Children with significant respiratory conditions often require the use of various airway clearance devices and techniques to help keep their airways clear. Some children, such as those with neuromuscular diseases, are unable to cough, while others may have conditions like cystic fibrosis that make normal secretions thick and sticky.
Traditionally, families have relied on vibrating vests, cough assist devices, percussors, manual percussion, and suctioning to keep the lungs clear. Recently, many families have had access to intrapulmonary percussive ventilation (IPV), a treatment from a device that was previously only available in hospitals. IPV is an excellent way to promote airway clearance, especially for children who are extremely medically complex, and should be considered for children who do not have success with other methods.
What is IPV?
In some ways, an IPV device is similar to a vibrating or shaker vest, which is officially called high frequency chest-wall oscillation. However, instead of delivering the oscillations to the chest wall, an IPV uses a special circuit called a Phasitron to deliver fast bursts of air directly into the airway. These bursts of air, which are accompanied by a mist to thin secretions, pop open the airways, allowing mucus to be coughed or suctioned easily.
IPV must always be given with a nebulized mist. Typically, saline is used, but hypertonic saline may also be added to promote clearance. Most other nebulized medications, such as albuterol or xopenex, may also be given during treatments. The treatments can be given with or without oxygen.
Treatments usually last 10-15 minutes, broken into several different cycles with coughing or suctioning between. Some children maintain a high pressure and frequency during the entire treatment, while others gradually change their settings.
Most children who use IPV devices use a Percussionaire device. While the traditional hospital devices may be used at home, Percussionaire has also developed a portable, self-contained, and more homecare friendly version called the TravelAir.
IPV Hospital Model Used at Home
Who is a candidate for IPV?
IPV treatments are appropriate for any child, regardless of diagnosis, who needs assistance in mobilizing secretions from the airway. There are some contraindications, such as a pneumothorax (collapsed lung), rib fractures, or recent surgeries of the face, esophagus, or mouth. Most children who eat orally or receive tube feedings into the stomach will need to stop feeds for about an hour prior to treatment, though most children who receive feedings into the intestine can continue feeds during treatment.
The best candidates for IPV are children with trachs who can tolerate at least slight deflation of the cuff. IPV is very simple to perform through a trach and highly effective. Inline suctioning can be performed with the IPV circuit in place. Children who require continuous ventilation can also use IPV, though it does not work effectively in all ventilator modes, and may require the ventilation mode to be switched during IPV treatments. In addition, using an IPV circuit requires opening up the ventilator circuit, which may not be advisable in some children with a high risk of infection.
IPV treatments can also be given by mask or even using a mouthpiece, but this may be difficult for many small children, and the effect may not be as significant if a good mask seal or mouth seal cannot be achieved.
Does Insurance or Medicaid cover IPV?
IPV Home Model
IPV devices are FDA approved, and coverage of devices and supplies is becoming more common. Some insurers do not cover IPV devices because there have not been enough studies yet confirming their efficacy, especially in home care settings. For example, Aetna states that IPV is “experimental and investigational for all indications,” as does Cigna. Anthem states IPV is, “investigational and not medically necessary for all indications as an airway clearance treatment.” United HealthCare states it is not covered because it has not been studied in home care settings. Despite these policies, it is sometimes possible to obtain coverage for the item if a letter of medical necessity outlines that the device is FDA approved, provides the benefits of the device, and supplies a list of medical studies to demonstrate IPV is no longer experimental for your child’s condition.
On the other hand, most—but not all—Blue Cross Blue Shield plans cover IPV. Many state Medicaid plans also cover IPV, though a letter of medical necessity and documentation is almost universally required.
Will it work?
Families report differing opinions on the success of IPV treatments at home. While some swear by it, others say their children find it a bit uncomfortable, and that other airway clearance options, such as oscillating vests or cough assist devices, are more helpful. Some find it particular helpful for children with weak bones that could be injured during manual percussion or oscillating vest treatments. It is definitely worth a try if your child is continuously struggling with airway clearance despite trying other airway clearance devices.