Guideline implementation powered by feedback and education improves manual hyperinflation performance

Manual and ventilator hyperinflation parameters used by intensive care physiotherapists in Sri Lanka: An online survey

INTRODUCTION

Hyperinflation is a common procedure to clear secretion, increase lung compliance and enhance oxygenation in mechanically ventilated patients. Hyperinflation can be provided as manual hyperinflation (MHI) or ventilator hyperinflation (VHI), where outcomes depend upon the methods of application. Hence it is crucial to assess the application of techniques employed in Sri Lanka due to observed variations from recommended practices.

OBJECTIVE

This study is aimed to evaluate the application and parameters used for MHI and VHI by physiotherapists in intensive care units (ICUs) in Sri Lanka.

METHODOLOGY

An online survey was conducted among physiotherapists who are working in ICUs in Sri Lanka using WhatsApp groups and other social media platforms.

RESULTS

A total of 96 physiotherapists responded. The survey comprised of three sections to obtain information about socio-demographic data, MHI practices and VHI practices. Most of the respondents (47%) worked in general hospitals and 74% of participants had a bachelor's degree in physiotherapy; 31.3% had 3-6 years of experience; 93.8% used hyperinflation, and 78.9% used MHI. MHI was performed routinely and as needed to treat low oxygen levels, abnormal breath sounds, and per physician orders while avoiding contraindications. Self-inflation bags are frequently used for MHI (40.6%). Only a few participants (26%) used a manometer or tracked PIP. In addition to the supine position, some participants (37.5%) used the side-lying position. Most physiotherapists followed the recommended MHI technique: slow squeeze (57.3%), inspiratory pause (45.8%), and quick release (70.8%). VHI was practised by 19.8%, with medical approval and it was frequently performed by medical staff compared to physiotherapists. Treatment time, number of breaths, and patient positioning varied, and parameters were not well-defined.

CONCLUSION

The study found that MHI was not applied with the recommended PIP, and VHI parameters were not identified. The study indicates a need to educate physiotherapists about current VHI and MHI practice guidelines.

Trends in guideline implementation: an updated scoping review

Background

Guidelines aim to support evidence-informed practice but are inconsistently used without implementation strategies. Our prior scoping review revealed that guideline implementation interventions were not selected and tailored based on processes known to enhance guideline uptake and impact. The purpose of this study was to update the prior scoping review.

Methods

We searched MEDLINE, EMBASE, AMED, CINAHL, Scopus, and the Cochrane Database of Systematic Reviews for studies published from 2014 to January 2021 that evaluated guideline implementation interventions. We screened studies in triplicate and extracted data in duplicate. We reported study and intervention characteristics and studies that achieved impact with summary statistics.

Results

We included 118 studies that implemented guidelines on 16 clinical topics. With regard to implementation planning, 21% of studies referred to theories or frameworks, 50% pre-identified implementation barriers, and 36% engaged stakeholders in selecting or tailoring interventions. Studies that employed frameworks (n=25) most often used the theoretical domains framework (28%) or social cognitive theory (28%). Those that pre-identified barriers (n=59) most often consulted literature (60%). Those that engaged stakeholders (n=42) most often consulted healthcare professionals (79%). Common interventions included educating professionals about guidelines (44%) and information systems/technology (41%). Most studies employed multi-faceted interventions (75%). A total of 97 (82%) studies achieved impact (improvements in one or more reported outcomes) including 10 (40% of 25) studies that employed frameworks, 28 (47.45% of 59) studies that pre-identified barriers, 22 (52.38% of 42) studies that engaged stakeholders, and 21 (70% of 30) studies that employed single interventions.

Conclusions

Compared to our prior review, this review found that more studies used processes to select and tailor interventions, and a wider array of types of interventions across the Mazza taxonomy. Given that most studies achieved impact, this might reinforce the need for implementation planning. However, even studies that did not plan implementation achieved impact. Similarly, even single interventions achieved impact. Thus, a future systematic review based on this data is warranted to establish if the use of frameworks, barrier identification, stakeholder engagement, and multi-faceted interventions are associated with impact.

Trial registration

The protocol was registered with Open Science Framework (https://osf.io/4nxpr) and published in JBI Evidence Synthesis.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13012-022-01223-6.

Effects of manual hyperinflation, clinical practice versus expert recommendation, on displacement of mucus simulant: A laboratory study

Introduction

Manual hyperinflation (MH), a maneuver applied in mechanically ventilated patients to facilitate secretion removal, has large variation in its performance. Effectiveness of MH is usually evaluated by its capacity to generate an expiratory flow bias. The aim of this study was to compare the effects of MH—and its resulting flow bias—applied according to clinical practice versus according to expert recommendation on mucus movement in a lung model simulating a mechanically ventilated patient.

Methods

Twelve physiotherapists were asked to apply MH, using a self-inflating manual resuscitator, to a test lung as if to remove secretions under two conditions: according to their usual clinical practice (pre-instruction phase) and after verbal instruction to perform MH according to expert recommendation was given (post-instruction phase). Mucus simulant movement was measured with a photodensitometric technique. Peak inspiratory flow (PIF), peak inspiratory pressure (P_IP), inspiratory time (T_INSP), tidal volume (V_T) and peak expiratory flow (PEF) were measured continuously.

Results

It was found that MH performed post-instruction delivered a smaller V_T (643.1 ± 57.8 ml) at a lower P_IP (15.0 ± 1.5 cmH₂O), lower PIF (38.0 ± 9.6 L/min), longer T_INSP (1.84 ±0.54 s) and lower PEF (65.4 ± 6.7L/min) compared to MH pre-instruction. In the pre-instruction phase, MH resulted in a mean PIF/PEF ratio of 1.73 ± 0.38 and mean PEF-PIF difference of -54.6 ± 28.3 L/min, both out of the range for secretion removal. In the post-instruction phase both indexes were in the adequate range. Consequently, the mucus simulant was moved outward when MH was applied according to expert recommendation and towards the test lung when it was applied according to clinical practice.

Conclusions

Performance of MH during clinical practice with PIF higher than PEF was ineffective to clear secretion in a lung model simulating a mechanically ventilated patient. In order to remove secretion, MH should result in an adequate expiratory flow bias.