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Background: Extubation failure, defined as reintubation within 48 hours is associated with increased intensive care unit (ICU) length of stay and higher mortality risk. One cause of extubation failure is secretion retention, resulting from an inability to cough effectively. Mechanical Insufflation-Exsufflation (MI-E) simulates a cough aiding secretion clearance. However, MI-E is not routinely used in the ICU setting for invasively ventilated patients. This study aims to determine the feasibility and acceptability of a randomised controlled trial (RCT) examining MI-E use to promote extubation success in intubated, ventilated adults. Methods: Single centre, feasibility RCT with semi-structured interviews, economic scoping, and an exploratory physiology study. The feasibility RCT (n=50) will compare standard care to a MI-E protocol including a minimum of two MI-E sessions via the endotracheal tube prior to extubation. Post-extubation, MI-E will be delivered via facemask or mouthpiece up to two times/day for 48 hours. MI-E settings will be individualised based on patient tolerance, chest expansion and secretion clearance. All patients will receive standard care in relation to mechanical ventilation, weaning, rehabilitation, physiotherapy techniques such as positioning, manual airway clearance techniques, manual/ventilator hyperinflation, endotracheal suctioning and nebulisation. Clinical data collection will occur before, on completion and 5 minutes after all physiotherapy sessions (intervention and control arms). Resource use will be calculated for each 24 hour period. Analyses will be descriptive and address feasibility outcomes. We will conduct semi-structured online interviews informed by the Theoretical Framework of Acceptability (TFA) with patients, clinicians and family members, exploring the acceptability of the MI-E intervention and study processes. Interview data will be analysed using reflexive thematic analysis based on TFA domains through first level coding. The embedded physiology study will use Electrical Impedance Tomography and Lung Ultrasound to explore lung recruitment and de-recruitment during MI-E in a subset of 5-10 patients. Discussion: This study will examine the feasibility and acceptability of a RCT protocol of MI-E to promote extubation success. Study findings will inform further design modification and conduct of a future adequately powered trial. Furthermore, the study will contribute and advance the understanding of MI-E use in critically ill intubated adults. Trial Registration: ISRCTN 24603037; IRAS 303674.

BACKGROUND: Mechanical insufflation-exsufflation (MI-E) is a noninvasive technique performed to simulate cough and remove sputum from proximal airways. To date, the effects of MI-E on critically ill patients on invasive mechanical ventilation are not fully elucidated. In this randomized crossover trial, we evaluated the efficacy and safety of MI-E combined to expiratory rib cage compressions (ERCC). METHODS: Twenty-six consecutive subjects who were sedated, intubated, and on mechanical ventilation > 48 h were randomized to perform 2 sessions of ERCC with or without additional MI-E before tracheal suctioning in a 24-h period. The primary outcome was sputum volume following each procedure. Secondary end points included effects on respiratory mechanics, hemodynamics, and safety. RESULTS: In comparison to ERCC alone, median (interquartile range) sputum volume cleared was significantly higher during ERCC+MI-E (0.42 [0–1.39] mL vs 2.29 [1–4.67] mL, P < .001). The mean ± SD respiratory compliance improved in both groups immediately after the treatment, with the greater improvement in the ERCC+MI-E group (54.7 ± 24.1 mL/cm H(2)O vs 73.7 ± 35.8 mL/cm H(2)O, P < .001). Differences between the groups were not significant (P = .057). Heart rate increased significantly in both groups immediately after each intervention (P < .05). Additionally, a significant increase in oxygenation was observed from baseline to 1 h post-intervention in the ERCC+MI-E group (P < .05). Finally, several transitory hemodynamic variations occurred during both interventions, but these were nonsignificant and were considered clinically irrelevant. CONCLUSIONS: In mechanically ventilated subjects, MI-E combined with ERCC increased the sputum volume cleared without causing clinically important hemodynamic changes or adverse events. (ClinicalTrials.gov registration: NCT03316079.)

When noninvasive interventions such as chest physiotherapy fail, then more aggressive interventions for airway secretion clearance with nasotracheal airway suctioning may be required. Clinicians however have to insert the nasotracheal suction catheter "blindly" and the success of being able to trigger a cough and pass through the vocal folds with a suction catheter is low.The patient, a 48-year-old male underwent a heart and lung transplant. Following extubation, the patient developed secretion retention with a weak ineffective cough and swallow and required physiotherapy interventions with frequent "blind" passes of nasotracheal suctioning.The patient required nasotracheal suction with frequent multiple failed attempts before successful passage of the suction catheter to trigger a cough reflex and clear secretions. A combined physiotherapist and speech and language therapist intervention during fiberoptic endoscopic evaluation of swallow (FEES) was recorded to both evaluate swallow and passage of the suction catheter. The video illustrated the successful passage of a suctioning catheter through the vocal folds leading to an effective cough and airway clearance.We present a case report demonstrating that it is feasible to visualize the upper airways during nasotracheal suctioning as an objective means to guide the more accurate successful insertion of the suction catheter past the vocal folds. Rather than "blind" placement of nasotracheal suction catheters visualization using transnasal laryngoscopy should be useful to increase chances of passing through the vocal folds.

Lung ultrasound (LUS) for physiotherapists is an emerging bedside tool. The LUS score of aeration presents as a possible means of assessing and monitoring lung aeration associated with respiratory physiotherapy treatments. There are no studies to date that have assessed the interrater reliability (IRR) of physiotherapists assigning the LUS score of aeration. This study assessed the IRR of assigning the LUS score among adult, mechanically ventilated patients in an intensive care unit with a clinical suspicion of acute lobar atelectasis.A convenience sample of patients had an LUS performed by a physiotherapist, and images were independently reviewed by two physiotherapists. Each lung zone was assigned an LUS score between 0 and 3 (with 0 being normal aeration and 3 being complete consolidation, presence of effusion, or pneumothorax). IRR was assessed using the kappa statistic.A total of 1032 LUS images were obtained. Assigning of the LUS across all lung zones demonstrated substantial agreement with kappa 0.685 (95% confidence interval: 0.650, 0.720). Right (0.702 [0.653, 0.751]) and left (0.670 [0.619, 0.721]) lung zones also demonstrated substantial agreement.We found substantial IRR between physiotherapists in assigning the LUS score in a mechanically ventilated adult population in the intensive care unit.ACTRN12619000783123.

Lung ultrasound (LUS) is an emerging tool for acute respiratory physiotherapists. In Australia, there are a select few LUS training courses run for physiotherapists. Research to date has evaluated LUS training courses for physiotherapists in terms of knowledge and skill acquisition. The impact of LUS training on user competence and confidence and whether LUS is used in clinical practice has yet to be evaluated. This study therefore explored the impact of attending a physiotherapy LUS training course on acquisition of competence and confidence and the barriers and facilitators for physiotherapists in achieving competence in LUS.A quantitative survey containing 21 questions was distributed to 77 Australian physiotherapists.Of the invited physiotherapists, 39 (50%) completed the survey. Most participants were working in intensive care, in the public hospital setting. Binary logistic regression was performed and demonstrated no significant difference in the relationship between years of clinical experience and having confidence in performing or interpreting LUS images. There was also no statistical significance in the relationship between years of clinical experience and gaining competence and accreditation in LUS. Of the 39 responders, 20 physiotherapists had performed at least one LUS scan since completing training; however, most identified they never use LUS to inform clinical decision-making. Only one physiotherapist had gained accreditation through an ultrasound-governing body. The most frequently reported barriers to achieving competence were lack of clinical time to devote to training and lack of an LUS supervisor.A majority of physiotherapists who participated in an LUS training course did not attain competence or accreditation, nor were they confident in performing LUS and interpreting images. Barriers exist that prevent intensive care physiotherapists from being able to use LUS in clinical practice. LUS is also not frequently used by acute respiratory physiotherapists to make clinical decisions.

Question In mechanically ventilated adults in intensive care, what is the accuracy of lung ultrasound (LUS) for the diagnosis of pleural effusion, lung consolidation and lung collapse when compared with chest radiograph (CXR) and lung auscultation, with computed tomography (CT) as the reference standard? Design Systematic review with meta-analysis of prospective cohort studies. Participants Adult patients admitted to intensive care, with diagnostic uncertainty at enrolment regarding pleural effusion, lung consolidation and/or collapse/atelectasis. Index test The diagnostic accuracy of LUS as the index test was estimated against CXR and/or lung auscultation as comparators, with thoracic CT scan as the reference standard. Outcome measures Measures of diagnostic accuracy. Results Seven eligible studies were identified, five of which (with 253 participants) were included in the meta-analysis. It was found that LUS had a pooled sensitivity of 92% and 91% in the diagnosis of consolidation and pleural effusion, respectively, and pooled specificity of 92% for both pathologies. CXR had a pooled sensitivity of 53% and 42% and a pooled specificity of 78% and 81% in the diagnosis of consolidation and pleural effusion, respectively. A meta-analysis for lung auscultation was not possible, although a single study reported a sensitivity and specificity of 8% and 100%, respectively, for diagnosing consolidation, and a sensitivity and specificity of 42% and 90%, respectively, for diagnosing pleural effusion. Conclusion This systematic review with meta-analysis demonstrated high sensitivity of LUS compared with CXR, with similar specificities when diagnosing pleural effusion and lung consolidation/collapse. Registration PROSPERO CRD42018095555.

IntroductionApplication of non-invasive positive airway pressure may provoke laryngeal responses that obstruct the airways, especially in patients with disturbed laryngeal control. To control and adjust for this, transnasal fibre-optic laryngoscopy (TFL) is used to visualise laryngeal movements during therapeutic interventions. Being an invasive procedure, this may be unpleasant for patients. The aim of this study is to evaluate if ultrasound (US) imaging of the larynx may be used as an alternative less invasive diagnostic tool for evaluating the upper airway responses to non-invasive ventilation (NIV) and mechanical insufflation–exsufflation (MI-E).Methods and analysisThis protocol presents an experimental cross-sectional study of a novel method to study laryngeal responses in adult healthy volunteers (n=30). The participants will be assessed with simultaneous TFL and laryngeal US imaging (anterior and lateral approaches) during NIV and MI-E therapy. Additionally, airflow and pressure signals will be registered during the procedures. The primary outcome is whether laryngeal US is a feasible method to study laryngeal responses and, if so, to compare the laryngeal responses visualised with TFL and US. The participants’ perception of the examinations will be recorded. Secondary outcomes include airflow curve shapes and calculated ventilation volumes during the interventions.Ethics and disseminationThe study has been approved by The Regional Committee for Medical Research Ethics in Norway, and registered in ClinicalTrials.gov. Results will be disseminated through peer-reviewed journals, presentation of scientific abstracts at international medical conventions and oral presentations in relevant medical conventions.Trial registration numberNCT04586855.

Physiotherapists are integral members of the multidisciplinary team managing critically ill adult patients. However, the scope and role of physiotherapists vary widely internationally, with physiotherapists in some countries moving away from providing early and proactive respiratory care in the intensive care unit (ICU) and focusing more on early mobilization and rehabilitation. This article provides an update of cardiorespiratory physiotherapy for patients receiving mechanical ventilation in ICU. Common and some more novel assessment tools and treatment options are described, along with the mechanisms of action of the treatment options and the evidence and physiology underpinning them. The aim is not only to summarize the current state of cardiorespiratory physiotherapy but also to provide information that will also hopefully help support clinicians to deliver personalized and optimal patient care, based on the patient's unique needs and guided by accurate interpretation of assessment findings and the current evidence. Cardiorespiratory physiotherapy plays an essential role in optimizing secretion clearance, gas exchange, lung recruitment, and aiding with weaning from mechanical ventilation in ICU. The physiotherapists' skill set and scope is likely to be further optimized and utilized in the future as the evidence base continues to grow and they get more and more integrated into the ICU multidisciplinary team, leading to improved short- and long-term patient outcomes.

Background: As the global outbreak of COVID-19 continues to ravage the world, it is important to understand how frontline clinicians manage ventilatory support and the various limiting factors. / Methods: An online survey composed of 32 questions was developed and validated by an international expert panel. / Results: Overall, 502 respondents from 40 countries across six continents completed the survey. The mean number (±SD) of ICU beds was 64 ± 84. The most popular initial diagnostic tools used for treatment initiation were arterial blood gas (48%) and clinical presentation (37.5%), while the national COVID-19 guidelines were the most used (61.2%). High flow nasal cannula (HFNC) (53.8%), non-invasive ventilation (NIV) (47%), and invasive mechanical ventilation (IMV) (92%) were mostly used for mild, moderate, and severe COVID-19 cases, respectively. However, only 38.8%, 56.6% and 82.9% of the respondents had standard protocols for HFNC, NIV, and IMV, respectively. The most frequently used modes of IMV and NIV were volume control (VC) (36.1%) and continuous positive airway pressure/pressure support (CPAP/PS) (40.6%). About 54% of the respondents did not adhere to the recommended, regular ventilator check interval. The majority of the respondents (85.7%) used proning with IMV, with 48.4% using it for 12– 16 hours, and 46.2% had tried awake proning in combination with HFNC or NIV. Increased staff workload (45.02%), lack of trained staff (44.22%) and shortage of personal protective equipment (PPE) (42.63%) were the main barriers to COVID-19 management. / Conclusion: Our results show that general clinical practices involving ventilatory support were highly heterogeneous, with limited use of standard protocols and most frontline clinicians depending on isolated and varied management guidelines. We found increased staff workload, lack of trained staff and shortage of PPE to be the main limiting factors affecting global COVID-19 ventilatory support management.

Mechanical insufflation-exsufflation (MI-E) is traditionally used in the neuromuscular popula-tion. There is growing interest of MI-E use in invasively ventilated critically ill adults. We aimed to map current evidence on MI-E use in invasively ventilated critically ill adults. Two authors independently searched electronic databases MEDLINE, Embase, and CINAHL via the Ovid platform; PROSPERO; Cochrane Library; ISI Web of Science; and International Clinical Trials Registry Platform between January 1990–April 2021. Inclusion criteria were (1) adult critically ill invasively ventilated subjects, (2) use of MI-E, (3) study design with original data, and (4) published from 1990 onward. Data were extracted by 2 authors independently using a bespoke extraction form. We used Mixed Methods Appraisal Tool to appraise risk of bias. Theoretical Domains Framework was used to interpret qualitative data. Of 3,090 citations identi-fied, 28 citations were taken forward for data extraction. Main indications for MI-E use during invasive ventilation were presence of secretions and mucus plugging (13/28, 46%). Perceived contraindications related to use of high levels of positive pressure (18/28, 68%). Protocolized MI-E settings with a pressure of ±40 cm H2O were most commonly used, with detail on timing, flow, and frequency of prescription infrequently reported. Various outcomes were re-intubation rate, wet sputum weight, and pulmonary mechanics. Only 3 studies reported the occurrence of adverse events. From qualitative data, the main barrier to MI-E use in this subject group was lack of knowledge and skills. We concluded that there is little consistency in how MI-E is used and reported, and therefore, recommendations about best practices are not possible.

This document provides an update to the recommendations for physiotherapy management for adults with coronavirus disease 2019 (COVID-19) in the acute hospital setting. It includes: physiotherapy workforce planning and preparation; a screening tool for determining requirement for physiotherapy; and recommendations for the use of physiotherapy treatments and personal protective equipment. New advice and recommendations are provided on: workload management; staff health, including vaccination; providing clinical education; personal protective equipment; interventions, including awake proning, mobilisation and rehabilitation in patients with hypoxaemia. Additionally, recommendations for recovery after COVID-19 have been added, including roles that physiotherapy can offer in the management of post-COVID syndrome. The updated guidelines are intended for use by physiotherapists and other relevant stakeholders caring for adult patients with confirmed or suspected COVID-19 in the acute care setting and beyond. ispartof: JOURNAL OF PHYSIOTHERAPY vol:68 issue:1 pages:8-25 ispartof: location:Netherlands status: published

Introduction: Lung ultrasound (LUS) is an emerging assessment tool for intensive care unit (ICU) therapists (physiotherapists, physical therapists and respiratory therapists) to aid pathology identification, intervention selection, clinical reasoning and as an outcome measure to assess intervention efficacy. However, the extent of LUS adoption and use by ICU therapists internationally has not been described in the literature. Objectives: This survey explored the interest in LUS amongst ICU therapists internationally. In addition, LUS training, use in clinical practice and barriers to implementation were also explored. The survey findings were used to facilitate recommendations for future adoption. Methods: International ICU therapists were invited to answer a 37 question cross-sectional open e-survey, distributed using the online survey tool REDCap®. The exact sample size of eligible ICU therapists from around the world is unknown, therefore the participant responses received were a representative convenience sample of the international ICU therapist population. Survey links were posted on the relevant web pages and social media forums utilised by various ICU therapist associations and professional organisations worldwide. A snowballing technique was used to encourage survey participants to forward the survey link within their professional networks. The survey was open on REDCap® for an 8-week period between March and May 2021. Results: Three hundred twenty ICU therapists from 30 countries responded with most respondents coming from either the United Kingdom ( n = 94) or Australia ( n = 87). Eighty-nine of the ICU therapist respondents (30%) reported being users of LUS, however, 40 of those 89 respondents reported having no formal accreditation. The top clinical indications to perform a LUS scan were changes on chest radiograph, altered findings on auscultation and a low partial pressure of arterial oxygen/fraction of inspired oxygen ratio. The 71% of LUS users reported that their ICU does not have a local policy in place to guide ICU therapists’ use of LUS. Most LUS users (82%) only document their LUS findings in the patient’s medical notes and (73%) only store the LUS clips on the ICU’s ultrasound machine. The 85% of respondents perceive LUS becoming an increasing part of their objective assessment in the future and 96% report that they have other ICU therapist colleagues interested in adopting LUS. Main reasons why respondents believe that ICU therapists are not adopting LUS in their ICU are a difficulty in access to appropriate training, mentorship, and a lack of local governance policy guiding their use of LUS. Conclusions: To the authors’ knowledge this is the first study to explore the international adoption and utility of LUS by ICU therapists. LUS is a growing technique with widespread interest from ICU therapists internationally with a desire to adopt LUS into their assessments and upskill their practice. ICU therapists’ use of LUS could allow more targetted and appropriate treatment for patients on ICU. Barriers to LUS adoption could be mitigated by having access to quality training programmes and mentorship. Development of profession specific guidance and policies within local infrastructure should facilitate growth and ensure robust quality assurance and governance processes.

Background/objective: Endotracheal suction is an invasive and potentially harmful technique used for airway clearance in mechanically ventilated children. Choice of suction intervention remains a complex and variable process. We sought to develop appropriate use criteria (AUC) for endotracheal suction interventions used in paediatric populations. \ud Methods: The RAND Corporation and University of California, Los Angeles Appropriateness Method was used to develop the Paediatric AirWay Suction - PAWS appropriateness guide. This included defining key terms, synthesising current evidence, engaging an expert multidisciplinary panel, case scenario development, and 2 rounds of appropriateness ratings (weighing harm with benefit). Indications (clinical scenarios) were developed from common applications or anticipated use, current practice guidelines, clinical trial results and expert consultation. \ud Results: Overall, 148 (19%) scenarios were rated as appropriate (benefit outweighs harm), 542 (67%) as uncertain, and 94 (11%) were rated as inappropriate (harm outweighs benefit). Disagreement occurred in 24 (3%) clinical scenarios, namely pre- and post-suction bagging across populations and age groups. In general, the use of closed suction was rated as appropriate, particularly in the sub speciality population ‘patients with highly infectious respiratory disease’. Routine application of 0.9% saline for non-respiratory indications was more likely to be inappropriate/uncertain than appropriate. Panellists preferred clinically indicated suction versus routine suction in most circumstances. \ud Conclusion: AUC for endotracheal suction in the Paediatric Intensive Care have the potential to impact clinical decision making, reduce practice variability and improve patient outcomes. Furthermore, recognition of uncertain clinical scenarios facilitates identification of areas that would benefit from future research.

INTRODUCTION/PURPOSE: Diagnostic ultrasound of the respiratory system and peripheral muscular systems is increasingly being used by clinicians. The aim of this study was to evaluate the knowledge outcomes of a bespoke one‐day curriculum for physiotherapists that incorporated lung, diaphragm and lower limb muscle diagnostic ultrasound theory and practical training in image acquisition and analysis. METHODS: A one‐day course comprised of three instructors and 32 participants on key diagnostic ultrasound findings of the lungs, diaphragm and lower limb musculature included didactic lectures combined with expert‐led hands‐on training in practical sessions. Participants undertook pre‐ and post‐course knowledge questionnaire covering key ultrasound findings for normal lungs, pleural/pulmonary pathologies and normal and abnormal findings for the diaphragm and key lower limb muscle groups. The pre‐test and post‐test questionnaire and survey results were reported using parametric descriptive statistics (means SD) as the data were normally distributed. RESULTS: Of the 32 physiotherapists who undertook the one‐day training, 25 (78%) completed the pre‐ and post‐course questionnaires. The pre‐course knowledge scores (mean percentage, SD) were 63% (21), and the post‐course scores were 62% (20) after training. DISCUSSION: This novel diagnostic ultrasound course led to limited improvements of ultrasound knowledge in the specific areas of the key ultrasound findings pulmonary system and lower limb muscle anatomy. The pre‐reading material and course structure may have been too burdensome for the participants. CONCLUSION: Combined lung and muscle diagnostic ultrasound course may require more than the standard one‐day training for appropriate knowledge acquisition, and use of online pre‐course video lectures may facilitate learning.

BackgroundThe potential influence of thoracic ultrasound on clinical decision-making by physiotherapists has never been studied. The aim of this study was to assess the impact of thoracic ultrasound on clinical decision-making by physiotherapists for critical care patients.MethodsThis prospective, observational multicentre study was conducted between May 2017 and November 2020 in four intensive care units in France and Australia. All hypoxemic patients consecutively admitted were enrolled. The primary outcome was the net reclassification improvement (NRI), quantifying how well the new model (physiotherapist’s clinical decision-making including thoracic ultrasound) reclassifies subjects as compared with an old model (clinical assessment). Secondary outcomes were the factors associated with diagnostic concordance and physiotherapy treatment modification.ResultsA total of 151 patients were included in the analysis. The NRI for the modification of physiotherapist’s clinical decisions was—40% (95% CI (−56 to −22%), p=0.02). Among the cases in which treatment was changed after ultrasound, 41% of changes were major (n=38). Using a multivariate analysis, the physiotherapist’s confidence in their clinical diagnosis was associated with diagnostic concordance (adjusted OR=3.28 95% CI (1.30 to 8.71); p=0.014). Clinical diagnosis involving non-parenchymal conditions and clinical signs reflecting abolished lung ventilation were associated with diagnostic discordance (adjusted OR=0.06 95% CI (0.01 to 0.26), pConclusionThoracic ultrasound has a high impact on the clinical decision-making process by physiotherapists for critical care patients.Trial registration numberNCT02881814;https://clinicaltrials.gov.

BACKGROUND Diaphragmatic dysfunction is common after cardiothoracic surgery, but few studies report its incidence and consequences after lung transplantation. We aimed to estimate the incidence of diaphragmatic dysfunction using ultrasound in lung transplant patients up to 3 months postoperatively and evaluated the impact on clinical outcomes. METHODS This was a single-center prospective observational cohort study of 27 lung transplant recipients using diaphragmatic ultrasound preoperatively, at 1 day, 1 week, 1 month, and 3 months postoperatively. Diaphragmatic dysfunction was defined as excursion

International audience; Background: The cuff leak test (CLT) is used to assess laryngeal edema prior to extubation. There is limited evidence for its diagnostic accuracy and conflicting guidelines surrounding its use in critically ill patients who do not have risk factors for laryngeal edema. The primary study aim was to describe intensivists' beliefs, attitudes, and practice regarding the use of the CLT. Methods: A 13-item survey was developed, pilot-tested, and subjected to clinical sensibility testing. The survey was distributed electronically through MetaClinician®. Descriptive statistics and multivariable regression analysis were performed to examine associations between participant demographics and survey responses. Results: 1184 practicing intensivists from 17 countries in North and South America, Europe, Oceania, and Asia participated. The majority (59%) of respondents reported rarely or never perform the CLT prior to extubating patients not at high risk of laryngeal edema, which correlated with 54% of respondents reporting they believed a failed CLT did not predict reintubation. Intensivists from the Middle East were 2.4 times more likely to request a CLT compared to those from North America. Intensivists with base training in medicine or emergency medicine were more likely to request a CLT prior to extubation compared to those with base training in anesthesiology. Conclusion: Use of the CLT prior to extubating patients not at high risk of laryngeal edema in the intensive care unit is highly variable. Practice appears to be influenced by country of practice and base specialty training.

Objectives: 1) To identify studies which have used ultrasound imaging to evaluate respiratory musculature; and 2) evaluate, synthesize and compare the methodology for image acquisition and analysis. Methods: Data Sources: Five electronic databases (Medline, CINAHL, EMBASE, Scopus and Cochrane Library) with the last search run in February 2020.Eligibility: English language quantitative studies assessing ultrasound imaging of the respiratory musculature. No restriction based on clinical pathology. Data Extraction and Synthesis: Two authors independently screened studies for inclusion and performed data extraction. Results: A total of 123 papers on 8,131 participants were identified with 46% published since 2018. The three most common clinical populations were: ICU (n=48/123, 39%); respiratory (n=20/123, 16%) and neurological (n=20/123, 16%). Studies were predominantly undertaken in Europe (n=45/123, 37%) and Asia (n=31/123, 25%). Within the ICU field the main focus was on the predictive validity of diaphragm ultrasonography for successful extubation and/or weaning failure. Two studies specifically evaluated the intercostal muscle. The most commonly evaluated diaphragm muscle characteristics were: thickness, thickening fraction and excursion. There was wide variation in the ultrasound machine and probe used. If patient position was specified the most common position was supine to semi recumbent with most common imaging view being either: intercostal and/or subcostal. Conclusion: This systematic review highlights the recent literature growth on respiratory muscle imaging. There is an urgent need to understand the clinimetric properties and utility of ultrasonography as a predictive tool.

Background As the global outbreak of COVID-19 continues to ravage the world, it is important to understand how frontline clinicians manage ventilatory support and the various limiting factors. Methods An online survey composed of 32 questions was developed and validated by an international expert panel. Results Overall, 502 respondents from 40 countries across six continents completed the survey. The mean number (±SD) of ICU beds was 64 ± 84. The most popular initial diagnostic tools used for treatment initiation were arterial blood gas (48%) and clinical presentation (37.5%), while the national COVID-19 guidelines were the most used (61.2%). High flow nasal cannula (HFNC) (53.8%), non-invasive ventilation (NIV) (47%), and invasive mechanical ventilation (IMV) (92%) were mostly used for mild, moderate, and severe COVID-19 cases, respectively. However, only 38.8%, 56.6% and 82.9% of the respondents had standard protocols for HFNC, NIV, and IMV, respectively. The most frequently used modes of IMV and NIV were volume control (VC) (36.1%) and continuous positive airway pressure/pressure support (CPAP/PS) (40.6%). About 54% of the respondents did not adhere to the recommended, regular ventilator check interval. The majority of the respondents (85.7%) used proning with IMV, with 48.4% using it for 12–16 hours, and 46.2% had tried awake proning in combination with HFNC or NIV. Increased staff workload (45.02%), lack of trained staff (44.22%) and shortage of personal protective equipment (PPE) (42.63%) were the main barriers to COVID-19 management. Conclusion Our results show that general clinical practices involving ventilatory support were highly heterogeneous, with limited use of standard protocols and most frontline clinicians depending on isolated and varied management guidelines. We found increased staff workload, lack of trained staff and shortage of PPE to be the main limiting factors affecting global COVID-19 ventilatory support management.

Decisions on weaning from veno-venous extra-corporeal membrane oxygenation (VV-ECMO) requires the ability to maintain adequate gas exchange and work of breathing with reductions in ECMO pump flow and fresh gas flow. Testing of the readiness to wean the patient from ECMO however may vary dependent upon local protocols and clinical judgment. This study sought to validate the use of the LUS-score during VV-ECMO against the changes in chest x-ray infiltrates, dynamic lung compliance (CLdyn) and VV-ECMO settings (as standard measures of native lung function and the level of ECMO support) during the ECMO cycle. This prospective cohort study of 10 patients on VV-ECMO compared the LUS score (range 0–36) within 48-h, day 5 and day 10 of commencement of ECMO (or on the day of ECMO decannulation) to dynamic lung compliance, Murray Lung Injury Score and ECMO settings. Seven Male and three Female patients were included (average age 37 years (SD 14.8) and weight 71 Kg (SD 16.9). Median (IQR) duration of ECMO, ICU and hospital length of stay was 7.5 days (5.2–19.0), 12.5 days (8.5–22.7), 19.0 days (12.1– 36.1), respectively. There was a strong negative association between LUS-score and dynamic lung compliance (rs(33) = –0.66, p

This document outlines recommendations for physiotherapy management for COVID-19 in the acute hospital setting. It includes: recommendations for physiotherapy workforce planning and preparation; a screening tool for determining requirement for physiotherapy; and recommendations for the selection of physiotherapy treatments and personal protective equipment. It is intended for use by physiotherapists and other relevant stakeholders in the acute care setting caring for adult patients with confirmed or suspected COVID-19. ispartof: JOURNAL OF PHYSIOTHERAPY vol:66 issue:2 pages:73-82 ispartof: location:Netherlands status: published

BACKGROUND: Clinicians may use adventitious breath sounds on lung auscultation and a “sawtooth” pattern on the ventilator expiratory flow waveform as indicators of the need for chest physiotherapy for airway-secretion clearance in mechanically ventilated patients. This study seeks to identify potential clinical and novel indicators of the weight of airway secretions cleared from a single session of chest physiotherapy in mechanically ventilated subjects. METHODS: We recorded airway crackles using artificial airway acoustic sound monitoring and computerized lung-sound amplitude using artificial airway acoustic sound detection and compared them to standard clinical assessments in 71 mechanically ventilated subjects immediately prior to a single session of chest physiotherapy. Correlational analyses were undertaken between the weight of airway secretions obtained after the single session of chest physiotherapy as the dependent variable and novel assessments, clinical assessments, patient characteristics, and ventilator parameters as the independent variables. Multiple linear regression analyses were then used to determine the best model to predict the weight of airway secretions obtained from the single chest physiotherapy session. Data are reported as mean and median as appropriate. Significance was set at P RESULTS: 71 mechanically ventilated subjects were included for analysis. Statistically significant associations with the weight of airway secretions included the presence of a sawtooth waveform on expiration and the novel assessment of average airway crackles during inspiration. The best predictive model of the weight of airway secretions included the presence of the sawtooth waveform on expiration and ventilator tidal volume. CONCLUSIONS: Simple clinical assessments used in this study were able to independently predict the weight of airway secretions cleared during a single session of chest physiotherapy. The novel assessments used in this investigation did not add any further value.

BACKGROUND: In patients on mechanical ventilation, lung hyperinflation is often performed to reverse atelectasis and clear retained mucus. We evaluated the effects of manual hyperinflation and ventilator hyperinflation on mucus clearance, gas exchange, pulmonary mechanics, and hemodynamics. METHODS: Six mechanically ventilated pigs with severe Pseudomonas aeruginosa pneumonia randomly received either 12 manual hyperinflation breaths over a period of 2 min (through a gradual manual compression of a resuscitation bag within 4 s to achieve 40 cm H2O of airway pressure), or 12 ventilator hyperinflation over 2 min to achieve the same ventilatory end points as in manual hyperinflation. Mucus clearance rate was measured through fluoroscopic tracking of tracheal markers. Prior to each maneuver and 15 min thereafter, we assessed arterial and mixed gas exchange, pulmonary mechanics, and hemodynamics. RESULTS: Both manual hyperinflation and ventilator hyperinflation significantly decreased inspiratory flow by approximately 16 L/min (P CONCLUSIONS: In an animal model of severe P. aeruginosa pneumonia, neither manual hyperinflation nor ventilator hyperinflation improved mucus clearance. If confirmed in comprehensive clinical experimentations, these findings should promote reappraisal of indications for both manual hyperinflation and ventilator hyperinflation as a therapeutic technique for mucus clearance and atelectasis reversal.

AIM To investigate the factors associated with the functional progress of hospitalized patients following an intensive care admission. METHODS Retrospective study including data from a cohort of 198 hospitalized patients following an intensive care admission and not requiring mechanical ventilation in a single tertiary referral hospital. A generalized linear model was used to identify the main effects of clinical and demographic variables on the outcomes of functionality (KATZ Index of Independence in Activities of Daily Living) and muscle strength (MRC Scale). The covariates identified as independent predictors were analysed using the receiver operating characteristic curves. The analysis differentiated the periods in the intensive care unit (ICU), in the Ward (WARD) and the total time of hospital stay (TOT). RESULTS Considering the functional outcome (ΔKATZ), the variables that significantly contributed to the model (P < 0.05) were the KATZ and MRC on admission, age, sepsis (no), and total length of stay (TLS). Regarding the muscle strength outcome model (ΔMRC), the predictors were MRC on admission, Simplified Acute Physiology Score III, previous stroke, TLS, and sex (female). The variable age (AUC = 0.664) discriminated the ΔKATZICU. The variables age (AUC = 0.712), KATZ in ICU (AUC = 0.590) and on ward admission (AUC = 0.746), and MRC on ward admission (AUC = 0.721) were discriminative for ΔKATZWARD. For ΔKATZTOT the variables KATZ on ICU admission (AUC = 0.621) and TLS (AUC = 0.617) were discriminative. For ΔMRCICU the variables SAPSIII (AUC = 0.661) and MRC on ICU admission (AUC = 0.653) were discriminative. MRC on ICU (AUC = 0.681) and ward admission (AUC = 0.553) were discriminative for ΔMRCWARD. TLS (AUC = 0.649) and MRC on ward admission (AUC = 0.696) discriminative for the ΔMRCTOT. CONCLUSION Specific functional, clinical and demographical variables at ICU admission are associated with the functional prognosis during the hospitalization period.

BACKGROUND: Clinicians often use numerous bedside assessments for secretion retention in participants who are receiving invasive mechanical ventilation. This study aimed to evaluate inter-rater agreement between clinicians when using standard clinical assessments of secretion retention and whether differences in clinician experience influenced inter-rater agreement. METHODS: Seventy-one mechanically ventilated participants were assessed by a research clinician and by one of 13 ICU clinicians. Each clinician conducted a standardized assessment of lung auscultation, palpation for chest-wall (rhonchal) fremitus, and ventilator inspiratory/expiratory flow-time waveforms for the sawtooth pattern. RESULTS: On the presence of breath sounds, agreement ranged from absolute to moderate in the upper zones and the lower zones, respectively. Kappa values for abnormal and adventitious lung sounds achieved moderate agreement in the upper zones, less than chance agreement to substantial agreement in the middle zones, and moderate agreement to almost perfect agreement in the lower zones. Moderate to almost perfect agreement was established for palpable fremitus in the upper zones, moderate to substantial agreement in the middle zones, and less than chance to moderate agreement in the lower zones. Inter-rater agreement on the presence of expiratory sawtooth pattern identification showed moderate agreement. The level of percentage agreement between the research and ICU clinicians for each respiratory assessment studied did not relate directly to level of clinical experience. CONCLUSIONS: Inter-rater agreement for all assessments showed variability between lung regions but maintained reasonable percentage agreement in mechanically ventilated participants. The level of percentage agreement achieved between clinicians did not directly relate to clinical experience for all respiratory assessments. Therefore, these respiratory assessments should not necessarily be viewed in isolation but interpreted within the context of a full clinical assessment.

Objectives To develop a decision tree that objectively identifies the most discriminative variables in the decision to provide out-of-bed rehabilitation, measure the effect of this decision and to identify the factors that intensive care unit (ICU) practitioners think most influential in that clinical decision. Design A prospective 3-part study: (1) consensus identification of influential factors in mobilization via survey; (2) development of an early rehabilitation decision tree; (3) measurement of practitioner mobilization decision-making. Treating practitioners of patients expected to stay >96 hours were asked if they would provide out-of-bed rehabilitation and rank factors that influenced this decision from an a priori defined list developed from a literature review and expert consultation. Setting Four tertiary metropolitan ICUs. Participants Practitioners (ICU medical, nursing, and physiotherapy staff) (N=507). Interventions Not applicable. Main Outcome Measures A decision tree was constructed using binary recursive partitioning to determine the factor that best classified patients suitable for out-of-bed rehabilitation. Descriptive statistics were used to describe practitioner and patient samples as well as patient adverse events associated with out-of-bed rehabilitation and the factors prioritized by ICU practitioners. Results There were 1520 practitioner decisions representing 472 individual patient decisions. Practitioners classified patients suitable for out-of-bed rehabilitation on 149 occasions and not suitable on 323 occasions. Decision tree analysis showed the presence of an endotracheal tube (ETT) and sedation state were the only discriminative variables that predicted patient suitability for rehabilitation. In contrast, medical staff and nurses reported that ventilator status was the most influential factor in their decision not to provide rehabilitation while physiotherapists ranked sedation most highly. The presence of muscle weakness did not inform the decision to provide rehabilitation. Conclusion These results confirm previous observational reports that the presence of an ETT remains a major obstacle to the provision of rehabilitation for critically ill patients. Despite rehabilitation being effective for improving muscle strength, the presence of muscle weakness did not influence the decision to provide rehabilitation.

Background Tracheal tube biofilm develops during mechanical ventilation. We compared a novel closed-suctioning system vs standard closed-suctioning system in the prevention of tracheal tube biofilm. Methods Eighteen pigs, on mechanical ventilation for 76 h, with P. aeruginosa pneumonia were randomized to be tracheally suctioned via the KIMVENT* closed-suctioning system (control group) or a novel closed-suctioning system (treatment group), designed to remove tracheal tube biofilm through saline jets and an inflatable balloon. Upon autopsy, two tracheal tube hemi-sections were dissected for confocal and scanning electron microscopy. Biofilm area, maximal and minimal thickness were computed. Biofilm stage was assessed. Results Sixteen animals were included in the final analysis. In the treatment and control group, the mean (sd) pulmonary burden was 3.34 (1.28) and 4.17 (1.09) log cfu gr−1, respectively (P=0.18). Tracheal tube P. aeruginosa colonization was 5.6 (4.9–6.3) and 6.2 (5.6–6.9) cfu ml−1 (median and interquartile range) in the treatment and control group, respectively (P=0.23). In the treatment group, median biofilm area was 3.65 (3.22–4.21) log10 μm2 compared with 4.49 (4.27–4.52) log10 μm2 in the control group (P=0.031). In the treatment and control groups, the maximal biofilm thickness was 48.3 (26.7–71.2) µm (median and interquartile range) and 88.8 (43.8–125.7) µm, respectively. The minimal thickness in the treatment and control group was 0.6 (0–4.0) µm and 23.7 (5.3–27.8) µm (P=0.040) (P=0.017). Earlier stages of biofilm development were found in the treatment group (P Conclusions The novel CSS reduces biofilm accumulation within the tracheal tube. A clinical trial is required to confirm these findings and the impact on major outcomes.

Mechanically ventilated patients are at increased risk of developing physical and psychological complications that are associated with prolonged weaning from mechanical ventilation, increased morbidity and mortality. These complications include intensive care unit acquired weakness, delirium and a loss of physical function that may persist well beyond ICU and hospital discharge. Factors such as the requirement for intubation and mechanical ventilation, sedation, systemic inflammation and immobility are associated with the development of these physical and psychological complications. Implementation of rehabilitation in mechanically ventilated patients has been demonstrated to be both safe and feasible and provide benefits in terms of physical and psychological function and assist with weaning from mechanical ventilation. The recent relevant literature on the role of rehabilitation interventions in the mechanically ventilated patient will be discussed.

This case report describes the physiotherapy assessments and interventions provided to a 56-year-old male in an Australian intensive care unit. The non-intubated patient suffered from respiratory deterioration, secretion retention, complete opacification of the left hemithorax on chest X-ray (CXR) and widespread coarse crackles on lung auscultation. The addition of lung ultrasound (LUS) facilitated more accurate diagnosis than what was formed on the basis of CXR and lung auscultation resulting in more effective treatment.The method used is a case report. Written consent was obtained from the patient for these data to be published.Secretion retention was initially suspected (based on clinical examination and CXR) and treated with airway clearance techniques, patient positioning and nasopharyngeal suction. Even though this assisted with secretion removal, the patient continued to have a high perceived work of breathing and increasing oxygen requirements. Physiotherapist performed LUS, under supervision, and revealed a large pleural effusion (1500 mL), which was then drained by the medical team.The addition of LUS to the critical care physiotherapist's assessment skills may provide clinical benefit. The increased diagnostic accuracy of LUS compared with other routine assessments warrants further investigation.

© 2014 Bentham Science Publishers. Intubation, mechanical ventilation and subsequent immobilization, sedation and drying of airways predisposes to retained secretions. This can lead to a number of complications including endotracheal tube occlusion, ventilator associated infection, hemodynamic compromise and life threatening hypoxemia. Identification of retained secretions can be difficult with a poor specificity for many components of the examination. Ideally, it is important to have a high confidence in the methods of detecting airways secretions in order to be able to effectively manage them in order to prevent an emergent situation developing. The various components of examination including auscultation, oxygenation status, radiology, pulmonary mechanics and waveform analysis are discussed together with validity and repeatability information. Two of the most promising areas for accurate bedside localization of secretions are auscultation and waveform analysis.

© 2014 Bentham Science Publishers. Secretion retention in the intubated and mechanically ventilated patient has been poorly described and investigated to date. There is no gold standard for the diagnosis or detection of secretion retention in the intubated and mechanically ventilated patient. Hence, the impact of secretion retention on patient outcomes is unknown and driven by either anecdote or opinion or by the use of surrogate measures. Surrogate measures such as the increased need for airway suctioning have been related to the increased re-intubation rates after elective extubation. In the intubated and mechanically ventilated patient secretion retention may impact on gas exchange, pulmonary complications such as atelectasis or pneumonia, endotracheal tube occlusion, need for change of artificial airway or therapeutic bronchoscopy or chest physiotherapy. Factors such as mucus volume, mucus viscosity, mucus depth, mucus location (peripheralised versus centralized secretions), patient factors (e.g. inspiratory and or expiratory muscle strength, pre-existing diseases such as COPD or neuromuscular disorders), and the interplay with intubation and mechanical ventilation or the combination thereof may determine whether patient outcomes are affected. In the intubated and mechanically ventilated patient the difficulties in the detection and monitoring the movement of secretions within the airways pose the greatest challenge to identifying the clinical impact and hence optimal methods to facilitate secretion clearance. This article will review the literature on secretion retention and patient outcomes in the intubated and mechanically ventilated patient.

Background In critical care, part of the physiotherapist's respiratory assessment aims to identify parenchymal pulmonary pathology, which may be amenable to respiratory physiotherapy. In addition to clinical assessment, the tools that are most readily available to the respiratory physiotherapist to distinguish between acute pulmonary pathologies include auscultation and chest Xray. The limited diagnostic accuracy of these tools may not allow for the accurate differentiation between conditions such as lung collapse, consolidation and pleural effusion. Although computed tomography allows for this differentiation, it requires patient transport and exposes the patient to increased risk and high levels of radiation. Diagnostic lung ultrasound (LUS) has emerged as a highly sensitive bedside diagnostic tool with high level evidence to support its use for the differentiation of various common acute pulmonary pathologies. In this review, the diagnostic performances of auscultation, chest Xray and LUS are reviewed, and the usefulness of LUS as an adjunct to respiratory physiotherapy assessment is discussed. The issues surrounding training physiotherapists and the implementation of LUS are also explored. Methods The method used is a narrative review of the literature. Conclusion To our knowledge, LUS is not routinely utilized by critical care physiotherapists. However, its superior sensitivity and specificity would enable the physiotherapist to make an accurate, timely and point of care diagnosis of lung pathology and determine whether the pathology is amenable to respiratory physiotherapy. Copyright © 2014 John Wiley & Sons, Ltd.

Introduction/aims To describe the processes of care for secretion clearance in adult, intubated and mechanically ventilated patients in Australian and New Zealand Intensive Care Units (ICUs). Methods/results A prospective, cross-sectional study was conducted through the Australian and New Zealand Intensive Care Society Clinical Trials Group (ANZICS CTG) Point Prevalence Program. Forty-seven ICUs collected data from 230 patients intubated and ventilated on the study day. Secretion clearance techniques beyond standard suctioning were used in 84/230 (37%) of patients during the study period. Chest wall vibration 34/84 (40%), manual lung hyperinflation 24/84 (29%), chest wall percussion 20/84 (24%), postural drainage/patient positioning 17/84 (20%) and other techniques including mobilisation 15/84 (18%), were the most common secretion clearance techniques employed. On average (SD), patients received airway suctioning 8.8 (5.0) times during the 24-h study period. Mucus plugging events were infrequent (2.7%). The additional secretion clearance techniques were provided by physiotherapy staff in 24/47 (51%) ICUs and by both nursing and physiotherapy staff in the remaining 23/47 (49%) ICUs. Conclusion One-third of intubated and ventilated patients received additional secretion clearance techniques. Mucus plugging events were infrequent with these additional secretion clearance approaches. Prospective studies must examine additional secretion clearance practices, prevalence of mucus plugging episodes and impact on patient outcomes.

Background: Chest physiotherapy may aid sputum clearance during conventional ventilation. However, the role of chest physiotherapy during high-frequency oscillatory ventilation (HFOV) is unclear. This study aimed to determine the effects manually-assisted cough (MAC), postural drainage, saline instillation and airway suction during HFOV. Methods: This was an observational study of a chest physiotherapy intervention in adult critically ill patients during HFOV. Measures included gas exchange, HFOV and haemodynamic variables 1h before, immediately before, and 15min, 1h, 6h and 12h after intervention. Wet weight of airway secretions was also measured. Linear mixed modelling compared pre-intervention gas exchange, HFOV and haemodynamic variables with the four specified time-points after intervention. Results: Seventeen adults (ten females) with moderate to severe respiratory failure were studied (age, 49 years SD 14; Acute Physiology and Chronic Health Evaluation II score (APACHE II score) 21 SD 6; PaO2/FiO2 of 139mmHg SD 51). There was a statistically, although not clinically significant reduction in PaO2/FiO2 for up to 1h after intervention, but no significant changes in oxygenation index, PaCO2, pH, or haemodynamic parameters up to 12h after intervention. A reduction in delta pressure (ΔPaw) at 15min (p

Introduction/purpose Diagnostic thoracic ultrasound is increasingly being used by non-physicians; hence, we evaluated a curriculum for acute care physiotherapists in critical care. Methods The one-day course included didactic lectures combined with expert-led hands-on training. Participants undertook pre- and post-course knowledge questionnaire covering key ultrasound findings for normal lungs, pleural and pulmonary pathologies. Course participants who worked at the institution where the course was undertaken undertook a practical examination. We also did a 4- to 6-week follow-up survey of participants. The pretest and post-test questionnaire and survey results were reported using descriptive statistics (means SD or median and IQR). Results A total of 12 acute care physiotherapists undertook the training and questionnaire scores (mean percentage, SD, 95% CI) increased from 73.3 ± 15.5% (63.4–83.2) before the training to 86.3 ± 5.5% (82.8–89.8) after training. Discussion This diagnostic thoracic ultrasound training course resulted in improvements of diagnostic thoracic ultrasound knowledge including lung and pleural pathology image recognition skills in a small group of acute care physiotherapists with nil previous diagnostic thoracic ultrasound skills. Two-thirds of the participants who responded to the survey undertook only one to three scans in clinical practice, and the most frequent barrier to clinical use of diagnostic thoracic ultrasound was time constraints. Conclusion Further investigation of such a diagnostic thoracic ultrasound training programme on knowledge and skills retention and image acquisition and interpretation in real life clinical practice in a larger group of acute care physiotherapists is warranted.

Background: Intubation and mechanical ventilation can impair mucociliary clearance and cause secretion retention, airway occlusion, atelectasis, and pneumonia. Animal and laboratory work has demonstrated that mechanical ventilator settings can generate a flow bias (inspiratory or expiratory) that may result in mucus movement either away from the ventilator (deeper into the lungs) or toward the ventilator (toward the mouth), respectively. An absolute difference of 17 L/ min, and a relative difference of ≥ 10%, between the expiratory and inspiratory flow have been reported as thresholds for mucus movement. Methods: We measured baseline peak inspiratory and expiratory flows during quiet mechanical ventilation in a convenience sample of 20 intubated and ventilated adult patients. Results: Nineteen patients had an inspiratory flow bias of ≥ 10%. Eight patients had an absolute mean inspiratory flow bias of ≥ 17 L/min. Conclusions: Commonly used mechanical ventilator settings generate an inspiratory flow bias that may promote secretion retention. © 2011 Daedalus Enterprises.