Expiratory rib cage compression in mechanically ventilated adults: systematic review with meta-analysis

Nursing Process Related to the Nursing Focus "Airway Clearance": A Scoping Review

BACKGROUND

Airway clearance impairment has a significant impact on self-care and quality of life. Identifying clinical data, nursing diagnoses, and nursing interventions is essential to clinical reasoning and enhancing nursing care. This study aims to map the existing evidence on clinical data, nursing diagnoses, and nursing interventions addressing the nursing focus on "airway clearance".

METHODS

Research was conducted based on Joanna Briggs's Scoping Review Methodology. We searched four databases for published studies until December 2023.

RESULTS

From the initial 1854 studies identified, 123 were included in the review. The findings highlighted two areas of nursing attention: one related to signs and symptom management, and the other related to education and coping strategies. The data that led to nursing diagnoses were divided into cognitive and clinical data. The nursing diagnoses were mostly related to secretion retention, excessive mucus production, and airway obstruction. The most commonly identified nursing interventions were educational interventions assembled into predesigned education programs rather than patient-tailored programs.

CONCLUSIONS

Findings can add substantial value for systematizing the nursing process related to "airway clearance", improving nursing decision-making and care quality. This study was prospectively registered with the Open Science Framework (OSF) on 02 December 2022, with the registration number wx5ze.

An Update on Cardiorespiratory Physiotherapy during Mechanical Ventilation

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.

Effects of Mechanical Insufflation-Exsufflation on Sputum Volume in Mechanically Ventilated Critically Ill Subjects

BACKGROUND

Mechanical insufflation-exsufflation (MI-E) is a noninvasive technique performed to simulate cough and remove sputum from proximal airways. To date, the effects of MI-E on critically ill patients on invasive mechanical ventilation are not fully elucidated. In this randomized crossover trial, we evaluated the efficacy and safety of MI-E combined to expiratory rib cage compressions (ERCC).

METHODS

Twenty-six consecutive subjects who were sedated, intubated, and on mechanical ventilation > 48 h were randomized to perform 2 sessions of ERCC with or without additional MI-E before tracheal suctioning in a 24-h period. The primary outcome was sputum volume following each procedure. Secondary end points included effects on respiratory mechanics, hemodynamics, and safety.

RESULTS

In comparison to ERCC alone, median (interquartile range) sputum volume cleared was significantly higher during ERCC+MI-E (0.42 [0-1.39] mL vs 2.29 [1-4.67] mL, P < .001). The mean ± SD respiratory compliance improved in both groups immediately after the treatment, with the greater improvement in the ERCC+MI-E group (54.7 ± 24.1 mL/cm H₂O vs 73.7 ± 35.8 mL/cm H₂O, P < .001). Differences between the groups were not significant (P = .057). Heart rate increased significantly in both groups immediately after each intervention (P < .05). Additionally, a significant increase in oxygenation was observed from baseline to 1 h post-intervention in the ERCC+MI-E group (P < .05). Finally, several transitory hemodynamic variations occurred during both interventions, but these were nonsignificant and were considered clinically irrelevant.

CONCLUSIONS

In mechanically ventilated subjects, MI-E combined with ERCC increased the sputum volume cleared without causing clinically important hemodynamic changes or adverse events. (ClinicalTrials.gov registration: NCT03316079.).

Physical Therapy and Rehabilitation in Chronic Obstructive Pulmonary Disease Patients Admitted to the Intensive Care Unit

Chronic obstructive pulmonary disease (COPD) is a progressive lung condition that affects a person's ability to exercise and undertake normal physical function due to breathlessness, poor physical fitness, and muscle fatigue. Patients with COPD often experience exacerbations due to pulmonary infections, which result in worsening of their symptoms, more loss of function, and often require hospital treatment or in severe cases admission to intensive care units. Recovery from such exacerbations is often slow, and some patients never fully return to their previous level of activity. This can lead to permanent disability and premature death.Physical therapists play a key role in the respiratory management and rehabilitation of patients admitted to intensive care following acute exacerbation of COPD. This article discusses the key considerations for respiratory management of patients requiring invasive mechanical ventilation, providing an evidence-based summary of commonly used interventions. It will also explore the evidence to support the introduction of early and structured programs of rehabilitation to support recovery in both the short and the long term, as well as active mobilization, which includes strategies to minimize or prevent physical loss through early retraining of both peripheral and respiratory muscles.

Décubitus ventral et kinésithérapie respiratoire : y a-t-il une indication ? Description d’un cas clinique

Contexte : Le décubitus ventral (DV) est appliqué dans un objectif de recrutement alvéolaire, dans le cadre de syndrome de détresse respiratoire aiguë (SDRA). Le DV mobilise parfois des sécrétions bronchiques, interrogeant l’intérêt d’une kinésithérapie de désencombrement.

Matériel et méthode : Une femme de 43 ans, myopathe de Steinert, est hospitalisée pour une insuffisance hépatique aiguë. À j3, elle présente une pneumopathie d’inhalation, suivie d’un SDRA. Le positionnement en DV est réalisé, mobilisant des sécrétions bronchiques. Une séance de kinésithérapie respiratoire est alors appliquée.

Résultats : Après la mise en DVet la séance de kinésithérapie, la quantité de sécrétions recueillies est de 2,4 g. Le rapport entre la pression partielle en oxygène et la fraction inspirée en oxygène (PaO2/FiO2) s’améliore, passant de 64 à 180 au bout de 11 heures de DV. La pression motrice et la pression de plateau sont restées inférieures aux valeurs délétères au cours de la séance de kinésithérapie, celle-ci n’ayant pas généré d’hypoxie pendant ou après la séance.

Discussion : Le positionnement en DV libère les parties postérieures des poumons, permettant une amélioration du rapport PaO2/FiO2. La clairance mucociliaire a été améliorée, mais il n’est pas possible de discriminer les effets du DVou de la kinésithérapie. Dans la littérature, la kinésithérapie respiratoire n’a pas montré son efficacité pour ces patients, même si aucun effet délétère n’a été observé à travers ce cas clinique. Les risques de dé-recrutement alvéolaire restent importants.

Conclusion : Il est difficile de recommander en pratique courante la kinésithérapie respiratoire de désencombrement en DV. Des études ultérieures sont nécessaires, dans un objectif de recherche centré plutôt sur le recrutement alvéolaire que sur le désencombrement, chez ces patients fragiles.

Comparison of bronchial hygiene techniques in mechanically ventilated patients: a randomized clinical trial

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.