Physiospot CardioRespiratory

Oxygenation and static compliance is improved immediately after early manual hyperinflation following myocardial revascularisation: a randomised controlled trial

Clarissa Blattner C, Guaragna JC, Saadi E.

This randomised controlled trial of 55 patients undergoing myocardial revascularisation assessed the effect of an early treatment of manual hyperinflation. 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. Oxygenation and static lung compliance were measured immediately after suction.

PaO2 and static compliance were greater in the experimental group than in the control group. The experimental group was extubated 76 minutes earlier than the control group. Hospital length of stay and the incidence of post operative pulmonary complications were similar in the two groups.

Australian Journal of Physiotherapy 2008; 54: 173–178

Functional Residual Capacity Changes After Different Endotracheal Suctioning Methods

Heinze H, Sedemund-Adib B, Heringlake M, Gosch UW, Eichler W

This study set out to investigate the effects of three different endotracheal suctioning procedures on functional residual capacity (FRC). In a crossover design study, twenty postoperative cardiac surgery patients received three different suctioning methods in randomized order: closed suctioning during pressure-controlled ventilation, closed suctioning during volume-controlled ventilation, and open suctioning. FRC was measured before and 20 min after the intervention.

The results showed that FRC is reduced in post cardiac surgery patients after suctioning, regardless of which method is used.

Anesthesia and Analgesia 2008; 107: 941 - 944

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Noninvasive ventilation in acute cardiogenic pulmonary edema.

Gray A, Goodacre S, Newby DE, Masson M, Sampson F, Nicholl J

This large multicenter, randomized, controlled trial set out to establish whether; noninvasive ventilation (continuous positive airway pressure (CPAP) or noninvasive intermittent positive-pressure ventilation (NIPPV)) reduces mortality and if there are important differences in outcome associated with the method of treatment, in a group of patients with acute cardiogenic pulmonary oedema.

Their findings included no significant difference in; 7-day mortality between patients receiving standard oxygen therapy and those undergoing noninvasive ventilation, or in the combined end point of death or intubation within 7 days between the two groups of patients undergoing noninvasive ventilation. Noninvasive ventilation was associated with greater mean improvements at 1 hour after the beginning of treatment in patient-reported dyspnea, heart rate, acidosis and hypercapnia. There were no treatment-related adverse events.

New England Journal of Medicine 2008; 359: 142-51.

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Predictors of Adverse Events in Patients After Discharge From the Intensive Care Unit

Chayboyer W, Thalib L, Foster M, Ball C, Richards B

This study looked at the types, frequency and predictors of adverse events occurring within the first 72 hours after discharge from an intensive care unit in a mixed group of medical and surgical patients. The three most common adverse events (accounting for 44.9% of complications) were hospital-incurred infection or sepsis, hospital-incurred accident or injury and other complications including deep vein thrombosis, pulmonary oedema, or myocardial infarct.

Out of 21 possible predictor variables only two were significant independent predictors. They were a respiratory rate of below 10/min or above 25/ min and a pulse rate exceeding 110 /min.

American Journal of Critical Care 2008; 17: 255 – 263

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Pulmonary Effects of Noninvasive Ventilation Combined with the Recruitment Maneuver after Cardiac Surgery

Serdar Celebi, Özge Köner, Ferdi Menda, O uz Omay, lhan Günay, Kaya Suzer, and Nahit Cakar

The authors evaluated the pulmonary effects of non-invasive ventilation (NIV) with or without a recruitment manoeuvre (RM) in a group of patients following coronary artery bypass graft surgery. Patients excluded were those with pre-existing pulmonary disease, age > 65 years, ejection fraction < 40%, BMI > 30Kg/M2 and current smokers. The study sample was divided into 4 groups; RM, RM and NIV, NIV and a control group.

NIV together with RM was associated with better oxygenation during and after mechanical ventilation while NIV either alone or together with RM showed better early pulmonary function tests and lower atelectasis scores when compared to the control group. However there was no difference between the groups in terms of; duration of mechanical ventilation, length of ICU or hospital stay.NIV combined with RM is recommended to prevent postoperative atelectasis and hypoxaemia, but lacks justification as a routine intervention as it would seem not to reduce length of ICU or hospital stay in the above sample of patients.

Anaesthesia and Analgesia 2008; 107: 614 – 619

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Early intensive care unit mobility therapy in the treatment of acute respiratory failure.

Morris PE, Goad A, Thompson C, Taylor K, Harry B, Passmore L, Ross A, Anderson L, Baker S, Sanchez M, Penley L, Howard A, Dixon L, Leach S, Small R, Hite RD, Haponik E.

This study included 330 (divided into two groups, usual care and mobility protocol) medical intensive care unit patients with acute respiratory failure requiring mechanical ventilation on admission. An intensive care unit Mobility Team (critical care nurse, nursing assistant, physical therapist) initiated a mobility protocol within 48 hrs of mechanical ventilation. Protocol patients were out of bed earlier (5 vs. 11 days), had therapy initiated more frequently in the intensive care unit (91% vs. 13%), and had similar low complication rates compared with Usual Care. In addition protocol patients had shorter intensive care unit length of stay (5.5 vs. 6.9 days); hospital length of stay (11.2 vs. 14.5 days).

There were no untoward events during an intensive care unit Mobility session and no cost difference. The authors concluded that a Mobility Team using a mobility protocol initiated earlier physical therapy that was feasible, safe, did not increase costs and was associated with decreased intensive care unit and hospital length of stay in survivors who received physical therapy during intensive care unit treatment compared with patients who received usual care.

Critical Care Medicine 2008; 36 (8): 2238 – 2243

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Position affects distribution of ventilation in the lungs of older people: an experimental study

Krieg S., Alison J.A., McCarren B., Cowell S.

Ten healthy adults older than 65 years were assessed for the effect of sitting and right side lying on the distribution of ventilation during tidal volume breathing. In sitting 9% more ventilation went to the right lung while the cranial – caudal distribution was greatest in the middle region followed by the basal region with least distribution to the apical region. In right side lying ventilation to the right lung was 32% more than to the left lung. The cranial-caudal distribution in this position was once again most distribution to the middle region, followed by the basal region and least to the apical region.

Clinical relevance: It is possible in the older adult that closing volume affects distribution of ventilation to the most gravity dependant regions of the lung which may mean modifying positions when basal regions are being treated.

Australian Journal of Physiotherapy 2007; 53: 179 – 184

Patients with respiratory failure increase ambulation after transfer to an intensive care unit where early activity is a priority.

Thomsen G.E, Snow G.L, Rodriguez L., Hopkins R.O.

This study included 104 respiratory failure patients who required mechanical ventilation for >4 days. Patients were assessed to be fit for activity if they could: 1) follow commands and cooperate; 2) were on a FiO2 of ≤0.6 and positive end-expiratory pressure of ≤10; were not receiving any catecholamine drips and had no symptomatic orthostasis. If a patient was ventilated FiO2 was increased by 0.2 before activity. Oxygen saturation and orthostatic symptoms were monitored. Activities included sit on the edge of the bed, sit in a chair after transfer from bed and ambulate using a walker.

The results show that 28% of patients were able to ambulate 24 hours after transfer to RICU (respiratory intensive care unit) and this increased to 41% of patients within 48hrs. Of the patients who ambulated in the 24 - 48 hours after transfer to RICU 60-62% of patients had endotracheal tubes, 7-33% had a tracheostomy and 31 – 8% were not mechanically ventilated patients who ambulated.

Critical Care Medicine 2008; 36: 1119-1124

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Efficacy of prone ventilation in adult patients with acute respiratory failure: A meta-analysis

Tiruvoipati R., Bangash M., Manktelow B., Peek G.A.

This meta-analysis included studies for the period 1966 to July 2006 which were prospective randomized controlled trials, comparing prone position ventilation with supine ventilation, in managing adult patients with acute lung injury (ALI) or acute respiratory distress syndrome (ARDS) requiring intubation and mechanical ventilation. Outcome measures included: primary mortality and secondary; changes in oxygenation, incidence of ventilator associated pneumonia, duration of mechanical ventilation, ICU and hospital stay, complications related to ET tube, intravascular catheters and pressure sores.

The pooled results showed that prone ventilation significantly improves oxygenation in patients with acute severe hypoxemic respiratory failure. Mortality, ICU stay, VAP, and ET tube complications were not significantly affected. A trend towards increased pressure sores exists.

Journal of Critical Care 2008; 23: 101 – 110

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Physiotherapy for adult patients with critical illness: recommendations of the European Respiratory Society and European Society of Intensive Care Medicine Task Force on Physiotherapy for Critically Ill Patients

Gosselink R., Bott J., Johnson M., Dean E., Nava S., Norrenberg M., Schönhofer B., Stiller K., van der Leur H., Vincent J.L

This ESICM statement reviews and discusses the available literature on the effectiveness of physiotherapy for acute and chronic critically ill adult patients. Evidenced based targets for deconditioning, impaired airway clearance, atelectasis, intubation avoidance and weaning failure were identified and where possible recommendations made for practice.

Clinical relevance: an up to date evidenced based recommendation for physiotherapy practice in ICU.

Intensive Care Medicine: Published online 19 February 2008 ahead of print

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