Intensive Care - manual and ventilator hyperinflation
SEE ALSO ICU Physiotherapy Overview
Allen GB, Suratt BT, Rinaldi L, Petty JM, Bates JH (2006) Choosing the frequency of deep inflation in mice: balancing recruitment against ventilator-induced lung injury. Am J Physiol Lung Cell Mol Physiol, 291, L710L717
www.ncbi.nlm.nih.gov/pubmed/16698851
low tidal volume ventilation protects against ventilator-induced lung injury but can promote atelectasis
periodic deep inflation can open alveoli, but if delivered too frequently may cause damage by repeated overdistention
frequent ventilator deep breaths can safely improve gas exchange and lung mechanics and may confer protection from biotraum
Anning L, Paratz J, Wong WP et al (2003) Effect of manual hyperinflation on haemodynamics in an animal modal. Respir Care, 8, 3, 155-63
www3.interscience.wiley.com/cgi-bin/abstract/112510534/ABSTRACT
mechanism of effect on manual hyperinflation on cardiac output
Barke M, Eales CJ (1994) Ambubagging as a therapeutic technique. S.African J.Phys, 50, 26-7
Barker M, Adams S (2002) An evaluation of a single chest physiotherapy treatment on mechanically ventilated patients with acute lung injury. Physiother Res Int, 7, 3, 157-69
www3.interscience.wiley.com/journal/112501201/abstract
PaO2:FiO2 ratio did not alter significantly with (a) suction, (b) positioning and suction, (c) positioning, MH and suction.
Berney S, Denehy L (2002) A comparison of the effects of manual and ventilator hyperinflation on static lung compliance and sputum production. Physiother Res Internat, 7, 100-108
both methods improve lung compliance and clear secretions
Berney S, Denehy L (2003) The effect of physiotherapy on oxygen consumption and haemodynamics in patients who are critically ill. Austr J Physiother, 49, 99-105
ajp.physiotherapy.asn.au/AJP/vol_49/2/AustJPhysiotherv49i2Berney.pdf
Sensible physiotherapy does not upset metabolic or haemodynamic variables;
MHI increases compliance, resolves atelectasis and clear secretions
Corrects other articles mistakenly asserting that PT can be dangerous:
Berney S, Denehy L, Pretto J (2004) Head-down tilt and manual hyperinflation enhance sputum clearance in patients who are intubated and ventilated. Aust J Physiother, 50, 914
www.physiotherapy.asn.au/AJP/50-1/AustJPhysiotherv50i1Berney.pdf
during manual hyperinflation, a head-down tilt increases sputum production
Choi JS-P, Jones A Y-M (2005) Effects of manual hyperinflation and suctioning on respiratory mechanics in mechanically ventilated patients with ventilator-associated pneumonia. Austr J Physiother, 51, 25-30
www.physiotherapy.asn.au/AJP/vol_51/1/AustJPhysiotherv51i1Choi.pdf
manual hyperinflation improves lung compliance in people with ventilator-associated pneumonia
Clapham L, Harrison J, Raybould T (1995) A multidisciplinary audit of manual hyperinflation. Int Crit Care Nurs, 11, 265-71
www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6WGN-4DK6DNY-N&_user=10&_handle=V-WA-A-W-AE-MsSAYVA-UUW-U-AAVWCVBYEC-AAVUAWVZEC-ZCYCZZZVY-AE-U&_fmt=summary&_coverDate=10%2F31%2F1995&_rdoc=5&_orig=browse&_srch=%23toc%236827%231995%23999889994%23567056!&_cdi=6827&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=3cb88e001e92e2738f31b220c875dc88
audit leading to a standardised technique
Claxton BA, Morgan P, Mckeague H (2003) Alveolar recruitment strategy improves arterial oxygenation after cardiopulmonary bypass. Anaesthesia, 58, 111-16
Constantin JM, Futier E (2010) A recruitment maneuver increases oxygenation after intubation of hypoxemic intensive care unit
patients. Crit Care, 14:R76
www.biomedcentral.com/content/pdf/cc8989.pdf
randomised controlled study showing how a recruitment maneuver (CPAP of 40 cmH2O over 30 seconds) following intubation in hypoxemic patients improved oxygenation, without adverse effects.
Corley M et al (1993) The myth of 100% oxygen delivery through manual resuscitation bags. J Emerg Nurs, 19, 45-4
different bags have different FIO2
Davies N, Igo S (2004) Manual hyperinflation: a survey investigating the use of current best evidence. ACPRC Journal, 36, 8-17
a manometer in the circuit should be mandatory
Denehy L (1999) The use of manual hyperinflation in airways clearance. Eur Resp J, 14, 958-65
erj.ersjournals.com/cgi/reprint/14/4/958?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&andorexactfulltext=and&searchid=1140033961325_2670&FIRSTINDEX=0&sortspec=relevance&volume=14&firstpage=958&resourcetype=1&journalcode=erj
includes a further exhortation to use a manometer
Dueck R (2006) Alveolar recruitment versus hyperinflation: A balancing act. Curr Opin Anaesthesiol, 19, 6, 650-4.
www.ncbi.nlm.nih.gov/pubmed/17093370?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_SingleItemSupl.Pubmed_Discovery_RA&linkpos=4&log$=relatedreviews&logdbfrom=pubmed
PEEP levels must be high enough to minimise recruitment/derecruitment cycling.
balancing recruitment versus overdistension may require thoracic tomography.
Dyhr T et al (2002) Effects of lung recruitment maneuvre and PEEP on lung volume, respiratory mechanics and alveolar gas mixing in patients ventilated after cardiac surgery. Acta Anaesthesiol Scand, 46, 717-25
www.blackwell-synergy.com/doi/abs/10.1034/j.1399-6576.2002.460615.x
maintenance of PEEP with manual hyperinflation
Dyhr T et al (2003) Lung recruitment manoeuvres are effective in regaining lung volume and oxygenation after open endotracheal suctioning in acute respiratory distress syndrome. Crit Care, 7(1): 5562
ccforum.com/content/7/1/55
MH is effective in regaining lung volume after suction
Eaton JM (1984) Adult manual resuscitators. Br J Hosp Med, 31, 67-70
max safe pressure is 70 cmH2O in normal lungs
Ellis ER, Redfern J, Rusterholtz B (1999) The effects of feedback on the performance of manual hyperinflation by physiotherapists. WCPT Proc. p.31
manometer ensures effective and safe pressures
Gammon RB (1991) Pulmonary interstitial emphysema in mechanically ventilated patients. Am Rev Resp Dis, 143, 4, A693
barotrauma on x-ray - mediastinal emphysema, interstitial emphysema
Gammon RB (1992) Pulmonary barotrauma in IPPV. Chest, 102, 568-72
www.chestjournal.org/cgi/content/abstract/102/2/568
incidence and risk factors for pneumothorax and pneumomediastinum
Goldstein (1989) The role of in-line manometers in minimizing peak and mean airway pressure in newborn infants. Respir Care, 34, 23-7.
Griffiths R (2000) Breathing circuits and their uses. Br J Periop Nurs, 10, 55-9
Haake R et al (1987) Barotrauma. Chest, 91, 608-13
unevenly damaged lungs are at risk
Halter JM (2003) Positive End-Expiratory Pressure after a recruitment maneuver prevents both alveolar collapse and recruitment/derecruitment. Am J Respir Crit Care Med, 167, 1620-26
ajrccm.atsjournals.org/cgi/content/full/167/12/1620
effect of recruitment maneuver using peak pressure of 45 cmH2O and PEEP of 35 cmH2O for 1 minute, followed by PEEP of 5 or 10 cmH2O
Hess D et al (1994) Imposed work and oxygen delivery during spontaneous breathing with adult disposable manual ventilators. Anesthesiol, 81, 1256-63
breathing spontaneously through the bag increases the work of breathing
Hess DR, Bigatello LM (2002) Lung recruitment: the role of recruitment maneuvers. Respir Care, 47, 308-17
www.rcjournal.com/contents/03.02/03.02.0308.asp
open lung strategies by extra PEEP, sustained inflation, stepwise inflation, sighs & spontaneous breathing
Hicky J (2006) Manually ventilating & suctioning in-line with a SensorMedics 3100B high frequency oscillatory ventilator bench test. AARC Conference, Texas
www.cardinal.com/mps/focus/respiratory/abstracts/abstracts/ab2006/OF-06-157.asp
method for manual hyperinflation and suction without losing airway pressure with HFO
Hila J, Ellis E (2002) Feedback withdrawal and changing compliance during manual hyperinflaiton. Physiother Res Internat, 7, 53-64
pressure manometer recommended for safe and effective practice
Hillman K, Albin M (1986) Pulmonary barotrauma during cardiopulmonary resuscitation. Crit Care Med, 14, 606-9
barotrauma is inevitable at 90 cmH20 pressure
Hodgson C et al (1996) The acute cardiorespiratory effects of manual lung hyperinflation. Eur Resp J, 9 (suppl.23), 37s
MH increases lung compliance and SaO2
Hodgson C et al (2000) An investigation of the early effects of manual lung hyperinflation in critically ill patients. Anaesth Int Care, 28, 255-61
MH increases sputum clearance
Jantz MA (1994) Pneumothorax and barotrauma. Clin Chest Med, 15, 1, 75-92
identification of early barotrauma on x-ray
Jellema WT et al (2000) Haemodynamic effects of intermittent manual hyperinflation in patients with septic shock. Heart Lung, 29, 356-66
risk of haemodynamic compromise with MH is relatively small
Jones A et al (1992) Peak expiratory flow rates produced with the Laerdal and Mapleson-C bagging circuits. Austr Physiotherapy J, 38, 211-15
Jones A, Hutchinson RC (1992) Effects of bagging and percussion on total static compliance of the respiratory system. Physiotherapy, 78, 661-66
percussion/vibs/suction increases heart rate and BP, MH increases lung compliance
Lapinsky SE et al (1997) Safety and efficacy of a sustained inflation maneuver for alveolar recruitment. Chest, 112, 126S
sustained inflations at 30-40 cmH2O for 20 secs are safe through ventilator
Lapinsky SE (2003) Recruitment and retention of lung volume. Crit Care, 7, 9-10
ccforum.com/content/7/1/9
editorial relating to Dyhr et al (2003), above
Maa S-H, Hung T-J, Hsu K-H (2005) Manual hyperinflation improves alveolar recruitment in difficult-to-wean patients. Chest, 128, 2714-21.
chestjournal.chestpubs.org/content/128/4/2714.full?sid=c3f28d99-318b-4fa9-b66e-916a84952698
manual hyperinflation significantly recruits collapsed alveoli
Maxwell L, Ellis E (1998) Secretion clearance by manual hyperinflation. Physiother Th Pract, 14, 89-97
Maxwell L, Ellis ER (2002) The effects of three manual hyperinflation techniques on pattern of ventilation in a test lung. Anaesth Int Care, 30, 283-8
www.aaic.net.au/
how different techniques affect pressure and volume
Maxwell LJ, Ellis ER (2003) The effect of circuit type, volume delivered and rapid release on flow rates during manual hyperinflation. Austr J Physiother, 49, 31-8
assessment of different bags and different techniques
Maxwell LJ, Ellis ER (2004) Effect of maintaining bag compression during manual hyperinflation. Austr J Physiother, 50, 49
www.physiotherapy.asn.au/AJP/50-1/AustJPhysiotherv50i1Maxwell.pdf
McCarren B (1998) Description of manual hyperinflation in intubated patients with atelectasis. Physiother Theory Pract, 14, 199-210
Nielsen J (2006) Central hemodynamics during lung recruitment maneuvers at hypovolemia, normovolemia and hypervolemia. Int Care Med, 32, 4, 585-94
www.springerlink.com/(accux3esn5ttldic1i3hpc55)/app/home/contribution.asp?referrer=parent&backto=issue,16,37;journal,4,297;linkingpublicationresults,1:100428,1
lung recruitment maneuvers significantly decreased cardiac output at hypovolemia; hypervolemia partly counteracted this compromise. Also a marked right-ventricular dysfunction was found
Novak RA et al (1987) Do periodic hyperinflations improve gas exchange in patients with hypoxemic respiratory failure? Crit Care Med, 15, 1081-5
pressure of 40 cmH2O is required to reverse venous admixture.
MH can upset haemodynamics
Ntoumenopoulos G (2005) Indications for manual lung hyperinflation in the mechanically ventilated patient with COPD. Chron Respir Dis, 2: 199-207
Ntoumenopoulos G, Gild A (1998) The effect of manual lung hyperinflation and postural drainage on pulmonary complications. Anaesth Int Care, 26, 492-6
www.aaic.net.au/ (summary available)
trend towards reduced nosocomial pneumonia in patients receiving manual hyperinflation and postural drainage
Nunn JF et al (1965) Factors influencing the arterial oxygen tension during anaesthesia with artificial ventilation. Br J Anaesth. 37, 898-914
sustained pressure of 40 cmH2O is required to reverse atelectasis
Paratz et al (2002) Effect of manual hyperinflation on hemodynamics, gas exchange, and respiratory mechanics in ventilated patients. J Int Care Med, 17, 317-324
jic.sagepub.com/cgi/content/abstract/17/6/317?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&andorexactfulltext=and&searchid=1&FIRSTINDEX=0&sortspec=relevance&volume=17&firstpage=317&resourcetype=HWCITMHI improves lung mechanics and gas exchange without impairing the cardiovascular system
Patman S, Jenkins S, Smith K (2001) Manual hyperinflation: consistency and modification of the technique by physiotherapists. Phys Res Int, 6, 106-17
Patman S, Jenkins S (1998) Cardiovascular responses to manual hyperinflation in postoperative coronary artery surgery. Physiother Theory Pract, 14, 5-12
Patman S, Jenkins S, Stiller K (2000) Manual hyperinflation: effects on respiratory parameters. Physiother Res Internat, 5(3), 157-71
MH improves lung compliance, (A-a)PO2, PaO2/FiO2
Pearson SJ (1996) Peak airway pressures exerted during manual hyperinflation. Br J Ther Rehab, 3, 261-6
Redfern J, Ellis E, Holmes W (2001) The use of a pressure manometer enhances students physiotherapists performance during manual hyperinflation. Austr J Physiother, 47, 121-31
ajp.physiotherapy.asn.au/AJP/vol_47/2/AustJPhysiotherv47i2Redfern.pdf
manometer provides effective feedback
Reick CW (1996) Auto-PEEP associated with excessive oxygen flow through five manual resuscitators. Respir Care, 41, 1009-12
advice for MH with slow flow rate to avoid intrinsic PEEP
Robson WP (1998) To bag or not to bag? Int Crit Care Nurs. 14, 239-43
www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6WGN-4DHNT8N-5S&_user=10&_handle=V-WA-A-W-E-MsSAYZA-UUA-U-AAVWEZBUBA-AAVUCVBYBA-ZZEUEBEUE-E-U&_fmt=summary&_coverDate=10%2F31%2F1998&_rdoc=5&_orig=browse&_srch=%23toc%236827%231998%23999859994%23540603!&_cdi=6827&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=7e8b20d0d97301ecbc59ea21082170d3
literature review
Rothen HU, Neumann P, Berglund JE et al (1999) Dynamics of re-expansion of atelectasis during general anaesthesia. Br J Anaesth, 82, 551-6
pressure of 40 cmH2O (i.e. to vital capacity) eliminates atelectasis
Rusterholz B, Ellis D (1998) The effect of lung compliance and experience on manual hyperinflation. Austr J Physiother, 44, 23-8
Silbergleit R et al (1996) Sudden severe barotrauma from self-inflating bag-valve devices. J Trauma, 40, 320-2
www.jtrauma.com/pt/re/jtrauma/abstract.00005373-199602000-00031.htm;jsessionid=D4ysC2SXIab2U16fBKL0MjvTvi0Y9gDgOBs1XPUoObXLcAYn1ve4!-477899252!-949856144!9001!-1
bag with reservoir may push up pressures if valve blocked
Singer M, Vermaat J (1994) Hemodynamic effects of manual hyperinflation in critically ill patients. Chest, 106, 1182-7
chestjournal.chestpubs.org/content/106/4/1182.full.pdf+html?sid=8887ec47-ee48-4fb9-acb3-b621a795883b
MH can increase or decrease BP, but cardiac output is consistently reduced and takes up to 15 mins to recover
Sommers MS (1991) Potential for injury. Heart Lung, 20, 287-95.
max safe pressure is 60 cmH2O in normal lungs
Stone KS et al (1991) The effect of lung hyperinflation and endotracheal suctioning on cardiopulmonary haemodynamics. Nurs Res, 40, 76-80
mechanism of how MH can increase BP
Tusman G, Bohm SH, Tempra A et al (2003) Effects of recruitment maneuver on atelectasis in anesthetized children. Anesthiol, 98, 14-22
www.anesthesiology.org/pt/re/anes/fulltext.00000542-200301000-00006.htm;jsessionid=D4zrItG5sPaPQCx2FEttl6IefE6ttfsZtLZ3K1bXSCdbMe62SfjW!-477899252!-949856144!9001!-1
atelectasis was reduced in children given manual hyperinflation with peak pressure of 40 cmH2O and PEEP of 15 cmH2O for 10 breaths
ACPRC = Association of Chartered Physiotherapists in Respiratory Care
ARDS = acute respiratory distress syndrome
CPAP = continuous positive airways pressure
FIO2 = fraction of inspired oxygen
MH = manual hyperinflation
PaO2:FiO2 = arterial oxygen to fraction of inspired oxygen ratio
PEEP = positive end-expiratory pressure
WCPT = World Confederation of Physical Therapy