George Ntoumenopoulos

Chest physiotherapy for the prevention of ventilator-associated pneumonia

AbstractObjective. Pneumonia is an important complication in patients who are intubated and mechanically ventilated, when it is commonly referred to as ventilator-associated pneumonia (VAP). Since VAP may be contributed to by impaired sputum clearance, we studied whether chest physiotherapy designed to enhance sputum clearance decreases the occurrence of VAP.n Design. Prospective controlled systematic allocation trial.n Setting. Tertiary teaching hospital ICU.n Patients and participants. Sixty adult patients intubated and mechanically ventilated for at least 48xa0h.n Interventions. Chest physiotherapy (intervention group) or sham physiotherapy (control group).n Measurements and results. Control and intervention groups were well matched for age, sex, and admission PaO2/FiO2 ratio, APACHE II score, and Glasgow Coma Score. There were no differences in the duration of mechanical ventilation, length of stay in ICU or mortality. VAP was assessed daily by combined clinical assessment and the clinical pulmonary infection score (CPIS). VAP occurred in 39% (14/36) of the control group and 8% (2/24) of the intervention group (OR=0.14, 95% CI 0.03 to 0.56, P=0.02). After adjustment was made by logistic regression for other important variables (APACHE II score, duration of mechanical ventilation, presence of tracheostomy, and GCS score), chest physiotherapy was independently associated with a reduced occurrence of VAP (adjusted OR=0.16, 95% CI 0.03 to 0.94, P=0.02).n Conclusions. In this small trial, chest physiotherapy in ventilated patients was independently associated with a reduction in VAP. This suggested benefit of physiotherapy in prevention of VAP requires confirmation with a larger randomised controlled trial.

Non-invasive ventilation assists chest physiotherapy in adults with acute exacerbations of cystic fibrosis

Background: Chest physiotherapy is essential to the management of cystic fibrosis (CF). However, respiratory muscle fatigue and oxygen desaturation during treatment have been reported. The aim of this study was to determine whether non-invasive ventilation (NIV) during chest physiotherapy could prevent these adverse effects in adults with exacerbations of CF. Methods: Twenty six patients of mean (SD) age 27 (6) years and forced expiratory volume in 1 second (FEV1) 34 (12)% predicted completed a randomised crossover trial comparing standard treatment (active cycle of breathing technique, ACBT) with ACBT + NIV. Respiratory muscle strength (PImax, PEmax), spirometric parameters, and dyspnoea were measured before and after treatment. Pulse oximetry (Spo2) was recorded during treatment. Sputum production during treatment and 4 and 24 hours after treatment was evaluated. Results: There was a significant reduction in PImax following standard treatment that was correlated with baseline PImax (r=0.73, p<0.001). PImax was maintained following NIV (mean difference from standard treatment 9.04 cm H2O, 95% confidence interval (CI) 4.25 to 13.83 cm H2O, p=0.006). A significant increase in PEmax was observed following the NIV session (8.04 cm H2O, 95% CI 0.61 to 15.46 cm H2O, p=0.02). The proportion of treatment time with Spo2 ⩽90% was correlated with FEV1 (r=−0.65, p<0.001). NIV improved mean Spo2 (p<0.001) and reduced dyspnoea (p=0.02). There were no differences in FEV1, forced vital capacity (FVC) or sputum weight, but FEF25–75 increased following NIV (p=0.006). Conclusion: Reduced inspiratory muscle strength and oxygen desaturation during chest physiotherapy are associated with inspiratory muscle weakness and severity of lung disease in adults with exacerbations of CF. Addition of NIV improves inspiratory muscle function, oxygen saturation and small airway function and reduces dyspnoea.

Does unsupported upper limb exercise training improve symptoms and quality of life for patients with chronic obstructive pulmonary disease

PURPOSEnMany patients with chronic obstructive pulmonary disease (COPD) report dyspnea and fatigue when performing upper limb activities. Unsupported upper limb training has been shown to improve upper limb endurance, but its effects on symptoms and quality of life have not been examined. The aim of this study was to compare the effects of upper limb and lower limb training with lower limb training alone on exercise capacity, symptoms, and quality of life with COPD.nnnMETHODSnFor this study, 38 patients with moderate to severe COPD were randomly allocated to unsupported upper limb endurance training or to a control group that completed a sham training task. All the patients underwent lower limb endurance training. The 6-minute walk test, the Incremental Unsupported Upper Limb Exercise Test, and the Chronic Respiratory Disease Questionnaire (CRQ) were completed before training and then 6 weeks afterward. Both patients and assessors were blinded to group allocation.nnnRESULTSnAll the patients reported symptoms associated with upper limb activities on the initial CRQ. Both groups showed significant improvements in all domains of the CRQ and in the 6-minute walk test after training. Only the upper limb training group showed improvement in upper limb endurance time (57 +/- 75 vs 2 +/- 58 seconds; P = .02). There were no significant differences between the groups for 6-minute walk test or any domain of the CRQ.nnnCONCLUSIONSnUnsupported upper limb training for patients COPD improves upper limb exercise capacity, but has no additional effect on symptoms or quality of life, as compared with leg training alone. This type of upper limb training may not adequately address the complex interaction between respiratory mechanics and upper limb function.

The Mapleson C circuit clears more secretions than the Laerdal circuit during manual hyperinflation in mechanically-ventilated patients: a randomised cross-over trial

QUESTIONnWhat 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?nnnDESIGNnProspective, randomised, cross-over trial.nnnPARTICIPANTSnTwenty patients from a tertiary-level intensive care unit who were being mechanically ventilated.nnnINTERVENTIONnManual 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.nnnOUTCOME MEASURESnSecretion 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.nnnRESULTSnThe 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).nnnCONCLUSIONnAlthough 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.

The validation of a clinical algorithm for the prevention and management of pulmonary dysfunction in intubated adults: A synthesis of evidence and expert opinion

BACKGROUNDnPulmonary dysfunction (PDF) in intubated patients remains a serious and costly complication of intensive care unit care. Optimal cardiopulmonary therapy strategies to prevent and manage PDF need clarification to reduce practice variability. The purpose of this paper is to report on the content validation of an evidence-based clinical management algorithm (EBCMA) aimed at the prevention, identification and management of PDF in critically ill patients.nnnMETHODSnForty-four draft algorithm statements extracted from the extant literature by the primary research team were verified and rated by research clinicians (n = 7) in an electronic three-round Delphi process. Statements which reached a priori defined consensus [semi-interquartile range (SIQR) <0.5] were collated into the EBCMA.nnnRESULTSnOne hundred per cent response rate. Forty-four statements were added after round one. Consensus was reached on rating of 83% (73/88) statements. Differences in interpretation of the existing evidence base, and variations in accepted clinical practice were identified. Four themes were identified where panel failed to reach consensus.nnnCONCLUSIONnThe internationally agreed hierarchical framework of current available evidence and clinical expertise developed through this Delphi process provides clinicians with a tool to inform clinical practice. This tool has the potential to reduce practice variability thereby maximizing safety and treatment outcome. The clinical utility of the EBCMA requires further evaluation.

Effects of cardiothoracic physiotherapy on intrapulmonary shunt in abdominal surgical patients.

This study investigated the provision of additional evening physiotherapy on pulmonary complications and intrapulmonary shunt (Qs/Qt) after abdominal surgery. Thirty-one elderly patients received either daylight only or daylight plus evening physiotherapy for up to 48 hours. Physiotherapy included combinations of positioning, gravity assisted drainage, breathing exercises, manual techniques, coughing and airway suctioning. Measurements included Qs/Qt and post-operative pulmonary complications. While no significant difference in atelectasis was found, the post-operative Qs/Qt data averaged into six-hour time frames demonstrated significantly lower mean Qs/Qt for the daylight plus evening physiotherapy group between 18 and 24 hours post-surgery. Additional evening physiotherapy may reduce post-operative deterioration in gas exchange after major abdominal surgery.

Variation in the provision of cardiothoracic physiotherapy in Australian hospitals

The chief physiotherapists of 47 Australian metropolitan public hospitals were asked about the hours of provision and organisation of cardiothoracic physiotherapy services. Forty three per cent provided physiotherapy services only during the day, 12 per cent during the day and evening, and 45 per cent provided 24-hour coverage. Variation among the states was found in the provision of cardiothoracic physiotherapy. Most hospitals which provided 24-hour coverage used on-call. Thirty three per cent of hospitals rostered staff to work during the evening and only 7 per cent had rostered night shifts. Differences could not be attributed to variations in hospital size. The implications of these findings for the physiotherapy profession and patient care are discussed and the need for further research highlighted.

Lung Ultrasound for Critical Care Physiotherapists: A Narrative Review

BACKGROUNDnIn critical care, part of the physiotherapists respiratory assessment aims to identify parenchymal pulmonary pathology, which may be amenable to respiratory physiotherapy. In addition to clinical assessment, the tools that are most readily available to the respiratory physiotherapist to distinguish between acute pulmonary pathologies include auscultation and chest Xray. The limited diagnostic accuracy of these tools may not allow for the accurate differentiation between conditions such as lung collapse, consolidation and pleural effusion. Although computed tomography allows for this differentiation, it requires patient transport and exposes the patient to increased risk and high levels of radiation. Diagnostic lung ultrasound (LUS) has emerged as a highly sensitive bedside diagnostic tool with high level evidence to support its use for the differentiation of various common acute pulmonary pathologies. In this review, the diagnostic performances of auscultation, chest Xray and LUS are reviewed, and the usefulness of LUS as an adjunct to respiratory physiotherapy assessment is discussed. The issues surrounding training physiotherapists and the implementation of LUS are also explored.nnnMETHODSnThe method used is a narrative review of the literature.nnnCONCLUSIONnTo our knowledge, LUS is not routinely utilized by critical care physiotherapists. However, its superior sensitivity and specificity would enable the physiotherapist to make an accurate, timely and point of care diagnosis of lung pathology and determine whether the pathology is amenable to respiratory physiotherapy.

Do commonly used ventilator settings for mechanically ventilated adults have the potential to embed secretions or promote clearance

BACKGROUND: Intubation and mechanical ventilation can impair mucociliary clearance and cause secretion retention, airway occlusion, atelectasis, and pneumonia. Animal and laboratory work has demonstrated that mechanical ventilator settings can generate a flow bias (inspiratory or expiratory) that may result in mucus movement either away from the ventilator (deeper into the lungs) or toward the ventilator (toward the mouth), respectively. An absolute difference of 17 L/min, and a relative difference of ≥ 10%, between the expiratory and inspiratory flow have been reported as thresholds for mucus movement. METHODS: We measured baseline peak inspiratory and expiratory flows during quiet mechanical ventilation in a convenience sample of 20 intubated and ventilated adult patients. RESULTS: Nineteen patients had an inspiratory flow bias of ≥ 10%. Eight patients had an absolute mean inspiratory flow bias of ≥ 17 L/min. CONCLUSIONS: Commonly used mechanical ventilator settings generate an inspiratory flow bias that may promote secretion retention.

Computerised lung sound monitoring to assess effectiveness of chest physiotherapy and secretion removal: a feasibility study

OBJECTIVESnTo explore the feasibility of computerised lung sound monitoring to evaluate secretion removal in intubated and mechanically ventilated adult patients.nnnDESIGNnBefore and after observational investigation.nnnSETTINGnIntensive care unit.nnnPARTICIPANTSnFifteen intubated and mechanically ventilated adult patients receiving chest physiotherapy.nnnINTERVENTIONSnChest physiotherapy included combinations of standard closed airway suctioning, saline lavage, postural drainage, chest wall vibrations, manual-assisted cough and/or lung hyperinflation, dependent upon clinical indications.nnnMAIN OUTCOME MEASURESnLung sound amplitude at peak inspiration was assessed using computerised lung sound monitoring. Measurements were performed immediately before and after chest physiotherapy. Data are reported as mean [standard deviation (SD)], mean difference and 95% confidence intervals (CI). Significance testing was not performed due to the small sample size and the exploratory nature of the study.nnnRESULTSnFifteen patients were included in the study [11 males, four females, mean age 65 (SD 14) years]. The mean total lung sound amplitude at peak inspiration decreased two-fold from 38 (SD 59) units before treatment to 17 (SD 19) units after treatment (mean difference 22, 95% CI of difference -3 to 46). The mean total lung sound amplitude from the lungs of patients with a large amount of secretions (n=9) was over four times louder than the lungs of patients with a moderate or small amount of secretions (n=6) [56 (SD 72) units vs 12 (13) units, respectively; mean difference -44, 95% CI of difference -100 to 11]. The mean total lung sound amplitude decreased in the group of loud right and left lungs (n=15) from 37 (SD 36) units before treatment to 15 (SD 13) units after treatment (mean difference 22, 95% CI of difference 6 to 38).nnnCONCLUSIONnComputerised lung sound monitoring in this small group of patients demonstrated a two-fold decrease in lung sound amplitude following chest physiotherapy. Subgroup analysis also demonstrated decreasing trends in lung sound amplitude in the group of loud lungs following chest physiotherapy. Due to the small sample size and large SDs with high variability in the lung sound amplitude measurements, significance testing was not reported. Further investigation is needed in a larger sample of patients with more accurate measurement of sputum wet weight in order to distinguish between secretion-related effects and changes due to other factors such as airflow rate and pattern.