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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 8: Comments on the technique of MHI

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

POSTED COMMENTS:

  • If you are using te Laerdal bag, you won't be maintaining the pressure in the bag during expiration, thus I believe the last item of this subject should be reevaluated

  • The recomedndations are based on using a Laerdel circuit which is not the preferred circuit in the literature. The Mapleson circuit can only use a single hand squeeze

  • Paratz (2002, 2006) used 30cmH20
 

SUBJECT 9: Comments on the duration of MHI

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

POSTED COMMENTS:

  • Duration until clinically indicated eg added sounds, fremitus, ventilation, gas exchange, volume of secretions

  • There is no proof that these durations are effective

  • Again, perhaps 20 minutes is too much for some patients
 

SUBJECT 10: Comments on the addition of the headdown tilt position

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

POSTED COMMENTS:

  • I have not seen any evidence supporting the head-down tilt, only evidence of complications (some serious) relating to this practice
 

SUBJECT 11: Comments on the pathologies contra indicated for use of a hyperinflation manouvre

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

POSTED COMMENTS:

  • ARDS may respond well to lung recruitment

  • Constantin JM et al Respiratory effects of different recruitment maneuvers in acute respiratory distress syndrome. Crit Care. 2008 Apr 16;12(2):R50. [Epub ahead of print] PMID: 18416847

  • In early ARDS it is beneficial to use a recruitment manouvre

  • A head injury is not an avsolute contra-indication as the level of intra-cranial pressure is the issue not the head injury per se

  • Would add hyperinflation, pneumothorax or previous pneumothorax.

  • Recruitment manouvre is often applied to patients with ARDS and have been shown to improve lung compliance and reexpand atelectasis. However the patient should be carefully assessed and not present with the criteria mentioned in the item above
 

SUBJECT 12: Comments on pulmonary criteria used to decide on the safety of the recruitment manouvre

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

POSTED COMMENTS:

  • If you are using ventilator hyperinflation then peep 10 should be more than acceptable see Berney 2004

  • Peak inspiratory pressures are not meaningful if the patient is being ventilated in a pressure controlled strategy. A measure of pulmonary compliance would be more meaningful

  • Recruitment manouvre can be performed in patients with PEEP over 10, but always monitoring the PIP during the technique
 

SUBJECT 13: Comments on the ventilator settings for VHI

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

POSTED COMMENTS:

  • Could also use what is termed peep or cpap recruitment Constantin JM, Jaber S, Futier E, Cayot-Constantin S, Verny-Pic M, Jung B, Bailly A, Guerin R, Bazin JE.

  • Respiratory effects of different recruitment maneuvers in acute respiratory distress syndrome. Crit Care. 2008 Apr 16;12(2):R50. [Epub ahead of print] PMID: 18416847 [PubMed - as supplied by publisher]

  • The settings using a square wave form and 20l/min refelct ventilators at the time of the research. Newer modes of ventilation such as pressure regulated volume control delivered in SIMV mode can be used effectively to deliver VHI
 

SUBJECT 14: Comments on the technique of VHI

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

POSTED COMMENTS:

  • 20 minutes is perhaps too long for some patients. I believe it would be fair to say that you perform the technique untill you either see an imprvement in compliance, improvement on breath sound, or removal of larg amounts of secretion (depending on the aim of the technique)
 

SUBJECT 15: Comments on the dosage of physiotherapy intervention for VAP and atelectasis

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

POSTED COMMENTS:

  • Depends on clinical response eg changes in breath sounds, clinical condition so may not be needed as often as hourly for six hours as advised by Stiller

  • If atelectasis is present one effective session should assist in resolution, not hourly

  • I agree with the VAP recommendation

  • Agree with recommendation of the Stiller article for atelectasis
    Disagree with the recommendation of Ntoumenopolous for infiltrates - poorly powered study
 
 
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