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Shkurka E, Wray J, Peters MJ, Shannon H. Chest physiotherapy for mechanically ventilated children: a survey of current UK practice. Physiotherapy 2022; 119:17-25. [PMID: 36706622 DOI: 10.1016/j.physio.2022.11.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 11/02/2022] [Accepted: 11/12/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVES Chest physiotherapy is a treatment option for mechanically ventilated children. However, there is a lack of consensus regarding its value and informal discussions suggest variation in practice. This study describes chest physiotherapy practices for mechanically ventilated children in the UK and explores clinical decision making related to its delivery. DESIGN Cross-sectional study, using an anonymous, electronic survey. PARTICIPANTS Qualified physiotherapists working in UK NHS paediatric intensive care units (PICUs). RESULTS The response rate was 61% (72/118), this included physiotherapists from 26/27 (96%) PICUs. All participants reported using manual hyperinflations and position changes 'always' or 'often'. Variation in practice was evident for some techniques, including Metaneb® and percussion. DNase (99%, 71/72) and hypertonic saline (90%, 65/72) were the most frequently used mucoactives: 91% (59/65) of physiotherapists reported only nebulising hypertonic saline and 69% (49/71) use both nebulised and instilled DNase. Use and delivery of N-acetylcysteine was inconsistent (nebulised only 55%, 26/47; instilled only 15%, 7/47; both 30%, 14/47). Chest physiotherapy was most commonly delivered with a nurse (67%, 48/72). Clinical decision making processes were comparable between physiotherapists and encompassed three main elements: individual patient assessment, involvement of the multidisciplinary team, and risk versus benefit analysis. CONCLUSIONS A range of chest physiotherapy treatments and adjuncts were used with ventilated children. Variation was apparent and may be due to individual preferences of those training staff or local policies. Pragmatic, interventional studies are required to determine best practice. Further exploration is necessary to understand the variation in practice and intricacies of decision making.
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Affiliation(s)
- Emma Shkurka
- Physiotherapy Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK; Infection, Immunity & Inflammation Department, UCL Great Ormond Street Institute of Child Health, London, UK.
| | - Jo Wray
- Centre for Outcomes and Experience Research in Children's Health, Illness and Disability, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Mark J Peters
- Infection, Immunity & Inflammation Department, UCL Great Ormond Street Institute of Child Health, London, UK; Paediatric Intensive Care Unit, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Harriet Shannon
- Infection, Immunity & Inflammation Department, UCL Great Ormond Street Institute of Child Health, London, UK
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Apps C, Morris K, Allum L, Shah N, Mylott L, Hinton I, Spencer D, Farley R, Mitchell H, Osman L. Use of mechanical insufflation exsufflation and manual techniques in an intubated adult with COVID-19 positioned in prone-A case study. PHYSIOTHERAPY RESEARCH INTERNATIONAL 2022; 27:e1961. [PMID: 35716377 PMCID: PMC9349782 DOI: 10.1002/pri.1961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 04/27/2022] [Accepted: 05/07/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE The therapeutic benefits of prone positioning have been described over the last 50 years culminating in a systematic review supporting this management strategy for patients with severe hypoxaemic respiratory failure. Early work detailing treatment approaches for COVID-19 have advocated the use of prone positioning. Limited data exists regarding physiotherapy intervention in patients with COVID-19 owing to the recent emergence of this novel disease. Despite the acknowledged beneficial effects of physiotherapy on secretion clearance and lung recruitment in the general critical care population, there is a lack of evidence pertaining to physiotherapeutic intervention for acutely unwell intubated adults in prone lying. METHODS This case study report follows the CARE case report guidelines. One patient with COVID-19 pneumonitis who underwent physiotherapy intervention in prone lying is discussed. Informed consent was gained from next of kin for data to be published. RESULTS Treatment techniques including mechanical insufflation-exsufflation in prone were feasible and well tolerated by this patient with only transient adverse effects noted. Treatment techniques assisted with secretion clearance. DISCUSSION Further work on safety, feasibility, and efficacy of physiotherapy intervention in patients with and without COVID-19 in prone will contribute to the evidence base on this subject.
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Affiliation(s)
- Chloe Apps
- Critical Care Research GroupGuy's and St. Thomas' NHS Foundation TrustLondonUK
- Physiotherapy DepartmentGuy's and St. Thomas' NHS Foundation TrustLondonUK
- GKT School of Medical EducationKing's College LondonGuy's CampusLondonUK
| | - Kelly Morris
- Physiotherapy DepartmentGuy's and St. Thomas' NHS Foundation TrustLondonUK
| | - Laura Allum
- Lane Fox Clinical Respiratory Physiology Research CentreSt. Thomas' HospitalGuy's and St. Thomas' NHS Foundation TrustLondonUK
- Florence Nightingale Faculty of NursingMidwifery and Palliative CareKing's College LondonLondonUK
- National Institute for Health Research Biomedical Research Centre, Guy's and St. Thomas' NHS Foundation Trust and King's College LondonLondonUK
| | - Neeraj Shah
- Lane Fox Clinical Respiratory Physiology Research CentreSt. Thomas' HospitalGuy's and St. Thomas' NHS Foundation TrustLondonUK
| | - Laura Mylott
- Physiotherapy DepartmentGuy's and St. Thomas' NHS Foundation TrustLondonUK
| | - Isobel Hinton
- Physiotherapy DepartmentGuy's and St. Thomas' NHS Foundation TrustLondonUK
| | - Danielle Spencer
- Physiotherapy DepartmentGuy's and St. Thomas' NHS Foundation TrustLondonUK
| | - Rachel Farley
- Physiotherapy DepartmentGuy's and St. Thomas' NHS Foundation TrustLondonUK
| | - Hannah Mitchell
- Physiotherapy DepartmentGuy's and St. Thomas' NHS Foundation TrustLondonUK
| | - Leyla Osman
- Physiotherapy DepartmentGuy's and St. Thomas' NHS Foundation TrustLondonUK
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Connolly B, Barclay M, Blackwood B, Bradley J, Anand R, Borthwick M, Chikhani M, Dark P, Shyamsundar M, Warburton J, McAuley DF, O'Neill B. Airway clearance techniques and use of mucoactive agents for adult critically ill patients with acute respiratory failure: a qualitative study exploring UK physiotherapy practice. Physiotherapy 2020; 108:78-87. [PMID: 32721607 DOI: 10.1016/j.physio.2020.06.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To explore and describe current UK physiotherapy practice relating to airway clearance techniques and mucoactive agents in critically ill adult patients with acute respiratory failure in the intensive care unit. DESIGN A descriptive, qualitative study using focus group interviews. Focus groups were audio-recorded, independently transcribed, and data analysed thematically. Participants Senior, experienced physiotherapists, clinically active in critical care. RESULTS Fifteen physiotherapists participated in four interview sessions. Five themes emerged describing airway clearance techniques: 'Repertoire of airway clearance techniques', 'Staffing and skillset', 'Commencing respiratory physiotherapy', 'Technique selection', and 'Determining effectiveness' were themes related to airway clearance techniques. Five themes were also identified in relation to mucoactive agents: 'Use in clinical practice', 'Decision to commence', 'Selection of agent', 'Stopping mucoactive agents', and 'Determining effectiveness'. A summary of key features of standard practice was developed. CONCLUSIONS Standard UK physiotherapy practice of airway clearance techniques is variable, but patient-centred and targeted to individual need, with adjunctive use of mucoactive agents to enhance and optimise patient management if required. Based on this study, key features of airway clearance techniques have been summarised to help capture standard care, which could be used in future trials involving ACT as part of usual care.
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Affiliation(s)
- Bronwen Connolly
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK; Lane Fox Clinical Respiratory Physiology Research Centre, Guy's and St. Thomas' NHS Foundation Trust, London, UK; Centre for Human and Applied Physiological Sciences, King's College London, London, UK; Department of Physiotherapy, The University of Melbourne, Australia.
| | - Matthew Barclay
- Lane Fox Clinical Respiratory Physiology Research Centre, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Bronagh Blackwood
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Judy Bradley
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Rohan Anand
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Mark Borthwick
- John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Marc Chikhani
- Nottingham University Hospitals NHS Trust, Nottingham, UK; Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Paul Dark
- Division of Infection, Immunity and Respiratory Medicine, NIHR Biomedical Research Centre, Manchester University NHS Foundation Trust, University of Manchester, Manchester, UK
| | - Murali Shyamsundar
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - John Warburton
- Bristol Royal Infirmary, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Daniel F McAuley
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Brenda O'Neill
- Centre for Health and Rehabilitation Technologies, Institute of Nursing and Health Research, Ulster University, Newtownabbey, UK. https://twitter.com/@OneillBon
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Anand R, McAuley DF, Blackwood B, Yap C, ONeill B, Connolly B, Borthwick M, Shyamsundar M, Warburton J, Meenen DV, Paulus F, Schultz MJ, Dark P, Bradley JM. Mucoactive agents for acute respiratory failure in the critically ill: a systematic review and meta-analysis. Thorax 2020; 75:623-631. [PMID: 32513777 PMCID: PMC7402561 DOI: 10.1136/thoraxjnl-2019-214355] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 04/08/2020] [Accepted: 04/21/2020] [Indexed: 12/29/2022]
Abstract
PURPOSE Acute respiratory failure (ARF) is a common cause of admission to intensive care units (ICUs). Mucoactive agents are medications that promote mucus clearance and are frequently administered in patients with ARF, despite a lack of evidence to underpin clinical decision making. The aim of this systematic review was to determine if the use of mucoactive agents in patients with ARF improves clinical outcomes. METHODS We searched electronic and grey literature (January 2020). Two reviewers independently screened, selected, extracted data and quality assessed studies. We included trials of adults receiving ventilatory support for ARF and involving at least one mucoactive agent compared with placebo or standard care. Outcomes included duration of mechanical ventilation. Meta-analysis was undertaken using random-effects modelling and certainty of the evidence was assessed using Grades of Recommendation, Assessment, Development and Evaluation. RESULTS Thirteen randomised controlled trials were included (1712 patients), investigating four different mucoactive agents. Mucoactive agents showed no effect on duration of mechanical ventilation (seven trials, mean difference (MD) -1.34, 95% CI -2.97 to 0.29, I2=82%, very low certainty) or mortality, hospital stay and ventilator-free days. There was an effect on reducing ICU length of stay in the mucoactive agent groups (10 trials, MD -3.22, 95% CI -5.49 to -0.96, I2=89%, very low certainty). CONCLUSION Our findings do not support the use of mucoactive agents in critically ill patients with ARF. The existing evidence is of low quality. High-quality randomised controlled trials are needed to determine the role of specific mucoactive agents in critically ill patients with ARF. PROSPERO REGISTRATION NUMBER CRD42018095408.
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Affiliation(s)
- Rohan Anand
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Daniel F McAuley
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Bronagh Blackwood
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Chee Yap
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Brenda ONeill
- Centre for Health and Rehabilitation Technologies, Institute of Nursing and Health Research, Ulster University, Newtownabbey, UK
| | - Bronwen Connolly
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK.,Department of Physiotherapy, The University of Melbourne, Melbourne, Victoria, Australia.,Lane Fox Respiratory Unit, Guy's and Saint Thomas' NHS Foundation Trust, London, UK
| | - Mark Borthwick
- Oxford Critical Care, Oxford University Hospitals NHS Foundation Trust, Oxford, Oxfordshire, UK
| | - Murali Shyamsundar
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - John Warburton
- Bristol Royal Infirmary, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - David van Meenen
- University of Amsterdam, Academic Medical Center Department of Intensive Care Medicine, Amsterdam, Noord-Holland, Netherlands
| | - Frederique Paulus
- University of Amsterdam, Academic Medical Center Department of Intensive Care Medicine, Amsterdam, Noord-Holland, Netherlands
| | - Marcus J Schultz
- University of Amsterdam, Academic Medical Center Department of Intensive Care Medicine, Amsterdam, Noord-Holland, Netherlands.,Mahidol University, Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand.,Nuffield Department of Medicine, Oxford University, Oxford, Oxfordshire, UK
| | - Paul Dark
- Division of Infection, Immunity and Respiratory Medicine, NIHR Manchester Biomedical Research Centre, The University of Manchester, Manchester, UK
| | - Judy M Bradley
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
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