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Mechanical insufflation-exsufflation (MI-E) has been proposed as a potential strategy to generate high expiratory flows and simulate cough in the critically ill. However, efficacy and safety of MI-E during invasive mechanical ventilation are still to be fully elucidated. This study in intubated and mechanically ventilated pigs aimed to evaluate the effects of 8 combinations of insufflation-exsufflation pressures during MI-E on mucus displacement, respiratory flows, as well as respiratory mechanics and hemodynamics.Six healthy Landrace-Large White female pigs were orotracheally intubated, anesthetized, and invasively ventilated for up to 72 h. Eight combinations of insufflation-exsufflation pressures (+40/-40, +40/-50, +40/-60, +40/-70, +50/-40, +50/-50, +50/-60, +50/-70 cm HIn 3 of the animals, experiments were conducted twice; and for the remaining 3, they were conducted once. In comparison to baseline mucus movement (2.85 ± 2.06 mm/min), all insufflation-exsufflation pressure combinations significantly increased mucus velocity (MI-E appeared to be an efficient strategy to improve mucus displacement during invasive ventilation, particularly when set at +40/-70 cm H

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.)

Background: Early mobilization in the intensive care unit (ICU) helps improve patients' functional status at discharge. However, many barriers hinder this practice. Aim and objectives: To identify mobility levels acquired by critically ill patients and their variables. Design: A multi-centre cohort study was conducted in adult patients receiving invasive mechanical ventilation for at least 48 hours. Methods: The primary outcome was level of mobility according to the ICU mobility scale. The secondary outcome was human resource availability and existence of ABCDEF bundle guidelines. A logistic regression was performed, based on days 3 to 5 of the ICU stay and significant association with active mobility. Results: Six hundred and forty-two patients were included from 80 ICUs. Active moving in and out of bed was found on 9.9% of patient-days from day 8 of the ICU stay. Bed exercises, or passive transfers, and immobility were observed on 45.6% and 42.2% of patient-days, respectively. Patients achieving active mobility (189/642, 29.4%) were in ICUs with more physiotherapist hours. Active mobility was more likely with a 1:4 nurse-patient ratio (odds ratio [OR] 3.7 95% confidence interval [CI] [1.2-11.2]), high MRC sum-score (OR 1.05 95% CI [1.04-1.06]) and presence of delirium (OR 1.01 95% CI [1.00-1.02]). By contrast, active mobility was hindered by higher BMI (OR 0.92 95% CI [0.88-0.97]), a 1:3 nurse-patient ratio (OR 0.54 95% CI [0.32-0.93]), or a shift-dependent nurse-patient ratio (OR 0.27 95% CI [0.12-0.62]). Conclusions: Immobility and passive mobilization were prevalent. A high MRC sumscore and presence of delirium are protective factors of mobilization. A 1:4 nursepatient ratio shows a stronger association with active mobility than a 1:3 ratio. Relevance to clinical practice: Severity-criteria-based nurse-patient ratios hinder mobilization. Active mobilization may be enhanced by using nursing-interventionbased ratios, increasing physiotherapist hours, and achieving wider application of the ABCDEF bundle, resulting in more awake, cooperative patients.

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: Mechanical insufflation-exsufflation (MI-E) applied through the endotracheal tube (ETT) can effectively eliminate airway secretions in intubated patients. However, the effect of the interface (ETT vs face mask) on expiratory air flow generated by MI-E has not been investigated. This study aimed to investigate the effect of the ETT on peak expiratory flow (PEF) along with other associated factors that could influence PEF generated by MI-E. METHODS: Intubated participants received 2 sessions of MI-E via ETT therapy per d for 2 consecutive days. One MI-E session consisted of 5 sets of either constant (+40/−40 cm H(2)O) or incremental (+30/−30 to +50/−50 cm H(2)O) pressure applications. Following extubation, MI-E sessions were repeated using face mask. Expiratory air flow during MI-E therapy was continuously measured, and every PEF during each application was analyzed using linear mixed-effect and generalized linear mixed models. RESULTS: A total of 12 participants (9 [75.0%] men; mean [SD] age, 74.0 [10.2] y) completed all MI-E sessions with both ETT and face mask interfaces. The PEF generated during MI-E treatment was influenced by the interface (ETT vs face mask), pressure gradient, and number of session repetitions. Adjusted mean PEF values for MI-E via ETT and face mask at +40/−40 cm H(2)O were −2.521 and −3.114 L/s, respectively, and −2.956 and −3.364 L/s at +50/−50 cm H(2)O, respectively. At a pressure gradient of +40/−40 cm H(2)O, only 172 of 528 MI-E trials via ETT (32.6%) achieved a PEF faster than −2.7 L/s, whereas 304 of 343 MI-E trials via face mask (88.6%) exceeded PEF < −2.7 L/s. CONCLUSIONS: MI-E via ETT generated slower PEF than via face mask, suggesting that a higher-pressure protocol should be prescribed for intubated patients. An insufflation-exsufflation pressure up to +50/−50 cm H(2)O could be considered to produce a PEF faster than 2.7 L/s, and the applications were safe and feasible for subjects on invasive mechanical ventilation.

Background: The ABCDE bundle is a set of evidence-based practices to systematically reduce the risks of sedation, delirium, and immobility in intensive care patients. Implementing the bundle improves clinical outcome. Aims and Objectives: To investigate the association between patient outcomes and compliance with bundle components ABC (analgosedation algorithms), D (delirium protocol), and E (early mobilization protocol). Design: A Spanish multicentre cohort study of adult patients receiving invasive mechanical ventilation (IMV) for ≥48 h until extubation. Methods: The primary outcome was pain level, cooperation to permit Medical Research Council Scale administration, patient days of delirium, and mobility. The secondary outcome was cumulative drug dosing by IMV days. Tertiary outcomes (ICU days, IMV days, bed rest days, ICU mortality, ICUAW) and independent variables (analgosedation, delirium, early mobilization protocols) were also studied. Results: Data were collected from 605 patients in 80 ICUs and 5214 patient days with IMV. Two-thirds of the ICUs studied applied no protocols. Pain was not assessed on 83.6% of patient days. Patient cooperation made scale administration feasible on 20.7% of days. Delirium and immobility were found on 4.2% and 69.9% of days, respectively. Patients had shorter stays in ICUs with bundle protocols and fewer days of IMV in ICUs with delirium and mobilization bundle components (P = 0.006 and P = 0.03, respectively). Analgosedation protocols were associated with more opioid dosing (P = 0.02), and delirium and early mobilization protocols with more propofol (P = 0.001), dexmedetomidine (P = 0.001), and lower benzodiazepine dosing (P = 0.008). Conclusions: The implementation rate of ABCDE bundle components was very low in our Spanish setting, but when implemented, patients had a shorter ICU stay, more analgesia dosing, and lighter sedation. Relevance to clinical practice: Applying some but not all the bundle components, there is increased analgesia and light sedation drug use, decreased benzodiazepines, and increased patient cooperation and mobility, resulting in a shorter ICU stay and fewer days of IMV.

Chronic obstructive pulmonary disease (COPD) is a progressive lung condition that affects a person's ability to exercise and undertake normal physical function due to breathlessness, poor physical fitness, and muscle fatigue. Patients with COPD often experience exacerbations due to pulmonary infections, which result in worsening of their symptoms, more loss of function, and often require hospital treatment or in severe cases admission to intensive care units. Recovery from such exacerbations is often slow, and some patients never fully return to their previous level of activity. This can lead to permanent disability and premature death.Physical therapists play a key role in the respiratory management and rehabilitation of patients admitted to intensive care following acute exacerbation of COPD. This article discusses the key considerations for respiratory management of patients requiring invasive mechanical ventilation, providing an evidence-based summary of commonly used interventions. It will also explore the evidence to support the introduction of early and structured programs of rehabilitation to support recovery in both the short and the long term, as well as active mobilization, which includes strategies to minimize or prevent physical loss through early retraining of both peripheral and respiratory muscles.

Invasive mechanical ventilation (IMV) is a live-saving strategy often implemented in critically ill patients to overcome respiratory failure from either an acute, exacerbated or planned (e.g. surgery) clinical situation. However, several respiratory adverse effects may result from the use of mechanical ventilation, increasing morbidity and healthcare costs in these patients. Indeed, mucus retention is highly prevalent in the critically ill, independent of a pre-existent respiratory disease, with associated risk for atelectasis or respiratory infections. Moreover, respiratory muscle weakness is also recognized as a common adverse effect derived from IMV, which may result in a prolonged need for ventilation or intensive care unit length of stay. The knowledge of pathophysiological consequences derived from IMV and adequate respiratory management of critically ill patients is mandatory to ensure the quality of daily care in these patients, whilst also maximizing the potential for a successful ICU discharge. Thus, the purpose of this chapter is to describe the basics of pulmonary complications resulting from intubation and the use of mechanical ventilation in critically ill adults, presenting the most commonly implemented strategies for its management.

Objetivo: Adaptar la ICU Mobility Scale (IMS) al ámbito de las unidades de cuidados intensivos (UCI) de España y evaluar las propiedades métricas de la IMS versión española (IMS-Es). Método: Estudio descriptivo de carácter métrico desarrollado en dos fases. Fase 1: adaptación al español de la IMS mediante equipo de enfermeras y fisioterapeutas (traducción, piloto, retrotraducción y acuerdo). Fase 2: análisis de propiedades métricas (validez convergente, divergente y predictiva, fiabilidad interobservador, sensibilidad y diferencia mínima importante) de la IMS-Es. Se registraron características de los pacientes (Barthel, Charlson, IMC, sexo), nivel de sedación/agitación (RASS), estancias en UCI y hospital, supervivencia, calidad de vida (SF-12), debilidad muscular (MRC-SS) y movilidad (IMS-Es) en los pacientes del estudio multicéntrico nacional MOviPre. Resultados Tras obtener la IMS-Es, se implementó en 645 pacientes de 80 UCI españolas entre abril y junio de 2017. Validez convergente: moderada correlación entre IMS-Es y MRC-SS (r = 0,389; p < 0,001) y comparación significativa entre grupos con y sin debilidad adquirida en la UCI (p < 0,001). Validez divergente: no correlación entre IMS-Es e IMC (r [IC 95%]: −0,112 [−0,232 a 0,011]), peso (r [IC 95%]: −0,098 [−0,219 a 0,026]), Charlson (r [IC 95%]: −0,122 [−0,242 a 0,001]) y Barthel (r [IC 95%]: −0,037 [−0,160 a 0,087]) y sin diferencias entre sexos (p = 0,587) ni categorías de IMC (p = 0,412). Validez predictiva: moderadas y significativas correlaciones con estancia en hospital post-UCI (r [IC 95%]: −0,442 [−0,502 a −0,377]) y componente físico del SF-12 (PCS) (r [IC 95%]: 0,318 [0,063 a 0,534]); pacientes sin movilización activa en UCI mayor riesgo de mortalidad hospitalaria (OR [IC 95%]: 3,769 [1,428 a 9,947]). Fiabilidad interobservador: muy buena concordancia entre enfermeras (CCI [IC 95%]: 0,987 [0,983 a 0,990]) y entre enfermera-fisioterapeuta (CCI [IC 95%]: 0,963 [0,948 a 0,974]). Sensibilidad al cambio: efecto pequeño al alta de UCI (d = 0,273) y moderado a los 3 meses del alta hospitalaria (d = 0,709). Diferencia mínima importante: punto de corte de la diferencia de 2 puntos, sensibilidad del 91,1% y especificidad del 100,0%. Conclusiones: La IMS-Es es útil, válida y fiable para ser implementada por enfermeras de UCI y por fisioterapeutas al valorar la movilidad de los pacientes críticos. Objective: To adapt the ICU Mobility Scale (IMS) to the area of intensive care units (ICU) in Spain and to evaluate the metric properties of the Spanish version of the IMS (IMS-Es). Method: Descriptive metric study developed in two phases. Phase 1, adaptation to Spanish of the IMS by a team of nurses and physiotherapists (translation, pilot, backtranslation and agreement). Phase 2, analysis of metric properties (convergent, divergent and predictive validity, interobserver reliability, sensitivity and minimum important difference) of the IMS-Es. Patient characteristics (Barthel, Charlson, BMI, sex), sedation/agitation level (RASS), ICU and hospital stays, survival, quality of life (SF-12), muscle weakness (MRC-SS) and mobility (IMS-Es) were recorded in the patients of the MOviPre national multicentre study. Results After obtaining the IMS-Es, it was implemented in 645 patients from 80 Spanish ICUs between April and June 2017. Convergent validity: moderate correlation between IMS-Es and MRC-SS (r = .389; P < .001) and significant comparison between groups with and without ICU-acquired weakness (P < .001). Divergent validity: no correlation between IMS-Es and BMI [r (95% CI): −.112 (−.232 to .011)], weight [r (95% CI): −.098 (−.219 to .026)], Charlson [r (95% CI): −.122 (−.242 to .001)] and Barthel [r(95% CI): −.037 (−.160 to .087)] and no differences between sexes (P = .587) or BMI categories (P = .412). Predictive validity: moderate and significant correlations with post-ICU hospital stay [r (95% CI): −.442 (−.502 to −.377)] and physical component of SF-12 (PCS) [r (95% CI): .318 (.063 to .534)]; patients without active mobilisation in ICU increased risk of hospital mortality [OR (95% CI): 3.769 (1.428 to 9.947)]. Interobserver reliability: very good concordance between nurses [CCI (95% CI): .987 (.983 to .990)] and nurse-physiotherapist [CCI (95% CI): .963 (.948 to .974)]. Sensitivity to change: small effect on discharge from ICU (d = .273) and moderate effect at 3 months after hospital discharge (d = .709). Minimal important difference: 2-point difference cut-off point, 91.1% sensitivity and 100.0% specificity. Conclusions: The IMS-Es is useful, valid and reliable for implementation by ICU nurses and physiotherapists in assessing the mobility of critical patients. Sin financiación No data JCR 2020 0.239 SJR (2020) Q3, 31/61 Advanced and Specialized Nursing No data IDR 2020 UEM

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.

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.

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.

BACKGROUND Improvements in the design of the endotracheal tube (ETT) have been achieved in recent years. We evaluated tracheal injury associated with ETTs with novel high-volume low-pressure (HVLP) cuffs and subglottic secretions aspiration (SSA) and the effects on mucociliary clearance (MCC). METHODS Twenty-nine pigs were intubated with ETTs comprising cylindrical or tapered cuffs and made of polyvinylchloride (PVC) or polyurethane. In specific ETTs, SSA was performed every 2 h. Following 76 h of mechanical ventilation, pigs were weaned and extubated. Images of the tracheal wall were recorded before intubation, at extubation, and 24 and 96 h thereafter through a fluorescence bronchoscope. We calculated the red-to-green intensity ratio (R/G), an index of tracheal injury, and the green-plus-blue (G+B) intensity, an index of normalcy, of the most injured tracheal regions. MCC was assessed through fluoroscopic tracking of radiopaque markers. After 96 h from extubation, pigs were killed, and a pathologist scored injury. RESULTS Cylindrical cuffs presented a smaller increase in R/G vs tapered cuffs (P = .011). Additionally, cuffs made of polyurethane produced a minor increase in R/G (P = .012) and less G+B intensity decline (P = .022) vs PVC cuffs. Particularly, a cuff made of polyurethane and with a smaller outer diameter outperformed all cuffs. SSA-related histologic injury ranged from cilia loss to subepithelial inflammation. MCC was 0.9 ± 1.8 and 0.4 ± 0.9 mm/min for polyurethane and PVC cuffs, respectively (P CONCLUSIONS HVLP cuffs and SSA produce tracheal injury, and the recovery is incomplete up to 96 h following extubation. Small, cylindrical-shaped cuffs made of polyurethane cause less injury. MCC decline is reduced with polyurethane cuffs.

Ventilator-associated pneumonia (VAP) is an iatrogenic pulmonary infection that develops in tracheally intubated patients on mechanical ventilation for at least 48 hours. VAP is the nosocomial infection with the greatest impact on patient outcomes and health care costs. Endogenous colonization by aerobic gram-negative pathogens, that is, Pseudomonas aeruginosa, and methicillin-resistant Staphylococcus aureus play a pivotal role in the pathogenesis of VAP. Several preventive strategies have shown efficacy in decreasing VAP incidence and are often implemented altogether as a prevention bundle. In patients with clinical suspicion of VAP, respiratory samples should be promptly collected. The empiric treatment should be based on the local prevalence of pathogens, duration of hospital stay, and prior antimicrobial therapy. The antibiotics can be stopped or adjusted to more narrow-spectrum once cultures and susceptibilities are available.

Physical activity is associated with a decreased prevalence of obstructive sleep apnea and improved sleep efficiency. Studies on the effects of a comprehensive exercise program in a community setting remain limited. Our objective was to investigate the effects of a combined physical and oropharyngeal exercise program on the apnea-hypopnea index in patients with moderate to severe obstructive sleep apnea. This was a randomized clinical trial where the intervention group followed an eight-week urban-walking program, oropharyngeal exercises, and diet and sleep recommendations. The control group followed diet and sleep recommendations. A total of 33 patients were enrolled and randomized and, finally, 27 patients were included in the study (IG, 14, CG, 13) Obstructive sleep apnea patients were analyzed with a median age of 67 (52&ndash, 74) and median apnea-hypopnea index of 32 events/h (25&ndash, 41). The apnea-hypopnea index did not differ between groups pre- and post-intervention. However, in intervention patients younger than 60 (n = 6) a reduction of the apnea-hypopnea index from 29.5 (21.8&ndash, 48.3) to 15.5 (11&ndash, 34) events/h (p = 0.028) was observed. While a comprehensive multimodal program does not modify the apnea-hypopnea index, it could reduce body weight and increase the walking distance of patients with moderate to severe obstructive sleep apnea. Patients younger than 60 may also present a decreased apnea-hypopnea index after intervention.

Background: Obstructive sleep apnea syndrome (OSA) consists in repetitive obstruction of the upper airway during sleep. Physical activity, diet control, and oropharyngeal exercises have been associated, separately, with decreased Apnea-Hypopnea Index (AHI). Aim: To investigate, in patients with moderate to severe OSA, the effects of a comprehensive program of physical training, diet control and oropharyngeal exercises in the AHI. Methods: This is a randomized clinical trial in patients with moderate to severe OSA evaluated by polysomnography or respiratory polygraphy. The intervention group (IG) followed eight-weeks urban-walking program, oropharyngeal exercises, diet and sleep recommendations. The control group (CG) followed diet and sleep recommendations. Anthropometrical measurements and six minutes walking test (6MWT) were evaluated. Results: We enrolled 27 patients with a median age of 67 [52-74] years and median AHI of 32 events/h [25-41]. IG patients (n=14) presented a decrease in body weight (86.0 Kg [80.5-90.5] vs 85.3 Kg [77-88.3]; p=0.003), and distance walked during 6MWT (548±84 m vs. 567±85 m; p=0.013). No significant changes were observed in the CG. AHI did not differ in the IG. However, in patients 60 years (n=8) from 31.5 [21-38.8] to 43.5 [24.8-48] events/h (p=0.017). Conclusions: A comprehensive multimodal program reduced body weight and increased the walking distance of patients with moderate to severe OSA. In patients

Background Hemoperfusion through a column containing polymyxin B-immobilized fiber (PMX-HP) is beneficial in abdominal sepsis. We assessed the effects of PMX-HP in a model of severe Pseudomonas aeruginosa pneumonia. Methods Eighteen pigs with severe P. aeruginosa pneumonia were mechanically ventilated for 76 h. Pigs were randomized to receive standard treatment with fluids and vasoactive drugs, or standard treatment with two 3-h PMX-HP sessions. Antibiotics against P. aeruginosa were never administered. We assessed endotoxemia through the endotoxin activity assay (EA). We measured the static lung elastance, ratio of arterial partial pressure per inspiratory fraction of oxygen (PaO2/FIO2), mean arterial pressure, cardiac output, systemic vascular resistance and inotropic score. Finally, every 24 h, we assessed complete blood count. Results In comparison with the control group, PMX-HP decreased percentage of circulating neutrophils from 47.4 ± 13.8 to 40.8 ± 11.5 % (p = 0.009). In a subgroup of animals with the worst hemodynamic impairment, EA in the control and PMX-HP groups was 0.50 ± 0.29 and 0.29 ± 0.14, respectively (p = 0.018). Additionally, in the control and PMX-HP groups, static lung elastance was 26.9 ± 8.7 and 25.3 ± 7.5 cm H2O/L (p = 0.558), PaO2/FIO2 was 347.3 ± 61.9 and 356.4 ± 84.0 mmHg (p = 0.118), mean arterial pressure was 81.2 ± 10.3 and 81.6 ± 13.1 mmHg (p = 0.960), cardiac output was 3.30 ± 1.11 and 3.28 ± 1.19 L/min (p = 0.535), systemic vascular resistance was 1982.6 ± 608.4 and 2011.8 ± 750.0 dyne/s/cm–5 (p = 0.939), and inotropic score was 0.25 ± 0.10 and 0.26 ± 0.18 (p = 0.864). Conclusions In mechanically ventilated pigs with severe P. aeruginosa pneumonia, PMX-HP does not have any valuable clinical benefit, and studies are warranted to fully evaluate a potential role of PMX-HP in septic shock associated with severe pulmonary infections. Electronic supplementary material The online version of this article (doi:10.1186/s13613-016-0155-3) contains supplementary material, which is available to authorized users.

Critically ill and mechanically ventilated patients are at an increased risk of developing serious complications that are associated with increased morbidity and mortality. Common factors for pulmonary and neuromuscular sequelae during critical illness include endotracheal intubation, mechanical ventilation, systemic inflammation, and immobility. Moreover, the physiological impairment because of critical illness may be prevalent for a long time after discharge from the intensive care unit. Implementation of physiotherapy in critically ill patients, even at the very early stages of critical illnesses, has been demonstrated to be safe and feasible and to provide short-term physiological benefits. However, there is limited randomized-controlled trial evidence for physiotherapy to prevent and/or treat pulmonary and neuromuscular sequelae. The aim of this review is to present the recent literature on the role of physiotherapy in the critically ill and mechanically ventilated patients. Copyright © 2013 by Lippincott Williams & Wilkins.

Objectives: During mechanical ventilation, air flows may play a role in mucus transport via two-phase gas liquid flow. The aim of this study was to evaluate effects of duty cycles and positive end-expiratory pressure on mucus clearance in pigs using mechanical ventilation, and to assess their safety. Design: Prospective randomized animal study. Setting: Animal research facility, University of Barcelona, Spain. Subjects: Eight healthy pigs. Interventions: Pigs were intubated and on volume-control mechanical ventilation for up to 84 hrs. After 4, 24, 48, and 72 hrs of mechanical ventilation, six levels of duty cycle (0.26, 0.33, 0.41, 0.50, 0.60, and 0.75) with no associated positive end-expiratory pressure or 5 cm H2O of positive end-expiratory pressure were randomly applied. Surgical bed was oriented 30 degrees in the reverse Trendelenburg position, as in the semirecumbent position. Measurement and Main Results: Inspiratory and expiratory flows and hemodynamics were measured after each 30-min ventilation period. Mucus movement was assessed through fluoroscopy tracking of radio-opaque markers. Mucus velocity was described by a positive vector (toward the glottis) or negative vector (toward the lungs). No effect of positive end-expiratory pressure was found; however, as duty cycle was increasingly prolonged, a trend toward reduced velocity of mucus moving toward the lungs and increased outward mucus velocity was found (p .064). Two clusters of mucus velocities were identified as duty cycle was prolonged beyond 0.41. Thus, duty cycle >0.41 increased mean expiratory‐inspiratory flow bias from 4.1 4.6 to 7.9 5.9 L/min (p < .0001) and promoted outward mucus velocity from 0.22 1.71 mm/min (range, 5.78 to 2.42) to 0.53 1.06 mm/min (1.91 to 3.88; p .0048). Duty cycle of 0.75 resulted in intrinsic positive end-expiratory pressure (2.1 1.1 cm H2O [p < .0001] vs. duty cycle 0.26‐0.5), with no hemodynamic compromise. Conclusions: In the semirecumbent position, mucus clearance is improved with prolongation of the duty cycle. However, in clinical practice, positive findings must be balanced against the potentially adverse hemodynamic and respiratory effects. (Crit Care Med 2012; 40:895‐902)

To the Editor: We read with interest the manuscript by Guimaraes et al,[1][1] who assessed in humans the pulmonary effects of manual rib cage compressions (MRCCs). The authors found a mild increase in the amount of cleared airway secretions with the use of MRCCs and no effects on respiratory

Bacterial Colonization (0.22 vs 2.27 and 2.31 log cfu/gr, p< 0.05) and VAP (0 vs 67 and 86 %, p< 0.05) were drastically reduced in TL position as compared to SR and SR-inv respectively. MAP was lower in SR and SRinv compared to TL position (80 and 73 vs 90 mmHg, p< 0.05). At the brain level, pigs in TL position presented high score of petequial hemorrhage (2.6 vs 1 and 1.5, p< 0.05), and higher levels of immunopositive cells to caspase (6.3 vs 2.5 and 1.7, p< 0.05) and TUNEL (5.17 vs 1 and 2.72, p< 0.05) in the dentate gyrus in the hippocampus, both indicators of apoptosis, in comparison with groups SR and SR-inv respectively. Conclusions In this pig model of MV, TL position prevents pulmonary colonization and VAP development, but enhances cerebral hemorrhage, and increased apoptosis in the hippocampus. These alterations in the brain could be related with the increase in MAP observed in TL position. More studies to evaluate risks and benefits of TL position are needed.