Manual hyperinflation causes norepinephrine release

Benefits and risks of manual hyperinflation in intubated and mechanically ventilated intensive care unit patients: a systematic review

Introduction

Manual hyperinflation (MH), a frequently applied maneuver in critically ill intubated and mechanically ventilated patients, is suggested to mimic a cough so that airway secretions are mobilized toward the larger airways, where they can easily be removed. As such, MH could prevent plugging of the airways.

Methods

We performed a search in the databases of Medline, Embase, and the Cochrane Library from January 1990 to April 2012. We systematically reviewed the literature on evidence for postulated benefits and risks of MH in critically ill intubated and mechanically ventilated patients.

Results

The search identified 50 articles, of which 19 were considered relevant. We included 13 interventional studies and six observational studies. The number of studies evaluating physiological effects of MH is limited. Trials differed too much to permit meta-analysis. It is uncertain whether MH was applied similarly in the retrieved studies. Finally, most studies are underpowered to show clinical benefit of MH. Use of MH is associated with short-term improvements in lung compliance, oxygenation, and secretion clearance, without changes in outcomes. MH has been reported to be associated with short-term and probably clinically insignificant side effects, including decreases in cardiac output, alterations of heart rates, and increased central venous pressures.

Conclusions

Studies have failed to show that MH benefits critically ill intubated and mechanically ventilated patients. MH is infrequently associated with short-term side effects.

Combined exogenous and endogenous catecholamine release associated with Tako-Tsubo like syndrome in a patient with atrio-ventricular block undergoing pace-maker implantation

We report the case of a 65-year-old woman with complete atrio-ventricular block who underwent orciprenaline administration and pacemaker implantation. The intervention was complicated by pneumothorax and acute left ventricular systolic dysfunction with typical apical ballooning (Tako-Tsubo like syndrome). The patient was treated with diuretics and calcium-sensitizers and completely recovered. We speculate that both external and internal catecholamine triggered an acute left ventricular impairment with typical Tako-Tsubo features.

Physiotherapy in intensive care is safe: an observational study

QUESTION

How often do adverse events (including adverse physiological changes) occur during physiotherapy intervention in intensive care?

DESIGN

A multi-centre prospective observational study.

PARTICIPANTS

Five tertiary level university-affiliated intensive care units.

OUTCOME MEASURES

All physiotherapy intervention in five intensive care units over a three month period. When certain specified changes occurred during physiotherapy intervention, details were noted including diagnosis of patient, intervention, vital signs, radiological changes, co-morbidities, chemical pathology, and fluid balance.

RESULTS

12 281 physiotherapy interventions were completed with 27 interventions resulting in adverse physiological changes (0.2%). This incidence was significantly lower than a previous study of adverse physiological changes (663 events in 247 patients over a 24-hour period); the incidence during physiotherapy intervention was lower than during general intensive care. Common factors in the patients who had an adverse physiological change were a deterioration in cardiovascular status (ie, decrease in blood pressure or arrhythmia) in patients on medium to high doses of inotropes/vasopressors, unstable baseline hemodynamic values, previous cardiac co-morbidities and intervention consisting of positive pressure or right side lying.

CONCLUSION

The incidence of adverse events during physiotherapy intervention in these five tertiary hospitals was low, demonstrating that physiotherapy intervention in intensive care is safe.