1
|
Thomas P, Paratz J. Ventilator hyperinflation - what settings generate an expiratory flow rate bias? Physiotherapy 2022; 119:44-53. [PMID: 36934465 DOI: 10.1016/j.physio.2022.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 10/06/2022] [Accepted: 11/13/2022] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To determine which mechanical ventilation settings influence the attainment of expiratory flow rate characteristics that may promote secretion mobilisation during ventilator hyperinflation (VHI). DESIGN Prospective, single centre study. SETTING Intensive care unit, tertiary metropolitan hospital. PARTICIPANTS Twenty-four patients receiving mechanical ventilation. INTERVENTIONS Patients were recruited to either a low PEEP or high PEEP group (5-9 cmH2O or 10-15 cmH2O PEEP respectively). Each group had three hyperinflation protocols applied. MAIN OUTCOME MEASURES Peak inspiratory flow rates (PIFR) and peak expiratory flow rates (PEFR) were measured and reported as PIFR/PEFR of less than or equal to 0.9; a PEFR-PIFR greater than or equal to 33 L/min; and PEFR greater than or equal to 40 L/min. RESULTS In both the low and high PEEP groups, VHI protocols using volume-controlled ventilation were significantly better at generating expiratory flow rate bias compared to pressure-controlled or Pressure Support ventilation. An expiratory flow rate bias was also achieved when VHI was performed in volume-controlled ventilation with either a peak inspiratory pressure target of 35 cmH2O or a driving pressure of 20 cmH2O. Median heart rate and blood pressure values did not change during VHI, but transient reductions in blood pressure were present in six participants (25%). CONCLUSIONS VHI performed using volume-controlled ventilation was more effective than pressure-controlled or Pressure Support ventilation to generate an expiratory flow rate bias. CONTRIBUTION OF THE PAPER Mechanical ventilator settings can be altered to perform hyperinflation and achieve expiratory flow rate properties that may increase the mobilisation of airway secretions. The results demonstrate that to achieve these properties.
Collapse
Affiliation(s)
- Peter Thomas
- Department of Physiotherapy, Royal Brisbane and Women's Hospital, Brisbane, Australia; Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia.
| | - Jennifer Paratz
- School of Health Sciences and Social Work, Griffith University, Nathan, Australia
| |
Collapse
|
2
|
Volpe MS, Naves JM, Ribeiro GG, Ruas G, Tucci MR. Effects of manual hyperinflation, clinical practice versus expert recommendation, on displacement of mucus simulant: A laboratory study. PLoS One 2018; 13:e0191787. [PMID: 29432468 PMCID: PMC5809045 DOI: 10.1371/journal.pone.0191787] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Accepted: 01/03/2018] [Indexed: 11/23/2022] Open
Abstract
Introduction Manual hyperinflation (MH), a maneuver applied in mechanically ventilated patients to facilitate secretion removal, has large variation in its performance. Effectiveness of MH is usually evaluated by its capacity to generate an expiratory flow bias. The aim of this study was to compare the effects of MH—and its resulting flow bias—applied according to clinical practice versus according to expert recommendation on mucus movement in a lung model simulating a mechanically ventilated patient. Methods Twelve physiotherapists were asked to apply MH, using a self-inflating manual resuscitator, to a test lung as if to remove secretions under two conditions: according to their usual clinical practice (pre-instruction phase) and after verbal instruction to perform MH according to expert recommendation was given (post-instruction phase). Mucus simulant movement was measured with a photodensitometric technique. Peak inspiratory flow (PIF), peak inspiratory pressure (PIP), inspiratory time (TINSP), tidal volume (VT) and peak expiratory flow (PEF) were measured continuously. Results It was found that MH performed post-instruction delivered a smaller VT (643.1 ± 57.8 ml) at a lower PIP (15.0 ± 1.5 cmH2O), lower PIF (38.0 ± 9.6 L/min), longer TINSP (1.84 ±0.54 s) and lower PEF (65.4 ± 6.7L/min) compared to MH pre-instruction. In the pre-instruction phase, MH resulted in a mean PIF/PEF ratio of 1.73 ± 0.38 and mean PEF-PIF difference of -54.6 ± 28.3 L/min, both out of the range for secretion removal. In the post-instruction phase both indexes were in the adequate range. Consequently, the mucus simulant was moved outward when MH was applied according to expert recommendation and towards the test lung when it was applied according to clinical practice. Conclusions Performance of MH during clinical practice with PIF higher than PEF was ineffective to clear secretion in a lung model simulating a mechanically ventilated patient. In order to remove secretion, MH should result in an adequate expiratory flow bias.
Collapse
Affiliation(s)
- Marcia S. Volpe
- Department of Human Movement Sciences, Federal University of São Paulo, Santos, São Paulo, Brazil
- * E-mail:
| | - Juliane M. Naves
- Department of Applied Physiotherapy, Federal University of Triângulo Mineiro, Uberaba, Minas Gerais, Brazil
| | - Gabriel G. Ribeiro
- Department of Applied Physiotherapy, Federal University of Triângulo Mineiro, Uberaba, Minas Gerais, Brazil
| | - Gualberto Ruas
- Department of Applied Physiotherapy, Federal University of Triângulo Mineiro, Uberaba, Minas Gerais, Brazil
| | - Mauro R. Tucci
- Laboratory for Medical Research 09, School of Medicine, University of São Paulo, São Paulo, Brazil
| |
Collapse
|
3
|
Zeiser E. [Physiotherapy interventions in the ICU : Outcome-relevant measurement parameters]. Med Klin Intensivmed Notfmed 2017; 112:356-370. [PMID: 28116462 DOI: 10.1007/s00063-016-0259-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Revised: 08/28/2016] [Accepted: 10/04/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND Guidelines cannot provide differentiated recommendations for physiotherapy (PT) in intensive care medicine. Scientific publications for PT in the intensive care unit (ICU) usually only have low levels of evidence and often express safety and feasibility of PT in the ICU. OBJECTIVE Which measurement parameters are relevant for defining outcome and what interventions should one take into consideration? MATERIALS AND METHODS A literature review was conducted. This was based on a PubMed search with full text access, as well as specific definitions for physical therapy, intensive care and four out of seven conditions from the manual "Physiotherapy in intensive care". RESULTS The availability of 172 studies clearly shows that there is certainly PT research concerning the critical environment of the ICU. However, parameters for quantitative and qualitative detection of vigilance and state of consciousness as well as assessments to evaluate the mobility and the ability to help themselves are important for everyday use. CONCLUSIONS The difficulties of using PT in the ICU are not useful in ensuring the safety of the patient or performing a PT treatment. The conditions of the intensive care environment are not an obstacle. It is of immanent importance to use the limited resources of PT in an optimal and targeted manner in the ICU environment. The determination of ICU-adapted goals plays a crucial role.
Collapse
Affiliation(s)
- E Zeiser
- Berufsförderungswerk Mainz, DIPLOMA Hochschule - Private Fachhochschule Nordhessen, z.H. Dorit Engelmann Lortzingstraße 4, 55127, Mainz, Deutschland.
| |
Collapse
|
4
|
de Godoy VCWP, Zanetti NM, Johnston C. Manual hyperinflation in airway clearance in pediatric patients: a systematic review. Rev Bras Ter Intensiva 2015; 25:258-62. [PMID: 24213091 PMCID: PMC4031853 DOI: 10.5935/0103-507x.20130043] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2013] [Accepted: 08/09/2013] [Indexed: 11/20/2022] Open
Abstract
Objective To perform an assessment of the available literature on manual hyperinflation as a
respiratory physical therapy technique used in pediatric patients, with the main
outcome of achieving airway clearance. Methods We reviewed articles included in the Lilacs (Latin American and Caribbean
Literature on Health Sciences/Literatura Latino Americana e do Caribe em Ciências
da Saúde), Cochrane Library, Medline (via Virtual Health Library and PubMed),
SciELO (Scientific Electronic Library), and PEDro (Physiotherapy Evidence
Database) databases from 2002 to 2013 using the following search terms:
"physiotherapy (techniques)", "respiratory therapy", "intensive care", and "airway
clearance". The selected studies were classified according to the level of
evidence and grades of recommendation (method of the Oxford Centre for
Evidence-Based Medicine) by two examiners, while a third examiner repeated the
search and analysis and checked the classification of the articles. Results Three articles were included for analysis, comprising 250 children (aged 0 to 16
years). The main diagnoses were acute respiratory failure, recovery following
heart congenital disease and upper abdominal surgery, bone marrow transplantation,
asthma, tracheal reconstruction, brain injury, airway injury, and heterogeneous
lung diseases. The studies were classified as having a level of evidence 2C and
grade of recommendation C. Conclusions Manual hyperinflation appeared useful for airway clearance in the investigated
population, although the evidence available in the literature remains
insufficient. Therefore, controlled randomized studies are needed to establish the
safety and efficacy of manual hyperinflation in pediatric patients. However,
manual hyperinflation must be performed by trained physical therapists only.
Collapse
|
5
|
Paulus F, Binnekade JM, Middelhoek P, Vroom MB, SchuItz MJ. Guideline implementation powered by feedback and education improves manual hyperinflation performance. Nurs Crit Care 2014; 21:36-43. [PMID: 24801958 DOI: 10.1111/nicc.12068] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2013] [Revised: 10/11/2013] [Accepted: 11/12/2013] [Indexed: 10/25/2022]
Abstract
AIM To determine whether a literature-based guideline, powered by educational meetings and individual feedback, improves manual hyperinflation (MH) performance by intensive care unit (ICU) nurses. BACKGROUND MH is frequently applied in intubated and mechanically ventilated ICU patients. MH is a complex intervention, and large variation in its performance has been found. MATERIALS AND METHODS First, a literature-based guideline on MH was developed. The intervention consisted of education of this guideline and individual feedback. Before and 3 months after the intervention, ICU nurses performed MH maneuvers in a skills laboratory. Data collected included applied volumes, peak inspiratory flows (PIF) and peak expiratory flows (PEF), and the use of inspiratory holds. RESULTS Eighty nurses participated. Decrease of PIF was not statistically significant. PEF increased from 52 ± 7 to 83 ± 23 L/min (P < 0·01). PIF to PEF ratio decreased from 1·4 [1·1-1·7] to 0·8 [0·6-1·1] (P < 0·01). Peak inspiratory pressures decreased from 40 ± 14 to 19 ± 6 cm H2 O (P < 0·01). The proportion of nurses applying inspiratory holds increased from 14% to 58%; use of rapid release of the resuscitation bag, considered mandatory, increased from 4% to 61%. CONCLUSION Implementation of a literature-based guideline on MH, powered by educational meetings and individual feedback, improves MH performance by ICU nurses. RELEVANCE TO CLINICAL PRACTICE If it is decided to practice MH in the care of the intubated and mechanical ventilated patient, a standardized, uniform performed MH procedure is a prerequisite.
Collapse
Affiliation(s)
- Frederique Paulus
- Department of Intensive Care Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Jan M Binnekade
- Department of Intensive Care Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Pauline Middelhoek
- Department of Intensive Care Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Margreeth B Vroom
- Department of Intensive Care Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Marcus J SchuItz
- Department of Intensive Care Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.,Laboratory for Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| |
Collapse
|
6
|
Nunes GS, Botelho GV, Schivinski CIS. Hiperinsuflação manual: revisão de evidências técnicas e clínicas. FISIOTERAPIA EM MOVIMENTO 2013. [DOI: 10.1590/s0103-51502013000200020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
INTRODUÇÃO: A técnica de hiperinsuflação manual (HM), também conhecida como "bag squeezing" ou "bagging", foi inicialmente descrita como um recurso para melhorar a oxigenação pré e pós-aspiração traqueal, mobilizar o excesso de secreção brônquica e reexpandir áreas pulmonares colapsadas. OBJETIVO: Apresentar evidências científicas sobre os efeitos da manobra de HM como recurso fisioterapêutico, bem como suas indicações clínicas. MATERIAIS E MÉTODOS: Realizou-se uma busca nas bases de dados eletrônicas SciELO, ScienceDirect, PubMed e PEDro, utilizando-se os descritores "hiperinsuflação manual" (manual hyperinflation) e "fisioterapia" (physiotherapy). Como critério de inclusão considerou-se: conter os descritores no título ou resumo; ensaios clínicos que abordassem "hiperinsuflação manual" e fisioterapia; textos em inglês e português; publicações entre 1994 e 2011. RESULTADOS: Foram selecionados 25 estudos e todos apontaram a importância dessa manobra na mobilização de secreções traqueobrônquicas e para reexpansão de alvéolos colapsados, devido à melhora do volume pulmonar. Adequação das trocas gasosas, melhora da oxigenação e da complacência pulmonar, prevenção e tratamento de atelectasias são outras indicações. Também é consensual a preocupação com a padronização na aplicação da técnica. Melhores resultados são alcançados quando o volume aplicado é cerca de 50% maior que o volume corrente do paciente. Precauções quanto a limites de pressão em torno de 40 cm H2O, para se evitar barotraumas, também são referidas pela maioria dos estudos. CONCLUSÃO: A literatura traz evidências que sustentam a indicação do HM para mobilização e eliminação de secreções traqueobrônquicas e prevenção de infecções/complicações, além da necessidade de padronização da técnica.
Collapse
|
7
|
van Aswegen H, van Aswegen A, Raan HD, Toit RD, Spruyt M, Nel R, Maleka M. Airflow distribution with manual hyperinflation as assessed through gamma camera imaging: a crossover randomised trial. Physiotherapy 2012; 99:107-12. [PMID: 23219638 DOI: 10.1016/j.physio.2012.05.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2012] [Accepted: 05/03/2012] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Manual hyperinflation (MHI) has been shown to improve lung compliance, reduce airway resistance, and enhance secretion removal and peak expiratory flow. The aims of this study were to investigate whether there is a difference in airflow distribution through patients' lungs when using the Laerdal and Mapleson-C circuits at a set level of positive end-expiratory pressure (PEEP), and to establish whether differences in lung compliance and haemodynamic status exist when patients are treated with both these MHI circuits. DESIGN Crossover randomised controlled trial. SETTING Adult multidisciplinary intensive care unit (ICU) at an academic hospital. PARTICIPANTS Fifteen adult patients were recruited and served as their own controls. INTERVENTION In the Nuclear Medicine Department, MHI with PEEP 7.5 cmH(2)O was performed in the supine position (Day 1) with either Laerdal or Mapleson-C circuits, in a random order, while technetium-99m (Tc-99m) aerosol was administered and images were taken with a gamma camera. Changes in heart rate (HR), mean arterial pressure (MAP) and dynamic lung compliance (C(D)) were documented at baseline, immediately after return to ICU, and 10, 20 and 30 minutes after return to ICU. The alternative circuit was used on Day 2. RESULTS Tc-99m deposition was greater in the right lung field (62% and 63% for Laerdal and Mapleson-C circuits, respectively) than the left lung field (38% and 37%, respectively) for all patients, and least deposition occurred in the left lower segments (6% and 6%, respectively). No differences in Tc-99m deposition in the lungs, HR, MAP or C(D) were noted between the two MHI circuits. CONCLUSION Airflow distribution through patients' lungs was similar when the Laerdal and Mapleson-C MHI circuits were compared using a set level of PEEP in the supine position.
Collapse
Affiliation(s)
- H van Aswegen
- Department of Physiotherapy, School of Therapeutic Sciences, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
| | | | | | | | | | | | | |
Collapse
|
8
|
de Abreu LC, Valenti VE, de Oliveira AG, Leone C, Siqueira AAF, Herreiro D, Wajnsztejn R, Manhabusque KV, Júnior HM, de Mello Monteiro CB, Fernandes LL, Saldiva PHN. Chest associated to motor physiotherapy improves cardiovascular variables in newborns with respiratory distress syndrome. Int Arch Med 2011; 4:37. [PMID: 22029840 PMCID: PMC3219586 DOI: 10.1186/1755-7682-4-37] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2011] [Accepted: 10/26/2011] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND We aimed to evaluate the effects of chest and motor physiotherapy treatment on hemodynamic variables in preterm newborns with respiratory distress syndrome. METHODS We evaluated heart rate (HR), respiratory rate (RR), systolic (SAP), mean (MAP) and diastolic arterial pressure (DAP), temperature and oxygen saturation (SO2%) in 44 newborns with respiratory distress syndrome. We compared all variables between before physiotherapy treatment vs. after the last physiotherapy treatment. Newborns were treated during 11 days. Variables were measured 2 minutes before and 5 minutes after each physiotherapy treatment. We applied paired Student t test to compare variables between the two periods. RESULTS HR (148.5 ± 8.5 bpm vs. 137.1 ± 6.8 bpm - p < 0.001), SAP (72.3 ± 11.3 mmHg vs. 63.6 ± 6.7 mmHg - p = 0.001) and MAP (57.5 ± 12 mmHg vs. 47.7 ± 5.8 mmHg - p = 0.001) were significantly reduced after 11 days of physiotherapy treatment compared to before the first session. There were no significant changes regarding RR, temperature, DAP and SO2%. CONCLUSIONS Chest and motor physiotherapy improved cardiovascular parameters in respiratory distress syndrome newborns.
Collapse
Affiliation(s)
- Luiz Carlos de Abreu
- Departamento de Saúde Materno-infantil, Universidade de São Paulo, Av. Dr. Arnaldo, 715, São Paulo, SP. 01246-904, Brazil
- Laboratório de Escrita Científica. Faculdade de Medicina do ABC, Av. Príncipe de Gales, 821, Santo André, SP. 09060-650, Brazil
| | - Vitor E Valenti
- Departamento de Patologia, Faculdade de Medicina, Universidade de São Paulo (USP), Av. Dr. Arnaldo, 455, São Paulo, SP. 01246903, Brazil
- Laboratório de Escrita Científica. Faculdade de Medicina do ABC, Av. Príncipe de Gales, 821, Santo André, SP. 09060-650, Brazil
| | - Adriana G de Oliveira
- Departamento de Saúde Materno-infantil, Universidade de São Paulo, Av. Dr. Arnaldo, 715, São Paulo, SP. 01246-904, Brazil
| | - Claudio Leone
- Departamento de Saúde Materno-infantil, Universidade de São Paulo, Av. Dr. Arnaldo, 715, São Paulo, SP. 01246-904, Brazil
| | - Arnaldo AF Siqueira
- Departamento de Saúde Materno-infantil, Universidade de São Paulo, Av. Dr. Arnaldo, 715, São Paulo, SP. 01246-904, Brazil
| | - Dafne Herreiro
- Departamento de Saúde Materno-infantil, Universidade de São Paulo, Av. Dr. Arnaldo, 715, São Paulo, SP. 01246-904, Brazil
| | - Rubens Wajnsztejn
- Laboratório de Escrita Científica. Faculdade de Medicina do ABC, Av. Príncipe de Gales, 821, Santo André, SP. 09060-650, Brazil
| | - Katia V Manhabusque
- Laboratório de Escrita Científica. Faculdade de Medicina do ABC, Av. Príncipe de Gales, 821, Santo André, SP. 09060-650, Brazil
| | - Hugo Macedo Júnior
- Laboratório de Escrita Científica. Faculdade de Medicina do ABC, Av. Príncipe de Gales, 821, Santo André, SP. 09060-650, Brazil
| | - Carlos B de Mello Monteiro
- Escola de Artes, Ciência e Humanidades da Universidade de São Paulo (USP), Rua Arlindo Béttio, 1000, São Paulo, SP. 03828-000, Brazil
| | - Laís L Fernandes
- Laboratório de Escrita Científica. Faculdade de Medicina do ABC, Av. Príncipe de Gales, 821, Santo André, SP. 09060-650, Brazil
| | - Paulo HN Saldiva
- Departamento de Patologia, Faculdade de Medicina, Universidade de São Paulo (USP), Av. Dr. Arnaldo, 455, São Paulo, SP. 01246903, Brazil
| |
Collapse
|