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Manual Hyperinflation

Questions/ Discussion

If peak inspiratory flow (PIF) exceeds peak expirtory flow the secretions might migrate deeper into the lung (PEF).

Current Literature

Physiological end points

  • Improved compliance in postcardiac surgery patients, patients with atlectasis and pneumonia [1]
  • Benefits and risks of manual hyperinflation in intubated and mechanically ventilated intensive care unit patients: a systematic review [1]

It is suggested that the effectiveness of MHI on sputum clearance is dependent on the difference between the peak inspiratory flow (PIF) and peak expiratory (PEF)(PEF rate needs to exceed the inspiratory flow rate by at least 10%) [5]. Achieved by a slow inspiration and a rapid release technique.

  • Improved arterial oxygenation postcardiac surgery patients [1]
  • PEF was greater in lungs of poor compliance than normal compliance suggesting MHI is effective as a secretion manoeuver technqiue in patients with poorer compliance, e.g ARDS[6]
  • Experimental study on effiency and safety of the manual hyperinflation maneuver as a secretion clearance technique [4]
  • MHI partly prevents a reduction in FRC in the early days post-extubation from ventilator [7]
  • MHI is not superior to VHI for improving arterial oxygenation or pulmonary compliance [1]

Technique

  • MHI resulted in improved oxygenation and static lung compliance [2]
  • Similar amounts of secretions were mobilised by VHI as MHI [1]
  • FRC reduction was not statistical significant at day 5 post extubation from ventilator [7]
  • Manual hyperinflation partly prevents reductions of functional residual capacity in cardiac surgucal patients - a randomized conrtolled trial [7]

Peak expiratory flow rate

Clinical end points

  • Did not reduced length of day in ICU or hospital [1 , 7]
  • Oxygenation and static compliance is improved immediately after manual hyperinflation follwoing myocardial revascularisation: a randomised controlled trial [2]
  • MHI was found to shorten the duration of mechanical ventilation in postcardiac surgery patients [1]

A technique that provides a tidal volume greater than the baseline volume. It produces a turbulent flow which aims to improves static lung compliance, increase oxygenation, mobilise secretions toward central airways and recruit collapsed lung (Maa et al, 2005)

  • The effect of positive end-expiratory pressure level on peak expiratory flow during manual hyperinflation [6]

Inspiratory Pause

Maintains the pressure gradient for an appropriate length of time to overcome the opening pressure of the alveoli and allow distribution of the air among ventilated areas.

Side effects

  • MHI is infrequently associated with side effects [1]
  • Unlikely to cause barotrauma [4]

Increased tidal volumes

Commonly used treatment by physiotherapist in intubated and mechanically ventilated patients.

Technique / Equipment

  • A significant reduction in peak expiratory flow (PEF) was observed as the level of PEEP increased [6]
  • Mapleson-C circuit with a PEEP valve would generate a PEF capable of mobilising secretions compared to Laerdal resus bag [6]

Larger than normal tidal volumes up to 150% of that delivered by the ventilator to increase alveoli recruitment and open up collateral channels [2]

Contraindications

  • Surgical emphysema
  • Recent lobectomy /pneumonectomy
  • Unexplained Haemoptysis
  • Undrained Pneumothorax
  • Severe Bronchospasm
  • Bullae on x-ray
  • Haemodynamically unstable
  • Raised ICP

Precautions

  • High PEEP on ventilator - disconnection
  • Pre-existing lung pathology, fibrosis COPD

Indications

  • Retained secretions
  • Areas of consolidation/atelectasis
  • Poor tidal volumes
  • Poor static lung compliance

References

Ellen Richardson

1. Paulus et al (2012); Benefits and risks of manual hyperinflation in intubated and mechanically ventilated intensive care unit patients: a systematic review; Crictical Care, 16:R14

2. Blattner et al (2008); Oxygenation and static compliance is improved immediately after manual hyperinflation follwoing myocardial revascularisation: a randomised controlled trial; Australian JOurnal of Physiotherapy Vol 54 pp173-178

3. Maa et al (2005); Manual hyperinflation improves alveolar recruitment in difficult-to wean patients. Chest 128: 2714-2721

4. Ortiz et al (2013) Experimental study on effiency and safety of the manual hyperinflation maneuver as a secretion clearance technique, Journal of Brazilian medicine 39 (2), 205-213

5. Ntoumenopoulos.G (2005) Indications for manual lung hyperinflation (MHI) in the mechanically ventilated patient with chronic obstructive pulmonary disease, Chronic Respiratory Disease, 2 ,199-207

6. Savian et al (2005) The effect of positive end-expiratory pressure level on peak expiratory flow during manual hyperinflation, Critical Care and Trauma 100, 1112-6.

7. Paulus et al (2011) Manual hyperinflation partly prevents reductions of functional residial capacity in cardiac surgucal patients - a randomized conrtolled trial, Critical Care 15, R187

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