head down tilt and manual hyperinflation in physio

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Information about head down tilt and manual hyperinflation in physio
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Published on July 24, 2008

Author: respi1502

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Paper review: Head down tilt and manual hyperinflation to enhance sputum clearance in patients who are intubated and ventilated. : Paper review: Head down tilt and manual hyperinflation to enhance sputum clearance in patients who are intubated and ventilated. Authors: Susan Berney, Linda Denehy and Jeff Pretto: Australian journal of physiotherapy 2004 vol 50, 9-14. presented by Kola Akinlabi Research objectives : Research objectives To find out if head down tilt improves sputum clearance in patients who are intubated and ventilated. To record peak expiratory flow rate ( PEFR) that is able to cause annular flow to improve sputum mobilisation. To compare sputum wet weight between flat side lying and head down tilt positions. To find out changes in static pulmonary compliance post physiotherapy treatment. Literature review. : Literature review. Several authors have reported combination of physiotherapy treatment techniques to reduce volume of retained secretions, improve both intra- pulmonary shunt, and lung and thorax compliance [1,2,3,4,5,6]. Use of head down tilt and manual hyperinflation in resolution of atelectasis, pulmonary compliance and sputum production have been well documented [2,1,6,7,8]. Past literatures had also reported that ventilated and intubated patients: : Past literatures had also reported that ventilated and intubated patients: Are at risk of development of ventilated – associated pneumonia (VAP) [5] Have high risk of Atelectasis [9] Have high risk of sputum retention [9,10,] Longer ICU stay because of weaning difficulty[11]. Excess morbidity and mortality [11]. Why MHI for intubated and ventilated patients? : Why MHI for intubated and ventilated patients? Increase in sputum production [10]. Impaired bronchial mucociliary transport velocity [13]. Increase incidence of pulmonary complications e.g secretion retention and pneumonia [12]. Collapse atelectasis [13,14] Impaired dynamic compliance [15,] Poor oxygenation [14,12,]. Principles in which MHI works : Principles in which MHI works Generation of annular two- phase – gas flow [15]. Able to cause annular flow velocity of 1000cm/second during expiration which is required for sputum mobilisation. Expressed in PEFR/cross sectional area of trachea.[16] Allows expiratory flow of 10% faster than inspiratory flow with I:E ratio of < 0.9 [15] Peak inspiratory pressure of 20-40 cmH20 with compression exceeding baseline tidal volume(VT) by 50% [10] Research methods : Research methods Design: A prospective randomised, cross over study was chosen in this study, and patient acted as their own control subject: 20 consecutive patients who met inclusion criteria were recruited , with mean age of 51.3 and mean fio2 applied at 0.41 Inclusion criteria were: patient must be intubated and ventilated, and would normally receive MHI as part of their physiotherapy treatment. Research methods continued : Research methods continued Exclusions 1-6 Patients were excluded if they : 1. Require Fio2 > 0.6 2. Require PEEP > 10cmH20 3. Had pulmonary pathology where lung hyperinflation was contra-indicated e.g ARDS, exacerbation of COPD. 4. Were prescribed head–up position for brain disease. 5. Had unstable cardiovascular condition as defined as mean arterial pressure (MAP) <75mmHg with ± 15mmHg with position change or HR>130 6. Had an arterial O2( Sa02) <90%. Treatment techniques : Treatment techniques MHI: Six sets of six MHI breaths were delivered by the use of Mapleson-C anaesthetic circuit using a 10 L/min oxygen gas flow. Each set of MHI is followed by peak airway pressure of 20cmH20. MHI steps are: Three seconds slow inspiratory hyperinflation breathe with airway pressure of 40cmH2O A two second end inspiration pause Followed by uninterrupted expiration Treatment time was 20 minutes. Treatment technique cont’d : Treatment technique cont’d Postioning: Head down tilt, foot of bed raised by 35-45 degrees whilst patient was in a side lying position Flat side lying alone. Suction: Using size 12 Baxter catheter, suction was done three times throughout procedure, each done every second set of hyperinflation. Pulse oximeter, ECG, arterial line, were used to monitor the patient continously during treatment session. Sessions: treatment was done 2 times daily; morning and afternoon with two hours gap between treatment sessions. Appropriate side-lying position for treatment was decided upon based on the result of the morning chest x ray. Results and outcome measures : Results and outcome measures The result of the study was measured using the following outcome measures: Sputum wet weight Peak expiratory flow rate (PEFR) Static pulmonary compliance. Express in SPC= Vt/IP-PEEP Gas velocity= PEFR/cross sectional area of trachea Result of chosen outcome measure were analysed using two ways analysis of variance (ANOVA). Probability values of P<0.05 were deemed significant. Mean, standard deviation, and mean difference at 95% confidence intervals. Table of results showing mean and standard deviation for PEFR (l/sec) and sputum production (grams) for each treatment position and static pulmonary compliance (pre and post treatment ml/cmH20) : Table of results showing mean and standard deviation for PEFR (l/sec) and sputum production (grams) for each treatment position and static pulmonary compliance (pre and post treatment ml/cmH20) Mean and Standard (SD) of PEFR achieved : Mean and Standard (SD) of PEFR achieved Flat side lying (morning and afternoon) Head down tilt (morning and afternoon) Mean ( SD) 1.97 ± 0.09 l/sec Mean ( SD) 2.14 ± 0.08 l/sec There was a significant increase in mean peak expiratory flow during MHI in head-down tilt position compared to flat side lying. ( flat 275.78, p< 0.01). Mean difference in flows between the two positions was 0.17 which represent 8% increase PEFR. Velocity of gas represented by PEFR/1.95 (cm²) : Velocity of gas represented by PEFR/1.95 (cm²) Flat side lying Head down tilt position Mean velocity was 1010cm/sec Mean was 1097cm/sec. Mean, SD sputum production : Mean, SD sputum production Flat side lying Mean, SD 3.69 ± 1.76g Head down tilt Mean, SD 4.63 ± 2.47g Mean sputum production between the two positions was 1.97g which represent a 25% increase in sputum production. Mean and SD of static pulmonary compliance (SPC) : Mean and SD of static pulmonary compliance (SPC) morning afternoon pre-treatment 41.91 ± 9.48 Post –treatment 47.53 ± 13.87 Pre-treatment 44.31 ± 9.81 Post-treatment 49.49 ± 11.46 SPC improved significantly post treatment with MHI in both positions ( F 11.51, p=0.003). The mean difference in compliance was 5.81 (95% CI 2.41 to 8.22ml/cmH20) which represent 12% post treatment. Further studies : Further studies Use of mechanical hyperinflation instead of manual hyperinflation in head down tilt may allow concurrent measurement of inspiratory and expiratory flows in the clinical setting Physiotherapist performing manual hyperinflation should be blinded to the measurement of PEFR. Concurrent measurement of both inspiratory and expiratory flow rates during MHI. conclusion : conclusion In conclusion, the addition of a head-down tilt to manual hyperinflation increases the sputum yield in patient who are intubated and ventilated. In addition, peak expiratory flow rates achieved during manual hyperinflation in flat side-lying and in the head-down tilt position were sufficient to produce movement of pulmonary secretion. references : references 1 Jones A, Hutchinson R and Oh T (1992): Effects of bagging and percussion on total static compliance of the respiratory system, physiotherapy 78:661-666. 2 Hodgson C, Deheny L, Ntoumenopoulos G, Santamaria J, Carroll S (2000): an investigation of the early effect of manual lung hyperinflation in critically ill patients. Anaesthesia and intensive care 28:255-262 3 Mackenzie C, Shin B, Hadi F and Imle P (1980): total lung/thorax compliance changes following chest physiotherapy. Anaesthesia and Analgesia 59: 207-210. 4 Mackenzie C, Shin B (1985): cardiorespiratory function before and after chest physiotherapy in mechanically ventilated patients with post traumatic respiratory failure. Critically care medicine 13: 483-486. 5 Ntoumenopoulos G, Presneill J, McElholum M and Cade J (2002): Chest physiotherapy for the prevention of ventilator-associated pneumonia. Intensive Care Medicine 28: 850-856. 6 Rothen HU, Sporre B, Engberg G, Wegenius G and Hedenstierna G (1993): Re-expansion of atelectasis during general anaesthesia: A computed tomography study. British Journal of Anaesthesia 71: 788-795. 7 Stiller K, Geake T, Taylor R and Hall B (1990): Acute lobar atelectasis: A comparison of two chest physiotherapy regimens. Chest 98: 1336-1340. 8 Suh-Hwa Maa, Tzong-Jen Hung, Kuang-Hung Hsu (2005) Manual Hyperinflation Improves Alveolar Recruitment In Difficult-to-wean Patients.Chest: 28: 2714-2721. 9 Tweed, WA, Phua, WT, Chong, KY, et al Tidal volume, lung hyperinflation and arterial oxygenation during general anaesthesia. Anaesth Intensive Care 1993; 21, 806-810. 10 Jones A (1997): Physiotherapy in intensive care. In Oh T (Ed) Intensive Care Manual (4th Ed.) London: Butterworth-Heinemann,pp 28-32. 11 Berney S and Denehy L (2002): A comparison of the effectsof manual and ventilator hyperinflation on static lung compliance and sputum production in intubated and ventilated intensive care patients. Physiotherapy Research International 7: 100-108 12 Konrand F, Schreiber T, Brecht –Kraus D and Georgieff M (1994) mucociliary transport in ICU patients. Chest 105:237-241. 13 McCarren, B, Chow, CM Description of manual hyperinflation in intubated patients with atelectasis. Physiotherapy theory and practice 1998; 14, 199-210 14 Patman, S , Jenkins, s, stiller , K manual hyperinflation : effect on respiratory parameters. Physiotherapy Res Inter 2000; 5 157-171 15 Maxwell L and Ellis E (2003): The effect of circuit type , volume delivered and “rapid release “: on flow rates during manual hyperinflation . Australian Journal of physiotherapy 49: 31-38. 16 Leith D (1968): Cough Physical therapy 48: 439-447.

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