Inspiratory muscle training facilitates weaning from mechanical ventilation among patients in the intensive care unit: a systematic review

The effectiveness of respiratory muscular training in athletes: A systematic review and meta-analysis

The aim of this review was to summarize the effectiveness of respiratory muscle training (RMT) in athletes in muscle strength, lung function and performance of athletes. Searches without date limits or language restrictions, in the databases: Medline via PubMed, Lilacs via Virtual Health Library, CENTRAL through the Cochrane Library, PEDro, EMBASE, ClinicalTrials.gov, reference lists of retrieved articles and gray literature. The selection of studies and data extraction was performed in duplicate by two independent reviewers. Twenty-five articles (involving 522 athletes) provided sufficient information to be included in the meta-analyzes. Most studies included swimmers and soccer players. The RMT was most commonly performed between 30 and 90% of MIP and/or MEP. Furthermore, in a meta-analysis involving 18 studies (different sports), RMT was favorable to increase MIP values (DM = 27.90cmH2O 95% CI: 16.18cmH2O to 39.62cmH2O, p = 0.00001) and in the meta-analysis involving soccer players, MEP values increased significantly (MD = 31.77cmH2O 95% CI: 22.49cmH2O to 41.05cmH2O, p = 0.00001). We conclude that the TMR favors the improvement of pulmonary function: MIP, FEV1, FVC, Tiffenau Index in athletes, mainly soccer players, who also improved their physical performance. However, these results are based on very low to low quality evidence.

A pilot feasibility study of a minimally invasive technique to collect microbiopsies from sternocleidomastoid muscle for histological analysis in humans

BACKGROUND

The fine-needle (microbiopsy) technique may be suitable for sampling extradiaphragmatic respiratory muscles, but has so far never been used for this purpose. If feasible it would allow to study structural properties and adaptations of these muscles in response to disuse or loading interventions in humans. The sternocleidomastoid muscle (SCM) might be a promising target.

AIM

To assess the feasibility of the microbiopsy technique to obtain muscle tissue of good-quality with cross-sectionally oriented muscle fibres for immunohistochemical analyses of fibre type composition, number of capillaries and satellite cells in human SCM.

METHODS

Three to five SCM microbiopsies were taken bilaterally under ultrasound guidance in four fresh-frozen human cadavers, and six recently deceased adult patients in the intensive care unit (ICU). Biopsies were frozen in liquid nitrogen-cooled isopentane. Sections were stained for presence and quality of muscle tissue (Hematoxylin&Eosin), fibre typing (myosin heavy chain immunostaining), capillaries (CD31 immunostaining), and satellite cells amount (Pax7 immunostaining).

RESULTS

Biopsy collection was poor in fresh-frozen cadavers, while muscle biopsies were successfully collected in 87% of all samples from recently deceased ICU patients. Good-quality muscle biopsies, with cross-sectionally oriented fibres (average:131±79, range:30-343 fibres), were obtained from at least one sample per deceased subject. Staining procedures were successful, allowing analyses of fibre type composition, number of capillaries and satellite cells.

CONCLUSION

In six recently deceased ICU patients, it was feasible to collect good-quality muscle tissue with cross-sectionally oriented fibres from the human SCM for immunohistochemical analyses of fibre type composition, number of capillaries and satellite cells.

Unraveling Ventilator-Induced Diaphragmatic Dysfunction: A Comprehensive Narrative Review on Pathogenesis, Diagnosis and Management of Ventilator-Induced Diaphragmatic Dysfunction

INTRODUCTION

Mechanical ventilation (MV) is a crucial intervention for patients with respiratory failure to ensure optimal gas exchange. However, there is strong evidence that MV exerts significant structural and functional alterations on the diaphragm, leading to a notable decline in its contractile force and the consequent atrophy of its muscle fibers. This condition, referred to as ventilator-induced diaphragmatic dysfunction (VIDD), is an integral factor contributing to challenges in weaning patients off MV, a reduction in their quality of life, and escalated Mortality Risks.

OBJECTIVES

This review highlights the complications of MV, with a focus on VIDD and its clinical implications. It explores bedside diagnostic tools for VIDD and examines exercise-based interventions aimed at preventing or reversing daiphragmatic weakness.

DISCUSSION

Rehabilitation programs, including early mobilization and inspiratory muscle training (IMT) for critically ill patients, have the potential to prevent or mitigate the adverse effects of prolonged Mechanical ventilator and improve clinical outcomes. Numerous studies have demonstrated that these interventions are both safe and feasible, offering benefits such as enhanced physical functioning, reduced duration of mechanical ventilation, and shorter stays in intensive care and hospital settings. However, despite these demonstrated advantages, the implementation of rehabilitation programs remains infrequent in routine clinical practice, often hindered by various perceived barriers.

CONCLUSION

Recognizing and addressing respiratory muscle weakness is crucial, as it represents a reversible and treatable factor that can significantly improve patient outcomes.

Similar Weaning Success Rate with High-Intensity and Sham Inspiratory Muscle Training: A Randomized Controlled Trial (IMweanT)

Rationale: Inspiratory muscle training (IMT) improves respiratory muscle function in patients with weaning difficulties. IMT protocols involve performing daily sets of breaths against external loads. However, the impact of IMT on weaning outcomes while incorporating sham control interventions remains unclear. Objectives: To compare the effects of a high-intensity IMT (Hi-IMT) intervention with a sham low-intensity (Lo-IMT) control group on weaning outcomes and respiratory muscle and pulmonary function 28 days after inclusion in patients with weaning difficulties. Methods: Both groups underwent daily IMT sessions until successful weaning or a maximum of 28 days. The Hi-IMT group (n = 44; 61% male; aged 57 ± 15 yr) performed maximal inspirations initiated from residual volume against an external load representing 30-50% of maximal inspiratory pressure (PImax), and the control group (n = 46; 52% male; aged 60 ± 12 yr) performed maximal inspirations against a load ⩽10% PImax. Measurements and Main Results: Training adherence (completed/planned sessions) was comparable between the groups (Hi-IMT, 77 ± 20%; Lo-IMT, 72 ± 17%; P = 0.25). Weaning success (64% Hi-IMT and 76% Lo-IMT; P = 0.43) and weaning duration (Hi-IMT, 45 ± 48 d; Lo-IMT, 37 ± 26 d; P = 0.33) were similar between groups. Both groups similarly improved PImax (Hi-IMT, +15 cm H2O [95% confidence interval (CI), 9, 20]; Lo-IMT, +14 cm H2O [95% CI, 9, 19]; P = 0.72). FVC improved more in the Hi-IMT group than in the Lo-IMT group (Hi-IMT, +0.33 L [95% CI, 0.22, 0.43]; Lo-IMT, +0.16 L [95% CI, 0.07, 0.25]; P = 0.04). Conclusions: Both high-intensity IMT and sham low-intensity IMT, with high adherence to the protocol, resulted in similar weaning success rates and pronounced improvements in maximal inspiratory muscle strength. Clinical trial registered with www.clinicaltrials.gov (NCT03240263).

Treatment advances of sepsis‑induced myopathy (Review)

Sepsis-induced myopathy (SIM) is a muscle disease caused by multiple pathological and physiological mechanisms associated with sepsis. The pathogenesis of SIM is extremely complex and still unclear, making treatment challenging. At present, clinical treatment includes early functional exercise, respiratory muscle strength training, regulation of nutritional structure and functional electrical stimulation. Drugs targeting the regulation of the ubiquitin-proteasome system, autophagy-lysosome system, calpain and caspase activation pathways, have provided potential therapeutic targets for the treatment of muscle atrophy. Stem cell transplantation therapy brings new hope for the treatment of SIM.

Diaphragm dysfunction: how to diagnose and how to treat?

The diaphragm, crucial for respiratory function, is susceptible to dysfunction due to various pathologies that can affect the nervous system, neuromuscular junction or the muscle itself. Diaphragmatic dysfunction presents with symptoms ranging from exertional dyspnoea to respiratory failure, significantly impacting patients' quality of life. Diagnosis involves clinical evaluation complemented by imaging and pulmonary function tests. Chest radiography, fluoroscopy, and ultrasonography are pivotal in assessing diaphragmatic movement and excursion, offering varying sensitivities and specificities based on the type and severity of dysfunction. Ultrasonography emerges as a noninvasive bedside tool with high sensitivity and specificity, measuring diaphragm thickness, thickening fraction, and excursion, and enabling monitoring of disease progression and response to treatment over time. Treatment strategies depend on the underlying aetiology and severity, ranging from conservative management to interventions such as surgical plication or diaphragmatic pacing. Ventilatory support, particularly noninvasive ventilation, plays a pivotal role in treatment, enhancing lung function and patient outcomes across unilateral and bilateral dysfunction. Despite advances in diagnostic techniques, awareness and systematic evaluation of diaphragmatic function remain inconsistent across clinical settings. This review consolidates the current understanding of diaphragmatic dysfunction, highlighting diagnostic modalities and treatment options to facilitate early recognition and management of this entity.

Weaning-associated interventions for ventilated intensive care patients: A scoping review

BACKGROUND

Mechanical ventilation is a core intervention in critical care, but may also lead to negative consequences. Therefore, ventilator weaning is crucial for patient recovery. Numerous weaning interventions have been investigated, but an overview of interventions to evaluate different foci on weaning research is still missing.

AIM

To provide an overview of interventions associated with ventilator weaning.

STUDY DESIGN

We conducted a scoping review. A systematic search of the Medline, CINAHL and Cochrane Library databases was carried out in May 2023. Interventions from studies or reviews that aimed to extubate or decannulate mechanically ventilated patients in intensive care units were included. Studies concerning children, outpatients or non-invasive ventilation were excluded. Screening and data extraction were conducted independently by three reviewers. Identified interventions were thematically analysed and clustered.

RESULTS

Of the 7175 records identified, 193 studies were included. A total of six clusters were formed: entitled enteral nutrition (three studies), tracheostomy (17 studies), physical treatment (13 studies), ventilation modes and settings (47 studies), intervention bundles (42 studies), and pharmacological interventions including analgesic agents (8 studies), sedative agents (53 studies) and other agents (15 studies).

CONCLUSIONS

Ventilator weaning is widely researched with a special focus on ventilation modes and pharmacological agents. Some aspects remain poorly researched or unaddressed (e.g. nutrition, delirium treatment, sleep promotion).

RELEVANCE TO CLINICAL PRACTICE

This review compiles studies on ventilator weaning interventions in thematic clusters, highlighting the need for multidisciplinary care and consideration of various interventions. Future research should combine different interventions and investigate their interconnection.

A Multidimensional Approach to the Management of Patients in Prolonged Weaning from Mechanical Ventilation: The Concept of Treatable Traits - A Narrative Review

BACKGROUND

Established structured weaning approaches, which are effective for patients in simple and difficult weaning, are often not appropriate for patients undergoing prolonged weaning. Addressing the complexity of weaning failure requires personalized precision medicine. The therapeutic concept of treatable traits (TTs) has been proposed as a new paradigm for the management of chronic respiratory diseases. It is based on a multidimensional assessment of specific characteristics, which can be addressed by specific interventions that go beyond traditional diagnostic criteria. The concept is increasingly adopted for other complex diseases.

SUMMARY

This is a narrative review and an expert opinion on the development of a concept of TTs for patients undergoing prolonged weaning. The proposed TTs are based on a systematic review of risk factors for prolonged weaning, an analysis of claims data to assess risk factors within 96 h of IMV onset and data from the WEAN SAFE study. A multidisciplinary team identified clinically important TTs and determined appropriate interventions. The following TTs have been identified: airway disorders and complications associated with tracheostomy or intubation, such as airway obstruction, strictures or tracheomalacia, infectious aspects, anxiety, depression, delirium, post-traumatic stress disorder, anemia, pulmonary and cardio-renal disease. The multidimensional holistic approach also includes tailored sedation and pain management, nutritional therapy, early mobilization, and physiotherapy.

KEY MESSAGE

We propose a framework of relevant considerations for a multidimensional approach to the management of patients undergoing prolonged weaning that supports the regain of respiratory capacity, reduces the respiratory load, and thus could resolve the respiratory workload imbalance.

Respiratory muscle dysfunction in acute and chronic respiratory failure: how to diagnose and how to treat?

Assessing and treating respiratory muscle dysfunction is crucial for patients with both acute and chronic respiratory failure. Respiratory muscle dysfunction can contribute to the onset of respiratory failure and may also worsen due to interventions aimed at treatment. Evaluating respiratory muscle function is particularly valuable for diagnosing, phenotyping and assessing treatment efficacy in these patients. This review outlines established methods, such as measuring respiratory pressures, and explores novel techniques, including respiratory muscle neurophysiology assessments using electromyography and imaging with ultrasound.Additionally, we review various treatment strategies designed to support and alleviate the burden on overworked respiratory muscles or to enhance their capacity through training interventions. These strategies range from invasive and noninvasive mechanical ventilation approaches to specialised respiratory muscle training programmes. By summarising both established techniques and recent methodological advancements, this review aims to provide a comprehensive overview of the tools available in clinical practice for evaluating and treating respiratory muscle dysfunction. Our goal is to present a clear understanding of the current capabilities and limitations of these diagnostic and therapeutic approaches. Integrating advanced diagnostic methods and innovative treatment strategies should help improve patient management and outcomes. This comprehensive review serves as a resource for clinicians, equipping them with the necessary knowledge to effectively diagnose and treat respiratory muscle dysfunction in both acute and chronic respiratory failure scenarios.

Effects of proprioceptive neuromuscular facilitation combined with threshold inspiratory muscle training on respiratory function in neurocritical patients with weaning failure: a randomized controlled trial

The purpose of this study was to determine the effects of combining proprioceptive neuromuscular facilitation (PNF) with threshold inspiratory muscle training (TIMT), compared with TIMT alone, on respiratory function in neurocritical patients who experienced a weaning failure. Forty-seven participants (mostly after a stroke), were randomly divided into the experimental group ( n  = 24) and the control group ( n  = 23). The control group received usual care and TIMT, whereas the experimental group, in addition, underwent four 90-s periods of manual PNF. Both groups performed training in the ICU twice a day for 5 consecutive days. The main outcome measures included maximum inspiratory pressure, diaphragmatic excursions, diaphragm thickening fraction, oxygenation index, and forced expiratory volume in 1 s/forced vital capacity. The results showed a significant group-by-time interaction effect for maximum inspiratory pressure [ F (1, 45) = 17.84, η2  = 0.328, P  < 0.001] and oxygenation index [ F [1, 45) = 5.58, η2  = 0.11, P  = 0.023]. When compared with the control group, the experimental group showed overall significantly higher maximum inspiratory pressure [mean difference = 4.37 cm H 2 O, 95% confidence interval (CI) 0.25-8.50, P  = 0.038]. No other significant group differences were found. Combining PNF with TIMT may improve respiratory function in neurocritical patients with weaning failure. This combination approach may increase the likelihood of survival of neurocritical patients in the ICU.

Impacts of three inspiratory muscle training programs on inspiratory muscles strength and endurance among intubated and mechanically ventilated patients with difficult weaning: a multicentre randomised controlled trial

BACKGROUND

Inspiratory muscle training (IMT) is well-established as a safe option for combating inspiratory muscles weakness in the intensive care setting. It could improve inspiratory muscle strength and decrease weaning duration but a lack of knowledge on the optimal training regimen raise to inconsistent results. We made the hypothesis that an innovative mixed intensity program for both endurance and strength improvement could be more effective. We conducted a multicentre randomised controlled parallel trial comparing the impacts of three IMT protocols (low, high, and mixed intensity) on inspiratory muscle strength and endurance among difficult-to-wean patients.

METHODS

Ninety-two patients were randomly assigned to three groups with different training programs, where each performed an IMT program twice daily, 7 days per week, from inclusion until successful extubation or 30 days. The primary outcome was maximal inspiratory pressure (MIP) increase. Secondary outcomes included peak pressure (Ppk) increase as an endurance marker, mechanical ventilation (MV) duration, ICU length of stay, weaning success defined by a 2-day ventilator-free after extubation, reintubation rate and safety.

RESULTS

MIP increases were 10.8 ± 11.9 cmH2O, 4.5 ± 14.8 cmH2O, and 6.7 ± 14.5 cmH2O for the mixed intensity (MI), low intensity (LI), and high intensity (HI) groups, respectively. There was a non-statistically difference between the MI and LI groups (mean adjusted difference: 6.59, 97.5% CI [- 14.36; 1.18], p = 0.056); there was no difference between the MI and HI groups (mean adjusted difference: - 3.52, 97.5% CI [- 11.57; 4.53], p = 0.321). No significant differences in Ppk increase were observed among the three groups. Weaning success rate observed in MI, HI and LI group were 83.7% [95% CI 69.3; 93.2], 82.6% [95% CI 61.2; 95.0] and 73.9% [95% CI 51.6; 89.8], respectively. MV duration, ICU length of stay and reintubation rate had similar values. Over 629 IMT sessions, six adverse events including four spontaneously reversible bradycardia in LI group were possibly related to the study.

CONCLUSIONS

Among difficult-to-wean patients receiving invasive MV, no statistically difference was observed in strength and endurance progression across three different IMT programs. IMT appears to be feasible in usual cares, but some serious adverse events such as bradycardia could motivate further research on the specific impact on cardiac system. Trial registration Clinicaltrials.gov identifier: NCT02855619. Registered 28 September 2014.

Acupuncture reduces mechanical ventilation time in critically ill patients: A systematic review and meta-analysis of randomized control trials

BACKGROUND

Mechanical Ventilation (MV) is an essential life support machine, frequently utilized in an Intensive Care Unit (ICU). Recently, a growing number of clinical trials have investigated the effect of acupuncture treatment on MV outcomes.

OBJECTIVES

This study investigated the safety and efficacy of acupuncture treatment for critically ill patients under MV.

METHODS

In this systematic review and meta-analysis of randomized controlled trials, the efficacy of acupuncture related interventions was compared to routine ICU treatments, and sham/control acupuncture as control interventions applied to ICU patients undergoing MV. The databases of PubMed, Cochrane Library, and Web of Science were extensively searched in the month of April 2022. The primary outcome measurements were defined as total MV time, ICU length of stay, and mortality. The Cochrane Collaboration risk of bias tool was employed to analyze the severity of bias. The meta-analysis was conducted using Review Manager 5.3 software. The quality of evidence was evaluated according to the GRADE approach.

RESULTS

A total of 10 clinical trials were included in this investigation. When comparing the performance of acupuncture-related interventions to that of the reported control interventions, the results of the meta-analysis revealed a significant reduction in the total number of MV days as well as the duration of ICU length of stay following acupuncture treatment (MD -2.06 [-3.33, -0.79] P = 0.001, I2 = 55 %, MD-1.26 [-2.00, -0.53] P = 0.0008, I2 = 77 %, respectively). A reduction in the total mortality was similarly observed (RR = 0.67 [0.47, 0.94] P = 0.02, I2 = 0 %).

CONCLUSION

This systematic review and meta-analysis identified a noteworthy reduction in the total MV days, time spent in the ICU, as well as the total mortality following acupuncture related interventions. However, the small sample size, risk of bias and existing heterogeneity should be taken into consideration. The results of this study are promising and further investigations in this field are warranted.

Low-Medium and High-Intensity Inspiratory Muscle Training in Critically Ill Patients: A Systematic Review and Meta-Analysis

Background and objectives: Mechanical ventilation is often used in intensive care units to assist patients' breathing. This often leads to respiratory muscle weakness and diaphragmatic dysfunction, causing weaning difficulties. Inspiratory muscle training (IMT) has been found to be beneficial in increasing inspiratory muscle strength and facilitating weaning. Over the years, different protocols and devices have been used. Materials and Methods: The aim of this systematic review and meta-analysis was to investigate the effectiveness of low-medium (LM-IMT) and high-intensity (H-IMT) threshold inspiratory muscle training in critically ill patients. A systematic literature search was performed for randomized controlled trials (RCTs) in the electronic databases Google Scholar, PubMed, Scopus, and Science Direct. The search involved screening for studies examining the effectiveness of two different intensities of threshold IMT in critically ill patients published the last 10 years. The Physiotherapy Evidence Database (PEDro) scale was chosen as the tool to assess the quality of studies. A meta-analysis was performed where possible. Results: Fourteen studies were included in the systematic review, with five of them having high methodological quality. Conclusions: When examining LM-IMT and H-IMT though, neither was able to reach statistically significant improvement in their maximal inspiratory pressure (MIP), while LM-IMT reached it in terms of weaning duration. Additionally, no statistical difference was noticed in the duration of mechanical ventilation. The application of IMT is recommended to ICU patients in order to prevent diaphragmatic dysfunction and facilitate weaning from mechanical ventilation. Therefore, further research as well as additional RCTs regarding different protocols are needed to enhance its effectiveness.

Inspiratory Training for Improving Respiratory Strength, Pulmonary Function, and Walking in Cerebral Palsy: A Meta-Analysis

PURPOSE

To investigate the effects of inspiratory strength training on respiratory muscle strength, pulmonary function, and walking capacity in children with cerebral palsy, with Gross Motor Function Classification System I to III.

METHODS

Searches were conducted in CINAHL, LILACS, MEDLINE, and Physiotherapy Evidence Database (PEDro) databases. The outcomes of interest were respiratory muscle strength, pulmonary function, and walking capacity. The quality was assessed by PEDro Scale. The Grading of Recommendations Assessment, Development, and Evaluation system was used to summarize the quality of evidence.

RESULTS

Inspiratory strength training increased the strength of inspiratory muscles and may increase the strength of the expiratory muscles. No changes were observed in pulmonary function or walking capacity.

CONCLUSIONS

This systematic review provides moderate-quality evidence that inspiratory strength training is effective for increasing inspiratory muscle strength in children with cerebral palsy. Benefits may be carried over to improving expiratory muscle strength but were not observed on pulmonary function or walking capacity.

Effects of haemodiafiltration or haemofiltration compared with haemodialysis on prognosis in patients with end-stage renal disease: protocol an updated systematic review and meta-analysis of randomised trials with trial sequential analysis

INTRODUCTION

Haemodialysis is the most common treatment option for patients with life-sustaining end-stage kidney disease (ESKD). In recent years, haemodiafiltration or haemofiltration has been widely used in patients with ESKD, and there are still conflicting findings as to whether both are superior to traditional haemodialysis. This systematic review and meta-analysis were designed to determine whether haemodiafiltration or haemofiltration is more effective than haemodialysis in reducing all-cause mortality risk in patients with ESKD.

METHODS AND ANALYSIS

We will perform a systematic PubMed, Embase, Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library and Scopus search, including studies published before September 2023. Randomised controlled trials will be included exploring the effects of haemodiafiltration or haemofiltration compared with haemodialysis on prognosis in patients with ESKD. Outcomes of interest include all-cause mortality, cardiovascular events, dialysis adequacy and adverse effects. The Cochrane Collaboration tools (ROB-2) will assess the bias risk. Available data will be used to calculate effect sizes. Heterogeneity between studies will be evaluated with I2. The trial sequential analysis will be used to eliminate false-positive results. The certainty of the evidence will be assessed using Grading of Recommendations, Assessment, Development and Evaluation criteria.

ETHICS AND DISSEMINATION

This systematic review and meta-analysis was deemed exempt from ethics review. Results will be disseminated through publication in peer-reviewed journals and research conferences.

PROSPERO REGISTRATION NUMBER

CRD42023464509.

The effects of inspiratory muscle training on physical function in critically ill adults: Protocol for a systematic review and meta-analysis

INTRODUCTION

Inspiratory muscle training (IMT) is one possible strategy to ameliorate respiratory muscle weakness due to invasive mechanical ventilation. Recent systematic reviews have focused on respiratory outcomes with minimal attention to physical function. The newest systematic review searched the literature until September 2017 and a recent preliminary search identified 5 new randomized controlled trials focusing on IMT in critical care. As such, a new systematic review is warranted to summarize the current body of evidence and to investigate the effect of IMT on physical function in critical care.

MATERIALS AND METHODS

We will search for three main concepts ("critical illness", "inspiratory muscle training", "RCT") across six databases from their inception (MEDLINE, EMBASE, Emcare, AMED, CINAHL, CENTRAL) and ClinicalTrials.gov. Two reviewers will independently screen titles, abstracts, and full texts for eligibility using the Covidence web-based software. Eligible studies must include: (1) adult (≥18 years) patients admitted to the intensive care unit (ICU) who required invasive mechanical ventilation for ≥24 hours, (2) an IMT intervention using a threshold device with the goal of improving inspiratory muscle strength, with or without usual care, and (3) randomized controlled trial design. The primary outcome of interest will be physical function. We will use the Cochrane Risk of Bias Tools (ROB2) and will assess the quality of the evidence using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) tool. This protocol has been reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA- P) guidelines and is registered with the International Prospective Register of Systematic Reviews (PROSPERO).

CONCLUSION

Results will summarize the body of evidence of the effect of IMT on physical function in critically ill patients. We will submit our findings to a peer-reviewed journal and share our results at conferences.

Adjunct Acupuncture Improved Respiratory Status and Weaning from Mechanical Ventilation After Severe COVID-19 Pneumonia

Background

A patient with severe COVID-19 pneumonia had adjunctive acupuncture to improve respiration and facilitate weaning off prolonged mechanical ventilation (MV).

Case

A man in his 40s with COVID-19 was in an advanced critical-care center on symptom day 5 for respiratory failure due to pneumonia requiring MV therapy. He received high-dose corticosteroid pulse therapy, antiviral agents, and multiple antibiotics for complicated bacterial pneumonia and bacteremia. Repeated MV weaning attempts failed, although his pneumonia gradually improved. Then, acupuncture 4 times per week was started to improve his respiration and facilitate MV weaning from day 49 of his symptoms' onset.

Results

His weaning-related indices improved, including reductions in respiratory rate and Rapid Shallow Breath Index. His O2 saturation increased immediately after each acupuncture treatment. The day after the first acupuncture treatment, his MV support was reduced by changing ventilation mode from synchronized intermittent mandatory ventilation mode to continuous positive airway pressure (CPAP) mode during the day without exacerbation of respiratory status. After 3 days of acupuncture, this patient was on CPAP support alone. MV therapy was discontinued completely after 8 days of acupuncture (6th acupuncture treatment).

Conclusions

Acupuncture improved respiration and facilitated MV weaning in a patient with respiratory failure secondary to COVID-19. Adjunctive acupuncture may benefit such patients and others after severe pneumonia. Large cohort studies are needed.

Acupuncture for ventilator-dependent patients at a hospital-based respiratory care center: A randomized controlled trial

Background

In intensive care units, mechanical ventilation is an important therapy to help patients with dyspnea. However, long-term ventilator dependence would consume huge medical resources and increase the risk of morbidity and mortality. The aim of the study was to examine the efficacy of the acupuncture combined with western medical care on ventilator parameters in ventilator-dependent patients.

Methods

In this clinical trial, 80 ventilator-dependent patients aged 20 to 80 years old were randomly assigned to acupuncture group and control group in the respiratory care center (RCC) of Changhua Christian Hospital. Besides regular medical care and therapy, participants in the acupuncture group received acupuncture therapy at the same 17 acu-points for 20 minutes once a day, a total of 12 sessions. The ventilator parameters were recorded to evaluate the respiratory efficiency for all participants. The primary outcome was rapid shallow breathing index (RSBI), and secondary outcomes were respiratory rate (RR), tidal volume (TV) and ventilation per minute (MV).

Results

Though there was no significant difference in the parameter between the acupuncture group and the control group, we found the trend of decreasing RSBI in the acupuncture group. In subgroup analyses, the mean of RSBI significantly decreased 16.02 (with the SD in 60.84) in acupuncture group, while it increased 17.84 (with the SD in 39.38) in control group (p=0.036) after 12 sessions.

Conclusion

Acupuncture treatment can improve breathing ability of patients with respirator dependence in respiratory care center.

A Comparison of Two Methods of Pre-operative Inspiratory Muscle Training on Post-operative Outcome Following Esophagectomy

Esophageal carcinoma is a multifaceted and complex disease of rapidly rising incidence that exerts an increasing social and financial burden on global healthcare systems. Esophagectomy is associated with high rates of peri- and post-operative morbidity and mortality because of complex anatomy, frail health of patients, and late diagnosis of the disease. The most common complication seen is post-operative pulmonary complication (PPC). This study was planned to compare and analyze the outcome of two different protocols of preoperative IMT program on the rate of PPCs in patients undergoing esophagectomy. Twenty patients who underwent esophagectomy for carcinoma esophagus were included in the study and were randomly divided into 2 groups of 10 each. Group A received IMT-HI training for 4 weeks, whereas the group B received IMT-E training for 4 weeks pre-operatively. All the patients included in the study underwent a baseline pulmonary assessment which included pulmonary function test (FVC, FEV1, and FEV1/FVC), maximum inspiratory pressure (MIP), and maximum expiratory pressure (MEP). Four-week preoperative IMT-HI lead to better outcome following esophagectomy as compared to IMT-E. Relative risk of PPC was 4:1 (IMT-E:IMT-HI). However, there was no statistically significant improvement in PFTs, MEP, and MIP from baseline or between two groups. The difference in PPC in two groups did not reach statistical significance despite the fact that relative risk of PPC was 4:1 (IMT-E:IMT-HI).

Effects of Inspiratory Muscle Training on Physiological Performance Variables in Women's Handball

Inspiratory muscle training (IMT) has been used in different sports, although there is no consensus on its benefits. We investigated the effects of eight weeks of IMT in women's handball. Twenty-four players were randomly distributed into experimental (EXP; n = 13) and control (CON; n = 11) groups. Only the EXP group performed IMT using the POWERBreathe device, following indications of the manufacturers. Before and after the intervention, spirometric variables were evaluated at rest and during a graded test using direct analysis of respiratory gases. Perception of exertion at submaximal intensity was also determined. No significant differences were observed post- vs. pre-intervention (p ≥ 0.05) regarding forced vital capacity (FVC), forced expiratory volume in the 1st second (VEF1), FVC/VEF1, maximal expiratory flow at 50% of FVC or peak inspiratory flow. Post-intervention, only the CON group increased their absolute and relative VO2max (2.1 ± 0.2 L/min pre vs. 2.2 ± 0.3 L/min post; 33.6 ± 3.6 ml/kg∙min pre vs. 34.5 ± 3.2 ml/kg∙min post, respectively). No significant improvements (p ≥ 0.05) were observed in VO2 associated with ventilatory threshold 1 (VT1), nor in the intensity associated with VO2max and VT1. However, there was a tendency for the mentioned variables to decrease in the CON group, while in the EXP group the trend was to maintain or increase previous values. IMT did not determine an improvement in the perception of exertion at submaximal intensity. The use of POWERBreathe, as described in the present study, is feasible in terms of time and effort, although its benefits may not be significant.

Can inspiratory muscle training benefit patients with COVID-19? A systematic review and meta-analysis

The possible benefits of inspiratory muscle training (IMT) on mechanical and clinical outcomes in patients with Coronavirus disease-2019 (COVID-19) remain controversial. We conducted a meta-analysis to evaluate the effect of IMT in the rehabilitation strategy of patients with COVID-19. The Pubmed, Embase, Web of Science (WOS), and Cochrane Central Register of Controlled Trials (CENTRAL) were searched to identify trials evaluating the efficacy of IMT in the treatment of patients with COVID-19. The primary outcome included change from baseline of VO2 max, maximal inspiratory pressure (PImax), 6-min walk test(6MWT), forced expiratory volume in the first second predicted (FEV1%pred), and quality of life (QOL). Six studies with 349 participants were analyzed. Significant improvements were found in change from baseline of VO2 max (MD: 4.54, 95% confidence interval [CI]: 1.79-7.30, Z = 3. 32, I2  = 0, p = 0.001), PImax (MD: 21.43, 95% CI: 1.33-41.52, Z = 2.09, I2  = 90%, p = 0.04), 6MWD (MD: 40.13, 95% CI: 24.92-55.35, Z = 5.17, I2  = 0, p < 0.00001) and FEV1%pred (MD: 8.73, 95% CI 3.07-14.39, Z = 3.02, p = 0.002) while no statistical improvements were found in QOL (SMD: 0.70, 95% CI: 0.37-1.03, Z = 4.15, I2  = 89% p = 0.32) between IMT group and control group. The application of IMT might elicit mechanical and clinical improvement in patients with COVID-19. IMT could be recommended as an effective strategy of pulmonary rehabilitation for COVID-19. However, the proper timing, optimal duration, as well as appropriate frequency and intensity of IMT remain uncertain and further studies are needed.

Inspiratory muscle training to reduce risk of pulmonary complications after coronary artery bypass grafting: a systematic review and meta-analysis

Background

Pulmonary complications occur in a substantial proportion of patients who undergo coronary artery bypass grafting. Inspiratory muscle training (IMT), a simple, well-tolerated physical therapy, has been proposed to reduce the risk of complications, but its efficacy remains controversial.

Method

Randomized controlled trials (RCTs) examining the influence of IMT on the risk of pulmonary complications after coronary artery bypass grafting were identified from PubMed, Embase, CENTRAL, CINAL, and Web of Science through March 2023. Data were meta-analyzed for the primary outcomes of pulmonary complications, defined as pneumonia, pleural effusion, and atelectasis; and in terms of the secondary outcomes of maximum inspiratory pressure, maximum expiratory pressure, length of hospitalization, 6 min walk test, and peak expiratory flow and other outcomes. Risk of bias and quality of evidence assessments were carried out using the RoB 2.0 and Grading of Recommendations Assessment, Development and Evaluation (GRADE) applied to primary outcomes of pulmonary complications.

Results

Data from eight RCTs involving 755 patients were meta-analyzed. IMT was associated with a significantly lower risk of postoperative pneumonia [relative risk (RR) 0.39, 95% confidence interval (CI) 0.25-0.62, P < 0.0001] and atelectasis (RR 0.43, 95% CI 0.27-0.67, P = 0.0002), but not pleural effusion (RR 1.09, 95% CI 0.62-1.93, P = 0.76). IMT was associated with significantly better maximum inspiratory pressure (preoperative: mean difference (MD) 16.55 cmH2O, 95% CI 13.86-19.24, P < 0.00001; postoperative: mean difference (MD) 8.99 cmH2O, 95% CI 2.39-15.60, P = 0.008) and maximum expiratory pressure (MD 7.15 cmH2O, 95% CI: 1.52-12.79, P = 0.01), and with significantly shorter hospitalization (MD -1.71 days, 95% CI -2.56 to -0.87, P < 0.001). IMT did not significantly affect peak expiratory flow or distance traveled during the 6 min walk test.

Conclusions

The available evidence from medium and high quality trials suggests that IMT can significantly decrease the risk of pneumonia and atelectasis after coronary artery bypass grafting while shortening hospitalization and improving the strength of respiratory muscles.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/, identifier: CRD42023415817.

The metabolic cost of inspiratory muscle training in mechanically ventilated patients in critical care

BACKGROUND

Diaphragmatic dysfunction is well documented in patients receiving mechanical ventilation. Inspiratory muscle training (IMT) has been used to facilitate weaning by strengthening the inspiratory muscles, yet the optimal approach remains uncertain. Whilst some data on the metabolic response to whole body exercise in critical care exist, the metabolic response to IMT in critical care is yet to be investigated. This study aimed to quantify the metabolic response to IMT in critical care and its relationship to physiological variables.

METHODS

We conducted a prospective observational study on mechanically ventilated patients ventilated for ≥ 72 h and able to participate in IMT in a medical, surgical, and cardiothoracic intensive care unit. 76 measurements were taken on 26 patients performing IMT using an inspiratory threshold loading device at 4 cmH₂O, and at 30, 50 and 80% of their negative inspiratory force (NIF). Oxygen consumption (VO₂) was measured continuously using indirect calorimetry.

RESULTS

First session mean (SD) VO₂ was 276 (86) ml/min at baseline, significantly increasing to 321 (93) ml/min, 333 (92) ml/min, 351(101) ml/min and 388 (98) ml/min after IMT at 4 cmH₂O and 30, 50 and 80% NIF, respectively (p = 0.003). Post hoc comparisons revealed significant differences in VO₂ between baseline and 50% NIF and baseline and 80% NIF (p = 0.048 and p = 0.001, respectively). VO₂ increased by 9.3 ml/min for every 1 cmH₂O increase in inspiratory load from IMT. Every increase in P/F ratio of 1 decreased the intercept VO₂ by 0.41 ml/min (CI - 0.58 to - 0.24 p < 0.001). NIF had a significant effect on the intercept and slope, with every 1 cmH₂O increase in NIF increasing intercept VO₂ by 3.28 ml/min (CI 1.98-4.59 p < 0.001) and decreasing the dose-response slope by 0.15 ml/min/cmH₂O (CI - 0.24 to - 0.05 p = 0.002).

CONCLUSIONS

IMT causes a significant load-dependent increase in VO₂. P/F ratio and NIF impact baseline VO₂. The dose-response relationship of the applied respiratory load during IMT is modulated by respiratory strength. These data may offer a novel approach to prescription of IMT.

TAKE HOME MESSAGE

The optimal approach to IMT in ICU is uncertain; we measured VO₂ at different applied respiratory loads to assess whether VO₂ increased proportionally with load and found VO₂ increased by 9.3 ml/min for every 1 cmH₂O increase in inspiratory load from IMT. Baseline NIF has a significant effect on the intercept and slope, participants with a higher baseline NIF have a higher resting VO₂ but a less pronounced increase in VO₂ as the inspiratory load increases; this may offer a novel approach to IMT prescription. Trial registration ClinicalTrials.gov, registration number: NCT05101850. Registered on 28 September 2021, https://clinicaltrials.gov/ct2/show/NCT05101850.

Managing respiratory muscle weakness during weaning from invasive ventilation

Weaning is a critical stage of an intensive care unit (ICU) stay, in which the respiratory muscles play a major role. Weakness of the respiratory muscles, which is associated with significant morbidity in the ICU, is not limited to atrophy and subsequent dysfunction of the diaphragm; the extradiaphragmatic inspiratory and expiratory muscles also play important parts. In addition to the well-established deleterious effect of mechanical ventilation on the respiratory muscles, other risk factors such as sepsis may be involved. Weakness of the respiratory muscles can be suspected visually in a patient with paradoxical movement of the abdominal compartment. Measurement of maximal inspiratory pressure is the simplest way to assess respiratory muscle function, but it does not specifically take the diaphragm into account. A cut-off value of -30 cmH2O could identify patients at risk for prolonged ventilatory weaning; however, ultrasound may be better for assessing respiratory muscle function in the ICU. Although diaphragm dysfunction has been associated with weaning failure, this diagnosis should not discourage clinicians from performing spontaneous breathing trials and considering extubation. Recent therapeutic developments aimed at preserving or restoring respiratory muscle function are promising.

The effect of threshold inspiratory muscle training on the duration of weaning in intensive care unit-admitted patients: A randomized clinical trial

Background

The purpose of this study was to evaluate the effect of threshold inspiratory muscle training (IMT) on the duration of weaning in intensive care unit (ICU)-admitted patients.

Materials and Methods

This randomized clinical trial enrolled 79 ICU-admitted, mechanically ventilated patients in 2020-2021 in Imam Reza Hospital, Mashhad. Patients were randomly divided into intervention (n = 40) and control (n = 39) groups. The intervention group received threshold IMT and conventional chest physiotherapy, while the control group only received conventional chest physiotherapy once a day. Before and after the end of the intervention, the strength of inspiratory muscles and the duration of weaning were measured in both the groups.

Results

The duration of weaning was shorter in the intervention group (8.4 ± 1.1 days) versus the control group (11.2 ± 0.6 days) (P < 0.001). The rapid shallow breathing index decreased by 46.5% in the intervention group and by 27.3% in the control group after the intervention (both P < 0.001), and the between-group comparison showed a significantly higher reduction in the intervention group than control group (P < 0.001). The patients' compliance after the intervention compared to the 1^st day increased to 16.2 ± 6.6 in the intervention group and 9.6 ± 6.8 in the control group (both P < 0.001), and the between-group comparison showed a significantly higher increase in the intervention group than control group. The maximum inspiratory pressure increased by 13.7 ± 6.1 in the intervention group and by 9.1 ± 6.0 in the control group (P < 0.001). Furthermore, the weaning success was 54% more probable in the intervention group than control group (P < 0.05).

Conclusion

The results of this study showed the positive effect of IMT with threshold IMT trainer on increased strength of respiratory muscles and reduced weaning duration.

Course of recovery of respiratory muscle strength and its associations with exercise capacity and handgrip strength: A prospective cohort study among survivors of critical illness

BACKGROUND

Mechanical ventilation affects the respiratory muscles, but little is known about long-term recovery of respiratory muscle weakness (RMW) and potential associations with physical functioning in survivors of critical illness. The aim of this study was to investigate the course of recovery of RMW and its association with functional outcomes in patients who received mechanical ventilation.

METHODS

We conducted a prospective cohort study with 6-month follow-up among survivors of critical illness who received ≥ 48 hours of invasive mechanical ventilation. Primary outcomes, measured at 3 timepoints, were maximal inspiratory and expiratory pressures (MIP/MEP). Secondary outcomes were functional exercise capacity (FEC) and handgrip strength (HGS). Longitudinal changes in outcomes and potential associations between MIP/MEP, predictor variables, and secondary outcomes were investigated through linear mixed model analysis.

RESULTS

A total of 59 participants (male: 64%, median age [IQR]: 62 [53-66]) were included in this study with a median (IQR) ICU and hospital length of stay of 11 (8-21) and 35 (21-52) days respectively. While all measures were well below predicted values at hospital discharge (MIP: 68.4%, MEP 76.0%, HGS 73.3% of predicted and FEC 54.8 steps/2m), significant 6-month recovery was seen for all outcomes. Multivariate analyses showed longitudinal associations between older age and decreased MIP and FEC, and longer hospital length of stay and decreased MIP and HGS outcomes. In crude models, significant, longitudinal associations were found between MIP/MEP and FEC and HGS outcomes. While these associations remained in most adjusted models, an interaction effect was observed for sex.

CONCLUSION

RMW was observed directly after hospital discharge while 6-month recovery to predicted values was noted for all outcomes. Longitudinal associations were found between MIP and MEP and more commonly used measures for physical functioning, highlighting the need for continued assessment of respiratory muscle strength in deconditioned patients who are discharged from ICU. The potential of targeted training extending beyond ICU and hospital discharge should be further explored.

Effectiveness of Nonpharmacological Interventions in the Field of Ventilation: An Umbrella Review

This umbrella review aimed to determine the effectiveness of nonpharmacological interventions in pulmonary ventilation and their impact on respiratory function. An individual with impaired ventilation displays visible variations manifested in their respiratory frequency, breathing rhythm ratio (I:E), thoracic symmetry, use of accessory muscles, dyspnea (feeling short of breath), oxygen saturation, diaphragm mobility, minute ventilation, peak flow, walking test, spirometry, Pimax/Pemax, diffusion, and respiratory muscle strength. Any variation in these markers demands the need for interventions in order to duly manage the signs and symptoms and to improve ventilation.

METHOD

Systematic reviews of the literature published in English, Spanish, French, and Portuguese were used, which included studies in which nonpharmacological interventions were used as a response to impaired ventilation in adults in any given context of the clinical practice. The recommendations given by the Joanna Briggs Institute (JBI) for umbrella reviews were followed. This research took place in several databases such as MEDLINE, CINAHL Complete, CINHAL, MedicLatina, ERIC, Cochrane Reviews (Embase), and PubMed. The Joanna Briggs critical analysis verification list was used for the systematic review. The data extraction was performed independently by two investigators based on the data extraction tools of the Joanna Briggs Institute, and the data were presented in a summary table alongside the support text.

RESULTS

Forty-four systematic reviews, thirty randomized clinical essays, and fourteen observational studies were included in this review. The number of participants varied between n = 103 and n = 13,370. Fifteen systematic revisions evaluated the effect of isolated respiratory muscular training; six systematic revisions evaluated, in isolation, breathing control (relaxed breathing, pursed-lip breathing, and diaphragmatic breathing exercises) and thoracic expansion exercises; and one systematic review evaluated, in isolation, the positions that optimize ventilation. Nineteen systematic reviews with combined interventions that reinforced the role of education and capacitation while also aiming for their success were considered. The articles analyzed isolated interventions and presented their efficacy. The interventions based on respiratory exercises and respiratory muscular training were the most common, and one article mentioned the efficacy of positioning in the compromisation of ventilation. Combined interventions in which the educational component was included were found to be effective in improving pulmonary function, diffusion, oxygenation, and functional capacity. The outcomes used in each study were variable, leading to a more difficult analysis of the data.

CONCLUSIONS

The interventions that were the focus of the review were duly mapped. The results suggest that nonpharmacological interventions used to optimize ventilation are effective, with a moderate to high level of evidence. There is a strong foundation for the use of the chosen interventions. The lack of studies on the intervention of "positioning to optimize ventilation" points out the need for a deeper analysis of its effects and for studies with a clear focus. This study supports the decisions and recommendations for the prescription of these interventions to patients with impaired ventilation.

Highlights from the Respiratory Failure and Mechanical Ventilation 2022 Conference

The Respiratory Intensive Care Assembly of the European Respiratory Society gathered in Berlin to organise the second Respiratory Failure and Mechanical Ventilation Conference in June 2022. The conference covered several key points of acute and chronic respiratory failure in adults. During the 3-day conference, ventilatory strategies, patient selection, diagnostic approaches, treatment and health-related quality of life topics were addressed by a panel of international experts. Lectures delivered during the event have been summarised by Early Career Members of the Assembly and take-home messages highlighted.

The Effects of Respiratory Training Combined with Limb Exercise on Pulmonary Function and Quality of Life in Patients with Bronchiectasis

Objective

To investigate the effects of respiratory rehabilitation training combined with limb rehabilitation on sputum clearance and quality of life in patients with bronchiectasis.

Methods

A retrospective analysis of 86 patients with bronchiectasis was divided into an intervention group and an observation group, with 43 cases in each group. All patients were above 18 years of age with no history of relevant drug allergies. Patients in the observation group were treated with conventional drugs, and those in the intervention group were given respiratory rehabilitation training and limb rehabilitation on this basis. After three months of treatment, the indexes of sputum discharge, sputum traits, lung function, and the 6-minute walk distance (6MWD) were compared and quality of life and survival skills were assessed using the Barthel index and a quality-of-life comprehensive assessment questionnaire (GQOLI-74).

Results

The percentage of patients with mild Barthel index in the intervention group was higher than that in the observation group, and the difference between the groups was statistically significant (P < 0.05). After treatment, the scores of life quality and the lung function in the intervention group were higher than those in the observation group (both P < 0.05). After three months of treatment, the sputum volume and sputum viscosity scores of the two groups were higher than those before treatment (P < 0.05).

Conclusion

Respiratory rehabilitation training with limb exercise rehabilitation can effectively improve the sputum clearance rate, lung function, and quality of life of patients with bronchiectasis and is thus worthy of clinical promotion and application.

The use of respiratory muscle training in patients with pulmonary dysfunction, internal diseases or central nervous system disorders: a systematic review with meta-analysis

OBJECTIVE

The aim of this systematic review with meta-analysis was to evaluate the effectiveness of RMT in internal and central nervous system disorders, on pulmonary function, exercise capacity and quality of life.

METHODS

The inclusion criteria were (1) publications designed as Randomized Controlled Trial (RCT), with (2) participants being adults with pulmonary dysfunction caused by an internal disease or central nervous system disorder, (3) an intervention defined as RMT (either IMT or EMT) and (4) with the assessment of exercise capacity, respiratory function and quality of life. For the methodological quality assessment of risk of bias, likewise statistical analysis and meta-analysis the RevMan version 5.3 software and the Cochrane Risk of Bias Tool were used. Two authors independently analysed the following databases for relevant research articles: PubMed, Scopus, Cochrane Library, Web of Science, and Embase.

RESULTS

From a total of 2200 records, the systematic review includes 29 RCT with an overall sample size of 1155 patients. Results suggest that patients with internal and central nervous system disorders who underwent RMT had better quality of life and improved significantly their performance in exercise capacity and in respiratory function assessed with FVC and MIP when compared to control conditions (i.e. no intervention, sham training, placebo or conventional treatments).

CONCLUSION

Respiratory muscle training seems to be more effective than control conditions (i.e. no intervention, sham training, placebo or conventional treatment), in patients with pulmonary dysfunction due to internal and central nervous system disorders, for quality of life, exercise capacity and respiratory function assessed with MIP and FVC, but not with FEV1.

Low Intensity Respiratory Muscle Training in COVID-19 Patients after Invasive Mechanical Ventilation: A Retrospective Case-Series Study

Worldwide, healthcare systems had to respond to an exponential increase in COVID-19 patients with a noteworthy increment in intensive care units (ICU) admissions and invasive mechanical ventilation (IMV). The aim was to determine low intensity respiratory muscle training (RMT) effects in COVID-19 patients upon medical discharge and after an ICU stay with IMV. A retrospective case-series study was performed. Forty COVID-19 patients were enrolled and divided into twenty participants who received IMV during ICU stay (IMV group) and 20 participants who did not receive IMV nor an ICU stay (non-IMV group). Maximal expiratory pressure (PEmax), maximal inspiratory pressure (PImax), COPD assessment test (CAT) and Medical Research Council (MRC) dyspnea scale were collected at baseline and after 12 weeks of low intensity RMT. A greater MRC dyspnea score and lower PImax were shown at baseline in the IMV group versus the non-IMV group (p < 0.01). RMT effects on the total sample improved all outcome measurements (p < 0.05; d = 0.38−0.98). Intragroup comparisons after RMT improved PImax, CAT and MRC scores in the IMV group (p = 0.001; d = 0.94−1.09), but not for PImax in the non-IMV group (p > 0.05). Between-groups comparison after RMT only showed MRC dyspnea improvements (p = 0.020; d = 0.74) in the IMV group versus non-IMV group. Furthermore, PImax decrease was only predicted by the IMV presence (R2 = 0.378). Low intensity RMT may improve respiratory muscle strength, health related quality of life and dyspnea in COVID-19 patients. Especially, low intensity RMT could improve dyspnea level and maybe PImax in COVID-19 patients who received IMV in ICU.

A multi-trial, retrospective analysis of the antihypertensive effects of high-resistance, low-volume inspiratory muscle strength training

Above-normal blood pressure (BP) is a primary risk factor for cardiovascular diseases. In a retrospective analysis of five pilot trials, we assessed the BP-lowering effects of high-resistance inspiratory muscle strength training (IMST) in adults aged 18-82 years and the impact of IMST on maximal inspiratory pressure (PIMAX), a gauge of inspiratory muscle strength and independent disease risk factor. Participants were randomized to high-resistance IMST (75% PIMAX) or low-resistance sham (15% PIMAX) training (30 breaths/day, 5-7 days/wk, 6 wk). IMST (n = 67) reduced systolic BP (SBP) by 9 ± 6 mmHg (P < 0.01) and diastolic BP (DBP) by 4 ± 4 mmHg (P < 0.01). IMST-related reductions in SBP and DBP emerged by week 2 of training (-4 ± 8 mmHg and -3 ± 6 mmHg; P ≤ 0.01, respectively) and continued across the 6-wk intervention. SBP and DBP were unchanged with sham training (n = 61, all P > 0.05). Select subject characteristics slightly modified the impact of IMST on BP. Greater reductions in SBP were associated with older age (β = -0.07 ± 0.03; P = 0.04) and greater reductions in DBP associated with medication-naïve BP (β = -3 ± 1; P = 0.02) and higher initial DBP (β = -0.12 ± 0.05; P = 0.04). PIMAX increased with high-resistance IMST and low-resistance sham training, with a greater increase from high-resistance IMST (+20 ± 17 vs. +6 ± 14 cmH2O; P < 0.01). Gains in PIMAX had a modest inverse relation with age (β = -0.20 ± 0.09; P = 0.03) and baseline PIMAX (β = -0.15 ± 0.07; P = 0.04) but not to reductions in SBP or DBP. These compiled findings from multiple independent trials provide the strongest evidence to date that high-resistance IMST evokes clinically significant reductions in SBP and DBP, and increases in PIMAX, in adult men and women.NEW & NOTEWORTHY In young-to-older adult men and women, 6 wk of high-resistance inspiratory muscle strength training lowers casual systolic and diastolic blood pressure by 9 mmHg and 4 mmHg, respectively, with initial reductions observed by week 2 of training. Given blood pressure outcomes with the intervention were only slightly altered by subject baseline characteristics (i.e., age, blood pressure medication, and health status), inspiratory muscle strength training is effective in lowering blood pressure in a broad range of adults.

Effect of abdominal weight training with and without cough machine assistance on lung function in the patients with prolonged mechanical ventilation: a randomized trial

Purpose

The patients with prolonged mechanical ventilation (PMV) have the risk of ineffective coughing and infection due to diaphragm weakness. This study aimed to explore the effect of abdominal weight training (AWT) intervention with/without cough machine (CM) assistance on lung function, respiratory muscle strength and cough ability in these patients.

Methods

Forty patients with PMV were randomly assigned to three groups: AWT group (n = 12), AWT + CM group (n = 14) and control group (n = 14). Change of maximum inspiratory pressure (MIP), Maximum expiratory pressure (MEP) and peak cough flow (PCF) between 1 day before and 2 weeks after the intervention were compared among these three groups.

Results

MIP before and after intervention in AWT group (30.50 ± 11.73 vs. 36.00 ± 10.79; p < 0.05) and AWT + CM group (29.8 ± 12.14 vs. 36.14 ± 10.42; p < 0.05) compared with control group (28.43 ± 9.74 vs 26.71 ± 10.77; p > 0.05) was significantly improved. MEP before and after intervention in AWT group (30.58 ± 15.19 vs. 41.50 ± 18.33; p < 0.05) and AWT + CM group (27.29 ± 12.76 vs 42.43 ± 16.96; p < 0.05) compared with control group (28.86 ± 10.25 vs. 29.57 ± 14.21; p > 0.05) was significantly improved. PCF before and after intervention in AWT group in AWT group (105.83 ± 16.21 vs. 114.17 ± 15.20; p < 0.05) and AWT + CM group (108.57 ± 18.85 vs. 131.79 ± 38.96; p < 0.05) compared to control group (108.57 ± 19.96 vs. 109.86 ± 17.44; p > 0.05) showed significant improvements. AWT + CM group had significantly greater improvements than control group in MIP and peak cough flow than control group (13.71 ± 11.28 vs 19.64 ± 29.90, p < 0.05).

Conclusion

AWT can significantly improve lung function, respiratory muscle strength, and cough ability in the PMV patients. AWT + CM can further improve their expiratory muscle strength and cough ability.

Trial registration ClinicalTrials.gov registry (registration number: NCT0529538 retrospectively registered on March 3, 2022).

Efficacy of Physiotherapy Interventions on Weaning in Mechanically Ventilated Critically Ill Patients: A Systematic Review and Meta-Analysis

Mechanical ventilation (MV) is currently considered a life-saving intervention. However, growing evidence highlighted that prolonged MV significantly affects functional outcomes and length of stay. In this scenario, controversies are still open about the optimal rehabilitation strategies for improving MV duration in ICU patients. In addition, the efficacy of physiotherapy interventions in critical ill patients without positive history of chronic respiratory conditions is still debated. Therefore, this systematic review of randomized controlled trials (RCTs) with meta-analysis aimed at characterizing the efficacy of a comprehensive physiotherapy intervention in critically ill patients. PubMed, Scopus, and Web of Science databases were systematically searched up to October 22, 2021 to identify RCTs assessing acute patients mechanical ventilated in ICU setting undergoing a rehabilitative intervention. The primary outcomes were MV duration, extubation, and weaning time. The secondary outcomes were weaning successful rate, respiratory function, ICU discharge rate and length of stay. Out of 2503 records, 12 studies were included in the present work. The meta-analysis performed in 6 RCTs showed a significant improvement in terms of MV duration (overall effect size: −3.23 days; 95% CI = −5.79, −0.67, p = 0.01; Z = 2.47) in patients treated with a comprehensive physiotherapy intervention including early mobilization, positioning, airway clearance techniques, lung expansion and respiratory muscle training. The quality assessment underlined 9 studies (75%) of good quality and 3 studies of fair quality according to the PEDro scale. In conclusion, our results provided previously unavailable data about the role of comprehensive physiotherapy intervention in improving MV duration in critical ill patients without chronic respiratory conditions. Further studies are needed to better characterize the optimal combination of rehabilitation strategies enhancing the improvements in critical ill patients without chronic respiratory disorders.

Perspectives of healthcare professionals in Nigeria about physiotherapists’ scope of practice and skills in ICU patients’ management: a cross-sectional study

Background

There is growing evidence for physiotherapy in the intensive care unit (ICU), but physiotherapy in the ICU and patients’ referral rate remains low in Nigeria. This study assessed the healthcare professionals’ perception of the physiotherapists’ scope of practice and skills in managing patients in the ICU of selected teaching hospitals in Southern Nigeria. The study was a cross-sectional survey that involved seventy healthcare professionals working in the ICU who completed an adapted and validated questionnaire. The data obtained from the cross-sectional study were presented using descriptive statistics of mean, standard deviation, frequency distribution, and percentage.

Results

The mean age of the participants was 39.74 ± 7.08 years. The majority of the participants had a bachelor’s degree and had worked for a minimum of 5 years in the ICU, with all the participants working in a mixed ICU and 46.7% work in ICUs with four to six beds. Physiotherapists (PTs) are not posted exclusively to the ICUs, and PTs were reported to be on call in most of the ICUs during the weekdays and weekends. Patients were referred for physiotherapy by the physicians. Healthcare professionals had negative perceptions about PTs’ scope in airway suctioning, nebulization, weaning, and adjustment of mechanical ventilators, intubation, extubation, and changing tracheostomy tubes for ICU patients. Participants had a positive perception about PTs’ assessment skills in the ICU except for hypoxemia calculation, readiness for weaning, and the need for humidification.

Conclusion

Healthcare professionals working in the ICU in the selected hospitals had both negative and positive perceptions regarding certain areas about the scope of practice and skills of PTs in managing patients in the ICU.

High-Intensity Inspiratory Muscle Training Improves Scalene and Sternocleidomastoid Muscle Oxygenation Parameters in Patients With Weaning Difficulties: A Randomized Controlled Trial

Background

Critically ill patients who have difficulties weaning from the mechanical ventilator are prone to develop respiratory muscle weakness. Inspiratory muscle training (IMT) can improve respiratory muscle strength. Whether IMT can improve scalene and sternocleidomastoid muscle oxygenation parameters is unknown.

Aim

To compare changes in muscle oxygenation parameters of scalene and sternocleidomastoid inspiratory muscles during a standardized task between patients with weaning difficulties who received either high-intensity IMT (intervention) or sham low-intensity IMT (control).

Method

Forty-one patients performed daily IMT sessions (4 sets, 6–10 breaths) until weaning success or for 28 consecutive days. The training load was progressively adjusted in the intervention group (n = 22) to the highest tolerable load, whilst the control group (n = 19) kept training at 10% of their baseline maximal inspiratory pressure (PImax). Breathing characteristics (i.e., work and power of breathing, PoB), respiratory muscle function [i.e., PImax and forced vital capacity (FVC)] were measured during a standardized loaded breathing task against a load of 30% of baseline PImax before and after the IMT period. In addition, during the same loaded breathing task, absolute mean and nadir changes from baseline in local scalene and sternocleidomastoid muscle oxygen saturation index (Δ%StiO2) (an index of oxygen extraction) and nadir Δ%StiO2 normalized for the PoB were measured by near-infrared spectroscopy.

Results

At post measures, only the intervention group improved mean PoB compared to pre measures (Pre: 0.42 ± 0.33 watts, Post: 0.63 ± 0.51watts, p-value &lt; 0.01). At post measures, both groups significantly improved nadir scalene muscles StiO2% normalized for the mean PoB (ΔStiOnadir%/watt) compared to pre measurements and the improvement was not significant different between groups (p-value = 0.40). However, at post measures, nadir sternocleidomastoid muscle StiO2% normalized for the mean PoB (ΔStiOnadir%/watt) was significantly greater improved in the intervention group (mean difference: +18.4, 95%CI: −1.4; 38.1) compared to the control group (mean difference: +3.7, 95%CI: −18.7; 26.0, between group p-value &lt; 0.01). Both groups significantly improved PImax (Intervention: +15 ± 13 cmH2O p-value &lt; 0.01, Control: +13 ± 15 cmH2O p-value &lt; 0.01). FVC only significantly improved in the intervention group (+0.33 ± 0.31 L p &lt; 0.01) report also change in control group.

Conclusion

This exploratory study suggests that high-intensity IMT induces greater improvements in scalene and sternocleidomastoid muscle oxygenation parameters attributed for oxygen delivery, utilization and oxygen saturation index compared to low-intensity IMT in patients with weaning difficulties.

Physiotherapy Practice Pattern in the Adult Intensive Care Units of Singapore – A Multi-Centre Survey

Background

The roles of physiotherapy in Intensive Care Unit (ICU) have significantly developed from the traditional management of respiratory conditions to early rehabilitation and mobilisation of patients on mechanical ventilation. Surveys of United Kingdom, Australia and regional ICU physiotherapy practice have been published but there are no local data sets. This study aims to report the physiotherapy practices across the adult ICUs of Singapore.

Methods

Twenty-nine item questionnaire was mailed to 90 physiotherapists working in 15 adult ICUs across restructured and private hospitals in Singapore. Data sets were summarised from the returned questionnaires. This includes identifying common physiotherapy techniques and exercise prescription protocols for both mechanically and non-mechanically ventilated patients in the ICU.

Results

A total of 63 (70%) questionnaires were returned. The most used physiotherapy interventions were airway secretion clearance, techniques to improve lung ventilation and mobilisation out of bed. Positioning was most used respiratory technique (60/61, 98%). Sitting on the edge of bed is the most preferred physical activity for ICU patients (43/44, 98%). Exercise was routinely prescribed (50/61, 83%) although only a minority (8/50, 16%) have established exercise prescription protocols. For mechanically ventilated patients, active/active assisted exercises were most used (40/44, 91%). 12% of ICU use either Chelsea Critical Care Physical Assessment Tool or the Functional Status Score for the Intensive Care Unit as routine outcome measures.

Conclusion

Airway clearance was stated as the most used physiotherapy technique. Exercise is routinely prescribed in ICU. Validated outcome measures are only used by few.

Feasibility of Chest Wall and Diaphragm Proprioceptive Neuromuscular Facilitation (PNF) Techniques in Mechanically Ventilated Patients

Physical therapy is part of the treatment for patients admitted to ICU. Proprioceptive neuromuscular facilitation (PNF) is one of the physiotherapy concepts including manual techniques and verbal stimulation. The purpose of this paper is to examine the feasibility of PNF techniques in mechanically ventilated (MV) ICU patients. Another aim is to verify whether the technique using resistance during the patient’s inhalation will have a different effect than the technique used to teaching the correct breathing patterns. Methods: Patients admitted to tertiary ICU were enrolled in this study, randomly divided into two groups, and received four 90-second manual breathing stimulations each. The following vital signs were assessed: HR, SBP, DBP, and SpO₂. Results: 61 MV ICU adult patients (mean age 67.8; 25 female and 36 male) were enrolled in this study. No significant differences in HR, SBP, and DBP were observed both for two techniques measured separately and between them. Statistically significant differences were noticed analysing SpO₂ in the rhythmic initiation technique (RIT) group (p-value = 0.013). Conclusions: Short-term PNF interventions did not influence clinically relevant vital parameters among MV patients and seem to be feasible in this group of ICU patients.

Impact of Inspiratory Muscle Training on Weaning Parameters in Prolonged Ventilator-Dependent Patients: A Preliminary Study

Introduction

Patients require prolonged mechanical ventilation to overcome respiratory failure in the chronic respiratory care ward; however, how to facilitate ventilator weaning using a nurse-led strategy is limited.

Objectives

This study aimed to examine the impact of adjusting ventilator trigger sensitivity as inspiratory muscle training on weaning parameters in patients with prolonged ventilator dependence.

Methods

Multiple pre-test–post-test with a non-equivalent control group design was conducted at a chronic respiratory care ward in southern Taiwan. A convenience sampling method was used to recruit patients who received prolonged mechanical ventilation for more than 21 days into control (n  =  20) and intervention groups (n  =  22). Adjustment of ventilator trigger sensitivity started from 10% of the initial maximum inspiratory pressure and increased to 40% after a training period of six weeks. The weaning parameters were collected for pre-test and multiple post-tests, and statistical analysis of treatment effects was performed using the generalized estimating equation.

Results

Magnitude of weaning parameters was significantly higher in the intervention group after the six-week training, including maximum inspiratory pressure, rapid shallow breathing index, tidal volume, and ratio of arterial-to-inspired oxygen.

Conclusion

Adjustment of ventilator trigger sensitivity as inspiratory muscle training can help prolonged ventilator-dependent patients improve their respiratory muscle strength, breathing patterns, and oxygenation.

Comparison of Two Protocols for the Assessment of Maximal Respiratory Pressures: Spanish Society of Pulmonology and Thoracic Surgery Versus American Thoracic Society/European Respiratory Society

Background The measurement of maximal respiratory pressures (MRPs) is commonly used to assess respiratory muscle strength. However, in Spain, there is no consensus on which is the most adequate measurement protocol, as theSpanish Society of Pneumology and Thoracic Surgery (SEPAR) protocol differs from the one endorsed by the American Thoracic Society/European Respiratory Society(ATS/ERS). This study compared the absolute and predictive values of maximal expiratory and inspiratory pressures (MEP and MIP) in healthy adults obtained with the two protocols. Methods A cross-sectional study with a sample of healthy adults was conducted. Lung function and MRPs were assessed. MEP and MIP were measured using a digital manometer according to the SEPAR and ATS/ERS. Protocols were applied in random order by the same trained physiotherapist. The comfort experienced with each protocol was assessed through a short questionnaire. Paired t-tests were used to compare the results from both protocols. Results A total of 31 subjects (mean age 35.7±12.4 years; 14 females; FEV1=108.3±10.5%; FVC=103.7±10%) were included. There was a significant difference between MRPs favouring the SEPAR protocol, with the mean difference being 34.9±28.1 cmH2O (p˂0.001) for MEP and 8±11.6 cmH2O (p=0.001) for MIP. ATS/ERS protocol was, however, considered more comfortable than SEPAR (p<0.005). Conclusions This study shows that, in healthy adults, higher MRPs are obtained using the SEPAR protocol. Yet, the ATS/ERS protocol is experienced as more comfortable. Future studies are needed to analyse the application of both protocols in other populations and their associated comfort.

Time-efficient, high-resistance inspiratory muscle strength training for cardiovascular aging

Cardiovascular diseases (CVD) remain the leading cause of death in developed and developing societies and aging is the primary risk factor for CVD. Much of the increased risk of CVD in midlife/older adults (i.e., adults aged 50 years and older) is due to increases in blood pressure, vascular endothelial dysfunction and stiffening of the large elastic arteries. Aerobic exercise training is an effective lifestyle intervention to improve CV function and decrease CVD risk with aging. However, <40% of midlife/older adults meet guidelines for aerobic exercise, due to time availability-related barriers and other obstacles to adherence. Therefore, there is a need for new lifestyle interventions that not only improve CV function with aging but also promote adherence. High-resistance inspiratory muscle strength training (IMST) is an emerging, time-efficient (5 min/day) lifestyle intervention. Early research suggests high-resistance IMST may promote adherence, lower blood pressure and potentially improve vascular endothelial function. However, additional investigation will be required to more definitively establish high-resistance IMST as a healthy lifestyle intervention for CV aging. This review will summarize the current evidence on high-resistance IMST for improving CV function with aging and will identify key research gaps and future directions.

Effects of respiratory muscle training on cough function in neurological disorders: A systematic review with meta-analysis

BACKGROUND

Patients with neurological disorders can present the weakness of respiratory muscle and impaired cough function. Previous studies have shown that respiratory muscle strength training (RMT) is an effective method of improving the strength of respiratory muscle. The effects of RMT on cough function remain controversial.

OBJECTIVE

We aimed to analyze randomized controlled trials (RCTs) that investigated the effects of RMT on cough function of patients with neurological disorders.

METHODS

Pubmed, Medline, Embase, and the Cochrane Library were searched electronically for RCTs. Two reviewers independently performed data extraction and quality assessment. Data were analyzed by using RevMan 5.3 software of The Cochrane Collaboration.

RESULTS

Five studies with 185 participants were included. The mean PEDro score was 6.2 (range 5 to 7), showing moderate methodological quality. Random-effects meta-analyses showed that respiratory muscle training improved peak expiratory cough flow of voluntary cough by 2.16 (95% CI 1.16 to 3.17) and involuntary cough by 2.84 (95% CI 1.29 to 4.39), with statistical significance (P < 0.0001, P = 0.0003). The experimental group had an improvement of 0.19 cmH2O (95% CI -0.12 to 0.5) on the maximal inspiratory pressure, 0.09 cmH2O (95% CI -0.23 to 0.42) on the maximal expiratory pressure, but with no statistical significance (P = 0.23, P = 0.58) between groups.

CONCLUSION

Respiratory muscle training was considered as an effective method for improving cough function. However, this review was insufficient to conclude whether respiratory muscle training was effective in improving inspiratory and expiratory muscle strength, this was opposite with previous meta-analysis. These effects might due to the small samples and different diseases.

Effect of external diaphragmatic pacing therapy on patients with chronic cor pulmonale: a randomized, controlled trial

Objectives

This study aimed to evaluate the effects of external diaphragmatic pacing (EDP) on patients with chronic cor pulmonale (CCP).

Methods

Fifty patients with CCP were enrolled in Kashgar Prefecture Second People’s Hospital in Xinjiang Uygur Autonomous Region of China from 2016 to 2017. The patients were randomized into a group that received anti-CCP therapy (negative control group) or a group that received additional EDP treatment (EDP group). We recorded and compared maximal inspiratory pressure (MIP), maximal expiratory pressure (MEP), forced expiratory volume in 1 s (FEV1), forced vital capacity (FVC), FEV1/FVC, and the 6-minute walking test between the two groups on the first and tenth days of treatment.

Results

Ten days after treatment began, MIP, FVC, and the 6-minute walking test were significantly improved in both groups. Importantly, MIP and FVC were significantly higher in the EDP group compared with the control group on the tenth day.

Conclusion

In addition to treatment for CCP, these patients can obtain extra benefit by using EDP treatment.

[Evaluation of Weaning Success in Long-Term Invasively Ventilated Patients at a Weaning Center]

Despite the use of enormous personnel and other resources in German weaning centers, approximately 20 % of patients currently fail to get weaned from mechanical ventilation (MV) and need out-of-hospital ventilation.Between 03/2015 and 11/2019, we carried out a pilot project with 33 patients (48 % female, mean age 68 ± 11 years at hospital admission) in order to re-evaluate their options of a possible weaning from MV. At this stage the patients had been invasively ventilated for 475 ± 775 days. The mean stay in our weaning center was 26 ± 19 days. 24/33 (73.53 %) patients were successfully weaned from MV. Of those, 11/24 (44 %) were discharged with non-invasive out-of-hospital ventilation. The completely weaned patients had a survival period of 3 or 12 months (92 % and 77 %), respectively. In those discharged with non-invasive ventilation, the survival period of 3 or months was 91 % and 81 %, respectively. In those discharged with invasive ventilation, this was 86 % and 71 %, respectively.The current results demonstrate that even those undergoing long-term out-of-hospital invasive ventilation can be successfully weaned from MV. Therefore, we suggest regular re-evaluations of weaning opportunities in invasively ventilated ambulatory patients.

Inspiratory Muscle Training With an Electronic Resistive Loading Device Improves Prolonged Weaning Outcomes in a Randomized Controlled Trial

OBJECTIVES

To test if the use of an inspiratory muscle training program with an electronic resistive loading device is associated with benefits as to muscle strength, weaning, and survival in the ICU.

DESIGN

Prospective randomized controlled trial.

SETTINGS

Study conducted at the ICU of a Navy's hospital, Rio de Janeiro, Brazil, from January 2016 to September 2018.

PATIENTS

Tracheostomized patients (18-86 yr) on prolonged weaning.

INTERVENTIONS

Participants were assigned to inspiratory muscle training (intervention group) or a traditional T-piece protocol (control group). In the inspiratory muscle training group, participants underwent training with an electronic inspiratory training device (POWERbreathe K-5; Technologies Ltd, Birmingham, United Kingdom).

MEASUREMENTS AND MAIN RESULTS

Changes in respiratory muscle strength and rates of ICU survival and weaning success were compared between groups. Forty-eight participants in the inspiratory muscle training group and 53 ones in the control group were included in the final analysis. The inspiratory muscle training was associated with a substantially higher gain on muscle strength as assessed by the maximal inspiratory pressure (70.5 [51.0-82.5] vs -48.0 cm H2O [36.0-72.0 cm H2O]; p = 0.003) and the timed inspiratory effort index (1.56 [1.25-2.08] vs 0.99 cm H2O/s [0.65-1.71 cm H2O/s]; p = 0.001). Outcomes at the 60th day of ICU were significantly better in the intervention group regarding both survival (71.1% vs 48.9%; p = 0.030) and weaning success (74.8% vs 44.5%; p = 0.001).

CONCLUSIONS

The use of an inspiratory muscle training program with an electronic resistive loading device was associated with substantial muscle strength gain and positive impacts in two very relevant clinical outcomes: the rates of ICU survival and successful weaning.

Mechanical ventilation strategy for pulmonary rehabilitation based on patient-ventilator interaction

Mechanical ventilation is an effective medical means in the treatment of patients with critically ill, COVID-19 and other pulmonary diseases. During the mechanical ventilation and the weaning process, the conduct of pulmonary rehabilitation is essential for the patients to improve the spontaneous breathing ability and to avoid the weakness of respiratory muscles and other pulmonary functional trauma. However, inappropriate mechanical ventilation strategies for pulmonary rehabilitation often result in weaning difficulties and other ventilator complications. In this article, the mechanical ventilation strategies for pulmonary rehabilitation are studied based on the analysis of patient-ventilator interaction. A pneumatic model of the mechanical ventilation system is established to determine the mathematical relationship among the pressure, the volumetric flow, and the tidal volume. Each ventilation cycle is divided into four phases according to the different respiratory characteristics of patients, namely, the triggering phase, the inhalation phase, the switching phase, and the exhalation phase. The control parameters of the ventilator are adjusted by analyzing the interaction between the patient and the ventilator at different phases. A novel fuzzy control method of the ventilator support pressure is proposed in the pressure support ventilation mode. According to the fuzzy rules in this research, the plateau pressure can be obtained by the trigger sensitivity and the patient's inspiratory effort. An experiment prototype of the ventilator is established to verify the accuracy of the pneumatic model and the validity of the mechanical ventilation strategies proposed in this article. In addition, through the discussion of the patient-ventilator asynchrony, the strategies for mechanical ventilation can be adjusted accordingly. The results of this research are meaningful for the clinical operation of mechanical ventilation. Besides, these results provide a theoretical basis for the future research on the intelligent control of ventilator and the automation of weaning process.

Could Physical Therapy Interventions Be Adopted in the Management of Critically Ill Patients with COVID-19? A Scoping Review

As part of COVID-19 consequences, it has been estimated that 5% of patients affected by this disease will require admission to the intensive care unit (ICU), and physical therapy techniques have been implemented in patients with other conditions admitted to ICU. The aim of the present study is to summarize all the available information about the implementation of physical therapy management in critically ill patients. From three clinical guidelines already published, we performed a search in PubMed, Scopus, ScienceDirect, and CINAHL, including systematic reviews, clinical guidelines, and randomized controlled trials, among others. Data extraction was performed independently by two reviewers. Quality assessment was developed through the AMSTAR-2 tool and PEDro Scale. A narrative synthesis was performed and 29 studies were included. The information extracted has been classified into four folders: ICU environment in COVID-19 (security aspects and management of the patient), respiratory physiotherapy (general indications and contraindications, spontaneously breathing and mechanically ventilated patient approaches), positional treatment, and exercise therapy (safety aspects and progression). The implementation of physiotherapy in patients affected with COVID-19 admitted to the ICU is a necessary strategy that prevents complications and contributes to the stabilization of patients in critical periods, facilitating their recovery.

Current developments and future directions in respiratory physiotherapy

Respiratory physiotherapists have a key role within the integrated care continuum of patients with respiratory diseases. The current narrative review highlights the profession's diversity, summarises the current evidence and practice, and addresses future research directions in respiratory physiotherapy. Herein, we describe an overview of the areas that respiratory physiotherapists can act in the integrated care of patients with respiratory diseases based on the Harmonised Education in Respiratory Medicine for European Specialists syllabus. In addition, we highlight areas in which further evidence needs to be gathered to confirm the effectiveness of respiratory therapy techniques. Where appropriate, we made recommendations for clinical practice based on current international guidelines.