Home
Clinical Algorithm Overview
Pulmonary Function
Mobility
Delphi Study Results
Contact Details
 
 
 
 
 
 
 
 
 
 
 
 
 
Delphi Study Results
 

Phase 1: Summary of Comments

Group 2: Changes on CxR

Clinical algorithm for the management of intubated patients presenting with changes visible on CxR

SUBJECT 1: Comments on the criteria used to decide on the use of CPT techniques

AGREEMENT: 4/7
DISAGREEMENT: 2/7
NO RESPONSE: 1/7

POSTED COMMENTS:

  • Would add hypercarbia as an indication for treatment as it may be expected to occur with secretion retention or volume loss/atelectasis.

  • Bilateral infiltrates and poor oxygenation are not sufficient evidence to commence hyperinflation unless accompanied by volume loss of CXR or the presence of excessive pulmonary secretions. In ARDS there is bilateral pulmonary inflitrates and poor oxygenation but no evidence to commence hyperinlfation

 

SUBJECT 2: Comments on the positioning of the patient

AGREEMENT: 6/7
DISAGREEMENT: 0/7
NO RESPONSE: 1/7

POSTED COMMENTS:

  • No Comments
 

SUBJECT 3: Comments on criteria documented to decide on cardiovascular safety of the hyperinflation maneuver

AGREEMENT: 3/7
DISAGREEMENT: 3/7
NO RESPONSE: 1/7

POSTED COMMENTS:

  • If invasive cardiac monitoring being used eg PICCO or LIDCO would be better to monitor cardiac output during lung recruitment as BP and heart rate not sensitive measures of changes in cardiac output

  • A HR of 135 is not stable, need to also look at invasive haemodynamics ie CO, SVRI

  • Personally I would consider a RM if MAP>65 (but agree that it needs to be stable / not vary >15 with position changes. I would consider RM if SaO2<90 - esp if acute collapse suspected

  • I would not necessarily feel the need to discuss with intensivist prior to RM
 

SUBJECT 4: Comments on the choice of equipment to use for the hyperinflation manouvre

AGREEMENT: 3/7
DISAGREEMENT: 3/7
NO RESPONSE: 1/7

POSTED COMMENTS:

  • VHI and MHI are equally effective

  • Generally my first choice would be the manual bag (spring loaded), particularly if I felt airway clearance was the priority; ability to manipulate flow rates, I:E ratios, PIP, on a breath by breath basis may be preferable.

    If high respiratory parameters, infection control issues, or collapse is major issue then I would consider the ventilator as primary/first option. I would never consider a silicon bag as a preference for hyperinflation

  • The evidence would suggest that either VHI or MHI could be used safely and effectively. VHI is however more reproducible for research purposes
 

SUBJECT 5: Comments on the optimal pressures/volume to include when using a ventilator hyperinflation technique

AGREEMENT: 5/7
DISAGREEMENT: 1/7
NO RESPONSE: 1/7

POSTED COMMENTS:

  • You do not have to reach a Peak pressure of 40mmHg to be effective
 

SUBJECT 6: Comments on the optimal pressures when using a MHI technique

AGREEMENT: 5/7
DISAGREEMENT: 1/7
NO RESPONSE: 1/7

POSTED COMMENTS:

  • Paratz (2002, 2006) used 30cmH2O, not 35cmH2O
 

SUBJECT 7: Comments on the components included into a MHI circuit

AGREEMENT: 3/7
DISAGREEMENT: 3/7
NO RESPONSE: 1/7

POSTED COMMENTS:

  • Ideal to use blender but not essential may connect MHI to O2 flow meter alone without blender

  • There is no proof that the Fio2 on preset level is preferable to that of 1.0

  • Only the Laedel circuit requires 15l/min of fresh gas flow other circuits require 10-12l/min. There is no evidence to support the use of a manometer in the circuitry. Manual hyperinflation has been successfully and safely performed in the literature without the use of a PEEP valve provided appropriate safety limits are in place

 

 
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
 
Copyright © 2008, All rights reserved, Design by Ck