Chest physiotherapy improves lung aeration in hypersecretive critically ill patients: a pilot randomized physiological study

Federico Longhini, Andrea Bruni, Eugenio Garofalo, Chiara Ronco, Andrea Gusmano, Gianmaria Cammarota, Laura Pasin, Pamela Frigerio, Davide Chiumello, Paolo Navalesi, Federico Longhini, Andrea Bruni, Eugenio Garofalo, Chiara Ronco, Andrea Gusmano, Gianmaria Cammarota, Laura Pasin, Pamela Frigerio, Davide Chiumello, Paolo Navalesi

Abstract

Background: Besides airway suctioning, patients undergoing invasive mechanical ventilation (iMV) benefit of different combinations of chest physiotherapy techniques, to improve mucus removal. To date, little is known about the clearance effects of oscillating devices on patients with acute respiratory failure undergoing iMV. This study aimed to assess (1) the effects of high-frequency chest wall oscillation (HFCWO) on lung aeration and ventilation distribution, as assessed by electrical impedance tomography (EIT), and (2) the effect of the association of HFCWO with recruitment manoeuvres (RM).

Methods: Sixty critically ill patients, 30 classified as normosecretive and 30 as hypersecretive, who received ≥ 48 h of iMV, underwent HFCWO; patients from both subgroups were randomized to receive RM or not, according to two separated randomization sequences. We therefore obtained four arms of 15 patients each. After baseline record (T0), HFCWO was applied for 10 min. At the end of the treatment (T1) or after 1 (T2) and 3 h (T3), EIT data were recorded. At the beginning of each step, closed tracheobronchial suctioning was performed. In the RM subgroup, tracheobronchial suctioning was followed by application of 30 cmH2O to the patient's airway for 30 s. At each step, we assessed the change in end-expiratory lung impedance (ΔEELI) and in tidal impedance variation (ΔTIV), and the center of gravity (COG) through EIT. We also analysed arterial blood gases (ABGs).

Results: ΔTIV and COG did not differ between normosecretive and hypersecretive patients. Compared to T0, ΔEELI significantly increased in hypersecretive patients at T2 and T3, irrespective of the RM; on the contrary, no differences were observed in normosecretive patients. No differences of ABGs were recorded.

Conclusions: In hypersecretive patients, HFCWO significantly improved aeration of the dorsal lung region, without affecting ABGs. The application of RM did not provide any further improvements.

Trial registration: Prospectively registered at the Australian New Zealand Clinical Trial Registry ( www.anzctr.org.au ; number of registration: ACTRN12615001257550; date of registration: 17th November 2015).

Keywords: Acute respiratory failure; Chest physiotherapy; Cough; Electrical impedance tomography; High-frequency chest wall oscillation; Lung aeration; Mechanical ventilation.

Conflict of interest statement

Dr. Navalesi’s research laboratory has received equipment and grants from Maquet Critical Care, Draeger, and Intersurgical S.p.A. He also received honoraria/speaking fees from Maquet Critical Care, Orionpharma, Philips, Resmed, MSD, and Novartis. Dr. Navalesi contributed to the development of the helmet Next, whose licence for patent belongs to Intersurgical S.P.A., and receives royalties for that invention. Dr. Longhini and Dr. Navalesi contributed to the development of a new device (not discussed in the present study), whose patent is in progress (European Patent application number EP20170199831). The remaining authors have no conflict of interest to disclose.

Figures

Fig. 1
Fig. 1
Flowchart of the study. The figure depicts the study flowchart, which includes four arms
Fig. 2
Fig. 2
Changes of electrical impedance tomography values in the four study arms. Box plots of changes of end-expiratory lung impedance (DEELI) and tidal impedance variation (DTIV) are depicted in the four study arms, at baseline (T0), squared at T1, triangles at T2, and rhombus at T3. The bottom and top of the box indicate the 25th and 75th percentile, the horizontal band near the middle of the box is the median, and the ends of the whiskers represent the 10th and 90th percentiles. Statistically significant p values within study arms are reported in the figures. *p < 0.05, compared to N RM− at the same time point; §p < 0.05, compared to N RM+ at the same time point

References

    1. Whitsett JA. Airway epithelial differentiation and mucociliary clearance. Ann Am Thorac Soc. 2018;15(Suppl 3):S143–S148.
    1. Sackner MA, Hirsch J, Epstein S. Effect of cuffed endotracheal tubes on tracheal mucous velocity. Chest. 1975;68(6):774–777.
    1. Pneumatikos IA, Dragoumanis CK, Bouros DE. Ventilator-associated pneumonia or endotracheal tube-associated pneumonia? An approach to the pathogenesis and preventive strategies emphasizing the importance of endotracheal tube. Anesthesiology. 2009;110(3):673–680.
    1. Trawoger R, Kolobow T, Cereda M, Giacomini M, Usuki J, Horiba K, Ferrans VJ. Clearance of mucus from endotracheal tubes during intratracheal pulmonary ventilation. Anesthesiology. 1997;86(6):1367–1374.
    1. Konrad F, Schreiber T, Brecht-Kraus D, Georgieff M. Mucociliary transport in ICU patients. Chest. 1994;105(1):237–241.
    1. Jelic S, Cunningham JA, Factor P. Clinical review: airway hygiene in the intensive care unit. Crit Care. 2008;12(2):209.
    1. Nakagawa NK, Franchini ML, Driusso P, de Oliveira LR, Saldiva PH, Lorenzi-Filho G. Mucociliary clearance is impaired in acutely ill patients. Chest. 2005;128(4):2772–2777.
    1. Hodgson C, Carroll S, Denehy L. A survey of manual hyperinflation in Australian hospitals. Aust J Physiother. 1999;45(3):185–193.
    1. Stiller K, Geake T, Taylor J, Grant R, Hall B. Acute lobar atelectasis. A comparison of two chest physiotherapy regimens. Chest. 1990;98(6):1336–1340.
    1. Mackenzie CF, Shin B. Cardiorespiratory function before and after chest physiotherapy in mechanically ventilated patients with post-traumatic respiratory failure. Crit Care Med. 1985;13(6):483–486.
    1. MacLean D, Drummond G, Macpherson C, McLaren G, Prescott R. Maximum expiratory airflow during chest physiotherapy on ventilated patients before and after the application of an abdominal binder. Intensive Care Med. 1989;15(6):396–399.
    1. Ntoumenopoulos G, Presneill JJ, McElholum M, Cade JF. Chest physiotherapy for the prevention of ventilator-associated pneumonia. Intensive Care Med. 2002;28(7):850–856.
    1. Wilson LM, Morrison L, Robinson KA. Airway clearance techniques for cystic fibrosis: an overview of Cochrane systematic reviews. Cochrane Database Syst Rev. 2019;1:CD011231.
    1. Morrison L, Agnew J. Oscillating devices for airway clearance in people with cystic fibrosis. Cochrane Database Syst Rev. 2014;7:CD006842.
    1. Whitsett JA, Kalin TV, Xu Y, Kalinichenko VV. Building and regenerating the lung cell by cell. Physiol Rev. 2019;99(1):513–554.
    1. Kim CS, Iglesias AJ, Sackner MA. Mucus clearance by two-phase gas-liquid flow mechanism: asymmetric periodic flow model. J Appl Physiol (1985) 1987;62(3):959–971.
    1. Clarke SW, Jones JG, Oliver DR. Resistance to two-phase gas-liquid flow in airways. J Appl Physiol. 1970;29(4):464–471.
    1. McCarren B, Alison JA. Physiological effects of vibration in subjects with cystic fibrosis. Eur Respir J. 2006;27(6):1204–1209.
    1. Dasgupta B, Brown NE, King M. Effects of sputum oscillations and rhDNase in vitro: a combined approach to treat cystic fibrosis lung disease. Pediatr Pulmonol. 1998;26(4):250–255.
    1. Dasgupta B, Tomkiewicz RP, Boyd WA, Brown NE, King M. Effects of combined treatment with rhDNase and airflow oscillations on spinnability of cystic fibrosis sputum in vitro. Pediatr Pulmonol. 1995;20(2):78–82.
    1. King M, Phillips DM, Gross D, Vartian V, Chang HK, Zidulka A. Enhanced tracheal mucus clearance with high frequency chest wall compression. Am Rev Respir Dis. 1983;128(3):511–515.
    1. Chang HK, Weber ME, King M. Mucus transport by high-frequency nonsymmetrical oscillatory airflow. J Appl Physiol (1985) 1988;65(3):1203–1209.
    1. Kuyrukluyildiz U, Binici O, Kupeli I, Erturk N, Gulhan B, Akyol F, Ozcicek A, Onk D, Karabakan G. What is the best pulmonary physiotherapy method in ICU? Can Respir J. 2016;2016:4752467.
    1. Chuang ML, Chou YL, Lee CY, Huang SF. Instantaneous responses to high-frequency chest wall oscillation in patients with acute pneumonic respiratory failure receiving mechanical ventilation: a randomized controlled study. Medicine (Baltimore) 2017;96(9):e5912.
    1. Costa EL, Lima RG, Amato MB. Electrical impedance tomography. Curr Opin Crit Care. 2009;15(1):18–24.
    1. Vaschetto R, Turucz E, Dellapiazza F, Guido S, Colombo D, Cammarota G, Della Corte F, Antonelli M, Navalesi P. Noninvasive ventilation after early extubation in patients recovering from hypoxemic acute respiratory failure: a single-centre feasibility study. Intensive Care Med. 2012;38(10):1599–1606.
    1. Navalesi P, Frigerio P, Moretti MP, Sommariva M, Vesconi S, Baiardi P, Levati A. Rate of reintubation in mechanically ventilated neurosurgical and neurologic patients: evaluation of a systematic approach to weaning and extubation. Crit Care Med. 2008;36(11):2986–2992.
    1. Vaschetto R, Longhini F, Persona P, Ori C, Stefani G, Liu S, Yi Y, Lu W, Yu T, Luo X, et al. Early extubation followed by immediate noninvasive ventilation vs. standard extubation in hypoxemic patients: a randomized clinical trial. Intensive Care Med. 2019;45(1):62–71.
    1. Khamiees M, Raju P, DeGirolamo A, Amoateng-Adjepong Y, Manthous CA. Predictors of extubation outcome in patients who have successfully completed a spontaneous breathing trial. Chest. 2001;120(4):1262–1270.
    1. Clinical Practice Guidelines AARC. Endotracheal suctioning of mechanically ventilated patients with artificial airways 2010. Respir Care. 2010;55(6):758–764.
    1. Bikker IG, Preis C, Egal M, Bakker J, Gommers D. Electrical impedance tomography measured at two thoracic levels can visualize the ventilation distribution changes at the bedside during a decremental positive end-expiratory lung pressure trial. Crit Care. 2011;15(4):R193.
    1. Longhini F, Maugeri J, Andreoni C, Ronco C, Bruni A, Garofalo E, Pelaia C, Cavicchi C, Pintaudi S, Navalesi P. Electrical impedance tomography during spontaneous breathing trials and after extubation in critically ill patients at high risk for extubation failure: a multicenter observational study. Ann Intensive Care. 2019;9(1):88.
    1. Allan JS, Garrity JM, Donahue DM. High-frequency chest-wall compression during the 48 hours following thoracic surgery. Respir Care. 2009;54(3):340–343.
    1. Lester MK, Flume PA. Airway-clearance therapy guidelines and implementation. Respir Care. 2009;54(6):733–750.
    1. Mauri T, Eronia N, Abbruzzese C, Marcolin R, Coppadoro A, Spadaro S, Patroniti N, Bellani G, Pesenti A. Effects of sigh on regional lung strain and ventilation heterogeneity in acute respiratory failure patients undergoing assisted mechanical ventilation. Crit Care Med. 2015;43(9):1823–1831.
    1. Luepschen H, Meier T, Grossherr M, Leibecke T, Karsten J, Leonhardt S. Protective ventilation using electrical impedance tomography. Physiol Meas. 2007;28(7):S247–S260.
    1. Frigerio P, Longhini F, Sommariva M, Stagni EG, Curto F, Redaelli T, Ciboldi M, Simonds AK, Navalesi P. Bench comparative assessment of mechanically assisted cough devices. Respir Care. 2015;60(7):975–982.
    1. Esguerra-Gonzales A, Ilagan-Honorio M, Kehoe P, Fraschilla S, Lee AJ, Madsen A, Marcarian T, Mayol-Ngo K, Miller PS, Onga J, et al. Effect of high-frequency chest wall oscillation versus chest physiotherapy on lung function after lung transplant. Appl Nurs Res. 2014;27(1):59–66.
    1. Clinkscale D, Spihlman K, Watts P, Rosenbluth D, Kollef MH. A randomized trial of conventional chest physical therapy versus high frequency chest wall compressions in intubated and non-intubated adults. Respir Care. 2012;57(2):221–228.
    1. Mahajan AK, Diette GB, Hatipoglu U, Bilderback A, Ridge A, Harris VW, Dalapathi V, Badlani S, Lewis S, Charbeneau JT, et al. High frequency chest wall oscillation for asthma and chronic obstructive pulmonary disease exacerbations: a randomized sham-controlled clinical trial. Respir Res. 2011;12:120.
    1. Keating JM, Collins N, Bush A, Chatwin M. High-frequency chest-wall oscillation in a noninvasive-ventilation-dependent patient with type 1 spinal muscular atrophy. Respir Care. 2011;56(11):1840–1843.
    1. Fitzgerald K, Dugre J, Pagala S, Homel P, Marcus M, Kazachkov M. High-frequency chest wall compression therapy in neurologically impaired children. Respir Care. 2014;59(1):107–112.
    1. Gauld LM, Keeling LA, Shackleton CE, Sly PD. Forced oscillation technique in spinal muscular atrophy. Chest. 2014;146(3):795–803.
    1. Park H, Park J, Woo SY, Yi YH, Kim K. Effect of high-frequency chest wall oscillation on pulmonary function after pulmonary lobectomy for non-small cell lung cancer. Crit Care Med. 2012;40(9):2583–2589.
    1. Branson RD. Secretion management in the mechanically ventilated patient. Respir Care. 2007;52(10):1328–1342.
    1. Lindgren S, Odenstedt H, Erlandsson K, Grivans C, Lundin S, Stenqvist O. Bronchoscopic suctioning may cause lung collapse: a lung model and clinical evaluation. Acta Anaesthesiol Scand. 2008;52(2):209–218.
    1. Foti G, Cereda M, Banfi G, Pelosi P, Fumagalli R, Pesenti A. End-inspiratory airway occlusion: a method to assess the pressure developed by inspiratory muscles in patients with acute lung injury undergoing pressure support. Am J Respir Crit Care Med. 1997;156(4 Pt 1):1210–1216.
    1. Navalesi P, Longhini F. Neurally adjusted ventilatory assist. Curr Opin Crit Care. 2015;21(1):58–64.
    1. Costa R, Navalesi P, Cammarota G, Longhini F, Spinazzola G, Cipriani F, Ferrone G, Festa O, Antonelli M, Conti G. Remifentanil effects on respiratory drive and timing during pressure support ventilation and neurally adjusted ventilatory assist. Respir Physiol Neurobiol. 2017;244:10–16.
    1. Vaschetto R, Cammarota G, Colombo D, Longhini F, Grossi F, Giovanniello A, Della Corte F, Navalesi P. Effects of propofol on patient-ventilator synchrony and interaction during pressure support ventilation and neurally adjusted ventilatory assist. Crit Care Med. 2014;42(1):74–82.
    1. Conti G, Ranieri VM, Costa R, Garratt C, Wighton A, Spinazzola G, Urbino R, Mascia L, Ferrone G, Pohjanjousi P, et al. Effects of dexmedetomidine and propofol on patient-ventilator interaction in difficult-to-wean, mechanically ventilated patients: a prospective, open-label, randomised, multicentre study. Crit Care. 2016;20(1):206.

Source: PubMed

Sponsors en medewerkers

Medische omstandigheden

Geneesmiddelinterventies

3
Abonneren