Physiotherapy and Rehabilitation Implementation in Intensive Care Units: A Survey Study.
Çakmak Aslıhan,İnce Deniz İnal,Sağlam Melda,Savcı Sema,Yağlı Naciye Vardar,Kütükcü Ebru Çalık,Özel Cemile Bozdemir,Ulu Hazal Sonbahar,Arıkan Hülya
Turkish thoracic journal
OBJECTIVES:Physiotherapy in the intensive care unit (ICU) improves patient outcomes. We aimed to determine the characteristics of physiotherapy practice and critical barriers toward applying physiotherapy in ICUs. MATERIALS AND METHODS:A 54-item survey for determining the characteristics of physiotherapists and physiotherapy applications in the ICU was developed. The survey was electronically sent to potential participants through Turkish Physiotherapy Association network. Sixty-five physiotherapists (47F and 18M; 23-52 years; ICU experience: 6.0±6.2 years) completed the survey. The data were analyzed using quantitative and qualitative methods. RESULTS:The duration of ICU practice was 3.51±2.10 h/day. Positioning (90.8%), active exercises (90.8%), breathing exercises (89.2%), passive exercises (87.7%), and percussion (87.7%) were the most commonly used applications. The barriers were related to physiotherapist (low level of employment and practice, lack of shift); patient (unwillingness, instability, participation restriction); teamwork (lack of awareness and communication); equipment (inadequacy, non-priority to purchase); and legal (reimbursement, lack of direct physiotherapy access, non-recognition of autonomy) procedures. CONCLUSION:The most common interventions were positioning, active, passive, and breathing exercises and percussion. Critical barriers toward physiotherapy are multifactorial and related to physiotherapists, patients, team, equipment, and legal procedures. Physiotherapist employment, service maintenance, and multidisciplinary teamwork should be considered for physiotherapy effectiveness in ICUs.
10.5152/TurkThoracJ.2018.18107
Profile of patients and physiotherapy patterns in intensive care units in public hospitals in Zimbabwe: a descriptive cross-sectional study.
Tadyanemhandu Cathrine,Manie Shamila
BMC anesthesiology
BACKGROUND:Physiotherapy is integral to patient management in the Intensive Care Unit. The precise role that physiotherapists play in the critical care differs significantly worldwide. The aim of the study was to describe the profile of patients and the current patterns of physiotherapy services delivered for patients admitted in the five public hospital intensive care units in Zimbabwe. METHODS:A prospective record review was performed and records of all consecutive patients admitted into the five units during a two months period were included in the analysis. The data was collected using a checklist and the following were recorded for each patient: 1) demographic information, 2) admission diagnoses, 3) surgery classification, 4) method and time of mechanical ventilation 5) physiotherapy techniques and frequency and 6) the length of stay. RESULTS:A total of 137 patients were admitted to five units during the study. The mean age of patients in the study was 36.0 years (SD = 16.6). A mortality rate of 17.5 % was observed with most of the patients being below the age of 45 years. The majority of the patients, 61(45 %) had undergone emergency surgery and were in the ICU for postoperative treatment, whilst only 19(14 %) were in the units for clinical treatment (non-surgical). On admission, 72(52.6 %) of the patients were on mechanical ventilation. The mean duration on mechanical ventilation for patients was 4.0 days (SD =2.7) and a length of stay in the unit of 4.5 days (SD = 3.0). Of the patients who were admitted into the ICU 120 (87.6 %) had at least one session of physiotherapy treatment during their stay. The mean number of days physiotherapy treatment was received was 3.71 (SD = 3.14) days. The most commonly used physiotherapy techniques were active assisted limb movements (66.4 %), deep breathing exercises (65.0 %) and forced expiratory techniques (65.0 %). CONCLUSION:A young population admitted in the ICU for post-surgical treatment was observed across all hospital ICUs. The techniques which were executed in Zimbabwean ICUs showed that the goal of the physiotherapy treatment was mainly to prevent and treat respiratory complications and a culture of promoting bed rest still existed. TRIAL REGISTRATION:PACTR201408000829202.
10.1186/s12871-015-0120-y
Regaining water swallowing function in the rehabilitation of critically ill patients with intensive-care-unit acquired muscle weakness.
Thomas Simone,Sauter Wolfgang,Starrost Ulrike,Pohl Marcus,Mehrholz Jan
Disability and rehabilitation
PURPOSE:Treatment in intensive care units (ICUs) often results in swallowing dysfunction. Recent longitudinal studies have described the recovery of critically ill people, but we are not aware of studies of the recovery of swallowing function in patients with ICU-acquired muscle weakness. This paper aims to describe the time course of regaining water swallowing function in patients with ICU-acquired weakness in the post-acute phase and to describe the risks of regaining water swallowing function and the risk factors involved. METHODS:This cohort study included patients with ICU-acquired muscle weakness in our post-acute department, who were unable to swallow. We monitored the process of regaining water swallowing function using the 3-ounce water swallowing test. RESULTS:We included 108 patients with ICU-acquired muscle weakness. Water swallowing function was regained after a median of 12 days (interquartile range =17) from inclusion in the study and after a median of 59 days (interquartile range= 36) from the onset of the primary illness. Our multivariate Cox Proportional Hazard model yielded two main risk factors for regaining water swallowing function: the number of medical tubes such as catheters at admission to the post-acute department (adjusted hazard ratio [HR] = 1.282; 95% confidence interval [CI]: 1.099-1.495) and the time until weaning from the respirator in days (adjusted HR =1.02 per day; 95%CI: 0.998 to 1.008). CONCLUSION:We describe a time course for regaining water swallowing function based on daily tests in the post-acute phase of critically ill patients. Risk factors associated with regaining water swallowing function in rehabilitation are the number of medical tubes and the duration of weaning from the respirator. Implications for rehabilitation Little guidance is available for the management of swallowing dysfunction in the rehabilitation of critically ill patients with intensive-care-units acquired muscle weakness. There is a time dependent pattern of recovery from swallowing dysfunction with daily water swallowing tests in the post-acute phase of critically ill patients. Daily water swallowing tests can be used to test swallowing dysfunction in the post-acute phase of critically ill patients The amount of medical tubes and the duration of weaning from respirator are associated risk factors for recovery of swallowing dysfunction.
10.1080/09638288.2017.1300341
[PROtocol-based MObilizaTION on intensive care units : Design of a cluster randomized pilot study].
Nydahl P,Diers A,Günther U,Haastert B,Hesse S,Kerschensteiner C,Klarmann S,Köpke S
Medizinische Klinik, Intensivmedizin und Notfallmedizin
BACKGROUND:Despite convincing evidence for early mobilization of patients on intensive care units (ICU), implementation in practice is limited. Protocols for early mobilization, including in- and exclusion criteria, assessments, safety criteria, and step schemes may increase the rate of implementation and mobilization. HYPOTHESIS:Patients (population) on ICUs with a protocol for early mobilization (intervention), compared to patients on ICUs without protocol (control), will be more frequently mobilized (outcome). METHODS:A multicenter, stepped-wedge, cluster-randomized pilot study is presented. Five ICUs will receive an adapted, interprofessional protocol for early mobilization in randomized order. Before and after implementation, mobilization of ICU patients will be evaluated by randomized monthly one-day point prevalence surveys. Primary outcome is the percentage of patients mobilized out of bed, operationalized as a score of ≥3 on the ICU Mobility Scale. Secondary outcome parameters will be presence and/or length of mechanical ventilation, delirium, stay on ICU and in hospital, barriers to early mobilization, adverse events, and process parameters as identified barriers, used strategies, and adaptions to local conditions. EXPECTED RESULTS:Exploratory evaluation of study feasibility and estimation of effect sizes as the basis for a future explanatory study.
10.1007/s00063-017-0358-x
Monitoring of hospital acquired pneumonia in patients with severe brain injury on first access to intensive neurological rehabilitation: First year of observation.
Beghi Gianfranco,De Tanti Antonio,Serafini Paolo,Bertolino Chiara,Celentano Antonietta,Taormina Graziella
Monaldi archives for chest disease = Archivio Monaldi per le malattie del torace
Nosocomial or hospital acquired pneumonia (HAP) is an illness contracted during a hospital stay, generally with onset 48 hours or more after admission to hospital, or within 14 days of discharge from hospital. HAP is divided into subgroups: Ventilator-associated pneumonia (VAP), accounting for 86% of hospital acquired pneumonia, and stroke-associated pneumonia (SAP). The incidence of SAP in neurological intensive care units (NICUs) is 4.1-56.6%, in medical intensive care units (MICUs) it is 17-50%, in stroke units it is 3.9-44% and in rehabilitation it is 3.2-11%, whereas in intensive rehabilitation following severe cranial trauma, the reported incidence of HAP is between 3.9 and 12% of cases. The aim of this study is to evaluate the cases of HAP occurring in a continuous series of patients with severe acquired brain injury (sABI) admitted to intensive rehabilitation units. The data collected can help evaluate the growing complexity of early rehabilitation of these patients, starting from how lung infections interfere with hospital stays and rehabilitation outcomes. This prospective observational cohort study evaluates, from 01/01/2015 to 31/12/2015, for patients with sABI on first admission to intensive neurological rehabilitation, the frequency of HAP and its impact on patient outcomes and complexity of care. A total of 61 patients were enrolled: 39 males and 22 females, average age 59.5 years (17-88 yrs, SD 3.53), coming from critical care (n=52), medical units (n=5), neurosurgery (n=3) and surgical units (n=1). The aetiology of hospital admission was haemorrhagic in 36% of cases, traumatic in 36%, anoxic in 13.1%, infectious in 6.5%, ischaemic in 4.9%, and other causes in 3.2%. Among the patients, 93.44% had received antibiotic therapy in their unit of provenance, and in 61.27% of cases a multidrug resistant (MDR) bacterium was isolated. On enrolment, 26 patients presented respiratory insufficiency, 29 subjects were in oxygen therapy, and 4 under invasive mechanical ventilation. There were 54 tracheostomized patients, 33 patients with percutaneous endoscopic gastrostomy (PEG) tubes, and 23 with nasogastric (NG) tubes. In 2015, among these subjects admitted to neurological rehabilitation, the incidence of HAP was 13.1%. For these 8 pneumonia cases, it was possible to isolate the bacterium in 62.5% of cases, and the detected microorganisms were K. pneumoniae (n=2), P. aeruginosa (n=1), P. mirabilis (n=1), S. maltophilia (n=1), E. cloacae + MRSCoN (n=1). Compared to the literature data, the results of the first year of monitoring show a slight increase in HAP cases (13.1%) in severe brain injury patients on first admission to neurological rehabilitation. These preliminary results need to be further confirmed and monitored over time. The findings moreover confirm the criticality and complexity of care for these patients admitted to neurological rehabilitation units.
10.4081/monaldi.2018.888
An update on pulmonary rehabilitation techniques for patients with chronic obstructive pulmonary disease.
Wouters Emiel Fm,Posthuma Rein,Koopman Maud,Liu Wai-Yan,Sillen Maurice J,Hajian Bita,Sastry Manu,Spruit Martijn A,Franssen Frits M
Expert review of respiratory medicine
: Pulmonary rehabilitation (PR) is one of the core components in the management of patients with chronic obstructive pulmonary disease (COPD). In order to achieve the maximal level of independence, autonomy, and functioning of the patient, targeted therapies and interventions based on the identification of physical, emotional and social traits need to be provided by a dedicated, interdisciplinary PR team.: The review discusses cardiopulmonary exercise testing in the selection of different modes of training modalities. Neuromuscular electrical stimulation as well as gait assessment and training are discussed as well as add-on therapies as oxygen, noninvasive ventilator support or endoscopic lung volume reduction in selected patients. The potentials of pulsed inhaled nitric oxide in patients with underlying pulmonary hypertension is explored as well as nutritional support. The impact of sleep quality on outcomes of PR is reviewed.: Individualized, comprehensive intervention based on thorough assessment of physical, emotional, and social traits in COPD patients forms a continuous challenge for health-care professionals and PR organizations in order to dynamically implement and adapt these strategies based on dynamic, more optimal understanding of underlying pathophysiological mechanisms.
10.1080/17476348.2020.1700796
Lung- and Diaphragm-Protective Ventilation.
American journal of respiratory and critical care medicine
Mechanical ventilation can cause acute diaphragm atrophy and injury, and this is associated with poor clinical outcomes. Although the importance and impact of lung-protective ventilation is widely appreciated and well established, the concept of diaphragm-protective ventilation has recently emerged as a potential complementary therapeutic strategy. This Perspective, developed from discussions at a meeting of international experts convened by PLUG (the Pleural Pressure Working Group) of the European Society of Intensive Care Medicine, outlines a conceptual framework for an integrated lung- and diaphragm-protective approach to mechanical ventilation on the basis of growing evidence about mechanisms of injury. We propose targets for diaphragm protection based on respiratory effort and patient-ventilator synchrony. The potential for conflict between diaphragm protection and lung protection under certain conditions is discussed; we emphasize that when conflicts arise, lung protection must be prioritized over diaphragm protection. Monitoring respiratory effort is essential to concomitantly protect both the diaphragm and the lung during mechanical ventilation. To implement lung- and diaphragm-protective ventilation, new approaches to monitoring, to setting the ventilator, and to titrating sedation will be required. Adjunctive interventions, including extracorporeal life support techniques, phrenic nerve stimulation, and clinical decision-support systems, may also play an important role in selected patients in the future. Evaluating the clinical impact of this new paradigm will be challenging, owing to the complexity of the intervention. The concept of lung- and diaphragm-protective ventilation presents a new opportunity to potentially improve clinical outcomes for critically ill patients.
10.1164/rccm.202003-0655CP
A comparison of the effects of manual and ventilator hyperinflation on static lung compliance and sputum production in intubated and ventilated intensive care patients.
Berney Susan,Denehy Linda
Physiotherapy research international : the journal for researchers and clinicians in physical therapy
BACKGROUND AND PURPOSE:Lung hyperinflation is a technique used by physiotherapists to mobilize and remove excess bronchial secretions, reinflate areas of pulmonary collapse and improve oxygenation. Hyperinflation may be delivered by the ventilator or manually, by use of a manual resuscitation circuit, depending upon the respiratory and cardiovascular status of the patient. The effects of manual hyperinflation, with respect to excess bronchial secretions and static lung compliance, have been well-established. There is, however, only limited evidence as to the efficacy of ventilator hyperinflation as a physiotherapy treatment technique. The purpose of the present study was to compare the effects of manual hyperinflation and ventilator hyperinflation on static pulmonary compliance and sputum clearance in stable intubated and ventilated patients. METHOD:Twenty patients who met the inclusion criteria were studied. This was a double crossover study where all patients were randomly allocated to one of two treatment sequences over two days. The first sequence involved manual hyperinflation followed two hours later by ventilator hyperinflation and the order was reversed on the second day. In the second sequence, ventilator hyperinflation preceded manual hyperinflation. The variables of static pulmonary compliance and sputum wet weight were analysed by use of an analysis of variance (ANOVA) for repeated measures. Statistical significance was set at p < 0.05. RESULTS:There was no significant difference in sputum wet weight production between either technique or on either day of treatment. Static pulmonary compliance improved with both hyperinflation techniques (p < 0.05). CONCLUSIONS:Hyperinflation as part of a physiotherapy treatment can be performed with equal benefit using either a manual resuscitation circuit or a ventilator. Both methods of hyperinflation improve static pulmonary compliance and clear similar volumes of pulmonary secretions.
10.1002/pri.246
Effectiveness of a perioperative pulmonary rehabilitation program following coronary artery bypass graft surgery in patients with and without COPD.
Chen Jui-O,Liu Jui-Fang,Liu Yu-Qi,Chen Yu-Mu,Tu Mei-Lien,Yu Hong-Ren,Lin Meng-Chih,Lin Chiu-Chu,Liu Shih-Feng
International journal of chronic obstructive pulmonary disease
Purpose:It is unclear whether the effectiveness of pulmonary rehabilitation program (PRP) after cardiac surgery differs between patients with and without COPD. This study aimed to compare the effectiveness of PRP between patients with and without COPD undergoing coronary artery bypass graft (CABG) surgery. Patients and methods:We retrospectively included patients who underwent CABG surgery and received 3-week PRP from January 2009 to December 2013. We excluded patients who underwent emergency surgery, had an unstable hemodynamic status, were ventilator dependent or did not complete the PRP. Demographics, muscle strength, degree of dyspnea, pulmonary function and postoperative complications were compared. Results:Seventy-eight patients were enrolled (COPD group, n=40; non-COPD group, n=38). Maximal inspiratory pressure (MIP; -34.52 cmHO vs -43.25 cmHO, <0.01; -34.67 cmHO vs -48.18 cmHO, <0.01), maximal expiratory pressure (MEP; 32.15 cmHO vs 46.05 cmHO, <0.01; 37.78 cmHO vs 45.72 cmHO, <0.01) and respiratory rate (RR; 20.65 breath/minute vs 17.02 breath/minute, <0.01; 20.65 breath/minute vs 17.34 breath/minute, <0.01) in COPD and non-COPD groups, respectively, showed significant improvement, but were not significantly different between the two groups. Forced vital capacity (FVC; 0.85 L vs 1.25 L, <0.01), forced expiratory volume in 1 second (FEV; 0.75 L vs 1.08 L, <0.01), peak expiratory flow (PEF; 0.99 L vs 1.79 L, <0.01) and forced expiratory flow between 25% and 75% of vital capacity (FEF; 0.68 L vs 1.15 L, <0.01) showed significant improvement between postoperative Days 1 and 14 in the COPD group. FVC (1.11 L vs 1.36 L, <0.05), FEV (96 L vs 1.09 L, <0.05) and FEF (1.03 L vs 1.26 L, <0.05) were significantly improved in the non-COPD group. However, only PEF (80.8% vs 10.1%, <0.01) and FEF (67.6% vs 22.3%, <0.05) were more significantly improved in the COPD group than in the non-COPD group. Conclusion:PRP significantly improved respiratory muscle strength and lung function in patients with and without COPD who underwent CABG surgery. However, PRP is more effective in improving PEF and FEF in COPD patients.
10.2147/COPD.S157967
Pulmonary rehabilitation after lung transplantation with severe complications: A case report.
Jing Guo-Qiang,Li Jie,Sun Bing,Chu Huiwen,Li Haichao,Wang Xue,Tang Xiao
Canadian journal of respiratory therapy : CJRT = Revue canadienne de la therapie respiratoire : RCTR
This case study describes a 59-year-old male with a body mass index of 14.4 kg/m and a diagnosis of interstitial lung disease, pneumoconiosis, and severe pulmonary hypertension who received a bilateral lung transplant in a hospital in mainland China. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) was initiated before the lung transplant; in addition, an emergency thoracotomy was performed three hours afterwards due to uncontrolled bleeding. VA-ECMO was weaned 34 hours later, but weaning from the ventilator failed multiple times due to bilateral pneumothorax, weak neuromuscular drive, and muscle strength. A full, personalized rehabilitation program was initiated with the help of a respiratory therapy team and the physician, drawing on the American Thoracic Society/European Respiratory Society Statement on Pulmonary Rehabilitation. This included nutrition support, draining air from the chest pleural cavity, aggressive bronchial-hygiene therapy, a weaning plan, breathing and physical exercises, and psychological support. Eighty-one days after the tracheotomy, the patient was successfully weaned, decannulated, and discharged. A careful, ongoing evaluation and a personalized program assisted with weaning this difficult patient.
[Management strategy of lung protection in patients with intra-abdominal infection].
Liu Y Q
Zhonghua wei chang wai ke za zhi = Chinese journal of gastrointestinal surgery
Lung protection is important in the treatment of patients with intra-abdominal infection (IAI). This article focuses on the management strategy of lung protection in IAI patients. In the implementation of IAI individual respiratory protection, good humidification and chest physical therapy, nutritional support, strict balloon management, keeping a semi-supine position, and reducing the duration and depth of analgesia and sedation are helpful to maintain effective coughing capacity and prevent silent aspiration. It is also necessary to prevent ventilator-associated lung injury in mechanical ventilation, and implement strategies of small tidal volume, limited platform pressure, diaphragmatic protection and right heart protection ventilation in acute respiratory distress syndrome (ARDS). Respiratory mechanical indicators, including airway resistance, respiratory compliance, maximum inspiratory pressure (MIP), and airway closure pressure (P0.1) can be used in IAI patients receiving mechanical ventilation for individualized assessment and monitoring of respiratory functional status. Patients with IAI who have not been treated with mechanical ventilation can use simplified bedside lung function indicators, including forced vital capacity of inhalation and exhalation, maximum inspiratory pressure and exhalation pressure, as well as volume and rate of 1s. In pulmonary rehabilitation, the protection technique of the seven-word principle of humidification, turning, patting, coughing, expansion, blowing and mobilization are implemented.
10.3760/cma.j.cn.441530-20200810-00469
Advanced Mechanical Ventilatory Constraints During Incremental Exercise in Class III Obese Male Subjects.
Chlif Mehdi,Temfemo Abdou,Keochkerian David,Choquet Dominique,Chaouachi Anis,Ahmaidi Said
Respiratory care
BACKGROUND:We investigated the role of mechanical ventilatory constraints in obese class III subjects during incremental exercise. METHODS:We examined 14 control subjects (body mass index [BMI], 23.6 ± 3.2 kg/m(2)), 15 obese class II subjects (BMI, 37.2 ± 4.5 kg/m(2)), and 17 obese class III subjects (BMI, 53.4 ± 6.8 kg/m(2)). All subjects performed pulmonary function tests and maximal inspiratory pressure at rest, ventilatory parameters, flow-volume loops, and rated perceived exertion and breathlessness during exercise. RESULTS:All subjects had normal pulmonary function. Obesity resulted in increased minute ventilation for a given submaximal work rate, although minute ventilation during peak exercise was lowest in the obese class III subjects. End-expiratory lung volume was significantly lower in the obese subjects at rest and during exercise at the ventilatory threshold but not during peak exercise. During heavy-to-peak exercise, the obese subjects increased their end-expiratory lung volume, whereas the control group continued to decrease this parameter. Compared with controls, end-inspiratory lung volume was significantly lower in obese class II subjects and obese class III subjects at rest and at the ventilatory threshold but not during peak exercise. At maximal exercise, obese class III subjects had a greater end-inspiratory lung volume than obese class II subjects and controls. Obese class III subjects displayed a greater expiratory air flow limitation at rest, at the ventilatory threshold, and during peak exercise than both controls and obese class II subjects. CONCLUSIONS:Mechanical ventilatory constraints increase progressively with degrees of obesity, contributing to exercise limitation in obese subjects.
10.4187/respcare.03206
Effect of lung recruitment on blood gas index, hemodynamics, lung compliance, and rehabilitation index in children with acute respiratory distress syndrome.
Li Bo,Li Duoling,Huang Wei,Che Yuanyuan
Translational pediatrics
Background:Acute respiratory distress syndrome (ARDS) is a common pediatric disease, with an increasing mortality rate in recent years. This study aims to explore the effects of lung recruitment on blood gas indexes, hemodynamics, lung compliance, and rehabilitation index in children with ARDS. Methods:Seventy children with ARDS admitted to our hospital from December 2017 to December 2018 were selected as the study subjects, and were divided into a study group (35 cases, treated with lung recruitment strategy) and a control group (35 cases, treated with routine therapy). The changes of blood gas indexes, such as partial pressure of oxygen (PO), partial pressure of carbon dioxide (PCO), and partial pressure of oxygen/fraction of inspired oxygen (PO/FiO) levels, as well as hemodynamic indexes, including cardiac output (CO), heart rate (HR), mean arterial pressure (MAP), central venous pressure (CVP), were compared before and after treatment in the two groups. Results:Results showed that the difference in blood gas indexes between the two groups was statistically significant after treatment (P<0.05), and that the levels of PaO, PaCO, pondus Hydrogenii (pH), and PO/FiO in the study group were all higher compared to the control group (P<0.05). The hemodynamic indexes showed that CO was significantly different between the two groups (P<0.05), but HR, MAP, and CVP were not (P>0.05). The lung compliance values of the two groups continued to increase at different time points after treatment (P<0.05), and the lung compliance of the study group was higher than that of the control group immediately after recruitment, as well as at 10 and 60 min of lung recruitment (P<0.05). In addition, the ventilator use, ICU stay, and hospital stay times of the study group were shorter than those in the control group (P<0.05), and the mortality rate of the study group was lower than that of the control group (P>0.05). Conclusions:The lung recruitment strategy has a significant therapeutic effect on children with ARDS. It can effectively improve blood and gas function and lung compliance, and has a positive effect on the hemodynamic stability of children with ARDS.
10.21037/tp-20-383
Indicators of Airway Secretion Weight in Mechanically Ventilated Subjects.
Ntoumenopoulos George,Berry Marc P,Camporota Luigi,Lam Lawrence
Respiratory care
BACKGROUND:Clinicians may use adventitious breath sounds on lung auscultation and a "sawtooth" pattern on the ventilator expiratory flow waveform as indicators of the need for chest physiotherapy for airway-secretion clearance in mechanically ventilated patients. This study seeks to identify potential clinical and novel indicators of the weight of airway secretions cleared from a single session of chest physiotherapy in mechanically ventilated subjects. METHODS:We recorded airway crackles using artificial airway acoustic sound monitoring and computerized lung-sound amplitude using artificial airway acoustic sound detection and compared them to standard clinical assessments in 71 mechanically ventilated subjects immediately prior to a single session of chest physiotherapy. Correlational analyses were undertaken between the weight of airway secretions obtained after the single session of chest physiotherapy as the dependent variable and novel assessments, clinical assessments, patient characteristics, and ventilator parameters as the independent variables. Multiple linear regression analyses were then used to determine the best model to predict the weight of airway secretions obtained from the single chest physiotherapy session. Data are reported as mean and median as appropriate. Significance was set at < .05. RESULTS:71 mechanically ventilated subjects were included for analysis. Statistically significant associations with the weight of airway secretions included the presence of a sawtooth waveform on expiration and the novel assessment of average airway crackles during inspiration. The best predictive model of the weight of airway secretions included the presence of the sawtooth waveform on expiration and ventilator tidal volume. CONCLUSIONS:Simple clinical assessments used in this study were able to independently predict the weight of airway secretions cleared during a single session of chest physiotherapy. The novel assessments used in this investigation did not add any further value.
10.4187/respcare.06437
Ventilator versus manual hyperinflation in clearing sputum in ventilated intensive care unit patients.
Dennis Diane,Jacob Wendy,Budgeon Charley
Anaesthesia and intensive care
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.
10.1177/0310057X1204000117
Chest physiotherapy with early mobilization may improve extubation outcome in critically ill patients in the intensive care units.
Wang Tsung-Hsien,Wu Chin-Pyng,Wang Li-Ying
The clinical respiratory journal
BACKGROUND:Extubation failure can lead to a longer intensive care unit (ICU) stay, higher mortality rate, and higher risk of requiring tracheostomy. Chest physiotherapy (CPT) can help patients in reducing the accumulation of airway secretion, preventing collapsed lung, improving lung compliance, and reducing comorbidities. Much research has investigated the correlation between CPT and respiratory system clearance. However, few studies have investigated the correlation between CPT and failed ventilator extubation. Therefore, this study aimed to investigate the use of CPT for reducing the rate of failed removal from mechanical ventilators. METHODS:This study was an intervention study with mechanical control. Subjects were divided into two groups. The control group, which received routine nursing chest care, was selected from a retrospective chart review. The intervention group was prospectively taken into the chest physiotherapy program. The chest physiotherapy treatment protocol consisted of inspiratory muscle training, manual hyperinflation, chest wall mobilization, secretion removal, cough function training, and early mobilization. RESULTS:A total of 439 subjects were enrolled in the intervention and control groups, with a mean age of 69 years. APACHE II score (P = .09) and GCS scores (P = .54) were similar between the two groups. Compared to the control group, patients in the intervention group had a significantly lower reintubation rate (8% vs 16%; P = .01). CONCLUSIONS:The results indicate that intensive chest physiotherapy could decrease extubation failure in mechanically ventilated patients in the ICU. In addition, chest physiotherapy could also significantly improve the rapid shallow breathing index score.
10.1111/crj.12965