NHS Lothian - University Hospitals Division Childrens Services PHYSIOTHERAPY GUIDELINES FOR MANUAL HYPERINFLATION THIS DOCUMENT MUST

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Purpose of this document Guidelines for physiotherapy staff using this technique. Who should use this document Physiotherapy, medical and nursing staff To whom this document applies Physiotherapy staff. Contact point Physiotherapy Department Further reference Articles in weekend folder Prasad and Hussey - Paediatric Respiratory Care Alex Hough - Physiotherapy in Respiratory Care Beverly Harden - Emergency Physiotherapy Reference list at back of document Review group Senior Respiratory Physiotherapists Intensivists Source Physiotherapy Department May 2002 Updated September 2007 Review Date September 2010

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Ref No: Published by: M Grant Ratified by: Issuing Officer: Fiona Gardner Page 1 of 4

Issue Date: September 2007 Level: TB EMT Signature:

Review Date: September 2010 DMT Signature: PSD PN

NHS Lothian - University Hospitals Division Childrens Services PHYSIOTHERAPY GUIDELINES FOR MANUAL HYPERINFLATION

Purpose of Manual Hyperinflation

To move secretions To inflate areas of collapse (Maxwell, L.; and Ellis, E. 1998) To bring down ICP To treat pulmonary hypertensive crisis Resuscitation (McCarren,B.; and Chow, C. M. 1998)

Indications for Physiotherapy Manual Hyperinflation

Atelectasis Increased secretions Poor lung compliance

Contraindications for any Manual Hyperinflation

Cardiovascular instability. Undrained pneumothorax. Very high PEEP Recent pneumonectomy Severe bullae. Recent lung surgery Clamped chest drain Haemoptysis High frequency oscillatory ventilation - (unless weaning), can position for V/Q; closed suction

Care should be taken with

Premature babies and neonates (only use if absolutely essential). Raised ICP High PEEP over 8mmHg Conscious patients Low cardiac output Dialysed patients Bronchospasm ARDS (only if secretions not cleared with suction alone) Recent abdominal surgery especially in infants

Dangers of Manual Hyperinflation

Increased intrathoracic pressure Increased Intra Cranial Pressure Barotrauma (Mcarren, B.; and Chow, C. M. 1998) Cardiac arrythmias Patient distress IVH Changes in BP (Patman, S. et al 1998) Reduced cardiac output (Patman, S. et al 1998)
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NHS Lothian - University Hospitals Division Childrens Services PHYSIOTHERAPY GUIDELINES FOR MANUAL HYPERINFLATION Pneumothorax

Carrying out Manual Hyperinflation If the technique is indicated and no contraindications are present the equipment should be prepared and the technique carried out.

Prior to Commencing
Nursing staff should be informed, suctioning and manual techniques should be prepared for where necessary An appropriate bag and circuit should be set up beside the bed. 0.5L babies 1L children 2-3L >7 years children The bag may be open ended or incorporate a valve to control the volume of gas fill. Analgesia or sedation should be prescribed and given as necessary. The patient should be positioned for best inflation and secretion clearance. In more unstable patients the nurse should by asked to position the patient well before physiotherapy. Monitors and ventilator settings should be checked for normal parameters and settings and the humidifier turned to standby to avoid overheating after reconnection An appropriate flow rate and gas mix in the bagging circuit should be achieved < 6L neonates < 10L babies < 15L older children with stiff lungs If patients are receiving nitric oxide the same parts per million mix should be used. For neonates and patients who are making significant respiratory effort an air/ oxygen mixture 10% above their normal FiO2 should be used The patient is told they will hear noise and feel a breath with cold air. They should be free of distractions and other procedures A manometer should be used to monitor pressure. This is vital where patient has high PEEP over 8mmHg If child is unstable or on high ventilatory support and manual hyperinflation is required to move secretions then medical staff or consultant can be asked to bag.

On Commencing
The disconnect alarm is turned off and the patient smoothly connected to the circuit. The ventilator is connected to the artificial lung. The catheter mount should be supported during connection and disconnection and throughout the treatment if mobile to avoid trauma. Chest movement and monitors should be observed immediately and throughout treatment to establish stability.

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NHS Lothian - University Hospitals Division Childrens Services PHYSIOTHERAPY GUIDELINES FOR MANUAL HYPERINFLATION

During Treatment
Slow inspiration with an end expiratory pause and quick expiratory release is used. This increases lung volume then promotes collateral flow followed by moving secretions towards the larger airways and stimulating a cough (Jones, A. M. et al 1991). The breath should be 2 tidal followed by 1 larger than tidal volume and approximately 20% above ventilator inspiratory pressure. PEEP should be maintained. The rate should be the same as the ventilator and timed with any patient effort (Mccarren, B.; and Chow, C. M.; 1998). Chest physiotherapy techniques and suction should be carried out where necessary This should be continued until secretions are cleared or the patient will not tolerate further treatment.

On Completion
The patient is informed and reconnected to warm breaths from ventilator. Chest movement, ventilator pressure and monitors should be observed Alarms and humidifier should be turned on.

References: Jones, A. M.; Jones, R. D.; and Bacon-shone, J. (1991) A comparison of expiratory flow rates in two breathing circuits used for manual inflation of the lungs. Physiotherapy, 77, 9, 593-597. Maxwell, B.; and Ellis, E. (1998) Secretion clearance by manual hyperinflation: possible mechanisms. Physiotherapy Theory and Practice. 14, 189-197. McCarren, B.; and Chow, C. M. (1998) Description of manual hyperinflation in intubated patients with atelectasis. Physiotherapy Theory and Practice. 14, 199-210. Patman, S.; Jenkins, S.; Bostock, S.; and Edlin, S. (1998) Cardiovascular responses to manual hyperinflation in post-operative coronary artery surgery patients. Physiotherapy Theory and Practice. 14, 5-12

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NHS Lothian - University Hospitals Division Childrens Services PHYSIOTHERAPY GUIDELINES FOR MANUAL HYPERINFLATION

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