Session 09.4 Routine versus on demand manual hyperinflation in ...

“<strong>Routine</strong>” Manual Hyperinflation
vs. “On Demand” Manual
Hyperinflation in Intubated and
Mechanically Ventilated Post–
Cardiothoracic Surgery Patients
– A Randomized Controlled Trial –
Frederique Paulus

Agenda
• background
• hypothesis
• patients and methods
• results

Manual Hyperinflation
“disconnecting the patient from the
mechanical ventilator and inflating the
lungs using a manual resuscitation bag”

Aim of Manual Hyperinflation
• removal of airway secretions
• prevention of atelectasis

Manual Hyperinflation Technique
• larger than normal breath (150% of
baseline V T )
• slow deep inspiration
• inspiratory hold
• rapid release

Manual Hyperinflation Practice
• widely used maneuver
• “routine respiratory care” in nearly all
ICUs in the Netherlands
• our ICU
• > 5.000 ventilation days/year
• routine MH 4 times/day
• 20.000 MH maneuvers/year
Paulus F. Int Crit Care Nurs 2009;25:199

Lung Function after Thoracic
Surgery
• strong reduction of TLC after extubation
(up to 38%)
• peripheral hemoglobin oxygen
saturation < 90 in up to 60% of patients
Reis Miranda D. Crit Care Med 2005;33:2253

Hypothesis
• “routine” MH prevents the reduction in
FRC after extubation in post thoracic
surgery patients

Aim of Study
• to compare a “routine” MH strategy with
an “on demand” MH strategy in post
cardiothoracic surgery patients with
respect to post–extubation FRC and
SpO 2
• if sputum is mobilized: removal via
suction

Patients
100 patients after planned CABG and/or
single valve surgery
• exclusion:
• (previous) pulmonary surgery
• pulmonary infection
• chronic obstructive pulmonary
disease (FEV 1 < 80%)
• restrictive pulmonary disease (VC max
< 80%)

FRC Measurement
• He re–breathing technique
(Masterscreen–PFT; Jaeger, Hoechberg,
Germany)
• during FRC measurements, patients are
in bed in an upright sitting position

Study Measurements
before
surgery
post
operative
day 1 after
extubation
day 3 after
extubation
day 5 after
extubation
Patient
characteristics
X* X*
FRC X X X X
SpO 2
X X* X* X X
ABA X* X*
CXR X*
* Part of routine daily care

Results
routine MH maneuvers
on demand MH maneuvers
airway suction

Results
FRC (L)
3.4
3.2
3.0
2.8
2.6
2.4
2.2
2.0
1.8
1.6
1.4
1.2
1.0
routine MH closed symbols
control group open symbols
Pre-op day 1 day 3 day 5

Results
Chest radiograph results.
routine MH group
(N = 46)
control group
(N = 47)
P–value
No atelectasis 8 (17) 0 (0) P = 0.002
Plate/subsegmental
atelectasis
20 (44) 22 (47) P = 0.10
Segmental atelectasis
(1 of 2 segments)
18 (39) 23 (49) P = 0.55
Lobar atelectasis 0 (0) 2 (4) P = 0.16
Data are presented as percentages of N (%)

Conclusions
MH partly prevents reduction of FRC in patients after
cardiac surgery in the first post–operative days.
Occurrence of atelectasis on post–operative chest
radiographs in this study was significant lower in
patients who received MH.
Future studies are needed to determine the effect of MH
on important clinical endpoints, including duration of
tracheal intubation, post–operative pulmonary
complications and duration of hospitalization.