Oxygenation and static compliance is improved immediately after early manual hyperinflation following myocardial revascularisation: a randomised controlled trial

Effect of manual hyperinflation on recurrent atelectasis in a ventilator-dependent C3 complete spinal cord injury patient: A case report

CLINICAL CASE

We present here the case of a ventilator-dependent 76-year-old man with C3 complete spinal cord injury (SCI) who presented with recurrent left lung atelectasis managed with manual hyperinflation (MH). Atelectasis was primarily assessed with chest X-ray (CXR). Additional monitoring included blood gas analysis, serum procalcitonin, and the Modified Borg Dyspnea Scale (MBS), as an objective measure of reported dyspnea. We found that MH successfully reversed the radiographic appearance of atelectasis after the first treatment and maintained this effect for the duration of the 2-week intervention period as well as at 2 weeks of follow-up post-intervention. Furthermore, MH decreased the patient's oxygen requirements and was associated with a decrease in serum procalcitonin. Clinically, the patient reported reduced subjective dyspnea post-MH, which was reflected as an improvement on the MBS. We conclude that MH may represent a therapeutic modality for consideration in the routine management of recurrent atelectasis in mechanically ventilated patients.

Efficacy of manual hyperinflation on arterial blood gases in patients with ventilator-associated pneumonia

Background

Tracheal intubation exposes mechanically ventilated patients to serious pulmonary complications such as ventilator-associated pneumonia (VAP). This study was conducted to compare the efficacy of manual hyperinflation in supine versus lateral decubitus position on arterial blood gases (ABG) in patients with VAP. Forty-two patients with ventilator-associated pneumonia with age range from 40 to 60 years were selected. They were randomly divided into two equal groups: group A who received manual hyperinflation from supine position and group B who received manual hyperinflation from lateral decubitus position (upper most affected). Both groups received respiratory physiotherapy. The patients received 2 sessions per day for 6 days. Outcome measures were arterial blood gases (PaO₂, PaCO₂, PaO₂/FiO₂, and SaO₂). They were assessed before the 1st morning session (pre), at day 3 (post 1), and at day 6 (post 2).

Results

After sessions, significant changes of measured variables (PaO₂, PaCO₂, PaO₂/FiO₂, and SaO₂) were obtained in both groups (P < 0.05, in all variables) and by comparison between groups post-intervention; a significant difference was observed between both groups in measures of oxygenation in favor of group B (P < 0.05), whereas there was a non-significant difference in the PaC02 between both groups (post 1 P = 0.52 and post 2 P = 0.33).

Conclusion

It was concluded that effect of the bag squeezing on arterial blood gases in patients with ventilator-associated pneumonia from lateral decubitus position was more effective than from supine position.

Trial registration

PACTR, PACTR201909817075549. Registered October 21, 2018—retrospectively registered

https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=4655

Temporal Changes in Ventilator Settings in Patients With Uninjured Lungs: A Systematic Review

In patients with uninjured lungs, increasing evidence indicates that tidal volume (VT) reduction improves outcomes in the intensive care unit (ICU) and in the operating room (OR). However, the degree to which this evidence has translated to clinical changes in ventilator settings for patients with uninjured lungs is unknown. To clarify whether ventilator settings have changed, we searched MEDLINE, Cochrane Central Register of Controlled Trials, and Web of Science for publications on invasive ventilation in ICUs or ORs, excluding those on patients <18 years of age or those with >25% of patients with acute respiratory distress syndrome (ARDS). Our primary end point was temporal change in VT over time. Secondary end points were changes in maximum airway pressure, mean airway pressure, positive end-expiratory pressure, inspiratory oxygen fraction, development of ARDS (ICU studies only), and postoperative pulmonary complications (OR studies only) determined using correlation analysis and linear regression. We identified 96 ICU and 96 OR studies comprising 130,316 patients from 1975 to 2014 and observed that in the ICU, VT size decreased annually by 0.16 mL/kg (-0.19 to -0.12 mL/kg) (P < .001), while positive end-expiratory pressure increased by an average of 0.1 mbar/y (0.02-0.17 mbar/y) (P = .017). In the OR, VT size decreased by 0.09 mL/kg per year (-0.14 to -0.04 mL/kg per year) (P < .001). The change in VTs leveled off in 1995. Other intraoperative ventilator settings did not change in the study period. Incidences of ARDS (ICU studies) and postoperative pulmonary complications (OR studies) also did not change over time. We found that, during a 39-year period, from 1975 to 2014, VTs in clinical studies on mechanical ventilation have decreased significantly in the ICU and in the OR.

Respiratory physiotherapy in intensive care unit: Bibliographic review

INTRODUCTION AND AIMS

Patients in intensive care unit are susceptible to complications due to different causes (underlying disease, immobilisation, infection risk…) The current main intervention in order to prevent these complications is respiratory physiotherapy, a common practice for nurses on a daily basis. Therefore, we decided to carry out this bibliographic review to describe the most efficient respiratory physiotherapy methods for the prevention and treatment of lung complications in patients in intensive care, taking into account the differences between intubated and non-intubated patients.

METHODOLOGY

The bibliographic narrative review was carried out on literature available in Pubmed, Cinahl and Cochrane Library. The established limits were language, evidence over the last 15 years and age.

RESULTS

Techniques involving lung expansion, cough, vibration, percussion, postural drainage, incentive inspirometry and oscillatory and non-oscillatory systems are controversial regarding their efficacy as respiratory physiotherapy methods. However, non-invasive mechanical ventilation shows clear benefits. In the case of intubated patients, manual hyperinflation and secretion aspirations are highly efficient methods for the prevention of the potential complications mentioned above. In this case, other RP methods showed no clear efficiency when used individually.

DISCUSSION AND CONCLUSIONS

Non-invasive mechanical ventilation (for non-intubated patients) and manual hyperinflation (for intubated patients) proved to be the respiratory physiotherapy methods with the best results. The other techniques are more controversial and the results are not so clear. In both types of patients this literature review suggests that combined therapy is the most efficient.

Methodological Quality of Randomized Clinical Trials of Respiratory Physiotherapy in Coronary Artery Bypass Grafting Patients in the Intensive Care Unit: a Systematic Review

OBJECTIVE

To assess methodological quality of the randomized controlled trials of physiotherapy in patients undergoing coronary artery bypass grafting in the intensive care unit.

METHODS

The studies published until May 2015, in MEDLINE, Cochrane and PEDro were included. The primary outcome extracted was proper filling of the Cochrane Collaboration's tool's items and the secondary was suitability to the requirements of the CONSORT Statement and its extension.

RESULTS

From 807 studies identified, 39 were included. Most at CONSORT items showed a better adequacy after the statement's publication. Studies with positive outcomes presented better methodological quality.

CONCLUSION

The methodological quality of the studies has been improving over the years. However, many aspects can still be better designed.

Factors Associated with Intubation Time and ICU Stay After CABG

OBJECTIVE

The aim of this study was to identify factors associated with intubation time and intensive care unit stay after coronary artery bypass grafting with cardiopulmonary bypass.

METHODS

This was a retrospective study, whose data collection was performed in the hospital charts of 160 patients over 18 years, who underwent surgery from September 2009 to July of 2013 in a hospital in the state of Espirito Santo, Brazil.

RESULTS

The mean age of the subjects was 61.44±8.93 years old and 68.8% were male. Subjects had a mean of 5.17±8.42 days of intensive care unit stay and mean intubation time of 10.99±8.41 hours. We observed statistically significant positive correlation between the following variables: patients' age and intubation time; patients' age and intensive care unit stay; intubation time and intensive care unit stay.

CONCLUSION

In conclusion, the study showed that older patients had longer intubation time and increased intensive care unit stay. Furthermore, patients with longer intubation time had increased intensive care unit stay.

Guideline implementation powered by feedback and education improves manual hyperinflation performance

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.

Manual hyperinflation combined with expiratory rib cage compression for reduction of length of ICU stay in critically ill patients on mechanical ventilation

OBJECTIVE

Although manual hyperinflation (MH) is widely used for pulmonary secretion clearance, there is no evidence to support its routine use in clinical practice. Our objective was to evaluate the effect that MH combined with expiratory rib cage compression (ERCC) has on the length of ICU stay and duration of mechanical ventilation (MV).

METHODS

This was a prospective randomized controlled clinical trial involving ICU patients on MV at a tertiary care teaching hospital between January of 2004 and January of 2005. Among the 49 patients who met the study criteria, 24 and 25 were randomly assigned to the respiratory physiotherapy (RP) and control groups, respectively. Of those same patients, 6 and 8, respectively, were later withdrawn from the study. During the 5-day observation period, the RP patients received MH combined with ERCC, whereas the control patients received standard nursing care.

RESULTS

The two groups were similar in terms of the baseline characteristics. The intervention had a positive effect on the duration of MV, as well as on the ICU discharge rate and Murray score. There were significant differences between the control and RP groups regarding the weaning success rate on days 2 (0.0% vs. 37.5%), 3 (0.0% vs. 37.5%), 4 (5.3% vs. 37.5%), and 5 (15.9% vs. 37.5%), as well as regarding the ICU discharge rate on days 3 (0% vs. 25%), 4 (0% vs. 31%), and 5 (0% vs. 31%). In the RP group, there was a significant improvement in the Murray score on day 5.

CONCLUSIONS

Our results show that the use of MH combined with ERCC for 5 days accelerated the weaning process and ICU discharge.

Hiperinsuflação manual: revisão de evidências técnicas e clínicas

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.

Efeitos da higienização brônquica nas variáveis cardiorrespiratórias de pacientes em ventilação mecânica

INTRODUÇÃO: Durante a ventilação mecânica (VM) as vias aéreas podem acumular secreção. Pacientes em VM são submetidos a Fisioterapia Respiratória (FR) e a aspiração traqueal, associados ou isoladamente, com objetivo de higienizar as vias aéreas. OBJETIVO: Comparar os efeitos da aplicação de diferentes protocolos de higiene brônquica na pressão arterial, frequência cardíaca, saturação de oxigênio e frequência respiratória de pacientes submetidos à VM. MATERIAIS E MÉTODOS: Realizou-se estudo prospectivo e aleatório, controlado do tipo cruzado, com amostra não probabilística intencional no Hospital das Clínicas da Faculdade de Medicina de Marília. Foram incluídos pacientes em VM invasiva que foram submetidos a três protocolos de higienização brônquica: PFR - protocolo de fisioterapia (compressão torácica manual e hiperinsuflação manual); PAT - protocolo de aspiração; e PFR + PAT. Frequência respiratória, pressão arterial sistólica (PAS), pressão arterial diastólica (PAD), saturação periférica de oxigênio e frequência cardíaca foram avaliadas em três momentos: antes (M1), imediatamente após (M2), e 30 minutos após (M3) cada protocolo. As diferenças entre protocolos e momentos foram verificadas por meio do teste ANOVA e pos-hoc de Student Newman-Keus (p < 0,05). RESULTADOS: Foram avaliados 18 pacientes com 71,2 ± 13,9 anos de idade e com 15,1 ± 17,7 dias de VM. Não houve diferenças entre os protocolos. Diminuíram de forma significativa a PAS (p = 0,0261) e a PAD (p = 0,0119) de M2 para M3 no protocolo de aspiração. CONCLUSÃO: Pacientes em VM apresentaram diminuição da pressão arterial após 30 minutos de aspiração e não apresentaram alteração nas outras variáveis estudadas. Não houve diferença entre os protocolos.

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.

Protocol: inspiratory muscle training for promoting recovery and outcomes in ventilated patients (IMPROVe): a randomised controlled trial

INTRODUCTION

Inspiratory muscle weakness is a known consequence of mechanical ventilation and a potential contributor to difficulty in weaning from ventilatory support. Inspiratory muscle training (IMT) reduces the weaning period and increases the likelihood of successful weaning in some patients. However, it is not known how this training affects the residual inspiratory muscle fatigability following successful weaning nor patients' quality of life or functional outcomes.

METHODS AND ANALYSIS

This dual centre study includes two concurrent randomised controlled trials of IMT in adult patients who are either currently ventilator-dependent (>7 days) (n=70) or have been recently weaned from mechanical ventilation (>7 days) in the past week (n=70). Subjects will be stable, alert and able to actively participate and provide consent. There will be concealed allocation to either treatment (IMT) or usual physiotherapy (including deep breathing exercises without a resistance device). Primary outcomes are inspiratory muscle fatigue resistance and maximum inspiratory pressures. Secondary outcomes are quality of life (Short Form-36v2, EQ-5D), functional status (Acute Care Index of Function), rate of perceived exertion (Borg Scale), intensive care length of stay (days), post intensive care length of stay (days), rate of reintubation (%) and duration of ventilation (days).

ETHICS AND DISSEMINATION

Ethics approval has been obtained from relevant institutions, and results will be published with a view to influencing physiotherapy practice in the management of long-term ventilator-dependent patients to accelerate weaning and optimise rehabilitation outcomes.

TRIAL REGISTRATION NUMBER

ACTRN12610001089022.

Manual hyperinflation partly prevents reductions of functional residual capacity in cardiac surgical patients--a randomized controlled trial

INTRODUCTION

Cardiac surgery is associated with post-operative reductions of functional residual capacity (FRC). Manual hyperinflation (MH) aims to prevent airway plugging, and as such could prevent the reduction of FRC after surgery. The main purpose of this study was to determine the effect of MH on post-operative FRC of cardiac surgical patients.

METHODS

This was a randomized controlled trial of patients after elective coronary artery bypass graft and/or valve surgery admitted to the intensive care unit (ICU) of a university hospital. Patients were randomly assigned to a "routine MH group" (MH was performed within 30 minutes after admission to the ICU and every 6 hours thereafter, and before tracheal extubation), or a "control group" (MH was performed only if perceptible (audible) sputum was present in the larger airways causing problems with mechanical ventilation, or if oxygen saturation (SpO2) dropped below 92%). The primary endpoint was the reduction of FRC from the day before cardiac surgery to one, three, and five days after tracheal extubation. Secondary endpoints were SpO2 (at similar time points) and chest radiograph abnormalities, including atelectasis (at three days after tracheal extubation).

RESULTS

A total of 100 patients were enrolled. Patients in the routine MH group showed a decrease of FRC on the first post-operative day to 71% of the pre-operative value, versus 57% in the control group (P = 0.002). Differences in FRC became less prominent over time; differences between the two study groups were no longer statistically significant at Day 5. There were no differences in SpO2 between the study groups. Chest radiographs showed more abnormalities (merely atelectasis) in the control group compared to patients in the routine MH group (P = 0.002).

CONCLUSIONS

MH partly prevents the reduction of FRC in the first post-operative days after cardiac surgery.

TRIAL REGISTRATION

Netherlands Trial Register (NTR): NTR1384. http://www.trialregister.nl.

Inspiratory muscle training improves maximal inspiratory pressure and may assist weaning in older intubated patients: a randomised trial

QUESTIONS

Does inspiratory muscle training improve maximal inspiratory pressure in intubated older people? Does it improve breathing pattern and time to wean from mechanical ventilation?

DESIGN

Randomised trial with concealed allocation and intention-to-treat analysis.

PARTICIPANTS

41 elderly, intubated adults who had been mechanically ventilated for at least 48 hr in an intensive care unit.

INTERVENTION

The experimental group received usual care plus inspiratory muscle training using a threshold device, with an initial load of 30% of their maximal inspiratory pressure, increased by 10% (absolute) daily. Training was administered for 5 min, twice a day, 7 days a week from the commencement of weaning until extubation. The control group received usual care only.

OUTCOME MEASURES

The primary outcome was the change in maximal inspiratory pressure during the weaning period. Secondary outcomes were the weaning time (ie, from commencement of pressure support ventilation to successful extubation), and the index of Tobin (ie, respiratory rate divided by tidal volume during a 1-min spontaneous breathing trial).

RESULTS

Maximal inspiratory pressure increased significantly more in the experimental group than in the control group (MD 7.6 cmH(2)0, 95% CI 5.8 to 9.4). The index of Tobin decreased significantly more in the experimental group than in the control group (MD 8.3 br/min/L, 95% CI 2.9 to 13.7). In those who did not die or receive a tracheostomy, time to weaning was significantly shorter in the experimental group than in the control group (MD 1.7 days, 95% CI 0.4 to 3.0).

CONCLUSIONS

In intubated older people, inspiratory muscle training improves maximal inspiratory pressure and the index of Tobin, with a reduced weaning time in some patients.

TRIAL REGISTRATION

NCT00922493.