepted 23 August 2017
outlines the first use of the Metaneb® with an intubated child in Australia. The 8 year old patient was
retrieved to Lady Cilento Children's Hospital with 61% total body surface area flame burns. The child was
difficult to ventilate, immobile, and had retained secretions. The chest x-ray (CXR) demonstrated
multifocal regions of atelectasis.
Study objectives: To report safe and effective use of the Metaneb® airway clearance in the paediatric
intubated patient.
Methods: The Metaneb® was applied using an open ended bagging circuit on Continuous High Frequency
Oscillation mode for a period of 10 min per treatment. The circuit contained an inline nebuliser con-
taining 5ml 0.9% normal saline. PEEP was maintained and variable volume breaths were delivered with
suction performed as required. Outcome variables to be measured included sputum weight and quality,
CXR, and Peak Inspiratory Pressure (PIP) values pre and post treatment. Vital signs were monitored
throughout.
Results: The patient's vital signs remained stable throughout intervention. After 4 days of treatment
twice daily, there was resolution of focal changes on CXR, improvement in secretions, a reduction in PIP
and the patient was extubated.
Conclusion: The Metaneb® was used safely and effectively in this patient to assist in resolution of res-
piratory pathology. Metaneb® provided a new option for physiotherapy treatment when positioning and
handling restrictions limited usual care. This ultimately optimised PICU Length of stay and patient
morbidity and mortality. Metaneb® provided by Hill-Rom Australia.
Crown Copyright © 2017 Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND
license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction reports ref. [4] and in ventilated paediatric patients a retrospective

The MetaNeb® System is a therapeutic device utilized by the
physiotherapist to assist with airway clearance and lung expansion
by providing a simultaneous combination of positive pressure,
continuous high frequency oscillations and aerosol delivery. This
type of therapy has been used in adult chronic respiratory patients
ref. [5] and there is previous evidence in the management of atel-
ectasis in children ref. [2]. In the critical care setting there are case
* Corresponding author. Physiotherapy Department, Level 7a, Lady Cilento Chil-
dren's Hospital, 501 Stanley St, South Brisbane, QLD 4101, Australia.
E-mail address: AlexandraH.Ferguson@health.qld.gov.au (A. Ferguson).
review ref. [3] and benchtop study ref. [1]. This case report outlines
the first use of The MetaNeb® System with an intubated child in
Australia.
2. Case summary
An 8-year-old boy, previously well, presented to a small regional
hospital in Queensland, Australia following a significant flame burn
injury. He was subsequently retrieved to a larger regional hospital
where he was intubated and ventilated for debridement of the
burns. The Total Body Surface Area affected by burns was classified
as 61%. Day 3 post injury the child was retrieved to a tertiary Pae-
diatric Intensive Care Unit (PICU) at Lady Cilento Children's

http://dx.doi.org/10.1016/j.rmcr.2017.08.020
2213-0071/Crown Copyright © 2017 Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/
4.0/).
 A. Ferguson, S. Wright / Respiratory Medicine Case Reports 22 (2017) 232e234 233

Hospital (LCCH) in Brisbane.

On day 4 post injury donor sites were harvested and burns
debrided. The child experienced significant blood loss and no
grafting was completed. On day 6 and 8 post burn the patient had a
Split Skin Graft (SSG) of his posterior torso, buttocks, posterior
upper thighs, right lower leg and bilateral upper arms (see Fig. 1).
The initial post-operative orders required that the patient remain
ventilated and deeply sedated in prone position, minimal move-
ment and repositioning was allowed so that shear forces over graft
sites were completely avoided. On day 6 post injury the patient
became septic, this was associated with a systemic inflammatory
response and respiratory deterioration. The patient became diffi-
cult to ventilate and the chest x-ray (CXR) demonstrated multifocal
regions of atelectasis change (see CXR 1). The patient's level of
sedation resulted in no spontaneous cough. Indicators for respira-
tory physiotherapy treatment included increasing ventilator re-
quirements, raised peak inspiratory pressures (PIP's), and retained
CXR 1. Pre- MetaNeb® bilateral midzone opacification and right upper lobe and left
secretions. The patient was systemically unwell with associated
lower lobe changes.
hemodynamic instability with episodes of hypotension requiring
fluid resuscitation and inotropes.
Conventional physiotherapy techniques were extremely limited Frequency Oscillation mode (230 breaths per minute, 3.8Hz) for a
due to the new grafting sites. Physiotherapy treatment included period of approximately 10 minutes per treatment. The occlusion
repositioning using bed tilt only, manual hyperinflation (MHI), sa- ring was placed in the circuit to ensure the exhalation port is
line lavage, suction and passive mobility of the unaffected joints. blocked to prevent loss of volume. The circuit contained an inline
These techniques had limited effectiveness and secretions nebuliser containing 5ml 0.9% normal saline. Pressure was main-
remained difficult to access with palpable secretions persisting post tained between 10 and 20cmH2O, monitored on the MetaNeb®
intervention. manometer and variable volume breaths were delivered. Following
MetaNeb® treatment was implemented, following consultation a series of breaths on the MetaNeb®, secretion mobilization was
with LCCH PICU Medical Consultants and USA centres with expe- evaluated via palpation; subsequently the patient was discon-
rience using the device in a ventilated patient. As the ventilator nected from the MetaNeb® and reconnected to the bagging circuit.
being used for this patient had not been tested with the MetaNeb® Manual Hyperinflation with expiratory flow bias technique was
it could not be used through the ventilator circuit. The MetaNeb® utilized to mobilize secretions to the main airways and suction via
was attached to an approved 50psi oxygen source and applied us- ETT performed as required. This cycle of treatment was repeated
ing an open-ended bagging circuit (FiO2 1.0) in Continuous High until secretions were no longer palpable and ETT mucus clearance

Fig. 1. Lund and browder body chart.

234 A. Ferguson, S. Wright / Respiratory Medicine Case Reports 22 (2017) 232e234
CXR 2. Post 4 days MetaNeb® intervention showing resolution of pathological
changes.
minimal.
Outcome variables measured included sputum volume and
quality, CXR, and PIP values pre and post treatment. Vital signs
were monitored throughout, most notably blood pressure. The
patient's vital signs remained stable throughout intervention,
blood pressure transiently decreased following disconnection from
ventilator (decrease in MAP <10 mmHg) but recovered without
intervention during the treatment. After 4 days of treatment twice
daily, there was resolution of focal changes on CXR (see CXR 2), a
reduction in secretions load, a reduction in PIP (25% post each
treatment) and the patient was extubated without incident.
After successful extubation of this patient, the physiotherapist
trialled using the MetaNeb® via a mouthpiece with this patient,
however it was poorly tolerated and discontinued due to behav-
ioural issues and lip pain and swelling which inhibited lip seal.
Following skin grafting on day 17, the patient required another 12
days of intubation, ventilation and immobility due to graft fragility.
The MetaNeb® was utilized during this phase to optimize secretion
clearance and decrease the risk of retained secretions and associ-
ated lung infection. The patient did not demonstrate any respira-
tory deterioration during this second bout of enforced ventilation
and was extubated successfully.
3. Discussion/conclusion
Observed benefits of utilizing The MetaNeb® System in this
patient case:
 The combined triple effects of the MetaNeb® including positive
pressure, flow oscillation and nebulisation provided an excellent
alternative treatment option for this patient where conventional
physiotherapy techniques were extremely limited due to the
nature of the patient's burn injuries.
 Minimal disconnection time from the ventilator which is vital in
PEEP dependent patients.
 Pressure monitoring throughout treatment on MetaNeb® e
attenuation of oscillation relates to ETT size, safe within paedi-
atric lung model with a range of ETT sizes.
 User friendly - mobile, no battery, easily connected to ventilated
and non-ventilated patients, short treatment time.
 Useful for patients where manual techniques contraindicated
e.g. burns, low platelets.
Observed limitations of The MetaNeb® in this patient case:
 Less tactile feedback through MHI circuit in oscillatory mode.
 Oscillation increased the resistance in MHI circuit, with subop-
timal ability to increase expiratory flows; this was resolved by
disconnecting the MetaNeb® and finishing treatment with MHI
to facilitate expiratory flow bias.
 If patient unstable and PEEP dependent it would beneficial to
use In-Line MetaNeb®; this may require validation from the
ventilator manufacturers to use MetaNeb® in-line.
This is a single case report and thus may have limitations in a
more generalised context; however, it demonstrates safe, effective
and successful use of the MetaNeb® in a paediatric ventilated
patient.
The Metaneb® System is an innovative device which was highly
successful in the treatment of this critically unwell child. This case
study suggests that this device may be beneficial in atelectasis
secondary to poor secretion clearance in ventilated paediatric pa-
tients, and future studies are recommended to further evaluate the
clinical efficacy in this population.
Conflict of interest
Hill-Rom Company, Inc. provided funding to cover the pub-
lishing fee for this journal.
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