The Mapleson C circuit clears more secretions than the Laerdal circuit during manual hyperinflation in mechanically-ventilated patients: a randomised cross-over trial. Manual hyperinflation improves alveolar recruitment in difficult-to-wean patients. Dynamics of re-expansion of atelectasis during general anaesthesia. Effects of manual hyperinflation and suctioning in respiratory mechanics in mechanically ventilated patients with ventilator-associated pneumonia. Manual hyperinflation--effects on respiratory parameters. Comparison of effects of manual versus ventilator hyperinflation on respiratory compliance and arterial blood gases in patients undergoing mitral valve replacement. Oxygenation and static compliance is improved immediately after early manual hyperinflation following myocardial revascularisation: a randomised controlled trial. Comparison of the effectiveness of manual and ventilator hyperinflation at different levels of positive end-expiratory pressure in artificially ventilated and intubated intensive care patients. The effect of circuit type, volume delivered and "rapid release" on flow rates during manual hyperinflation. A comparison of the effects of manual and ventilator hyperinflation on static lung compliance and sputum production in intubated and ventilated intensive care patients. Manual hyperinflation partly prevents reductions of functional residual capacity in cardiac surgical patients - a randomized controlled trial Ventilator versus Manual Hyperinflation in Clearing Sputum in Ventilated Intensive Care Unit Patients Physiotherapy does not prevent, or hasten recovery from, ventilator-associated pneumonia in patients with acquired brain injury Hemodynamic effects of intermittent manual lung hyperinflation in patients with septic shock. Performance of manual hyperinflation: a skills lab study among trained intensive care unit nurses. Manual hyperinflation: consistency and modification of the technique by physiotherapists. An evaluation of a single chest physiotherapy treatment on mechanically ventilated patients with acute lung injury. Effect of continuous lateral rotational therapy on lung mucus transport in mechanically ventilated patients. An Investigation of the Early Effects of Manual Lung Hyperinflation in Critically Ill Patients
QUESTION What is the effect of the Mapleson C circuit compared with the Laerdal circuit in removing secretions and improving ventilation and gas exchange during manual hyperinflation ? DESIGN Prospect i ve , r and omised , cross-over trial . PARTICIPANTS Twenty patients from a tertiary-level intensive care unit who were being mechanically ventilated . INTERVENTION Manual hyperinflation in side-lying with both the Mapleson C or Laerdal circuit on the one day , one circuit in the morning and one in the afternoon , with a washout period of at least three hours between them . OUTCOME MEASURES Secretion clearance was measured as sputum weight , ventilation was measured as respiratory compliance and tidal volume , while gas exchange was measured as oxygenation and CO2 removal . RESULTS The Mapleson C circuit cleared 0.89 g ( 95 % CI 0.80 to 1.15 ) more secretions than the Laerdal circuit ( p < 0.02 ) . There was no difference between the Mapleson C and the Laerdal circuits on respiratory compliance ( p = 0.81 ) , tidal volume ( p = 0.45 ) , oxygenation ( p = 0.28 ) , or CO2 removal ( p = 0.17 ) . CONCLUSION Although more secretions were cleared using the Mapleson C compared with the Laerdal circuit in this study , this had no consequence in terms of oxygenation and compliance only trended to improve . As the study was underpowered the clinical significance of these findings is not clear STUDY OBJECTIVES To investigate the effect of manual hyperinflation ( MH ) in patients with atelectasis associated with ventilation support . DESIGN Patients were r and omized to either an experimental group or a control group . SETTING Pulmonary ICUs from two hospitals . PATIENTS Twenty-three patients with atelectasis associated with ventilation support . INTERVENTIONS The MH technique was at a rate of 8 to 13 breaths/min for a period of 20 min each session , three times per day for 5 days . The control group received their st and ard prescribed mechanical ventilation without supplemental MH .  Sputum contents ( wet/dry weight ratio , viscosity ) , respiratory system capacity ( spontaneous tidal volume [ Vt ] , maximal inspiratory pressure , rapid shallow breathing index [ f/Vt ] , chest radiograph signs , and Pa(O2)/fraction of inspired oxygen [ Fi(O2 ) ] ) were measured just prior to the MH at day 0 as baseline , and at day 3 and day 6 of the study . MEASUREMENTS AND RESULTS There were significant improvements in scores over the 6-day study in the experimental group compared to the control group in spontaneous Vt ( p = 0.035 ) and chest radiograph signs ( p = 0.040 ) , and a trend toward improvement of f/Vt ( p = 0.066 ) and Pa(O2)/Fi(O2 ) ( p = 0.061 ) after adjustment for covariates . Other outcome variables did not differ significantly between the experimental and control groups . CONCLUSIONS MH performed on patients with atelectasis from ventilation support significantly improved alveolar recruitment A major cause of impaired gas exchange during general anaesthesia is atelectasis , causing pulmonary shunt . A ' vital capacity ' ( VC ) manoeuvre ( i.e. inflation of the lungs up to 40 cm H2O , maintained for 15 s ) may re-exp and atelectasis and improve oxygenation . However , such a manoeuvre may cause adverse cardiovascular effects . Reducing the time of maximal inflation may improve the margin of safety . The aim of this study was to analyse the change over time in the amount of atelectasis during a VC manoeuvre in 12 anaesthetized adults with healthy lungs .  I.v . anaesthesia with controlled mechanical ventilation ( VT 9 ( SD 1 ) ml kg-1 ) was used . For the VC manoeuvre , the lungs were inflated up to an airway pressure ( Paw ) of 40 cm H2O . This pressure was maintained for 26 s. Atelectasis was assessed by analysis of computed x-ray tomography . The amount of atelectasis , measured at the base of the lungs , was 4.0 ( SD 2.7 ) cm2 after induction of anaesthesia . The decrease in the amount of atelectasis over time during the VC manoeuvre was described by a negative exponential function with a time constant of 2.6 s. At an inspired oxygen concentration of 40 % , PaO2 increased from 17.2 ( 4.0 ) kPa before to 22.2 ( 6.0 ) kPa ( P = 0.013 ) after the VC manoeuvre . Thus in anaesthetized adults undergoing mechanical ventilation with healthy lungs , inflation of the lungs to a Paw of 40 cm H2O , maintained for 7 - 8 s only , may re-exp and all previously collapsed lung tissue , as detected by lung computed tomography , and improve oxygenation . We conclude that the previously proposed time for a VC manoeuvre may be halved in such subjects Ventilator-associated pneumonia results from bacterial colonisation of the aerodigestive tract or aspiration of contaminated secretions into the lower airways . As a consequence of infection of the lung parenchyma and alveolitis , accumulation of inflammatory exu date s and infiltration of airway mucosa can lead to unfavourable respiratory mechanics in ventilator-associated pneumonia . Tracheal suction is often employed by nursing staff in the management of mechanically ventilated patients with ventilator-associated pneumonia but this technique has the potential to increase respiratory resistance .  Manual hyperinflation is used by physiotherapists to improve lung volume and mobilise secretions and has been shown to increase lung compliance . The effect of manual hyperinflation on airway resistance has not been studied . This study aims to demonstrate an additional mechanical benefit to the respiratory system when manual hyperinflation and suction techniques are combined , by comparing the application of manual hyperinflation and suction with suction alone on static lung compliance ( C(L ) ) and inspiratory resistance ( R(AW ) ) in mechanically ventilated patients with ventilator-associated pneumonia . Fifteen adult patients with ventilator-associated pneumonia were recruited and acted as their own controls . Manual hyperinflation followed by suction ( manual hyperinflation plus suction ) and suction alone were applied consecutively , in r and om order , on two occasions , four hours apart . Respiratory variables , C(L ) and R(AW ) , were measured five times and the averaged value documented . Data were recorded before , immediately after , and 30 minutes after each intervention protocol . C(L ) increased by 22 % and R(AW ) decreased by 21 % , up to 30 minutes after manual hyperinflation plus suction , but not after suction alone . This study suggests that manual hyperinflation in conjunction with suction induces beneficial changes in respiratory mechanics in mechanically ventilated patients with ventilator-associated pneumonia BACKGROUND AND PURPOSE Manual hyperinflation ( MH ) of the lungs is commonly used by physiotherapists in the treatment of intubated mechanically ventilated patients with the aim of increasing alveolar oxygenation , reversing atelectasis or mobilizing pulmonary secretions . However , the efficacy of MH , used in isolation , has not been clearly established . METHOD This r and omized , controlled trial investigated the effects of MH on lung compliance ( CL ) , the arterial oxygen to fraction of inspired oxygen ratio ( PaO2:FIO2 ) and the alveolar-arterial oxygen tension difference (A-a)PO2 in 100 medically stable , mechanically ventilated subjects who had undergone coronary artery surgery ( CAS ) . Post-CAS subjects were used for this study as they constitute a large , homogeneous and accessible group . Subjects were r and omized to either a control group ( non-MH group ) or to a treatment group ( MH group ) which received MH within four hours of surgery . RESULTS After four minutes of MH there were significant improvements in CL , PaO2:FIO2 and (A-a)PO2 with values remaining above baseline measures at 60 min post-intervention . The mean improvement in CL was 6 ml/cmH2O ( approximately 15 % ) , 56 mmHg for PaO2:FIO2 ( approximately 17 % ) and 29 mmHg for (A-a)PO2 ( approximately 17 % ) immediately post-intervention . No significant changes in mean CL , PaO2:FIO2 or (A-a)PO2 were seen in the non-MH group . CONCLUSIONS MH performed in the stable ventilated patient significantly increased CL and PaO2:FIO2 and decreased (A-a)PO2 , but the clinical significance of this improvement is unclear . Further investigations are required to vali date the findings of this study as well as to determine the therapeutic value of MH on patient outcome OBJECTIVE To compare the effects of manual hyperinflation ( MHI ) and ventilator hyperinflation ( VHI ) delivered to completely se date d and paralyzed patients undergoing mitral valve replacement ( MVR ) while maintaining minute ventilation . METHODS This was a r and omized study with a 2-group , pre-test , post-test experimental design . Effects of hyperinflation were studied on static compliance ( C(stat ) ) , dynamic compliance ( C(dyn ) ) , oxygenation ( Pao(2):Fio(2 ) ) , partial pressure of carbon dioxide in arterial blood ( Paco(2 ) ) , and cologarithm of activity of dissolved hydrogen ions in arterial blood ( pH ) . A sample of 30 patients in the immediate postoperative phase of MVR surgery were included in the study . RESULTS No significant differences were found between the groups . Significant improvements were found in oxygenation at both 1minute and 20minutes after MHI , but only at 1minute after VHI ( P < .05 ) . VHI led to improved C(dyn ) ( P < .05 ) . CONCLUSION In the immediate postoperative phase of MVR , both techniques produced similar effects on respiratory compliance and oxygenation .  MHI produced longer lasting improvements in oxygenation than VHI , whereas VHI produced better improvements in dynamic compliance . Paco(2 ) and pH were maintained by both QUESTION Are oxygenation and static compliance improved immediately after manual hyperinflation following myocardial revascularisation ? Does this lead to earlier extubation and shorter hospital stay ? Does it reduce postoperative pulmonary complications ? DESIGN R and omised controlled trial with concealed allocation , blinded assessment and intention-to-treat analysis . PARTICIPANTS Fifty-five patients who underwent myocardial revascularisation . INTERVENTION After an hour in recovery , the experimental group received manual hyperinflation with positive end expiratory pressure followed by suction while the control group received suction only . OUTCOME MEASURES Oxygenation ( PaO(2 ) in mmHg ) and static lung compliance ( in ml/cmH(2)O ) were measured immediately after suction . Time to extubation ( in minutes ) and length of hospital stay ( in days ) were collected and postoperative pulmonary complications were confirmed by X-ray . RESULTS PaO(2 ) was 11.7 mmHg ( 95 % CI 9.4 to 14.0 ) greater in the experimental group while static compliance was 8.5 ml/cmH(2)0 ( 95 % CI 6.4 to 10.6 ) greater than in the control group . The experimental group was extubated 76 minutes ( 95 % CI 24 to 128 ) earlier than the control group but did not have a shorter length of stay ( mean difference 0.5 days , 95 % CI -0.2 to 1.2 ) . The relative risk of postoperative pulmonary complications was no greater ( RR 0.57 , 95 % Cl 0.20 to 1.60 ) in the experimental group than in the control group . CONCLUSION The group that received early manual hyperinflation had markedly better oxygenation and static compliance as well as shorter mechanical ventilation times than the control group . The length of hospital stay and incidence of postoperative pulmonary complications were similar in the two groups BACKGROUND Manual hyperinflation ( MHI ) and ventilator hyperinflation ( VHI ) are two methods of recruitment maneuvers used in ventilated patients to improve lung compliance and secretion mobilization . The use of VHI may minimize the adverse effects of disconnection from the ventilator , but it is uncertain whether high levels of positive end-expiratory pressure ( PEEP ) would decrease the peak expiratory flow rate ( PEFR ) and consequently affect secretion clearance . OBJECTIVES The aim of this study was to compare the effectiveness of MHI and VHI in terms of clearing pulmonary secretions ( sputum wet weight and PEFR ) , improving static respiratory system compliance and oxygenation ( arterial oxygen tension/fraction of inspired oxygen ) , and altering mean arterial pressure , heart rate , and carbon dioxide output at different levels of PEEP . METHODS This was a r and omized crossover study involving 14 general intensive care patients who were intubated and mechanically ventilated . RESULTS Sputum production was similar in both techniques and levels of PEEP . There were no differences in improvement in oxygenation and static respiratory system compliance between MHI and VHI . However , VHI increased Cst significantly at 30 minutes posttreatment ( P = .012 ) , and a significant difference was observed between levels 5 and 7.5 cmH(2)O ( P = .02 ) of PEEP for MHI . MHI generated higher PEFR than VHI ( P < .05 ) . No adverse change in heart rate or mean arterial pressure was observed during either technique ; however , VCO(2 ) was significantly different for techniques ( P = .045 ) and over time ( P = .05 ) . CONCLUSION The VHI technique seems to promote greater improvements in respiratory mechanics with less metabolic disturbance compared with MHI . Other variables such as sputum production , hemodynamics , and oxygenation were affected similarly by both techniques Traditionally , manual hyperinflation has been performed using " rapid release " to promote a fast peak expiratory flow rate ( PEFR ) but rapid release has not been described . In addition , it has been demonstrated that different resuscitation circuits provide varying degrees of resistance to expiratory flow and it is known that a variety of circuits are used in Australia for manual hyperinflation . The aim of this study was to document current practice , the effect of rapid release , controlling inspiration , different volumes and circuit type on flow rates , and the inspiratory to expiratory flow rate ( I : E ) ratio during manual hyperinflation . Using a test lung model , 15 physiotherapists performed 11 trials using the Air Viva 2 , a Mapleson-C and a Mapleson-F circuit , both with and without rapid release , and delivering two volumes . The order of the trials was r and omised . Rapid release produced a faster PEFR irrespective of circuit type or volume delivered . The effect of rapid release , and the absolute PEFR , was less for the Air Viva 2 compared with the Mapleson circuits . Expiratory flow rate was faster for the larger volume . The theoretically optimal I : E ratio to move secretions was achieved delivering the lower target volume with the Mapleson circuits and using rapid release 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 r and omly 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 Introduction Cardiac surgery is associated with post-operative reductions of functional residual capacity ( FRC ) . Manual hyperinflation ( MH ) aims to prevent airway plugging , and as such could prevent the reduction of FRC after surgery . The main purpose of this study was to determine the effect of MH on post-operative FRC of cardiac surgical patients . Methods This was a r and omized controlled trial of patients after elective coronary artery bypass graft and /or valve surgery admitted to the intensive care unit ( ICU ) of a university hospital . Patients were r and omly assigned to a " routine MH group " ( MH was performed within 30 minutes after admission to the ICU and every 6 hours thereafter , and before tracheal extubation ) , or a " control group " ( MH was performed only if perceptible ( audible ) sputum was present in the larger airways causing problems with mechanical ventilation , or if oxygen saturation ( SpO2 ) dropped below 92 % ) . The primary endpoint was the reduction of FRC from the day before cardiac surgery to one , three , and five days after tracheal extubation . Secondary endpoints were SpO2 ( at similar time points ) and chest radiograph abnormalities , including atelectasis ( at three days after tracheal extubation ) . Results A total of 100 patients were enrolled . Patients in the routine MH group showed a decrease of FRC on the first post-operative day to 71 % of the pre-operative value , versus 57 % in the control group ( P = 0.002 ) . Differences in FRC became less prominent over time ; differences between the two study groups were no longer statistically significant at Day 5 . There were no differences in SpO2 between the study groups . Chest radiographs showed more abnormalities ( merely atelectasis ) in the control group compared to patients in the routine MH group ( P = 0.002 ) . Conclusions MH partly prevents the reduction of FRC in the first post-operative days after cardiac surgery . Trial registration Netherl and s Trial Register ( NTR ) : NTR1384 . 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 . A total of 46 patients received two r and omly 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 Objective To investigate the effect of respiratory physiotherapy on the prevention and treatment of ventilator-associated pneumonia ( VAP ) for adults in an intensive care unit ( ICU ) with an acquired brain injury ( ABI ) . Design and setting Two-part , prospect i ve , r and omised controlled trial . Patients A total of 144 subjects with ABI admitted with a Glasgow Coma Scale ≤9 , requiring intracranial pressure monitoring , and invasive mechanical ventilation ( MV ) for > 24 h ; 33 subjects were subsequently diagnosed with VAP.InterventionRespiratory  physiotherapy comprised six treatments ( positioning , manual hyperinflation and suctioning ) in each 24-h period whilst on MV . The Control Group received st and ard medical/nursing care but no respiratory physiotherapy . Measurements and results There were no significant differences between groups for incidence of VAP , duration of MV , length of ICU stay or clinical variables such as requirement for re-ventilation . Conclusions In adults with ABI , regular respiratory physiotherapy in addition to routine medical/nursing care does not appear to prevent VAP , reduce length of MV or ICU stay . Due to small numbers , it is not possible to draw any conclusions as to whether or not respiratory physiotherapy hastens recovery from VAP OBJECTIVE The purpose s of this study were to investigate the hemodynamic changes induced by intermittent manual lung hyperinflation ( MHI ) and to assess if these changes are adverse enough to warrant prohibition of MHI as a routine procedure in the care of patients with septic shock . DESIGN The study 's design was experimental prospect i ve . SETTING The setting s were university hospital intensive care units . PATIENTS Subjects included 13 consecutive mechanically ventilated patients with septic shock who met the inclusion criteria . MEASUREMENTS AND RESULTS Phasic MHI-related increments in mean inspiratory airway pressure were concordant to changes in mean pulmonary artery pressure ( MPAP ) ( r(2 ) = 0.67 ) with a 0.6 mm Hg rise in MPAP per cm H(2)O airway pressure . The magnitude of MPAP changes was not reflected in magnitude of stroke volume index ( SVI ) ( r(2 ) = 0.06 ) . On average , MHI did not induce statistically significant hemodynamic changes and mean values returned to baseline level within 15 minutes . SVI during  MHI  increased slightly in 9 patients , from 37 + /- 15 ( mean + /- SD ) to 41 + /- 17 mL/m(2 ) ( P < .05 ) , and decreased in 4 , from 60 + /- 10 to 50 + /- 14 mL/m(2 ) ( not significant ) . Patients with an increase in SVI had lower baseline values for SVI , cardiac index , and left ventricular stroke work index ( P < .05 ) and higher values for systemic vascular resistance index compared with patients with a decrease in SVI ( P < .05 ) . Left ventricular stroke work index was higher in patients with a decrease in SVI than in patients with an increase in SVI ( 52 + /- 9 vs 34 + /- 8 ; P < .05 ) . Tidal volume increased from 499 + /- 176 mL before MHI to 587 + /- 82 mL , 5 minutes after MHI ( P < .05 ) with a return to baseline values within 15 minutes after the procedure . CONCLUSION The hemodynamic effects of intermittent MHI in patients with septic shock are relatively small and insignificant and seem to be related to the cardiovascular state before the procedure . The risk of inducing hemodynamic changes with MHI should not be considered as a contraindication in patients with septic shock who are mechanically ventilated BACKGROUND The aim of manual hyperinflation ( MH ) is to mobilize airway secretions and prevent sputum plugging in intubated and mechanically ventilated patients . With MH , the nurse applies a larger than normal breath with a slow inspiratory flow and , after an inspiratory pause , a high expiratory flow is created by completely releasing the resuscitation bag . MATERIAL / METHODS This was a prospect i ve observational study in a skills lab of a university hospital . Intensive care unit nurses performed MH procedures for an imaginary patient in three different compliance setting s. Data were collected via direct video recordings and an air-flow analyzer . RESULTS One hundred nurses participated . Video recordings demonstrated inappropriate performance of MH  , reflected by the appearance of inspirations which were too rapid ( 53 % of cases ) , absence of holds ( 60 % ) , and absence of complete release of the resuscitation bag ( 78 % ) . In the majority of cases the applied volumes were too large according to what was advised in the local guideline ( 80 % ) . Peak inspiratory flow was 70 ( range : 55 - 89 ) l/min for all compliance setting s and peak expiratory flows were low : for over-compliant ( 46 , range : 42 - 51 ) , normal ( 51 , range : 45 - 57 ) , and noncompliant lungs ( 58 , range : 52 - 64 l/min ) . CONCLUSIONS Performance of MH by certified ICU nurses is far from appropriate . These results emphasize the necessity for clearer guidelines with explicit directions for this frequently applied procedure , if it is decided to practice it in the daily care of intubated and mechanically ventilated patients BACKGROUND AND PURPOSE The present study aim ed to evaluate the consistency with which physiotherapists apply manual hyperinflation to a test lung using the Air-Viva-2 or Mapleson-B resuscitation circuit , and their ability to modify the technique as pulmonary characteristics change . METHOD A quasi-experimental , r and omized , repeated- measures design was used to study 16 volunteer physiotherapists performing manual hyperinflation to a test lung simulating three clinical situations . Each subject applied manual hyperinflation to the test lung for each simulation three times in one day using the resuscitation circuit that they would normally use in their clinical practice . Eight subjects used the Air-Viva-2 circuit and eight used the Mapleson-B circuit .  Measurements of tidal volume ( Vp ) , peak airway pressure ( Paw ) and fraction of delivered oxygen ( FDO2 ) were recorded during each testing period . Inflation rate and minute volume were calculated . RESULTS As compliance decreased and airway resistance increased , VT decreased and Paw increased . Of the eight subjects using the Air-Viva-2 circuit , only three subjects delivered greater than 0.80 FDO2 . All subjects using the Mapleson-B circuit delivered greater than 0.85 FDO2 . CONCLUSIONS Subjects demonstrated good consistency in the application of manual hyperinflation for all three simulations and modified their technique appropriately as simulated pulmonary characteristics changed BACKGROUND AND PURPOSE Acute lung injury is a lung pathology that presents frequently on the intensive care unit . Chest physiotherapy , in the form of endotracheal suction , alternate side-lying and manual hyperinflation , is usually given to patients with this condition with the intention of removing retained pulmonary secretions and recruiting collapsed distal lung units . Despite this common practice there is insufficient research on the effects of chest physiotherapy in patients with acute lung injury being ventilated mechanically . The aim of the present study was to further underst and ing of the effects of three modes of treatment in chest physiotherapy in an acute lung injury patient group . METHOD This r and omized , controlled trial investigated all mechanically ventilated patients with acute lung injury admitted to the adult intensive care unit at Guy 's and St Thomas ' NHS Trust between August 1996 and July 1997 , who matched the inclusion criteria . Patients were r and omized into one of three treatment groups : Group 1 ( suctioned only ) ; Group 2 ( positioned and suctioned ) ; and Group 3 ( positioned , manually hyperinflated and suctioned ) . Baseline and 10 , 30 and 60 minutes ' post-treatment data were recorded for dynamic pulmonary compliance , arterial blood gases and haemodynamic variables . Results were analysed by use of an SPSS software package with a repeated- measures analysis of variance ( ANOVA ) . RESULTS Eighteen patients fitted the inclusion criteria . Significant changes were observed in both PaCO2 ( p = 0.026 ) and dynamic compliance ( p = 0.019 ) over time for all three groups . The arterial oxygen to fraction of inspired oxygen ratio ( PaO2:FiO2 ) did not alter significantly in any of the groups . With respect to other oxygenation parameters , mixed venous oxygen saturation ( SvO2 ) showed a significant difference between the groups . Heart rate ( HR ) and systemic blood pressure ( BP ) showed statistically significant , but not clinical ly significant differences over time . CONCLUSIONS Patients with acute lung injury are notably complex to nurse and may require protracted physiotherapy intervention , which may take many forms . As de-recruitment was the single most important event that occurred in the present study population , a prescriptive chest physiotherapy approach to treating mechanically ventilated patients with acute lung should be question ed and adapted accordingly PURPOSE Continuous lateral rotational therapy ( CLRT ) < 40 degrees is a method of altering the position of the ventilated patient to help clear secretions from the lung . CLRT has not been shown to reduce the incidence of atelectasis or pneumonia but potentially offers a way to maximize positional drainage in these patients without producing adverse effects . Treatment intervention , bracketed by two ( nonrotational ) control periods . The purpose of this study was to determine if CLRT alters mucus transport in critically ill , intubated patients in the intensive care unit of a teaching hospital . MATERIAL S AND METHODS Thirteen critically ill , but stable , mechanically ventilated patients , mean age 74 years , were enrolled . They were placed supine on a Biodyne bed ( KCI , San Antonio , Texas ) and pressures in the cushions adjusted to patient 's weight . A radiolabeled aerosol was delivered by bagging for 2 to 3 minutes and repeated measurements of lung radioactivity were obtained by imaging of the thorax over the following 3 hours . A 90-minute period of rotation of the bed , 30 degrees to either side was preceded and followed by two 45-minute control periods during which the patient remained supine and stationary on the bed . Coughs and suctions were recorded and blood gases obtained pre and post study . RESULTS ( 1 ) The mucous clearance was slower than that reported in normal subjects and in ambulatory patients with COPD ; ( 2 ) there was a slight , but not significant , increase in clearance during CLRT ; ( 3 ) clearance reverted to pre-oscillation levels following therapy . Lack of significant effect may be attributed to too shallow an angle for rotation or too short an intervention period . CONCLUSION Positional drainage effected by short duration CLRT did not appear to stimulate significant mucous removal from the lung in critically ill patients but also did not cause any adverse effects This prospect i ve within-group multicentre study was design ed to assess the safety and short-term effectiveness of manual lung hyperinflation in mechanically ventilated patients . Eighteen patients from the intensive care units of two tertiary institutions were included and acted as their own control . Manual lung hyperinflation treatment involved patient positioning ( side-lying ) , suctioning and manual lung hyperinflation . Side-lying treatment involved patient positioning and suctioning alone . Patients received both treatments on the day of data collection . Results demonstrated significant improvement for static respiratory system compliance ( P=0.001 ) with manual lung hyperinflation treatment compared to side-lying treatment . Manual lung hyperinflation treatment also cleared a significantly greater wet weight of sputum ( P=0.039 ) . There were no differences between manual lung hyperinflation and side-lying treatment for gas exchange ( Pao2/FIO2 and Paco2 ) , mean arterial pressure or heart rate . In conclusion , total static respiratory system compliance and sputum clearance were improved by the addition of manual hyperinflation to a physiotherapy treatment of positioning and suctioning in mechanically ventilated patients without compromise to cardiovascular stability or gas exchange
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 .