• The literature on saline instillation has only addressed the issue of short term changes in oxygen saturation after the procedure that can be managed by monitoring or short-term increases in baseline FiO2. Saline instillation can augment the increased clearance of greater volume of secretions removed as demonstrated by Schreuder F.M. and Jones U.F. (2004). The effect of saline instillation on sputum yield and oxygen saturation measurements in adult intubated patients: single subject design. Physiotherapy 90: 108-109)
  
  
• the use of saline can be cliniclly useful when secretions are tenacious despite the lack of supporting evidence
  
  
• I don't think the recommendation should be "do not instill saline", but "instill as indicated eg tenacious secretion
  
  
• Diasagree, Regular suciton should be done. Saline can be useful and most studies claiming harm or no effect are very poor
  

• do not think the patient needs to be 'clear' of secretions. I think an assessment of the patients ability to clear the secretions they have
  
  
• I could see that accepting this recommendation could result is practice where this criteria would be satisfied via a simple ETT suction prior to extubation by the nurses (as per an extubation protocol, which is fine for the majority of patients), or cursory anterior upper chest auscultation from nurse which does not reveal added sounds, with subsequent assumption of no secretions being present. However I think for patients with EXCESSIVE Secretions, physiotherapy assessment +/- intervention prior to extubation is prudent; clearance of secretions from peripheral as well as central airways could then be attempted, along with assessment of respiratory muscles strength / ability to spontaneously cough. The challenge would be to agree on what is "Excessive", and what to do if the extubation is ready to occur but the physio is not around
  
• In addition to being relatively clear of secreions the patients needs to be able to be relaively co-operative and be able to cough and move effectively
  
  
• Disagree, can be extubated with secretions and PT not necessary
  
  

There is insufficient evidence to support the use of a recruitment manouvre in this patient population and is currently not reccomended practice in the ARDSnet protocol

Dyhr's study was extremely small (n=8) and despite the cross-over design, I don't know if it is appropriate to base a recommendation on such a small study. I also think the quality of evidence should be downgraded for the same reasons - there is a high risk of bias in this trial. We have shown in a paediatric study that a recruitment manoeuvre after suctioning was not found to significantly improve compliance or oxygenation when compared to a control group (Morrow et al, 2007. AJP). Of course, the paediatric situation is very different to that of adults but it is interesting that in our sample size of nearly 50 there were some patients who did respond to the RM - if we had sampled differently (and limited the sample size to that of Dhyr's study) - we may have gotten very different results which would have consituted a Type 1 error

Disagree airway should be routinely suciotned but closed suction done

• There is insufficient evidence to support this technique
  
  Why 27 hours - did you mean 24? Further evidence will show that theRM is helpful in select populations. I am not impressed that RM acheives any secretion removal effect
  
  Any studies on ARDS or ALI should consider whther intra or extra pulmonary type. This will alyer effect of recruitment manuever Agree there are other studies showing use of RM