ABSTRACT
The aim of the study was to analyze the effects of two respiratory physiotherapy protocols on respiratory mechanics and cardiorespiratory parameters of patients under mechanical ventilation compared to a tracheal aspiration protocol. Pilot study with quasi-experimental design and 50 patients, randomized into GI group (n=16): control group, submitted to tracheal aspiration; GII (n=17): submitted to vibrocompression and tracheal aspiration; GIII (n=17): submitted to vibrocompression, aspiration, and ventilator hyperinflation. The variables analyzed were: heart rate (HR), respiratory rate, systemic blood pressure, peripheral oxygen saturation, static lung compliance, dynamic lung compliance, and airway resistance. These were recorded at three moments: before the procedures (M1), immediately after them (M2), and 15 minutes after them (M3). To compare the effect and analyze the interaction between measurement time and groups, we used Two-Way ANOVA and post hoc Tukey's test. The effect size was determined by calculating Cohen's f2 and by statistical analysis using SPSS for Windows (version 20), with a significance level of 5%. In the intragroup comparison, no differences were observed, while in the comparison between groups the variable HR showed difference between GI and GII in M2 (p=0.02). Results suggest that the respiratory physiotherapy protocols evaluated had no favorable effects on respiratory mechanics; however, they showed to be safe regarding cardiorespiratory parameters.
Keywords:
Physiotherapy Modalities; Respiration, Artificial; Respiratory Mechanics; Intensive Care Units
RESUMO
O objetivo deste estudo foi analisar os efeitos de dois protocolos de fisioterapia respiratória na mecânica respiratória e parâmetros cardiorrespiratórios de pacientes em ventilação mecânica comparando-os com um protocolo de aspiração traqueal. Estudo piloto com desenho quase-experimental com 50 pacientes, randomizados em grupo GI (n=16): grupo controle, realizado aspiração traqueal; GII (n=17): realizado vibrocompressão e aspiração traqueal; GIII (n=17): realizado vibrocompressão, aspiração e hiperinsuflação pelo ventilador mecânico. As variáveis analisadas foram: frequência cardíaca (FC), frequência respiratória, pressão arterial sistêmica, saturação periférica de oxigênio, complacência pulmonar estática, complacência pulmonar dinâmica e resistência das vias aéreas. Estas foram registradas em três momentos: antes dos procedimentos (M1), imediatamente após (M2) e 15 minutos após (M3). Para comparar o efeito e analisar a interação entre tempo de mensuração e grupos, utilizou-se a ANOVA Two-Way e post hoc de Tukey. O tamanho do efeito foi determinado pelo cálculo f2 de Cohen e a análise estatística pelo programa SPSS para Windows (versão 20), nível de significância de 5%. Na comparação intragrupo não foram observadas diferenças, enquanto na comparação entre grupos a variável FC apresentou diferença entre o GI e GII no M2 (p=0,02). Os resultados sugerem que os protocolos de fisioterapia respiratória avaliados não promoveram benefícios quanto à mecânica respiratória, entretanto se mostraram seguros em termos de parâmetros cardiorrespiratórios.
Descritores:
Modalidades de Fisioterapia; Respiração Artificial; Mecânica Respiratória; Unidades de Terapia Intensiva
RESUMEN
El objetivo de este estudio fue analizar los efectos de dos protocolos de fisioterapia respiratoria en la mecánica respiratoria y parámetros cardiorespiratorios de los pacientes en ventilación mecánica, comparándolos con un protocolo de aspiración traqueal. Estudio piloto con diseño cuasi-experimental con 50 pacientes, randomizados en grupo GI (n=16): grupo control, realizado una aspiración traqueal; GII (n=17): realizado vibrocompresión y aspiración traqueal; GIII (n=17): realizado vibrocompresión, aspiración y hiperinflación por el ventilador mecánico. Las variables analizadas fueron: frecuencia cardiaca (FC), frecuencia respiratoria, presión arterial sistémica, saturación periférica de oxígeno, complacencia pulmonar estática, complacencia pulmonar dinámica y resistencia de las vías aéreas. Éstas se registraron en tres momentos: antes de los procedimientos (M1), inmediatamente después (M2) y 15 minutos después (M3). Para comparar el efecto y analizar la interacción entre el tiempo de medición y grupos, se utilizó el ANOVA Two-Way y post hoc de Tukey. Se determinó el tamaño del efecto mediante el cálculo f2 de Cohen y el análisis estadístico por el programa SPSS para Windows (versión 20), nivel de significancia del 5%. En la comparación intragrupo no se encontraron diferencias, mientras que en la comparación entre grupos la variable FC presentó diferencia entre el GI y GII en el M2 (p=0,02). Los resultados sugieren que los protocolos de fisioterapia respiratoria evaluados no promovieron beneficios en cuanto a la mecánica respiratoria, sin embargo resultaron seguros en términos de parámetros cardiorespiratorios.
Palabras clave:
Modalidades de Fisioterapia; Respiración Artificial; Mecánica Respiratoria; Unidades de Cuidados Intensivos
INTRODUCTION
Maintenance of airway permeability by endotracheal intubation and institution of mechanical ventilation (MV) are the pillars of therapeutic intensive care and a breakthrough in the treatment of acute respiratory failure or acutized chronic respiratory failure 11. Laghi F, Tobin MJ. Indications for mechanical ventilation. In: Tobin, MJ, editor. Principles and Practice of Mechanical Ventilation. 2. New York: MacGraw-Hill Co. 2006:129-62. . However, the application of positive pressure on lungs by use of prosthesis can generate systemic repercussions 22. Carvalho CRR. Ventilator-associated pneumonia. J Bras Pneumol. 2006;32(4):xx-ii. and, as a result, prolong the length of hospitalization 33. Esteban A, Anzueto A, Frutos F, Alía I, Stewart TE, Benito S, et al. Characteristics and outcomes in adult patients receiving mechanical ventilation: a 28-day international study. J Am Med Assoc. 2002;287(3):345-55. , as well as increase the risk of death4). Among these repercussions, the most frequent are hemodynamic instability and respiratory infections caused by reduction of local defense mechanisms due to the presence of the tube. Moreover, patients under MV may have increased airway resistance impose greater burden to the respiratory system 55. Smith BK, Gabrielli A, Davenport PW, Martin AD. Effect of training on inspiratory load compensation in weaned and unweaned mechanically ventilated ICU patients. Respir Care. 2014;59(1):22-31. .
The evaluation of respiratory mechanics has been studied in the MV context 66. Alotaibi GA. Effect of pressure support level, patient's effort, and lung mechanics on phase synchrony during pressure support ventilation. Middle East J Anaesthesiol. 2014;22(6):573-82.), (77. Valentini R, Aquino-Esperanza J, Bonelli I, Maskin P, Setten M, Danze F, et al. Gas exchange and lung mechanics in patients with acute respiratory distress syndrome: comparison of three different strategies of positive end expiratory pressure selection. J Crit Care. 2015;30(2):334-40. . A review study 88. Henderson WR, Sheel AW. Pulmonary mechanics during mechanical ventilation. Respir Physiol Neurobiol. 2012;180(2-3):162-72. argues that there are differences for the values of Static Compliance (Cst,rs), Dynamic Compliance (Cdyn), and Airway Resistance (Raw) when comparing patients under MV and under spontaneous ventilation.
Currently, physiotherapy has an important role in multi-professional teams assisting critical patients in most ICUs 99. França EET, Ferrari F, Fernandes P, Cavalcanti R, Duarte A, Martinez BP, et al. Fisioterapia em pacientes críticos adultos: recomendações do Departamento de Fisioterapia da Associação de Medicina Intensiva Brasileira. Rev Bras Ter Intensiva. 2012;24(1):6-22.), (1010. Sommers J, Engelbert RH, Dettling-Ihnenfeldt D, Gosselink R, Spronk PE, Nollet F, et al. Physiotherapy in the intensive care unit: an evidence-based, expert driven, practical statement and rehabilitation recommendations. Clin Rehabil. 2015 Feb 13. [Epub ahead of print] .
According to Siner 1111. Siner JM. An exogenous cough. Crit CareMed. 2013;41(3):929-30. , the advances in respiratory physiotherapy interventions contribute to reduce the accumulation of bronchial secretions in patients under MV. Physiotherapy procedures that aim to increase the permeability of the airways, optimize oxygenation, and improve respiratory mechanics are widely used in ICUs 1212. Castro AA, Calil SR, Freitas SA, Oliveira AB, Porto EF. Chest physiotherapy effectiveness to reduce hospitalization and mechanical ventilation length of stay, pulmonary infection rate and mortality in ICU patients. Respir Med. 2013;107(1):68-74.), (1313. Naue Wda S, Forgiarini Junior LA, Dias AS, Vieira SR. Chest compression with a higher level of pressure support ventilation: effects on secretion removal, hemodynamics, and respiratory mechanics in patients on mechanical ventilation. J Bras Pneumol. 2014;40(1):55-60. . Among these procedures, vibrocompression (VC), manual hyperinflation (MH), and ventilator hyperinflation (VH) are noteworthy.
Evidences of benefits resulting from MH and VC are referenced in the literature 1414. Jones AY. Secretion movement during manual lung inflation and mechanical ventilation. Respir Physiol Neurobiol. 2002;132(3):321-7.)-(1717. Ferreira LL, Valenti VE, Vanderlei LC. Chest physiotherapy on intracranial pressure of critically ill patients admitted to the intensive care unit: a systematic review. Rev Bras Ter Intensiva. 2013;25(4):327-33. ; however, VH requires further research. Standardization is necessary to achieve the best mode of ventilation for hyperinflation and consensus regarding application parameters 1818. Hayes K, Seller D, Webb M, Hodgson CL, Holland AE. Ventilator hyperinflation: a survey of current physiotherapy practice in Australia and New Zealand. N Z J Physiother. 2011;39(3):124-30. . Furthermore, few studies compared VH, a relatively new technique 1919. Berney S, Denehy L. A comparison of the effects of manual and ventilator hyperinflation on static lung compliance and sputum production in intubated and ventilated intensive care patients. Physiother Res Int. 2002;7(2):100-8. , with bronchial hygiene techniques such as VC, which, when combined, could enhance therapeutic effects. Possible benefits resulting from the combination of these techniques, to improve respiratory mechanics, would enable assessing their use as a means of feasible intervention to be applied on patients under MV.
Thus, the objective of this study was to analyze the effects of two respiratory physiotherapy protocols on respiratory mechanics and cardiorespiratory parameters of patients under MV, comparing them with a tracheal aspiration protocol.
METHODOLOGY
Pilot study with quasi-experimental, comparative design, conducted in an adult ICU of HUSM. It was approved by the local Ethics Committee under no. 220,812. Family members or guardians signed the Free and Informed Consent Form.
The study included patients of both sexes, aged over 18 years, hospitalized in the ICU, diagnosed with acute respiratory failure or acutized chronic respiratory failure, under MV (Inter 5-Plus(r)- Intermed(r), São Paulo, Brazil; SERVOi, Maquet GmbH&Co, KG, Rastatt, Germany) for more than 48 hours, deep to light level of sedation (Richmond Agitation Sedation Scale - RASS), closed tracheal aspiration system, and intubation. We defined as a criterion for respiratory failure: oxygen arterial pressure lower than or equal to 50mmHg or carbon dioxide arterial pressure higher than or equal to 50mmHg, regardless of the cause 2020. Batista CC, Goldbaum Júnior MA, Sztiler F, Goldim JR, Fritscher CC. Medical futility and respiratory failure: a prospective cohort study. Rev Bras Ter Intensiva. 2007;19(2):151-60. . Patients under mild sedation (RASS-2) and pressure support ventilation were included provided they showed no asynchrony with the ventilator. Patients submitted to use of tracheostomy tube were excluded; as well as those with: spinal cord injury, hemodynamic instability, acute arrhythmias, fracture of ribs, intracranial hypertension, burns, undrained pneumothorax, and severe asthma.
We collected demographic and clinical data, as well as cardiovascular, ventilation and respiratory mechanics parameters. The variables measured were: heart rate (HR); mean arterial pressure (MAP), systolic blood pressure; diastolic blood pressure, and peripheral oxygen saturation, in a non-invasive manner by observing the multiparameter monitor DX2022 (Dixtal Biomédica, Manaus, Brazil). Respiratory rate (RR), plateau pressure (Pplat), and peak inspiratory pressure (Ppi) were observed in the mechanical ventilator display.
Cst,rs was obtained by dividing the tidal volume (TV) by Pplat subtracting the value of PEEP; Cdyn was obtained by dividing the TV by Ppi subtracting the value of PEEP; and Raw was obtained by dividing the difference between the Ppi and Pplat by the inspiratory flow.
Variables were collected at three moments: baseline (M1), immediately after the interventions (M2), and 15 minutes after the interventions (M3). Patients were divided into three intervention groups, randomized by simple sortition conducted by a professional independent from the research, using envelopes containing the group to which they would be allocated, namely: Control group (GI) submitted to tracheal aspiration (TA); GII, vibrocompression (VC) maneuver followed by TA; or Group III, VC maneuver followed by TA and ventilator hyperinflation (VH). The protocols were applied by the same physical therapist in the three groups, in the afternoon, and evaluations were conducted by a physical therapist who did not know to which group the patient had been allocated.
In GI, TA was performed as recommended by the American Association for Respiratory Care 2121. Restrepo RD, Brown JM, Hughes JM. AARC Clinical Practice Guidelines. Endotracheal suctioning of mechanically ventilated patients with artificial airways 2010. Respir Care. 2010;55(6):758-64. , as many times as necessary until no more secretion was observed in the suction probe.
In GII, VC was conducted for 10 minutes at the end of inspiration until the end of expiration 2222. Castro AAM, Rocha S, Reis C, Leite JRO, Porto EF. Comparação entre as técnicas de vibrocompressão e de aumento do fluxo expiratório em pacientes traqueostomizados. Fisioter Pesqui. 2010;17(1):18-23. , with the patient supine and the physical therapist's hands flat on the rib cage. Next, TA was performed.
In GIII, VC and TA maneuvers were followed by the VH maneuver. This was performed with the increase in pressure or volume, depending on the ventilation mode in use, in order to achieve 40 cmH20 of Ppi for 10 minutes 2323. Dennis D, Jacob WJ, Samuel FD. A survey of the use of ventilator hyperinflation in Australian tertiary intensive care unit. Crit Care Resusc. 2010;12(4):262-8. .
At the time of application of the protocols, medical and nursing procedures were not carried out.
Sample calculation
Estimated to obtain a significance level of 5% (p<0.05) and power of 80% (WinPepi version 10.5). Considering the standard deviation of the variable Cst,rs of the study by Lemes et al.(2424. Lemes DA, Zin WA, Guimarães, FS. Hyperinflation using pressure support ventilation improves secretion clearance and respiratory mechanics in ventilated patients with pulmonary infection: a randomised crossover trial. Aust J Physiother. 2009;55(4):249-54. , a sample of 23 individuals in each group was calculated.
Statistical analysis
Results presented with mean and standard deviation. Shapiro-Wilk test verified the normal distribution of the data. Anthropometric variables were compared between groups by one-way ANOVA and post hoc Tukey's test. To compare the effect and analyze the interaction between measurement time and groups, we used two-way ANOVA and post hoc Tukey's test. Effect size was determined by using Cohen's f22. Carvalho CRR. Ventilator-associated pneumonia. J Bras Pneumol. 2006;32(4):xx-ii. for comparison between groups and classified as major, moderate, and minor 2525. Lindenau JD, Guimarães LSP. Calculando o tamanho de efeito no SPSS Revista HCPA. 2012;32(3):363-81. . We used the Statistical Package for the Social Sciences (SPSS), version 20, with a level of significance of 5% (p<0.05).
RESULTS
Of the 58 patients eligible for the study, three were excluded because of hemodynamic instability, and five because of use of tracheostomy tube. The remaining 50 were divided into three groups: GI (n=16), GII (n=17), and GIII (n=17). Subsequently, follow-up was lost for five patients, so the study was completed with 45 patients ( Figure 1 ).
Table 1 shows the characteristics of the sample, and we did not observe differences between groups.
Table 2 shows the cardiorespiratory and respiratory mechanics parameters in the three groups and the intragroup and intergroup comparison. In the intragroup comparison, no differences were observed, while in the intergroup comparison variable HR had a difference between GI and GII at M2 (77.4±12.7 → 87.3±20.6bpm; p=0.02), with major effect size (Cohen's f2 =0.39).
DISCUSSION
Currently, there has been discussion about the safety of the application of respiratory physiotherapy procedures in critically ill patients 1616. Cerqueira Neto ML, Moura AV, Cerqueira TC, Aquim EE, Reá-Neto A, Oliveira MC, et al. Acute effects of physiotherapeutic respiratory maneuvers in critically ill patients with craniocerebral trauma. Clinics. 2013;68(9):1210-4.), (2626. Dias CM, Siqueira TM, Faccio TR, Gontijo LC, Salge JA, Volpe MS. Efetividade e segurança da técnica de higiene brônquica: hiperinsuflação manual com compressão torácica. Rev Bras Ter Intensiva. 2011;23(2):190-8.), (2727. Sricharoenchai T, Parker AM, Zanni JM, Nelliot A, Dinglas VD, Needham DM. Safety of physical therapy interventions in critically ill patients: a single-center prospective evaluation of 1110 intensive care unit admissions. J Crit Care. 2014;29(3):395-400. ; however, there are few studies evaluating their effect on cardiorespiratory parameters. In this study, although HR was different between GI and GII at M2, it is emphasized that it was within normal limits and, thus, no clinical relevance was evident on the finding, indicating that the protocols adopted showed to be hemodynamically safe in these patients.
Despite the lack of evidence of the effects of VH combined with VC on cardiorespiratory parameters of critically ill patients, it is important to mention the study of Castro et al.(2222. Castro AAM, Rocha S, Reis C, Leite JRO, Porto EF. Comparação entre as técnicas de vibrocompressão e de aumento do fluxo expiratório em pacientes traqueostomizados. Fisioter Pesqui. 2010;17(1):18-23. , who evaluated the hemodynamic repercussions of VC in tracheostomy patients, observing that VC promoted reduction in MAP. In the study of Cerqueira Neto et al.16, it was observed that VC combined with acceleration of expiratory flow (AEF) did not alter the MAP in TBI patients under MV. Hemodynamic variables were maintained during VC and AEF; however, there was an increase in MAP, intracranial pressure, HR, and pulmonary artery pressure during TA. All values returned to baseline levels 10 minutes after the procedure.
In this study, the respiratory mechanics variables did had no change at any of the moments evaluated, suggesting that the protocols, as applied, were not effective to evidence, to date, the recovery of complacencies and the reduction of resistance. Importantly, the values of Cdyn, Cst,rs, and Raw were out of the normal parameters since M1 and remained like this at the other evaluated moments. It is also important to highlight that these findings were evidenced in the intragroup and intergroup comparisons.
Most studies on the effects of bronchial hygiene resources on respiratory mechanics of patients under MV analyzed VH alone or compared to MH, and there are few that analyzed the effects of VH combined with VC maneuvers, as in this study. By comparing VH to MH, Dennis et al.(2828. Dennis D, Jacob W, Budgeon C. Ventilator versus manual hyperinflation in clearing sputum in ventilated intensive care unit patients. Anaesth Intensive Care. 2012;40(1):142-9. found that there was no difference in relation to compliance and current volume. However, a similar study conducted by Berney et al.(1919. Berney S, Denehy L. A comparison of the effects of manual and ventilator hyperinflation on static lung compliance and sputum production in intubated and ventilated intensive care patients. Physiother Res Int. 2002;7(2):100-8. showed increased pulmonary compliance after application of both hyperinflation techniques. Among the few studies that combined VH with manual bronchial hygiene techniques, there is the study of Guimarães et al. 2929. Lopes AJ, Constantino SS, Lima JC, Canuto P, Menezes S. Expiratory rib cage in mechanically ventilated subjects: a randomized crossover trial. Respir Care 2014;59(5):678-85. , who used a technique that is similar to VC combined with hyperinflation using pressure support, observing no improvement in respiratory mechanics.
We consider as limitations of the present study the heterogeneity of the sample in relation to clinical reasons for hospitalization and the impossibility of using methods to quantify the volume of the tracheobronchial secretion eliminated.
Thus, our findings should be interpreted with caution. The continuation of the study, to reach the planned sample size, as well as the conduct of randomized clinical trials, may clarify the potential benefits of the interventions analyzed here and commonly used in the clinical practice of respiratory physiotherapy in ICU. At this time, the practical applicability of the research refer to the absence of negative implications regarding the investigated physiotherapy procedures, considering both hemodynamic and cardiorespiratory perspectives, evidence being required as for whether these procedures are favorable to the recovery of complacencies and reduction of airway resistance in patients under MV.
CONCLUSION
The respiratory physiotherapy protocols had no favorable effects on respiratory mechanics; however, they showed to be safe concerning cardiorespiratory parameters and, from this point of view, can be used safely.
REFERÊNCIAS
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1Laghi F, Tobin MJ. Indications for mechanical ventilation. In: Tobin, MJ, editor. Principles and Practice of Mechanical Ventilation. 2. New York: MacGraw-Hill Co. 2006:129-62.
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2Carvalho CRR. Ventilator-associated pneumonia. J Bras Pneumol. 2006;32(4):xx-ii.
-
3Esteban A, Anzueto A, Frutos F, Alía I, Stewart TE, Benito S, et al. Characteristics and outcomes in adult patients receiving mechanical ventilation: a 28-day international study. J Am Med Assoc. 2002;287(3):345-55.
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4Esteban A, Frutos-Vivar F, Muriel A, Ferguson ND, Peñuelas O, Abraira V, et al. Evolution of mortality over time in patients receiving mechanical ventilation. Am J Respir Crit Care Med. 2013;188(2):220-30.
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5Smith BK, Gabrielli A, Davenport PW, Martin AD. Effect of training on inspiratory load compensation in weaned and unweaned mechanically ventilated ICU patients. Respir Care. 2014;59(1):22-31.
-
6Alotaibi GA. Effect of pressure support level, patient's effort, and lung mechanics on phase synchrony during pressure support ventilation. Middle East J Anaesthesiol. 2014;22(6):573-82.
-
7Valentini R, Aquino-Esperanza J, Bonelli I, Maskin P, Setten M, Danze F, et al. Gas exchange and lung mechanics in patients with acute respiratory distress syndrome: comparison of three different strategies of positive end expiratory pressure selection. J Crit Care. 2015;30(2):334-40.
-
8Henderson WR, Sheel AW. Pulmonary mechanics during mechanical ventilation. Respir Physiol Neurobiol. 2012;180(2-3):162-72.
-
9França EET, Ferrari F, Fernandes P, Cavalcanti R, Duarte A, Martinez BP, et al. Fisioterapia em pacientes críticos adultos: recomendações do Departamento de Fisioterapia da Associação de Medicina Intensiva Brasileira. Rev Bras Ter Intensiva. 2012;24(1):6-22.
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10Sommers J, Engelbert RH, Dettling-Ihnenfeldt D, Gosselink R, Spronk PE, Nollet F, et al. Physiotherapy in the intensive care unit: an evidence-based, expert driven, practical statement and rehabilitation recommendations. Clin Rehabil. 2015 Feb 13. [Epub ahead of print]
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11Siner JM. An exogenous cough. Crit CareMed. 2013;41(3):929-30.
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12Castro AA, Calil SR, Freitas SA, Oliveira AB, Porto EF. Chest physiotherapy effectiveness to reduce hospitalization and mechanical ventilation length of stay, pulmonary infection rate and mortality in ICU patients. Respir Med. 2013;107(1):68-74.
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13Naue Wda S, Forgiarini Junior LA, Dias AS, Vieira SR. Chest compression with a higher level of pressure support ventilation: effects on secretion removal, hemodynamics, and respiratory mechanics in patients on mechanical ventilation. J Bras Pneumol. 2014;40(1):55-60.
-
14Jones AY. Secretion movement during manual lung inflation and mechanical ventilation. Respir Physiol Neurobiol. 2002;132(3):321-7.
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15Paulus F, Binnekade JM, Vroom MB, Schultz MJ. Benefits and risks of manual hyperinflation in intubated and mechanically ventilated intensive care unit patients: a systematic review. Crit Care. 2012;16(4):R145.
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16Cerqueira Neto ML, Moura AV, Cerqueira TC, Aquim EE, Reá-Neto A, Oliveira MC, et al. Acute effects of physiotherapeutic respiratory maneuvers in critically ill patients with craniocerebral trauma. Clinics. 2013;68(9):1210-4.
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17Ferreira LL, Valenti VE, Vanderlei LC. Chest physiotherapy on intracranial pressure of critically ill patients admitted to the intensive care unit: a systematic review. Rev Bras Ter Intensiva. 2013;25(4):327-33.
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18Hayes K, Seller D, Webb M, Hodgson CL, Holland AE. Ventilator hyperinflation: a survey of current physiotherapy practice in Australia and New Zealand. N Z J Physiother. 2011;39(3):124-30.
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19Berney S, Denehy L. A comparison of the effects of manual and ventilator hyperinflation on static lung compliance and sputum production in intubated and ventilated intensive care patients. Physiother Res Int. 2002;7(2):100-8.
-
20Batista CC, Goldbaum Júnior MA, Sztiler F, Goldim JR, Fritscher CC. Medical futility and respiratory failure: a prospective cohort study. Rev Bras Ter Intensiva. 2007;19(2):151-60.
-
21Restrepo RD, Brown JM, Hughes JM. AARC Clinical Practice Guidelines. Endotracheal suctioning of mechanically ventilated patients with artificial airways 2010. Respir Care. 2010;55(6):758-64.
-
22Castro AAM, Rocha S, Reis C, Leite JRO, Porto EF. Comparação entre as técnicas de vibrocompressão e de aumento do fluxo expiratório em pacientes traqueostomizados. Fisioter Pesqui. 2010;17(1):18-23.
-
23Dennis D, Jacob WJ, Samuel FD. A survey of the use of ventilator hyperinflation in Australian tertiary intensive care unit. Crit Care Resusc. 2010;12(4):262-8.
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24Lemes DA, Zin WA, Guimarães, FS. Hyperinflation using pressure support ventilation improves secretion clearance and respiratory mechanics in ventilated patients with pulmonary infection: a randomised crossover trial. Aust J Physiother. 2009;55(4):249-54.
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25Lindenau JD, Guimarães LSP. Calculando o tamanho de efeito no SPSS Revista HCPA. 2012;32(3):363-81.
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26Dias CM, Siqueira TM, Faccio TR, Gontijo LC, Salge JA, Volpe MS. Efetividade e segurança da técnica de higiene brônquica: hiperinsuflação manual com compressão torácica. Rev Bras Ter Intensiva. 2011;23(2):190-8.
-
27Sricharoenchai T, Parker AM, Zanni JM, Nelliot A, Dinglas VD, Needham DM. Safety of physical therapy interventions in critically ill patients: a single-center prospective evaluation of 1110 intensive care unit admissions. J Crit Care. 2014;29(3):395-400.
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28Dennis D, Jacob W, Budgeon C. Ventilator versus manual hyperinflation in clearing sputum in ventilated intensive care unit patients. Anaesth Intensive Care. 2012;40(1):142-9.
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29Lopes AJ, Constantino SS, Lima JC, Canuto P, Menezes S. Expiratory rib cage in mechanically ventilated subjects: a randomized crossover trial. Respir Care 2014;59(5):678-85.
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5
Study developed at the Adult Intensive Care Unit (ICU), Hospital Universitário de Santa Maria (HUSM) - Santa Maria (RS), Brazil.
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6
Financing sources: none
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8
Approved by the Research Ethics Committee under no. 220/812.
Publication Dates
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Publication in this collection
Jul-Sep 2015
History
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Received
May 2014 -
Accepted
Sept 2015