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

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.

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

CLINICAL CASE

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

The Effects of Manual Lung Hyperinflation on Pulmonary Function after Weaning from Mechanical Ventilation among Patients with Abdominal Surgeries: Randomized Clinical Trial

Introduction: After abdominal surgery, the patients who are separated from mechanical ventilation and provided with oxygen therapy via a T-piece are at risk for respiratory complications. Therefore, they need additional respiratory support. This study aimed to evaluate the effects of manual hyperinflation (MHI) on pulmonary function after weaning. Methods: This randomized clinical trial included 40 patients who had undergone abdominal surgery and were receiving oxygen via a T-piece. Patients were selected from the intensive care units (ICU) of two hospitals in Mashhad, Iran. The subjects were randomly allocated to intervention (MHI) and control groups. Patients in the MHI group were provided with three 20-minute MHI rounds using the Mapleson C, while the control group received routine cares. Tidal volume (Vt), Rapid Shallow Breathing Index (RSBI), and the ratio of arterial oxygen partial pressure to fractional inspired oxygen (P/F ratio) were measured before the intervention, as well as 5 and 20 minutes after the intervention. Atelectasis prevalence was assessed before and 24 hours after the intervention. Data were analysed by SPSS software version 13. Results: At baseline, there were no significant differences between the groups regarding Vt, RSBI, P/F ratio, and atelectasis rate. No significant difference was also found between the groups regarding atelectasis rate 24 hours after the intervention. However, at both posttests, Vt, RSBI, and P/F ratio in the MHI group were significantly better than the control group. Conclusion: In patients with artificial airway and spontaneous breathing, MHI improves pulmonary function.

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

Background

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

Results

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

Conclusion

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

Trial registration

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

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

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

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

Respiratory physiotherapy in intensive care unit: Bibliographic review

INTRODUCTION AND AIMS

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

METHODOLOGY

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

RESULTS

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

DISCUSSION AND CONCLUSIONS

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

Manual hyperinflation and the role of physical therapy in intensive care and emergency units

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.

Guideline implementation powered by feedback and education improves manual hyperinflation performance

AIM

To determine whether a literature-based guideline, powered by educational meetings and individual feedback, improves manual hyperinflation (MH) performance by intensive care unit (ICU) nurses.

BACKGROUND

MH is frequently applied in intubated and mechanically ventilated ICU patients. MH is a complex intervention, and large variation in its performance has been found.

MATERIALS AND METHODS

First, a literature-based guideline on MH was developed. The intervention consisted of education of this guideline and individual feedback. Before and 3 months after the intervention, ICU nurses performed MH maneuvers in a skills laboratory. Data collected included applied volumes, peak inspiratory flows (PIF) and peak expiratory flows (PEF), and the use of inspiratory holds.

RESULTS

Eighty nurses participated. Decrease of PIF was not statistically significant. PEF increased from 52 ± 7 to 83 ± 23 L/min (P < 0·01). PIF to PEF ratio decreased from 1·4 [1·1-1·7] to 0·8 [0·6-1·1] (P < 0·01). Peak inspiratory pressures decreased from 40 ± 14 to 19 ± 6 cm H2 O (P < 0·01). The proportion of nurses applying inspiratory holds increased from 14% to 58%; use of rapid release of the resuscitation bag, considered mandatory, increased from 4% to 61%.

CONCLUSION

Implementation of a literature-based guideline on MH, powered by educational meetings and individual feedback, improves MH performance by ICU nurses.

RELEVANCE TO CLINICAL PRACTICE

If it is decided to practice MH in the care of the intubated and mechanical ventilated patient, a standardized, uniform performed MH procedure is a prerequisite.

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

Introduction

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

Methods

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

Results

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

Conclusions

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

Year in review 2011: Critical Care - respirology

Management of acute respiratory failure is an important component of intensive care. In this review, we analyze 21 original research articles published last year in Critical Care in the field of respiratory and critical care medicine. The articles are summarized according to the following topic categories: acute respiratory distress syndrome, mechanical ventilation, adjunctive therapies, and pneumonia.