Manual hyperinflation in children

Lorena, Daiane Menezes; Frade, Maria Cecília Moraes; Silva, Thalis Henrique da

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Brasil

Revista Brasileira de Terapia Intensiva

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Brasil

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REVIEW ARTICLE • Rev. bras. ter. intensiva 33 (4) • 2021 • https://doi.org/10.5935/0103-507X.20210071 copy

Manual hyperinflation in children

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Manual hyperinflation is used in neonatal and pediatric intensive care units to promote expiratory flow bias, but there is no consensus on the benefits of the technique. Thus, a review that presents supporting evidence is necessary. This study aims to review the literature on the manual hyperinflation maneuver in neonatal and pediatric intensive care units to analyze the evidence for this technique in terms of the forms of application (associated with other techniques or not), its safety, the performance of manual resuscitators and the influence of the physical therapist’s experience, in addition to evaluating the methodological quality of the identified articles. A search was performed in the following databases: Web of Science, ScienceDirect, PubMedⓇ, Scopus, CINAHL and SciELO. Two researchers independently selected the articles. Duplicate studies were assessed, evaluated by title and abstract and then read in full. The quality of the articles was analyzed using the PEDro scale. Six articles were included, two of which had high methodological quality. The main results provided information on the contribution of the positive end-expiratory pressure valve to increasing lung volumes and the use of chest compressions to optimize expiratory flow bias, the negative influence of operator experience on the increase in peak inspiratory flow, the performance of different manual resuscitators when used with the technique and the safety of application in terms of maintaining hemodynamic stability and increasing peripheral oxygen saturation. The available studies point to a positive effect of the manual hyperinflation maneuver in children who are admitted to intensive care units.

Registration PROSPERO: CRD42018108056.

Keywords:
Physical therapy modalities; Respiration; artificial; Respiratory therapy; Respiratory mechanics; Ventilators; mechanical; Intensive care units; pediatric; Child; Infant; newborn

Author	Type of study	Sample	Sample size	Intervention
Gregson et al.(⁵5 Gregson RK, Shannon H, Stocks J, Cole TJ, Peters MJ, Main E. The unique contribution of manual chest compression-vibrations to airflow during physiotherapy in sedated, fully ventilated children. Pediatr Crit Care Med. 2012;13(2):e97-e102.)	Clinical trial	105 sedated children	Did not mention	MH was performed with or without TVC. The data were measured at three time points: (1) before the intervention, with the patient receiving mechanical ventilation; (2) while receiving MH and (3) while receiving MH associated with TVC during expiration
Viana et al.(¹⁷17 Viana CC, Nicolau CM, Juliani RC, Carvalho WB, Krebs VLJ. Effects of manual hyperinflation in preterm newborns under mechanical ventilation. Rev Bras Ter Intensiva. 2016;28(3):341-7.)	Randomized clinical trial	28 preterm neonates	28 individuals	In all patients, two respiratory physical therapy interventions were performed, and MH with and without the PEEP regulating valve was compared. The variables were measured 5 minutes before tracheal aspiration and at 1 and 30 minutes after aspiration
Soudararajan et al.(¹⁸18 Soundararajan LR, Thankappan SM. Effect of manual hyperinflation on arterial oxygenation in paediatric patients with upper lobe collapse after cardiac surgery. Eur J Gen Med. 2015;12(4):313-8.)	Clinical trial	18 pediatric patients during the postoperative period of cardiac surgery	Convenience sample	MH followed by TVC was applied to all patients. Two physical therapists were needed; one performed MH, and the other performed TVC. The variables were measured before and 30 minutes after MH
Novais de Oliveira et al.(¹⁹19 Novais de Oliveira PM, Almeida-Junior AA, Almeida CC, Gonçalves de Oliveira Ribeiro MA, Ribeiro JD. Does experience influence the performance of neonatal and pediatric manual hyperinflation? Respir Care. 2012;57(11):1908-13.)	Randomized crossover clinical trial	22 physical therapists	Based on previous studies	Two groups (experienced and inexperienced physical therapists) simulated MH in two neonatal test lungs (neonatal and pediatric) in two clinical situations each (one healthy lung and one with decreased compliance). The MRs were from 3 different manufacturers
de Oliveira et al.(²⁰20 de Oliveira PM, Almeida-Junior AA, Almeida CC, de Oliveira Ribeiro MA, Ribeiro JD. Neonatal and pediatric manual hyperinflation: Influence of oxygen flow rates on ventilatory parameters. Respir Care. 2013;58(12):2127-33.)	Cross-sectional randomized clinical trial	22 physical therapists	Did not mention	The performance of 3 MRs from different manufacturers was evaluated with two test lungs (neonatal and pediatric) and with different oxygen flow rates. Two situations were simulated: healthy (normal respiratory mechanics) and restrictive (decreased lung compliance). The lungs were connected to a 100% oxygen source with oxygen flow rates of 0, 5, 10 and 15 L/minute. All of the physical therapists performed 10 manual hyperinflations with each of the 3 resuscitators for both the neonatal and pediatric lungs
Koop et al.(²¹21 Koop L, Antunes VP. Avaliação das variáveis clínicas em recém-nascidos pré-termo submetidos à ventilação mecânica pré e pós hiperinsuflação manual. Rev Inspirar Mov Saude. 2011;3(4):50-3.)	Clinical trial	9 preterm newborns	Did not mention	In all patients, interventional neonatal physical therapy procedures were performed that included pulmonary auscultation, TVC, vibration and thoracoabdominal support. Subsequently, MH was applied, and the OTT was aspirated. Data were collected before the maneuver and at 1, 5 and 10 minutes after the intervention

PEDro scale	References
PEDro scale	Viana et al.(¹⁷17 Viana CC, Nicolau CM, Juliani RC, Carvalho WB, Krebs VLJ. Effects of manual hyperinflation in preterm newborns under mechanical ventilation. Rev Bras Ter Intensiva. 2016;28(3):341-7.)	Soudararajan et al.(¹⁸18 Soundararajan LR, Thankappan SM. Effect of manual hyperinflation on arterial oxygenation in paediatric patients with upper lobe collapse after cardiac surgery. Eur J Gen Med. 2015;12(4):313-8.)	de Oliveira et al.(²⁰20 de Oliveira PM, Almeida-Junior AA, Almeida CC, de Oliveira Ribeiro MA, Ribeiro JD. Neonatal and pediatric manual hyperinflation: Influence of oxygen flow rates on ventilatory parameters. Respir Care. 2013;58(12):2127-33.)	Novais de Oliveira et al.(¹⁹19 Novais de Oliveira PM, Almeida-Junior AA, Almeida CC, Gonçalves de Oliveira Ribeiro MA, Ribeiro JD. Does experience influence the performance of neonatal and pediatric manual hyperinflation? Respir Care. 2012;57(11):1908-13.)	Gregson et al.(⁵5 Gregson RK, Shannon H, Stocks J, Cole TJ, Peters MJ, Main E. The unique contribution of manual chest compression-vibrations to airflow during physiotherapy in sedated, fully ventilated children. Pediatr Crit Care Med. 2012;13(2):e97-e102.)	Koop et al.(²¹21 Koop L, Antunes VP. Avaliação das variáveis clínicas em recém-nascidos pré-termo submetidos à ventilação mecânica pré e pós hiperinsuflação manual. Rev Inspirar Mov Saude. 2011;3(4):50-3.)
1. The eligibility criteria were specified	✓	✓	X	X	✓	✓
2. The subjects were randomly allocated to groups	✓	X	X	X	X	X
3. The allocation of subjects was concealed	✓	X	✓	X	X	X
4. The groups were similar at baseline for the most important prognostic indicators	X	X	X	✓	X	X
5. There was blinding of all subjects	✓	X	X	X	X	X
6. There was blinding of all therapists who administered the therapy	X	X	✓	X	X	X
7. There was blinding of all assessors who measured at least one key outcome	✓	X	X	X	X	X
8. Measurements of at least one key result were obtained in more than 85% of the subjects initially allocated to the groups	✓	✓	✓	✓	✓	✓
9. All subjects for whom results were measured received the treatment or control condition according to the distribution or, when this was not the case, the data were analyzed for at least one of the results-key for an intention-to-treat analysis	✓	✓	✓	✓	✓	✓
10. The results of between-group statistical comparisons were reported for at least one key outcome	✓	X	✓	✓	✓	✓
11. The study provided both point measures and variable measures for at least one key outcome	✓	✓	✓	✓	✓	X
Total score	9/11	4/11	6/11	5/11	5/11	4/11

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[1] Conflicts of interest: None.