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Zhang J, Wang X, Xie J, Shen L, Mo G, Xie L. Effects of THE PEEP-ZEEP Maneuver in Adults Receiving Mechanical Ventilation: A Systematic Review with Meta-Analysis. Heart Lung 2024; 63:159-166. [PMID: 37922664 DOI: 10.1016/j.hrtlng.2023.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 08/31/2023] [Accepted: 10/15/2023] [Indexed: 11/07/2023]
Abstract
INTRODUCTION It is important to clarify the secretion clearance and lung-related effects of the PEEP-ZEEP maneuver in adults undergoing mechanical ventilation (MV). There is no published comprehensive meta-analysis of the effects of PEEP-ZEEP in adults receiving MV. OBJECTIVES The aim of this study was to analyze published randomized controlled trials, investigating the effects of the PEEP-ZEEP maneuver in adults undergoing mechanical ventilation. METHODS We searched Embase, PubMed, Cochrane Central Register of Controlled Trials, Scopus, and Web of Science from the date of inception of the databases until 6 May 2023. Quality assessment was using the Cochrane Systematic Assessment Handbook. The GRADE system was used to grade the quality of the evidence. RESULTS A total of 12 trials were included, and the results of the meta-analysis showed that PEEP-ZEEP was not superior to bag squeezing for the removal of bronchial secretions. One study showed a significant increase in the amount of secretion retrieved with the PEEP-ZEEP when compared with tracheal suctioning. Additionally, PEEP-ZEEP was more effective than bag squeezing at improving oxygen saturation. However, one trial showed that bag squeezing was better at improving dynamic compliance. No other differences were found between PEEP-ZEEP and other techniques, except for one study showing more frequent changes in diastolic blood pressure with PEEP-ZEEP compared with ventilator hyperinflation. CONCLUSION PEEP-ZEEP was not superior to bag squeezing in removing bronchial secretions. However, it improves oxygen saturation when compared to bag squeezing, and no adverse effects on patients' respiratory systems have yet been observed.
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Affiliation(s)
- Junhong Zhang
- Department of Respiratory and Critical Care Medicine, The Eighth Medical Center of PLA General Hospital, Beijing, China
| | - Xuling Wang
- Department of Neurology, The Eighth Medical Center of PLA General Hospital, Beijing, China
| | - Jinfeng Xie
- Department of Geriatrics, The Eighth Medical Center of PLA General Hospital, Beijing, China
| | - Li Shen
- Ruifang Medical Technology (Suzhou) Co, China
| | - Guoxin Mo
- Department of Respiratory and Critical Care Medicine, The Eighth Medical Center of PLA General Hospital, Beijing, China
| | - Lixin Xie
- Department of Respiratory and Critical Care Medicine, The Eighth Medical Center of PLA General Hospital, Beijing, China.
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Lockstone J, Love A, Chian K, Garnham K, Brumby S, Parry SM. Benefits and risks of ventilator hyperinflation in mechanically ventilated intensive care patients: A systematic review and meta-analysis. Aust Crit Care 2023; 36:1150-1158. [PMID: 36822978 DOI: 10.1016/j.aucc.2023.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 12/14/2022] [Accepted: 01/08/2023] [Indexed: 02/25/2023] Open
Abstract
OBJECTIVES Patients requiring mechanical ventilation in the intensive care unit (ICU) have diminished respiratory defences and are at high risk of respiratory compromise, leading to an increased risk of pulmonary infection and prolonged ventilation. Ventilator hyperinflation (VHI) is an airway clearance technique used by physiotherapists and is suggested to improve respiratory mechanics. The objective of this study was to review the evidence for the benefits and risks of VHI in intubated and mechanically ventilated patients in the ICU. REVIEW METHOD USED We conducted a systematic review. DATA SOURCES We searched PubMed, Embase, CINAHL, CENTRAL, and Scopus from inception to 31st May 2022 for all randomised control trials evaluating VHI in intubated and mechanically ventilated adults in the ICU. REVIEW METHODS Two authors independently performed study selection and data extraction. Individual study risk of bias was assessed using the Physiotherapy Evidence Database scale, and certainty in outcomes was assessed using the Grading of Recommendations, Assessment, Development and Evaluations framework. RESULTS We included 10 studies enrolling 394 patients. Compared to standard care, VHI had significant effects on sputum clearance (Standardise mean difference: 0.36, 95% confidence interval [CI]: 0.12 to 0.61; very low certainty), static pulmonary compliance (mean difference [MD]: 4.77, 95% CI: 2.40 to 7.14; low certainty), dynamic pulmonary compliance (MD: 1.59, 95% CI: 0.82 to 2.36; low certainty) and oxygenation (MD: 0.28, 95% CI: 0.01 to 0.55; low certainty). No significant adverse events or immediate side effects relating to VHI were reported. There is a paucity of data available on the effects of VHI on clinical outcomes including mechanical ventilation duration, ICU length of stay, and mortality. CONCLUSIONS Our findings suggest VHI has potential short-term respiratory benefits including increased secretion clearance, pulmonary compliance, and oxygenation, with no immediate adverse effects in intubated and mechanically ventilated ICU patients. However, there remains limited data on the longer term influence of VHI on clinical outcomes, and further research to inform clinical practice is needed. REGISTRATION This study is registered with the International Prospective Register of Systematic Reviews (PROSPERO; CRD42022341421).
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Affiliation(s)
- Jane Lockstone
- Physiotherapy Department, Launceston General Hospital, TAS, Australia.
| | - Annabel Love
- Physiotherapy Department, Launceston General Hospital, TAS, Australia
| | - Kimberly Chian
- Allied Health Department, Royal Melbourne Hospital, VIC, Australia
| | | | - Susan Brumby
- Physiotherapy Department, Launceston General Hospital, TAS, Australia
| | - Selina M Parry
- Physiotherapy Department, The University of Melbourne, VIC, Australia. https://twitter.com/selina_parry
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de Oliveira TF, Peringer VS, Forgiarini Junior LA, Eibel B. PEEP-ZEEP Compared with Bag Squeezing and Chest Compression in Mechanically Ventilated Cardiac Patients: Randomized Crossover Clinical Trial. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:2824. [PMID: 36833521 PMCID: PMC9957294 DOI: 10.3390/ijerph20042824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 01/28/2023] [Accepted: 02/03/2023] [Indexed: 06/18/2023]
Abstract
Background and Objectives: Perform the bag squeezing and PEEP-ZEEP techniques associated with manual chest compression in mechanically ventilated cardiac patients in order to observe their effectiveness in the removal of pulmonary secretions and safety from a hemodynamic and ventilatory point of view. Methods: This is a randomized crossover clinical trial developed in a hospital in southern Brazil. We included hemodynamically stable male and female patients aged over 18 years who used invasive mechanical ventilation for at least 48 h. The control group was established for the bag-squeezing technique and the intervention group for the PEEP-ZEEP maneuver, both associated with manual chest compression. Tracheal aspiration was performed 2 h before in order to match the groups in relation to the volume of secretion, and also immediately at the end of the techniques in order to measure the amount of secretion collected. Results: The sample had 36 individuals with a mean age of 70.3 years, 21% of the patients were male, and the majority (10.4%) were hospitalized for ischemic heart disease. DBP (p = 0.024), MAP (p = 0.004) and RR (p = 0.041) showed a significant difference in the post-moment in both groups. There was a significant difference in the reduction of peak pressure values (p = 0.011), in the moment after performing the techniques, and also in the Cdyn (p = 0.004) in the control group versus moment. Conclusions: Both maneuvers are safe in terms of hemodynamics and ventilatory mechanics, in addition to being capable of favoring airway clearance through secretion removal, and they can be used in routine physiotherapeutic care.
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Affiliation(s)
- Taís Flores de Oliveira
- Instituto de Cardiologia, Fundação Universitária de Cardiologia (IC/FUC), 395 Princesa Isabel Avenue, Porto Alegre 90620-001, Brazil
| | - Vinicius Serra Peringer
- Instituto de Cardiologia, Fundação Universitária de Cardiologia (IC/FUC), 395 Princesa Isabel Avenue, Porto Alegre 90620-001, Brazil
| | | | - Bruna Eibel
- Instituto de Cardiologia, Fundação Universitária de Cardiologia (IC/FUC), 395 Princesa Isabel Avenue, Porto Alegre 90620-001, Brazil
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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.
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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
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Sánchez Romero EA, Alonso Pérez JL, Vinuesa Suárez I, Corbellini C, Villafañe JH. Spanish experience on the efficacy of airways clearance techniques in SARS-CoV-2 (COVID-19) at intensive care unit: An editorial and case report. SAGE Open Med Case Rep 2022; 10:2050313X221112507. [PMID: 35875169 PMCID: PMC9297451 DOI: 10.1177/2050313x221112507] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 06/22/2022] [Indexed: 12/29/2022] Open
Abstract
COVID-19 pandemic did not impact all countries in the same way, and in Spain, the percentage of intensive care unit (ICU) and the mortality rate patients has been very high. The present work aims to present the first case of the new Coronavirus-2019 (COVID-19) on March 23, 2020, in Tenerife, Canary Islands, Spain, of a patient on Invasive Mechanical Ventilation (IMV) affected by acute pneumonia which was treated by airway clearance techniques (ACT) thinking that she was not infected with COVID-19, since the first polymerase chain reaction (PCR) test was negative. The subject presented septic shock, hypoxemic encephalopathy, and seizures. Right lung base consolidation and pleural effusion were visible in the echography. The thorax x-ray presented subcutaneous emphysema and pleural effusion in the right base and an alveolar-interstitial opacity pattern in the left. Bilateral crackles and rhonchus were evident in the right lung during the lung auscultation. The airway clearance protocol comprises Cough Assist (CA) and chest compressions. The variables collected were the ventilatory parameters, blood gas analysis, and thorax x-ray description. ACT protocol improves gas exchange and expands consolidated lung areas in this atypical clinical case presented. At that time, this type of treatment was not performed on patients affected by COVID-19, and the next day we found that the patient had improved, coinciding with the second PCR test, which was positive.
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Affiliation(s)
- Eleuterio A Sánchez Romero
- Musculoskeletal Pain and Motor Control Research Group, Faculty of Sport Sciences, Universidad Europea de Madrid, Madrid, Spain.,Department of Physiotherapy, Faculty of Sport Sciences, Universidad Europea de Madrid, Madrid, Spain.,Musculoskeletal Pain and Motor Control Research Group, Faculty of Health Sciences, Universidad Europea de Canarias, Tenerife, Spain.,Department of Physiotherapy, Faculty of Health Sciences, Universidad Europea de Canarias, Tenerife, Spain
| | - José Luis Alonso Pérez
- Musculoskeletal Pain and Motor Control Research Group, Faculty of Sport Sciences, Universidad Europea de Madrid, Madrid, Spain.,Department of Physiotherapy, Faculty of Sport Sciences, Universidad Europea de Madrid, Madrid, Spain.,Musculoskeletal Pain and Motor Control Research Group, Faculty of Health Sciences, Universidad Europea de Canarias, Tenerife, Spain.,Department of Physiotherapy, Faculty of Health Sciences, Universidad Europea de Canarias, Tenerife, Spain.,Onelifecenter, Multidisciplinary Pain Treatment Center, Madrid, Spain
| | - Inmaculada Vinuesa Suárez
- Musculoskeletal Pain and Motor Control Research Group, Faculty of Sport Sciences, Universidad Europea de Madrid, Madrid, Spain.,Musculoskeletal Pain and Motor Control Research Group, Faculty of Health Sciences, Universidad Europea de Canarias, Tenerife, Spain.,Hospital Universitario Nuestra Señora de Candelaria, Tenerife, Spain
| | - Camilo Corbellini
- Department of Physiotherapy, LUNEX International University of Health, Exercise and Sports, Differdange, Luxembourg.,Casa di cura "Villa Serena," Piossasco, Italy
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Effects of ventilator hyperinflation on pulmonary function and secretion clearance in adults receiving mechanical ventilation: A systematic review with meta-analysis. Heart Lung 2022; 56:8-23. [PMID: 35649308 DOI: 10.1016/j.hrtlng.2022.05.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 05/17/2022] [Accepted: 05/20/2022] [Indexed: 11/04/2022]
Abstract
INTRODUCTION It is important to clarify the effect of ventilator hyperinflation(VHI) on pulmonary function and secretion clearance in adults receiving mechanical ventilation(MV). There is no published meta-analysis on the effects VHI on pulmonary function and secretion clearance in adults receiving MV. Objective Analyze the published randomized clinical trials(RCTs) that investigated the effects of VHI on pulmonary function and secretion clearance in adults receiving MV, comparing VHI with isolated aspiration, VHI with manual hyperinflation(MHI), VHI +vibrocompression(VB) versus VB and VHI+VB versus isolated aspiration. METHODS The following databases PubMed, LILACS, EMBASE, SciELO, PEDro database and Cochrane Central Register of Controlled Trials (CENTRAL) were consulted up to December 2021. Secretion clearance, static and dynamic compliance of the respiratory system(Cstat and Cdyn), airway resistance(Raw) and oxygenation outcomes were evaluated. RESULTS Thirteen studies met the study criteria, but only 12 studies were included on meta-analysis. There was no difference between VHI versus isolated aspiration for amount of secretions removed(0.41 SMD; 95% CI: -0.08 to 0.89; n=270), VHI versus MHI(0.51 grams; 95% CI: -0.08 to 1.11; n=256), VHI+VB versus VB(0.31 grams; 95% CI: -0.42 to 1.05; n=130) and VHI+VB versus isolated aspiration(0.54 grams; 95% CI: -0.06 to 1.14; n=132). There was difference for VHI versus isolated aspiration to Cstat (4.77 ml/cm H2O; 95% CI: 2.41 to 7.14; n= 136). CONCLUSION No evidence was found that VHI was effective in increasing the amount of secretions removed, Cdyn and oxygenation, but VHI seems to show a slight improvement in Cstat when compared to isolated aspiration.
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Tronstad O, Martí JD, Ntoumenopoulos G, Gosselink R. An Update on Cardiorespiratory Physiotherapy during Mechanical Ventilation. Semin Respir Crit Care Med 2022; 43:390-404. [PMID: 35453171 DOI: 10.1055/s-0042-1744307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Physiotherapists are integral members of the multidisciplinary team managing critically ill adult patients. However, the scope and role of physiotherapists vary widely internationally, with physiotherapists in some countries moving away from providing early and proactive respiratory care in the intensive care unit (ICU) and focusing more on early mobilization and rehabilitation. This article provides an update of cardiorespiratory physiotherapy for patients receiving mechanical ventilation in ICU. Common and some more novel assessment tools and treatment options are described, along with the mechanisms of action of the treatment options and the evidence and physiology underpinning them. The aim is not only to summarize the current state of cardiorespiratory physiotherapy but also to provide information that will also hopefully help support clinicians to deliver personalized and optimal patient care, based on the patient's unique needs and guided by accurate interpretation of assessment findings and the current evidence. Cardiorespiratory physiotherapy plays an essential role in optimizing secretion clearance, gas exchange, lung recruitment, and aiding with weaning from mechanical ventilation in ICU. The physiotherapists' skill set and scope is likely to be further optimized and utilized in the future as the evidence base continues to grow and they get more and more integrated into the ICU multidisciplinary team, leading to improved short- and long-term patient outcomes.
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Affiliation(s)
- Oystein Tronstad
- Critical Care Research Group, Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, Australia.,Physiotherapy Department, The Prince Charles Hospital, Brisbane, Australia
| | - Joan-Daniel Martí
- Cardiac Surgery Critical Care Unit, Institut Clinic Cardiovascular, Hospital Clínic, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | | | - Rik Gosselink
- Department Rehabilitation Sciences, University of Leuven, University Hospitals Leuven, Belgium
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Kwan BPM, Hill AM, Elliott M, van der Lee L. A retrospective study of physiotherapy management for patients with pneumonia requiring invasive ventilation in a single-center Australian ICU. Hong Kong Physiother J 2022; 42:55-64. [PMID: 35782697 PMCID: PMC9244597 DOI: 10.1142/s1013702522500068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Accepted: 01/26/2022] [Indexed: 11/18/2022] Open
Abstract
Background: Pneumonia is a frequent diagnosis for patients admitted to Australian intensive care units (ICUs) for invasive ventilation. Physiotherapists in ICU provide interventions to enhance respiratory function and physical recovery. Objective: This retrospective cohort study aimed to describe physiotherapy management of adults with pneumonia who require invasive mechanical ventilation in a single Level 3 ICU in a quaternary teaching hospital. Methods: All adults admitted with a medical diagnosis of pneumonia requiring invasive mechanical ventilation over a two-year period were included. Demographic and clinical data, including APACHE II score, ventilator-free days (VFDs) to day 28, ICU length of stay (LOS), and type and frequency of physiotherapy episodes of care delivered in ICU, were collected from electronic medical records. Correlations between VFDs to day 28 and the frequency of physiotherapy interventions delivered per subject were examined using Spearman’s rho analysis. Results: From 208 records screened, 66 subjects with an ICU admission diagnosis of pneumonia, who required invasive mechanical ventilation, were included. Median (IQR) ICU LOS was 10 (5–17) days, and mortality rate was 15.2% (n=10). The cohort had a median of 20.5 (IQR 2–25) VFDs to day 28. Community-acquired pneumonia (66.7%, n=44) was the most frequent type of pneumonia diagnosis. There were 1110 episodes of physiotherapy care, with patients receiving a median of 13.5 (IQR 6.8–21.3) episodes during their ICU stay, with a median rate of 1.2 (IQR 1.0–1.6) episodes per day. Over 96.7% of patients with pneumonia received physiotherapy treatment during their ICU stay. Overall, physiotherapy treatments consisting only of respiratory techniques were most commonly provided (55.1%, n=612). Airway suctioning (92.4%, n=61), patient positioning (72.7%, n=48) or positioning advice to nurses (77.3%, n=51), and hyperinflation techniques (63.6%, n=42) were among the respiratory techniques most delivered. Conclusion: This study described the current intensive care physiotherapy management in a single center for adults with pneumonia who required invasive mechanical ventilation, demonstrating that respiratory physiotherapy interventions are often provided for this ICU patient cohort. Further research is warranted to determine the efficacy of respiratory physiotherapy interventions to justify their use for ICU patients with pneumonia receiving invasive mechanical ventilation.
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Affiliation(s)
- Baldwin Pok Man Kwan
- Discipline of Physiotherapy, School of Allied Health, Curtin University, GPO Box U1987, Perth, WA 6845, Australia
| | - Anne-Marie Hill
- Discipline of Physiotherapy, School of Allied Health, Curtin University, GPO Box U1987, Perth, WA 6845, Australia
| | - Mercedes Elliott
- Physiotherapy Department, Fiona Stanley Hospital Perth, Locked Bag 100, Palmyra DC, WA 6961, Australia
| | - Lisa van der Lee
- Physiotherapy Department, Fiona Stanley Hospital Perth, Locked Bag 100, Palmyra DC, WA 6961, Australia
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Valer BB, Bonczynski GS, Scheffer KD, Ibrahim Forgiarini SG, Eibel B, Lisboa Cordeiro AL, Friedman G, Forgiarini Júnior LA. Ventilator versus manual hyperinflation in adults receiving mechanical ventilation: A systematic review. PHYSIOTHERAPY RESEARCH INTERNATIONAL 2022; 27:e1936. [DOI: 10.1002/pri.1936] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Revised: 10/11/2021] [Accepted: 12/30/2021] [Indexed: 11/11/2022]
Affiliation(s)
| | | | | | | | - Bruna Eibel
- Institute of Cardiology (IC / FUC) Porto Alegre Brazil
| | | | - Gilberto Friedman
- Faculty of Medicine Federal University of Rio Grande do Sul Porto Alegre Brazil
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Ou GWM, Ng MJH, Ng CLW, Ong HK, Jayachandran B, Palanichamy V. Physiotherapy Practice Pattern in the Adult Intensive Care Units of Singapore – A Multi-Centre Survey. PROCEEDINGS OF SINGAPORE HEALTHCARE 2022. [DOI: 10.1177/20101058211068589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background The roles of physiotherapy in Intensive Care Unit (ICU) have significantly developed from the traditional management of respiratory conditions to early rehabilitation and mobilisation of patients on mechanical ventilation. Surveys of United Kingdom, Australia and regional ICU physiotherapy practice have been published but there are no local data sets. This study aims to report the physiotherapy practices across the adult ICUs of Singapore. Methods Twenty-nine item questionnaire was mailed to 90 physiotherapists working in 15 adult ICUs across restructured and private hospitals in Singapore. Data sets were summarised from the returned questionnaires. This includes identifying common physiotherapy techniques and exercise prescription protocols for both mechanically and non-mechanically ventilated patients in the ICU. Results A total of 63 (70%) questionnaires were returned. The most used physiotherapy interventions were airway secretion clearance, techniques to improve lung ventilation and mobilisation out of bed. Positioning was most used respiratory technique (60/61, 98%). Sitting on the edge of bed is the most preferred physical activity for ICU patients (43/44, 98%). Exercise was routinely prescribed (50/61, 83%) although only a minority (8/50, 16%) have established exercise prescription protocols. For mechanically ventilated patients, active/active assisted exercises were most used (40/44, 91%). 12% of ICU use either Chelsea Critical Care Physical Assessment Tool or the Functional Status Score for the Intensive Care Unit as routine outcome measures. Conclusion Airway clearance was stated as the most used physiotherapy technique. Exercise is routinely prescribed in ICU. Validated outcome measures are only used by few.
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Affiliation(s)
| | - Marcus Jun Hui Ng
- Physiotherapy, Singapore Institute of Technology, Singapore, Singapore
| | | | - Hwee Kuan Ong
- Physiotherapy, Singapore General Hospital, Singapore, Singapore
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van der Lee L, Hill AM, Jacques A, Patman S. Efficacy of Respiratory Physiotherapy Interventions for Intubated and Mechanically Ventilated Adults with Pneumonia: A Systematic Review and Meta-Analysis. Physiother Can 2021; 73:6-18. [PMID: 35106019 PMCID: PMC8774958 DOI: 10.3138/ptc-2019-0025] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2023]
Abstract
Purpose: A systematic review was conducted to investigate the effect of respiratory physiotherapy on mortality, quality of life, functional recovery, intensive care length of stay, duration of ventilation, oxygenation, secretion clearance, and pulmonary mechanics for invasively ventilated adults with pneumonia. Method: Five databases were searched for randomized trials published between January 1995 and November 2018. Study quality was assessed using a standardized Joanna Briggs Institute critical appraisal tool, and Review Manager software was used to pool the studies. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to evaluate the level of certainty of the evidence. Results: A total of 14 studies of moderate quality included 251 subjects with pneumonia. Eight studies were pooled for meta-analysis. Interventions that increased inspiratory volume appeared to benefit secretion clearance by nearly 2 grams (mean difference [MD] 1.97; 95% CI: 0.80, 3.14; very low GRADE evidence) and increase static lung compliance immediately after treatment by more than 5 millilitres/centimetre H20 (MD 5.40 mL/cm H2O; 95% CI: 2.37, 8.43; very low GRADE evidence) or by more than 6 millilitres/centimetre H2O after a 20- to 30-minute delay (MD 6.86 mL/cm H2O; 95% CI: 2.86, 10.86; very low GRADE evidence). No adverse events were found. Conclusions: Respiratory physiotherapy that increases tidal volume may benefit secretion clearance and lung compliance in invasively ventilated adults with pneumonia, but its impact on other outcomes, including mortality, length of stay, and other patient-centred outcomes, is unclear, and further research is required.
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Affiliation(s)
- Lisa van der Lee
- School of Physiotherapy
- Physiotherapy Department, Fiona Stanley Hospital, Murdoch
| | - Anne-Marie Hill
- School of Physiotherapy and Exercise Science, Curtin University, Perth, W.A., Australia
| | - Angela Jacques
- Institute for Health Research, University of Notre Dame, Fremantle
- School of Physiotherapy and Exercise Science, Curtin University, Perth, W.A., Australia
| | - Shane Patman
- Physiotherapy Department, Fiona Stanley Hospital, Murdoch
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van der Lee L, Hill AM, Patman S. Clinical validation of expert consensus statements for respiratory physiotherapy management of invasively ventilated adults with community-acquired pneumonia: A qualitative study. Intensive Crit Care Nurs 2020; 60:102854. [PMID: 32448631 DOI: 10.1016/j.iccn.2020.102854] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 01/27/2020] [Accepted: 02/20/2020] [Indexed: 01/09/2023]
Abstract
OBJECTIVES To conduct multidisciplinary peer-review of expert consensus statements for respiratory physiotherapy for invasively ventilated adults with community-acquired pneumonia, to determine clinical acceptability for development into a clinical practice guideline. RESEARCH METHODOLOGY A qualitative study was undertaken using focus groups (n = 3) conducted with clinician representatives from five Australian states. Participants were senior intensive care physiotherapists, nurses and consultants. Thematic analysis was used, with a deductive approach to confirm clinical validity, and inductive analysis to identify new themes relevant to the application of the 38 statements into practice. SETTING Adult intensive care. FINDINGS Senior intensive care clinicians from physiotherapy (n = 16), medicine (n = 6) and nursing (n = 4) participated. All concurred that the consensus statements added valuable guidance to practice; twenty-nine (76%) were deemed relevant and applicable for the intensive care setting without amendment, with modifications suggested for remaining nine statements to enhance utility. Overarching themes of patient safety, teamwork and communication and culture were identified as factors influencing clinical application. Cultural differences in practice, particularly related to patient positioning, was evident between jurisdictions. Participants raised practicality and safety concerns for two statements related to the use of head-down patient positioning. CONCLUSION Multidisciplinary peer-review established clinical validity of expert consensus statements for implementation with invasively ventilated adults with community-acquired pneumonia.
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Affiliation(s)
- Lisa van der Lee
- The University of Notre Dame Australia, School of Physiotherapy, 19 Mouat Street (PO Box 1225), Fremantle, WA 6959, Australia; Fiona Stanley Hospital Perth, Intensive Care Unit, Locked Bag 100, Palmyra DC, WA 6961, Australia.
| | - Anne-Marie Hill
- Curtin University, School of Physiotherapy and Exercise Science, Kent Street, Bentley Perth, WA 6102, Australia
| | - Shane Patman
- The University of Notre Dame Australia, School of Physiotherapy, 19 Mouat Street (PO Box 1225), Fremantle, WA 6959, Australia
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Jacob W, Dennis D, Jacques A, Marsh L, Woods P, Hebden-Todd T. Ventilator hyperinflation determined by peak airway pressure delivered: A randomized crossover trial. Nurs Crit Care 2020; 26:14-19. [PMID: 31957246 DOI: 10.1111/nicc.12498] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 11/21/2019] [Accepted: 12/19/2019] [Indexed: 11/29/2022]
Abstract
AIM The aim of this study was to see if a more sophisticated ventilator hyperinflation protocol might result in more sputum clearance compared to manual hyperinflation. BACKGROUND Hyperinflation has been used to mobilize lung secretions in mechanically ventilated patients in the intensive care unit setting for almost 50 years. In the past decade, rather than using a bag external to the ventilator circuit to deliver hyperinflation (known as "bagging" or "manual hyperinflation"), a new technique has evolved using existing ventilator circuitry (known as "ventilator hyperinflation"). One conservative ventilator hyperinflation protocol has demonstrated equivalence with manual hyperinflation in sputum clearance. DESIGN A randomized crossover study. METHOD Patients received manual hyperinflation and ventilator hyperinflation in two randomly ordered treatments on the same day by the same physiotherapist, using a ventilator hyperinflation protocol involving titration of hyperinflation according to airway pressure. RESULTS Between 2013 and 2018, 48 patients were enrolled in the study. Physiotherapy treatment using ventilator hyperinflation yielded significantly more wet weight sputum (median 2.84 g, IQR 1.81, 4.22) than treatment using manual hyperinflation (median 1.5 g, IQR 0.73, 2.31, P < .001), without significant differences in secondary measures. CONCLUSIONS A more sophisticated approach to the titration of the volume delivered using ventilator hyperinflation relative to the airway pressure resulted in greater wet weight sputum cleared during physiotherapy treatment. RELEVANCE TO CLINICAL PRACTICE The results presented in this paper demonstrate that the application of ventilator hyperinflation using peak airway pressure rather than tidal volume may be superior in facilitating sputum clearance and improved oxygenation without patient harm.
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Affiliation(s)
- Wendy Jacob
- Intensive Care Unit, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
| | - Diane Dennis
- Intensive Care Unit, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia.,Faculty of Health Sciences, Curtin University, Bentley, Western Australia, Australia
| | - Angela Jacques
- Department of Research, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia.,Institute for Health Research, University of Notre Dame Australia, Fremantle, Western Australia, Australia
| | - Lisa Marsh
- Intensive Care Unit, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
| | - Paul Woods
- Intensive Care Unit, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
| | - Tracy Hebden-Todd
- Intensive Care Unit, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
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Chicayban LM. Acute effects of ventilator hyperinflation with increased inspiratory time on respiratory mechanics: randomized crossover clinical trial. Rev Bras Ter Intensiva 2019; 31:289-295. [PMID: 31618346 PMCID: PMC7005952 DOI: 10.5935/0103-507x.20190052] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 02/21/2019] [Indexed: 11/20/2022] Open
Abstract
Objective To evaluate the effects of ventilator hyperinflation on respiratory mechanics. Methods A randomized crossover clinical trial was conducted with 38 mechanically ventilated patients with pulmonary infection. The order of the hyperinflation and control (without changes in the parameters) conditions was randomized. Hyperinflation was performed for 5 minutes in pressure-controlled ventilation mode, with progressive increases of 5cmH2O until a maximum pressure of 35cmH2O was reached, maintaining positive end expiratory pressure. After 35cmH2O was reached, the inspiratory time and respiratory rate were adjusted so that the inspiratory and expiratory flows reached baseline levels. Measurements of static compliance, total resistance and airway resistance, and peak expiratory flow were evaluated before the technique, immediately after the technique and after aspiration. Two-way analysis of variance for repeated measures was used with Tukey's post hoc test, and p < 0.05 was considered significant. Results Ventilator hyperinflation increased static compliance, which remained at the same level after aspiration (46.2 ± 14.8 versus 52.0 ± 14.9 versus 52.3 ± 16.0mL/cmH2O; p < 0.001). There was a transient increase in airway resistance (6.6 ± 3.6 versus 8.0 ± 5.5 versus 6.6 ± 3.5cmH2O/Ls-1; p < 0.001) and a transient reduction in peak expiratory flow (32.0 ± 16.0 versus 29.8 ± 14.8 versus 32.1 ± 15.3Lpm; p <0.05) immediately after the technique; these values returned to pretechnique levels after tracheal aspiration. There were no changes in the control condition, nor were hemodynamic alterations observed. Conclusion Ventilator hyperinflation promoted increased compliance associated with a transient increase in airway resistance and peak expiratory flow, with reduction after aspiration.
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Affiliation(s)
- Luciano Matos Chicayban
- Laboratório de Pesquisa em Fisioterapia Pneumofuncional e Intensiva, Institutos Superiores de Ensino do CENSA - Campos dos Goytacazes (RJ), Brasil.,Unidade de Terapia Intensiva, Hospital Geral de Guarus - Campos dos Goytacazes (RJ), Brasil
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Gonçalves JDSPDR, Shimoya-Bittencourt W, Santos VM, Belmonte M. Impacts in the Respiratory Mechanics of the Ventilator Hyperinsuflation in the Flow Bias Concept: a Narrative Review. JOURNAL OF HEALTH SCIENCES 2019. [DOI: 10.17921/2447-8938.2019v21n3p250-254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
AbstractPatients who require invasive ventilatory support are subject to the deleterious effects of this, mainly ventilator-associated pneumonia (VAP). The physiotherapist, a member of the multiprofessional team, assists the patient with the purpose of promoting the recovery and preservation of the functionality, being able to minimize / avoid secondary complications. This study aims to identify the repercussions of mechanical ventilation hyperinflation (MVH) in the flow bias concept in respiratory mechanics. This study is a narrative review. MVH is an important resource commonly used in clinical practice that involves the manipulation of mechanical ventilator configurations to provide larger pulmonary volumes, and the generated airflow gradient may play a relevant role in mucus transport, with the concept of flow bias the main factor responsible for its direction. For the mobilization of the mucus towards the cephalic direction to occur, there must be a predominant expiratory flow, guaranteeing the peak ratio of expiratory flow / inspiratory flow peak (EFP / IFP) greater than 1.11. Maintenance of mechanical ventilation assures the patient to maintain the positive end expiratory pressure (PEEP) and the oxygen inspired fraction, avoiding the deleterious effects of the mechanical ventilator disconnection. MVH is able to improve lung compliance without, however, increasing airway resistance. MVH in the cephalic flow bias concept is effective for the mucus mobilization in the central direction, being able to improve pulmonary compliance and peripheral oxygen saturation.Keywords: Respiration, Artificial. Intensive Care Units. Physical Therapy Department, Hospital.ResumoOs pacientes internados que necessitam de suporte ventilatório invasivo estão sujeitos aos efeitos deletérios deste, principalmente a pneumonia associada à ventilação mecânica (PAV). O fisioterapeuta, integrante da equipe multiprofissional, assiste o paciente com a finalidade de promover a recuperação e preservação da funcionalidade, podendo minimizar/evitar complicações secundárias. Este estudo consiste em identificar as repercussões da hiperinsuflação com ventilador mecânico (HVM) no conceito flow bias na mecânica respiratória. O presente estudo trata-se de uma revisão narrativa. A HVM é um importante recurso comumente utilizado na prática clínica que envolve a manipulação das configurações do ventilador mecânico para fornecer maiores volumes pulmonares, e o gradiente de fluxo de ar gerado pode desempenhar um papel relevante no transporte do muco, sendo o conceito de flow bias cefálico o principal fator responsável pelo direcionamento deste. Para que a mobilização do muco em direção cefálica ocorra, deve existir um fluxo expiratório predominante, garantindo a razão pico de fluxo expiratório/pico de fluxo inspiratório (PFE/PFI) maior do que 1,11. A manutenção da assistência ventilatória mecânica assegura ao paciente a manutenção da pressão positiva ao final da expiração (PEEP) e a fração inspirada de oxigênio (FiO2), evitando os efeitos deletérios da desconexão do ventilador mecânico. A HVM é capaz de melhorar a complacência pulmonar sem, no entanto, aumentar a resistência das vias aéreas. A HVM no conceito flow bias cefálico é eficaz para a mobilização do muco em direção central, sendo capaz de melhorar a complacência pulmonar e saturação periférica de oxigênio (SpO2).Palavras-chave: Respiração Artificial. Unidades de Terapia Intensiva. Serviço Hospitalar de Fisioterapia.
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Incidence and risk factors of pulmonary atelectasis in mechanically ventilated trauma patients in ICU: a prospective study. INT J EVID-BASED HEA 2019; 17:44-52. [PMID: 30113349 DOI: 10.1097/xeb.0000000000000150] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
AIM The aim of the study was to obtain information about the incidence and risk factors for pulmonary atelectasis in mechanically ventilated patients in the trauma ICU (TMICU). Pulmonary atelectasis is a common complication leading to serious lung dysfunction in patients in the TMICU and early identification of patients at risk is important for their effective management. METHODS All trauma patients admitted to the TMICU with mechanical ventilation for more than 1 day were included in a prospective 12-month study. Pulmonary atelectasis was diagnosed from chest radiographs by a critical care doctor and radiologist. RESULTS A total of 405 trauma patients were identified and data from 338 patients analyzed showing the incidence of pulmonary atelectasis to be 14%. Multivariate analysis revealed significant risk factors to be chest injury with an adjusted odds ratio (AOR) of 102.8, abdominal injury (AOR: 4.6), surgical intervention (AOR: 8.4), comorbidity (AOR: 13.7), Acute Physiology and Chronic Health Evaluation II score (APACHE II) of at least 15 (AOR: 4.8), sedation of at least 7 days (AOR: 7.5) and mechanical ventilation of at least 9 days (AOR: 3.43). Patients with chronic pulmonary disease tended to have higher risk for pulmonary atelectasis (AOR: 8.8). Patients with pulmonary atelectasis had longer stays in TMICU (P < 0.001) and higher mortality (P = 0.013). CONCLUSION The incidence of pulmonary atelectasis in TMICU in Thailand is comparable with that of the developed world. Pulmonary atelectasis is particularly associated with chest trauma, whereas abdominal injury, APACHE II of at least 15, surgery, comorbidity and prolonged mechanical ventilation are also significant risk factors. Early interventions to prevent or treat pulmonary atelectasis in these patients may improve outcome and shorten their stay in the TMICU and hospital.
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van der Lee L, Hill AM, Patman S. Expert consensus for respiratory physiotherapy management of mechanically ventilated adults with community-acquired pneumonia: A Delphi study. J Eval Clin Pract 2019; 25:230-243. [PMID: 30565374 DOI: 10.1111/jep.13077] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 10/29/2018] [Accepted: 10/29/2018] [Indexed: 01/04/2023]
Abstract
RATIONALE AND AIMS Patients with community-acquired pneumonia (CAP) are frequently admitted to an intensive care unit. Physiotherapy may be provided to optimize respiratory function; however, there is significant variability in clinical practice and limited research directing best practice for this cohort. This study aimed to determine expert consensus for best physiotherapy practice for invasively ventilated adults with CAP. METHOD A modified Delphi technique involved an international expert panel completing three rounds of an online questionnaire. The initial 35-statement questionnaire, based on a systematic literature review and survey of current clinical practice, covered physiotherapy assessment and treatment of intubated patients with CAP. Quantitative data using Likert scales determined level of agreement, with qualitative data collected through open-ended responses. Consensus threshold was set a priori at 70%. Items not achieving consensus were modified and new items added based on themes from qualitative data. Quantitative data were analysed descriptively, with thematic analysis used on qualitative data. RESULTS The panel comprised 29 international clinical and academic experts in critical care physiotherapy. Response rate was more than 95% for each round. Outcome achieved was 38 consensus statements covering assessment and treatment, with 28 statements (74%) providing consensus on recommended clinical practice, two consensus disagreement statements (7%) for what practice is not recommended, and eight statements (21%) indicating which treatments may be beneficial. CONCLUSION Expert consensus regarding physiotherapy for intubated adults with CAP patients provides an evidence-based approach to guide clinical practice. The consensus statements can also be used to guide research evaluating physiotherapy interventions for patients with CAP.
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Affiliation(s)
- Lisa van der Lee
- School of Physiotherapy, The University of Notre Dame Australia, Fremantle, Australia.,Intensive Care Unit, Fiona Stanley Hospital Perth, Australia
| | - Anne-Marie Hill
- School of Physiotherapy and Exercise Science, Curtin University, Bentley, Australia
| | - Shane Patman
- School of Physiotherapy, The University of Notre Dame Australia, Fremantle, Australia
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Naue WDS, Herve BB, Vieira FN, Deponti GN, Martins LDF, Dias AS, Vieira SRR. Comparison of bronchial hygiene techniques in mechanically ventilated patients: a randomized clinical trial. Rev Bras Ter Intensiva 2019; 31:39-46. [PMID: 30892477 PMCID: PMC6443316 DOI: 10.5935/0103-507x.20190005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2018] [Accepted: 11/27/2018] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE To compare the effects of vibrocompression and hyperinflation with mechanical ventilator techniques alone and in combination (hyperinflation with mechanical ventilator + vibrocompression) on the amount of aspirated secretion and the change in hemodynamic and pulmonary parameters. METHODS A randomized clinical trial with critically ill patients on mechanical ventilation conducted in the intensive care unit of a university hospital. The patients were randomly allocated to receive one of the bronchial hygiene techniques for 10 minutes (vibrocompression or hyperinflation with mechanical ventilator or hyperinflation with mechanical ventilator + vibrocompression). Afterwards, the patients were again randomly allocated to receive either the previous randomly allocated technique or only tracheal aspiration. The weight of aspirated secretions (in grams), ventilatory mechanics and cardiopulmonary data before and after the application of the techniques were analyzed. The tracheal reintubation frequency and time and mortality on mechanical ventilation were also evaluated. RESULTS A total of 93 patients (29 vibrocompression, 32 hyperinflation with mechanical ventilator and 32 hyperinflation with mechanical ventilator + vibrocompression) on mechanical ventilation for more than 24 hours were included. The hyperinflation with mechanical ventilator + vibrocompression group was the only one that presented a significant increase in aspirated secretions compared to tracheal aspiration alone [0.7g (0.1 - 2.5g) versus 0.2g (0.0 - 0.6g), p value = 0.006]. CONCLUSION Compared to tracheal aspiration alone, the combination of hyperinflation with mechanical ventilator + vibrocompression techniques was most efficient for increasing the amount of aspirated secretions.
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Affiliation(s)
- Wagner da Silva Naue
- Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul - Porto Alegre (RS), Brasil
| | - Bruno Barcelos Herve
- Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul - Porto Alegre (RS), Brasil
| | - Fernando Nataniel Vieira
- Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul - Porto Alegre (RS), Brasil
| | - Gracieli Nadalon Deponti
- Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul - Porto Alegre (RS), Brasil
| | - Luciane de Fraga Martins
- Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul - Porto Alegre (RS), Brasil
| | - Alexandre Simões Dias
- Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul - Porto Alegre (RS), Brasil
| | - Silvia Regina Rios Vieira
- Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul - Porto Alegre (RS), Brasil
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Silva-Guimarães F, Silveira-Menezes SL. Comment on «Respiratory physiotherapy in intensive care unit: Bibliographic review». ENFERMERIA INTENSIVA 2018; 30:94. [PMID: 30509875 DOI: 10.1016/j.enfi.2018.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Accepted: 07/18/2018] [Indexed: 11/19/2022]
Affiliation(s)
- F Silva-Guimarães
- Departamento de Fisioterapia, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brasil.
| | - S L Silveira-Menezes
- Departamento de Fisioterapia, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brasil
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Chapman RL, Shannon H, Koutoumanou E, Main E. Effect of inspiratory rise time on sputum movement during ventilator hyperinflation in a test lung model. Physiotherapy 2018; 105:283-289. [PMID: 30409468 DOI: 10.1016/j.physio.2018.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Accepted: 06/03/2018] [Indexed: 11/19/2022]
Abstract
OBJECTIVES Physiotherapists may use ventilator hyperinflation to enhance secretion clearance for intubated patients. This study investigated the effects of altering percentage inspiratory rise time (IRT) on sputum movement, ratio of peak inspiratory to expiratory flow rate (PIF:PEF ratio) and net peak expiratory flow (PEF) during ventilator hyperinflation in a test lung model. DESIGN Laboratory-based bench study. INTERVENTIONS Simulated sputum (two viscosities) was inserted into clean, clear tubing and connected between a ventilator and a resuscitation bag. Thirty-six ventilator hyperinflation breaths were applied for each 5% incremental increase in IRT between 0% and 20%. MAIN OUTCOME MEASURES The primary outcome was sputum displacement (cm). Secondary outcomes included PIF:PEF ratio and net PEF. RESULTS Significant cephalad sputum movement of 2.42cm (1.59 to 3.94) occurred with IRT between 5% and 20%, compared with caudad movement of 0.53 cm (0.31 to 1.53) at 0% IRT (median sputum movement difference 3.7cm, 95% confidence interval 2.2 to 4.8, P<0.001). Incremental increases in IRT percentage produced linear enhancements in PIF:PEF ratio and net PEF for both sputum concentrations (P<0.001). However, once the critical threshold for PIF:PEF ratio of 0.9 was achieved, the distance of sputum movement remained consistent for all IRT values exceeding 5%. CONCLUSIONS Significant increases in sputum movement occurred when IRT percentage was lengthened to achieve the optimal PIF:PEF ratio, irrespective of sputum viscosity. This provides a theoretical rationale for therapists to consider this technique when treating mechanically ventilated patients. As no additional sputum movement was seen beyond the critical PIF:PEF ratio threshold, a low IRT percentage may potentially be used to achieve effective sputum movement.
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Affiliation(s)
- R L Chapman
- Physiotherapy Programme, UCL Great Ormond Street Institute of Child Health, London, UK; Therapy Services, Hampshire Hospital's NHS Foundation Trust, Winchester, UK.
| | - H Shannon
- Physiotherapy Programme, UCL Great Ormond Street Institute of Child Health, London, UK
| | - E Koutoumanou
- Population, Policy and Practice Programme, UCL Great Ormond Street Institute of Child Health, London, UK
| | - E Main
- Physiotherapy Programme, UCL Great Ormond Street Institute of Child Health, London, UK
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Ribeiro BS, Lopes AJ, Menezes SLS, Guimarães FS. Selecting the best ventilator hyperinflation technique based on physiologic markers: A randomized controlled crossover study. Heart Lung 2018; 48:39-45. [PMID: 30336946 DOI: 10.1016/j.hrtlng.2018.09.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Revised: 08/26/2018] [Accepted: 09/18/2018] [Indexed: 12/01/2022]
Abstract
BACKGROUND Ventilator hyperinflation (VHI) is effective in improving respiratory mechanics, secretion removal, and gas exchange in mechanically ventilated subjects; however, there are no recommendations for the best ventilator settings to perform the technique. OBJECTIVE To compare six modes of VHI, concerning physiological markers of efficacy and safety criteria to support the selection of optimal settings. METHODS Thirty mechanically ventilated patients underwent six modes of VHI in a randomized order. The delivered volume, expiratory flow bias criteria, overdistension, patient-ventilator asynchronies and hemodynamic variables were assessed during the interventions. RESULTS Volume-controlled ventilation with inspiratory flow of 20 lpm (VC-CMV20) and pressure support ventilation (PSV) achieved the best effectiveness scores (P < 0.05). The target peak pressure of 40 cmH2O was associated with a high incidence of overdistension. PSV showed a lower incidence of patient-ventilator asynchronies. CONCLUSIONS The modes VC-CMV20 and PSV are the most effective for VHI. Alveolar overdistension and patient-ventilator asynchronies must be considered when applying VHI.
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Affiliation(s)
- Beatriz S Ribeiro
- Rehabilitation Sciences Post Graduation Program, Augusto Motta University Center, Rio de Janeiro, RJ, Brazil
| | - Agnaldo J Lopes
- Rehabilitation Sciences Post Graduation Program, Augusto Motta University Center, Rio de Janeiro, RJ, Brazil; Post-graduate Program in Medical Sciences, State University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Sara L S Menezes
- Rehabilitation Sciences Post Graduation Program, Augusto Motta University Center, Rio de Janeiro, RJ, Brazil; Physical Therapy Department, Federal University of Rio de Janeiro, RJ, Brazil
| | - Fernando S Guimarães
- Rehabilitation Sciences Post Graduation Program, Augusto Motta University Center, Rio de Janeiro, RJ, Brazil; Physical Therapy Department, Federal University of Rio de Janeiro, RJ, Brazil.
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Mase K, Yamamoto K, Murakami S, Kihara K, Matsushita K, Nozoe M, Takashima S. Changes in ventilation mechanics during expiratory rib cage compression in healthy males. J Phys Ther Sci 2018; 30:820-824. [PMID: 29950772 PMCID: PMC6016301 DOI: 10.1589/jpts.30.820] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Accepted: 03/15/2018] [Indexed: 02/02/2023] Open
Abstract
[Purpose] The purpose of this study was to clarify the differences in ventilation mechanics between quiet breathing and expiratory rib cage compression, and between expiratory rib cage compression on the upper rib cage and on the lower rib cage. [Subjects and Methods] Subjects comprised 6 healthy males. Expiratory rib cage compression was performed manually by compressing the upper and lower rib cages. Changes in the lung volume, flow rate, and esophageal and gastric pressure were examined. [Results] The end expiratory lung volume was significantly lower during expiratory rib cage compression than at rest, but the end inspiratory lung volume was not significantly different. When compared with the esophageal and gastric pressures on the upper and lower rib cages at rest, the gastric pressures were significantly higher at end expiration. Lung resistance was significantly higher during expiratory rib cage compression than at rest. [Conclusion] Although expiratory rib cage compression promoted expiration and increased tidal volume, the lung volume did not increase beyond end inspiratory levels at rest. Lung resistance may increase during expiratory rib cage compression due to a decrease in lung volume. The mechanism by which expiration is promoted differed between the upper and lower rib cages.
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Affiliation(s)
- Kyoushi Mase
- Department of Physical Therapy, Faculty of Nursing and Rehabilitation, Konan Women's University: 6-2-23 Morikitamachi, Higashinada, Kobe, Hyogo 658-0001, Japan
| | | | - Sigefumi Murakami
- Department of Rehabilitation, Hyogo College of Medicine Sasayama Medical Center, Japan
| | - Kazuaki Kihara
- Department of Physical Therapy, Faculty of Nursing and Rehabilitation, Konan Women's University: 6-2-23 Morikitamachi, Higashinada, Kobe, Hyogo 658-0001, Japan
| | - Kazuhiro Matsushita
- Department of Rehabilitation, Hyogo College of Medicine Sasayama Medical Center, Japan
| | - Masafumi Nozoe
- Department of Physical Therapy, Faculty of Nursing and Rehabilitation, Konan Women's University: 6-2-23 Morikitamachi, Higashinada, Kobe, Hyogo 658-0001, Japan
| | - Sachie Takashima
- Department of Physical Therapy, Faculty of Nursing and Rehabilitation, Konan Women's University: 6-2-23 Morikitamachi, Higashinada, Kobe, Hyogo 658-0001, Japan
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Automated Rotational Percussion Bed and Bronchoscopy Improves Respiratory Mechanics and Oxygenation in ARDS Patients Supported with Extracorporeal Membrane Oxygenation. ASAIO J 2017; 62:e27-9. [PMID: 26771392 DOI: 10.1097/mat.0000000000000341] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) has been used to provide "lung rest" through the use of low tidal volume (6 ml/kg) and ultralow tidal volume (<6 ml/kg) ventilation in acute respiratory distress syndrome (ARDS). Low and ultralow tidal volume ventilation can result in low dynamic respiratory compliance and potentially increased retention of airway secretions. We present our experience using automated rotational percussion beds (ARPBs) and bronchoscopy in four ARDS patients to manage increased pulmonary secretions. These beds performed automated side-to-side tilt maneuver and intermittent chest wall percussion. Their use resulted in substantial reduction in peak and plateau pressures in two patients on volume control ventilation, while the driving pressures (inspiratory pressure) to attain the desired tidal volumes in patients on pressure control ventilation also decreased. In addition, mean partial pressure of oxygen in arterial blood (PaO2)/fraction of inspired oxygen (FiO2) ratio (109 pre-ARPB vs. 157 post-ARPB), positive end-expiratory pressure (10 cm H2O vs. 8 cm H2O), and FiO2 (0.88 vs. 0.52) improved after initiation of ARPB. The improvements in the respiratory mechanics and oxygenation helped us to initiate early ECMO weaning. Based on our experience, the use of chest physiotherapy, frequent body repositioning, and bronchoscopy may be helpful in the management of pulmonary secretions in patients supported with ECMO.
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van der Lee L, Hill AM, Patman S. After-hours respiratory physiotherapy for intubated and mechanically ventilated patients with community-acquired pneumonia: An Australian perspective. Aust Crit Care 2017; 31:349-354. [PMID: 29153959 DOI: 10.1016/j.aucc.2017.10.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Revised: 08/03/2017] [Accepted: 10/03/2017] [Indexed: 10/18/2022] Open
Abstract
INTRODUCTION Community acquired pneumonia (CAP) is a common reason for admission to an intensive care unit for intubation and mechanical ventilation, and results in high morbidity and mortality. The primary aim of the study was to investigate availability and provision of respiratory physiotherapy, outside of normal business hours, for intubated and mechanically ventilated adults with CAP in Australian hospitals. MATERIALS AND METHODS A cross-sectional, mixed methods online survey was conducted. Participants were senior intensive care unit physiotherapists from 88 public and private hospitals. Main outcome measures included presence and nature of an after-hours physiotherapy service and factors perceived to influence the need for after-hours respiratory physiotherapy intervention, when the service was available, for intubated adult patients with CAP. Data were also collected regarding respiratory intervention provided after-hours by other ICU professionals. RESULTS Response rate was 72% (n=75). An after-hours physiotherapy service was provided by n=31 (46%) hospitals and onsite after-hours physiotherapy presence was limited (22%), with a combination of onsite and on-call service reported by 19%. Treatment response (83%) was the most frequent factor for referring patients with CAP for after-hours physiotherapy intervention by the treating day-time physiotherapist. Nurses performing respiratory intervention (77%) was significantly associated with no available after-hours physiotherapy service (p=0.04). DISCUSSION Physiotherapy after-hours service in Australia is limited, therefore it is common for intubated patients with CAP not to receive any respiratory physiotherapy intervention outside of normal business hours. In the absence of an after-hours physiotherapist, nurses were most likely to perform after-hours respiratory intervention to intubated patients with CAP. CONCLUSION Further research is required to determine whether the frequency of respiratory physiotherapy intervention, including after-hours provision of treatment, influences outcomes for ICU patients intubated with pneumonia.
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Affiliation(s)
- Lisa van der Lee
- The University of Notre Dame Australia, School of Physiotherapy, 19 Mouat Street, P.O. Box 1225, Fremantle, WA 6959, Australia; Fiona Stanley Hospital Perth, Intensive Care Unit, Locked Bag 100, Palmyra DC, WA 6961, Australia.
| | - Anne-Marie Hill
- Curtin University, School of Physiotherapy and Exercise Science, Kent Street, Bentley, Perth, WA 6102, Australia
| | - Shane Patman
- The University of Notre Dame Australia, School of Physiotherapy, 19 Mouat Street, P.O. Box 1225, Fremantle, WA 6959, Australia
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Approaches and adjuncts used by physiotherapists when suctioning adult patients who are intubated and ventilated in intensive care units in Australia and New Zealand: A cross-sectional survey. Aust Crit Care 2017; 30:307-313. [DOI: 10.1016/j.aucc.2017.01.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Revised: 01/11/2017] [Accepted: 01/15/2017] [Indexed: 11/19/2022] Open
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van der Lee L, Hill AM, Patman S. A survey of clinicians regarding respiratory physiotherapy intervention for intubated and mechanically ventilated patients with community-acquired pneumonia. What is current practice in Australian ICUs? J Eval Clin Pract 2017; 23:812-820. [PMID: 28345309 DOI: 10.1111/jep.12722] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Revised: 01/17/2017] [Accepted: 01/17/2017] [Indexed: 12/31/2022]
Abstract
RATIONALE, AIMS, AND OBJECTIVES Community-acquired pneumonia (CAP) is a common cause for intensive care unit (ICU) admission resulting in high morbidity and mortality. There is a paucity of evidence regarding respiratory physiotherapy for intubated and mechanically ventilated patients with CAP, and anecdotally clinical practice is variable in this cohort. The aims of this study were to identify the degree of variability in physiotherapy practice for intubated adult patients with CAP and to explore ICU physiotherapist perceptions of current practice for this cohort and factors that influence physiotherapy treatment mode, duration, and frequency. METHOD A survey was developed based on common aspects of assessment, clinical rationale, and intervention for intubated and mechanically ventilated patients. Senior ICU physiotherapists across 88 Australian public and private hospitals were recruited. RESULTS The response rate was 72%. Respondents (n = 75) stated their main rationale for providing a respiratory intervention were improved airway clearance (98%, n = 60/61), alveolar recruitment (74%, n = 45/61), and gas exchange (33%, n = 20/61). Respondents estimated that average intervention lasted between 16 and 30 minutes (70% of respondents, n = 41/59) and would be delivered once (44%) or twice (44%) daily. Results indicated large variability in reported practice; however, trends existed regarding positioning in alternate side-lying (81%, n = 52/64) or affected lung uppermost (83%, n = 53/64) and use of hyperinflation techniques (81%, 52/64). Decisions regarding duration were reported to be based on sputum volume (95%), viscosity (93%) and purulence (88%), cough effectiveness (95%), chest X-ray (87%), and auscultation (84%). Sixty percent reported that workload and staffing affected intervention duration and frequency. Intervention time was more likely increased when there was greater staffing (P = .03). CONCLUSION Respiratory physiotherapy treatment varies for intubated patients with CAP. Further research is required to determine what is considered best practice for this patient population.
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Affiliation(s)
- Lisa van der Lee
- School of Physiotherapy, The University of Notre Dame Australia, 19 Mouat Street, Fremantle, Western Australia, 6959, Australia.,Allied Health, Fiona Stanley Hospital, 11 Robin Warren Drive, Murdoch, Western Australia, 6150, Australia
| | - Anne-Marie Hill
- School of Physiotherapy and Exercise Science, Curtin University, Kent St, Bentley, Perth, Western Australia, 6845, Australia
| | - Shane Patman
- School of Physiotherapy, The University of Notre Dame Australia, 19 Mouat Street, Fremantle, Western Australia, 6959, Australia
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van der Lee L, Hill AM, Patman S. Efficacy of a respiratory physiotherapy intervention for intubated and mechanically ventilated adults with community acquired pneumonia: a systematic review protocol. ACTA ACUST UNITED AC 2017. [PMID: 28628508 DOI: 10.11124/jbisrir-2016-003145] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
REVIEW OBJECTIVES The objective of the review is to map evidence on the efficacy of a respiratory physiotherapy intervention for intubated and mechanically ventilated adults with community acquired pneumonia (CAP). Specifically, the review seeks to investigate if respiratory physiotherapy interventions can achieve the following for intubated and mechanically ventilated adults with CAP.
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Affiliation(s)
- Lisa van der Lee
- 1School of Physiotherapy, The University of Notre Dame, Fremantle, Australia 2School of Physiotherapy and Exercise Science, Curtin University, Perth, Australia 3Department of Allied Health, Fiona Stanley Hospital, Murdoch, Australia 4The Western Australian Group for Evidence Informed Healthcare Practice: a Joanna Briggs Institute Centre of Excellence, Perth, Australia
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Cruz RVS, Andrade FDSDSDD, Menezes PDGD, Gonçalves BO, Almeida RDS, Santos AR. Manual hyperinflation and the role of physical therapy in intensive care and emergency units. FISIOTERAPIA EM MOVIMENTO 2017. [DOI: 10.1590/1980-5918.030.s01.ao23] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Abstract Introduction: Although manual hyperinflation (MHI) is a physical therapy technique commonly used in intensive care and emergency units, there is little consensus about its use. Objective: To investigate the knowledge of physical therapists working in intensive care and emergency units about manual hyperinflation. Methods: Data were collected through self-administered questionnaires on manual hyperinflation. Data collection took place between September 2014 and January 2015, in Itabuna and Ilhéus, Bahia, Brazil. Results: The study sample was composed of 32 physical therapists who had between 4 months and 10 years working experience. All respondents affirmed that they used the technique in their professional practice. However, only 34.4% reported it to be a routine practice. 90.6% stated that the most common patient position during manual hyperinflation is “supine”. Participants were almost unanimous (93.8%) in citing secretion removal and cough stimulation as perceived benefits of MHI. High peak airway pressure was identified as being a precaution to treatment with MHI by 84.4% of participants, whilst 100% of the sample agreed that an undrained pneumothorax was a contraindication to MHI. Conclusion: The most common answers to the questionnaire were: supine position during MHI; secretion removal and cough stimulation as perceived benefits; high peak airway pressure as a precaution; and an undrained pneumothorax as a contraindication.
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Assmann CB, Vieira PJC, Kutchak F, Rieder MDM, Forgiarini SGI, Forgiarini Junior LA. Lung hyperinflation by mechanical ventilation versus isolated tracheal aspiration in the bronchial hygiene of patients undergoing mechanical ventilation. Rev Bras Ter Intensiva 2016; 28:27-32. [PMID: 27096673 PMCID: PMC4828088 DOI: 10.5935/0103-507x.20160010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2015] [Accepted: 01/25/2016] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To determine the efficacy of lung hyperinflation maneuvers via a mechanical ventilator compared to isolated tracheal aspiration for removing secretions, normalizing hemodynamics and improving lung mechanics in patients on mechanical ventilation. METHODS This was a randomized crossover clinical trial including patients admitted to the intensive care unit and on mechanical ventilation for more than 48 hours. Patients were randomized to receive either isolated tracheal aspiration (Control Group) or lung hyperinflation by mechanical ventilator (MVH Group). Hemodynamic and mechanical respiratory parameters were measured along with the amount of aspirated secretions. RESULTS A total of 50 patients were included. The mean age of the patients was 44.7 ± 21.6 years, and 31 were male. Compared to the Control Group, the MVH Group showed greater aspirated secretion amount (3.9g versus 6.4g, p = 0.0001), variation in mean dynamic compliance (-1.3 ± 2.3 versus -2.9 ± 2.3; p = 0.008), and expired tidal volume (-0.7 ± 0.0 versus -54.1 ± 38.8, p = 0.0001) as well as a significant decrease in peak inspiratory pressure (0.2 ± 0.1 versus 2.5 ± 0.1; p = 0.001). CONCLUSION In the studied sample, the MVH technique led to a greater amount of aspirated secretions, significant increases in dynamic compliance and expired tidal volume and a significant reduction in peak inspiratory pressure.
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Affiliation(s)
| | | | - Fernanda Kutchak
- Hospital Cristo Redentor - Porto Alegre (RS),
Brazil
- Universidade do Vale dos Sinos - Porto Alegre (RS),
Brazil
| | - Marcelo de Mello Rieder
- Centro Universitário Metodista - IPA - Porto
Alegre (RS), Brazil
- Hospital Cristo Redentor - Porto Alegre (RS),
Brazil
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Thomas PJ. The effect of mechanical ventilator settings during ventilator hyperinflation techniques: a bench-top analysis. Anaesth Intensive Care 2015; 43:81-7. [PMID: 25579293 DOI: 10.1177/0310057x1504300112] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Ventilator hyperinflations are used by physiotherapists for the purpose of airway clearance in intensive care. There is limited data to guide the selection of mechanical ventilator modes and settings that may achieve desired flow patterns for ventilator hyperinflation. A mechanical ventilator was connected to two lung simulators and a respiratory mechanics monitor. Peak inspiratory (PIFR) and expiratory flow rates (PEFR) were measured during manipulation of ventilator modes (pressure support ventilation [PSV], volume-controlled synchronised intermittent mandatory ventilation [VC-SIMV] and pressure-controlled synchronised intermittent mandatory ventilation [PC-SIMV]) and ventilator settings (including set tidal volume, positive end-expiratory pressure, inspiratory flow rate, inspiratory pause, pressure support, inspiratory time and/or inflation pressure). Additionally, each trial was conducted with high (0.05 l/cmH2O) and low (0.01 l/cmH2O) compliance settings on the lung simulators. Each trial was dichotomised into success or failure under three categories (attainment of PIFR-PEFR less than or equal to 0.9, PEFR/PIFR greater than 17 l/min, PEFR greater than or equal to 40 l/min). A total of 232 trials were conducted (96 VC-SIMV, 96 PC-SIMV, 40 PSV). A greater proportion of VC-SIMV trials were ceased due to high peak inspiratory pressures (35%). However, VC-SIMV trials were more likely to be successful at meeting all three outcome measures (26 VC-SIMV trials, 7 PC-SIMV trials, 0 PSV trials). It was found that manipulation of settings in VC-SIMV mode appears more successful than PSV and PC-SIMV for ventilator hyperinflations.
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Affiliation(s)
- P J Thomas
- Department of Physiotherapy, Royal Brisbane and Women's Hospital, Herston, Queensland
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Naue WDS, Forgiarini Junior LA, Dias AS, Vieira SRR. Chest compression with a higher level of pressure support ventilation: effects on secretion removal, hemodynamics, and respiratory mechanics in patients on mechanical ventilation. ACTA ACUST UNITED AC 2014; 40:55-60. [PMID: 24626270 PMCID: PMC4075919 DOI: 10.1590/s1806-37132014000100008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2013] [Accepted: 12/09/2013] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To determine the efficacy of chest compression accompanied by a 10-cmH2O increase in baseline inspiratory pressure on pressure support ventilation, in comparison with that of aspiration alone, in removing secretions, normalizing hemodynamics, and improving respiratory mechanics in patients on mechanical ventilation. METHODS This was a randomized crossover clinical trial involving patients on mechanical ventilation for more than 48 h in the ICU of the Porto Alegre Hospital de Clínicas, in the city of Porto Alegre, Brazil. Patients were randomized to receive aspiration alone (control group) or compression accompanied by a 10-cmH2O increase in baseline inspiratory pressure on pressure support ventilation (intervention group). We measured hemodynamic parameters, respiratory mechanics parameters, and the amount of secretions collected. RESULTS We included 34 patients. The mean age was 64.2 ± 14.6 years. In comparison with the control group, the intervention group showed a higher median amount of secretions collected (1.9 g vs. 2.3 g; p = 0.004), a greater increase in mean expiratory tidal volume (16 ± 69 mL vs. 56 ± 69 mL; p = 0.018), and a greater increase in mean dynamic compliance (0.1 ± 4.9 cmH2O vs. 2.8 ± 4.5 cmH2O; p = 0.005). CONCLUSIONS In this sample, chest compression accompanied by an increase in pressure support significantly increased the amount of secretions removed, the expiratory tidal volume, and dynamic compliance. (ClinicalTrials.gov Identifier:NCT01155648 [http://www.clinicaltrials.gov/]).
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Affiliation(s)
- Wagner da Silva Naue
- Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil, Physiotherapist. Adult ICU, Hospital de Clínicas de Porto Alegre - HCPA, Porto Alegre Hospital de Clínicas - Porto Alegre, Brazil
| | - Luiz Alberto Forgiarini Junior
- Methodist University Center, Porto Alegre Institute, Porto Alegre, Brazil, Professor of Physiotherapy. Methodist University Center, Porto Alegre Institute, Porto Alegre, Brazil
| | - Alexandre Simões Dias
- Federal University of Rio Grande do Sul, Porto Alegre, Brazil, Professor. Graduate Program in Human Movement Sciences and Respiratory Sciences, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Silvia Regina Rios Vieira
- Federal University of Rio Grande do Sul, School of Medicine, Porto Alegre, Brazil, Professor. Federal University of Rio Grande do Sul School of Medicine; and Head. Department of Intensive Care, Hospital de Clínicas de Porto Alegre - HCPA, Porto Alegre Hospital de Clínicas - Porto Alegre, Brazil
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Cork G, Barrett N, Ntoumenopoulos G. Justification for Chest Physiotherapy during Ultra-Protective Lung Ventilation and Extra-Corporeal Membrane Oxygenation: A Case Study. PHYSIOTHERAPY RESEARCH INTERNATIONAL 2014; 19:126-8. [DOI: 10.1002/pri.1563] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2013] [Revised: 06/17/2013] [Accepted: 07/02/2013] [Indexed: 11/09/2022]
Affiliation(s)
- G. Cork
- Physiotherapy Department; Guy's and St Thomas' NHS Foundation Trust; London UK
- Kings Health Partners; London UK
| | - N. Barrett
- Critical Care Department; Guy's and St Thomas' NHS Foundation Trust; London UK
- Kings Health Partners; London UK
| | - G. Ntoumenopoulos
- School of Physiotherapy; Australian Catholic University; Sydney Australia
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Berti JSW, Tonon E, Ronchi CF, Berti HW, Stefano LMD, Gut AL, Padovani CR, Ferreira ALA. Manual hyperinflation combined with expiratory rib cage compression for reduction of length of ICU stay in critically ill patients on mechanical ventilation. J Bras Pneumol 2013; 38:477-86. [PMID: 22964932 DOI: 10.1590/s1806-37132012000400010] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2011] [Accepted: 05/10/2012] [Indexed: 11/22/2022] Open
Abstract
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.
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Affiliation(s)
- Juliana Savini Wey Berti
- Hospital das Clínicas de Botucatu, Faculdade de Medicina de Botucatu, Universidade Estadual Paulista, Botucatu, SP, Brasil
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Dennis D, Jacob W, Budgeon C. Ventilator versus manual hyperinflation in clearing sputum in ventilated intensive care unit patients. Anaesth Intensive Care 2012; 40:142-9. [PMID: 22313075 DOI: 10.1177/0310057x1204000117] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The aim of hyperinflation in the ventilated intensive care unit patient is to increase oxygenation, reverse lung collapse and clear sputum. The efficacy and consistency of manual hyperventilation is well supported in the literature, but there is limited published evidence supporting hyperventilation utilising a ventilator. Despite this, a recent survey established that almost 40% of Australian tertiary intensive care units utilise ventilator hyperinflation. The aim of this non-inferiority cross-over study was to determine whether ventilator hyperinflation was as effective as manual hyperinflation in clearing sputum from patients receiving mechanical ventilation using a prescriptive ventilator hyperinflation protocol. Forty-six patients received two randomly ordered physiotherapy treatments on the same day by the same physiotherapist. The efficacy of the hyperinflation modes was measured by sputum wet weight. Secondary measures included compliance, tidal volume, airway pressure and PaO2/FiO2 ratio. There was no difference in wet weight of sputum cleared using ventilator hyperinflation or manual hyperinflation (mean 3.2 g, P=0.989). Further, no difference in compliance (P=0.823), tidal volume (P=0.219), heart rate (P=0.579), respiratory rate (P=0.929) or mean arterial pressure (P=0.593) was detected. A statistically significant difference was seen in mean airway pressure (P=0.002) between techniques. The effect of techniques on the PaO2/FiO2 response ratio was dependent on time (interaction P=0.024). Physiotherapy using ventilator hyperinflation cleared a comparable amount of sputum and was as safe as manual hyperinflation. This research describes a ventilator hyperinflation protocol that will serve as a platform for continued discussion, research and development of its application in ventilated patients.
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Affiliation(s)
- Diane Dennis
- Sir Charles Gairdner Hospital, Perth, Western Australia.
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Chicayban LM, Zin WA, Guimarães FS. Can the Flutter Valve improve respiratory mechanics and sputum production in mechanically ventilated patients? A randomized crossover trial. Heart Lung 2011; 40:545-53. [DOI: 10.1016/j.hrtlng.2011.05.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2010] [Revised: 05/17/2011] [Accepted: 05/18/2011] [Indexed: 10/17/2022]
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Naue WDS, da Silva ACT, Güntzel AM, Condessa RL, de Oliveira RP, Rios Vieira SR. Increasing pressure support does not enhance secretion clearance if applied during manual chest wall vibration in intubated patients: a randomised trial. J Physiother 2011; 57:21-6. [PMID: 21402326 DOI: 10.1016/s1836-9553(11)70003-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
QUESTIONS What is the effect of increasing pressure support during the application of manual chest wall compression with vibrations for secretion clearance in intubated patients in intensive care? DESIGN A randomised trial with concealed allocation, assessor blinding and intention-to-treat analysis. PARTICIPANTS 66 patients receiving mechanical ventilation for greater than 48 hours. INTERVENTION All participants were positioned supine in bed with the backrest elevated 30 degrees. The experimental group received manual chest wall compression with vibrations during which their pressure support ventilation was increased by 10 cm H(2)O over its existing level. The control group received manual chest wall compression with vibrations but no adjustment of the ventilator settings. Both groups then received airway suction. OUTCOME MEASURES The primary outcome was the weight of the aspirate. Secondary outcomes were pulmonary and haemodynamic measures and oxygenation. RESULTS Although both treatments increased the weight of the aspirate compared to baseline, the addition of increased pressure support during manual chest wall compression with vibrations did not significantly increase the clearance of secretions, mean between-group difference in weight of the aspirate 0.4 g, 95% CI -0.5 to 1.4. Although several other measures also improved in one or both groups with treatment, there were no significant differences between the groups for any of the secondary outcomes. CONCLUSION Although increasing pressure support has previously been shown to increase secretion clearance in intubated patients, the current study did not show any benefits when it was added to chest wall compression with vibrations. TRIAL REGISTRATION NCT01155648.
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Cader SA, Vale RGDS, Castro JC, Bacelar SC, Biehl C, Gomes MCV, Cabrer WE, Dantas EHM. Inspiratory muscle training improves maximal inspiratory pressure and may assist weaning in older intubated patients: a randomised trial. J Physiother 2010; 56:171-7. [PMID: 20795923 DOI: 10.1016/s1836-9553(10)70022-9] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
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.
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Affiliation(s)
- Samária Ali Cader
- University Federal do Estada do Rio de Janiero - LABIMH-UNIRIO, Brazil.
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Castro AAMD, Rocha S, Reis C, Leite JRDO, Porto EF. Comparação entre as técnicas de vibrocompressão e de aumento do fluxo expiratório em pacientes traqueostomizados. FISIOTERAPIA E PESQUISA 2010. [DOI: 10.1590/s1809-29502010000100004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
A fisioterapia respiratória tem papel fundamental nos casos de complicações pelo excesso de secreção broncopulmonar. Manobras de remoção de secreção brônquica como a vibrocompressão e o aumento do fluxo expiratório (AFE) garantem a perviabilidade das vias aéreas. O objetivo deste trabalho foi avaliar o efeito das manobras de AFE e vibrocompressão para remoção de secreção e suas repercussões hemodinâmicas e ventilatórias em pacientes traqueostomizados. Participaram 20 pacientes (com 18 a 73 anos) de ambos os sexos com diagnóstico fisioterapêutico de hipersecreção e/ou retenção de muco brônquico, submetidos à aplicação dessas técnicas e à remoção de secreção, que foram avaliados antes e depois da intervenção quanto a parâmetros hemodinâmicos e respiratórios. Com a aplicação da técnica de vibrocompressão foi verificada queda significativa (p<0,05) nas pressões arteriais (PA) diastólica e média de 82,2±13,4 para 77,4±13,3 mmHg e de 104,3±18,2 para 90,9±9,07 mmHg, respectivamente; o mesmo ocorreu com a PA média (p<0,05) após a aplicação da técnica de AFE, de 103,5±13,2 para 94,1±9,0 mmHg. Não houve diferença entre as técnicas aplicadas quanto ao volume de secreção removida (p=0,60). Pacientes traqueostomizados apresentaram pois redução da pressão arterial após 30 minutos da aplicação das técnicas fisioterapêuticas, mas não houve diferença entre as técnicas utilizadas quanto ao volume de secreção removida.
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Affiliation(s)
| | | | - Cléia Reis
- Centro Universitário Adventista de São Paulo
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