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Delphi Study Results

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Delphi Study Results
 

Phase 3: Summary of Comments

Group 2: Changes on CxR


BEST PRACTICE RECOMMENDATIONS:
CONSENSUS FORMULATION BY PANEL


(Consensus reached defined as 75% agreement. At least 6/7 responders agreed)

ATELECTASES

CPT MANAGEMENT OF ATELECTASIS
When volume loss is visible on CxR a CPT package of care that includes MHI; gravity assisted positioning if possible or modified position if contra indicated and suctioning might be initiated. This package should not be offered less than twice daily (Krause et al 2000) but optimally might be applied hourly for six hours (Stiller et al 1996). STRENGTH OF RECOMMENDATION: Weak recommendation: Implementation of this regime provided radiographic evidence of the resolution of areas of collaps in four RCT’s (Stiller et al 1996; Krause et al 2000; Suh-Hwa Maa 2005; Crowe et al 2006). The effect of this outcome on LOS or TOV has not been established QUALITY OF EVIDENCE: based on low quality evidence: 4 RCT’s (Stiller et al 1996; Krause et al 2000; Suh-Hwa Maa 2005; Crowe et al 2006) providing consistent results but downgraded for imprecision and moderate risk of bias.

POSTED COMMENTS:

  • I have never been impressed that MHI is effective in treating post-operative atelectais. MHI as a simluated cough to clear secretions seems important.

USE OF KINETIC BEDS: There is currently NO evidence to justify the purchasing of these beds but if kinetic therapy beds are available in the unit it might be initiated routinely for unresponsive critically ill patients admitted to the unit.
STRENGTH OF THE RECOMMENDATION: BASED ON THE INCORPORATION OF THE META ANALYSIS BY Goldhill et al 2007. Weak recommendation: In a systematic review and meta anlysis of the prophylactic use of kinetic beds indicated that this intervention did not efffect mortality (1.02 CI 0.77;1.34); time on ventilator (-1.06 CI -2.86 ;0.74) or LOS (-0.9 CI -2.82;1.01) it did however prevent the development of pneumonia (0.38 CI 0.27;0.53). ADAPT THE QUALITY OF EVIDENCE: Change from moderate to high quality evidence: Include the results from Goldhill DR et al 2007

POSTED COMMENTS:

  • From the results of Goldhill there is evidence to support the use of kinetic beds in reducing the incidence of pneumonia. However if this had no affect on TOV or mortality the clinincal significance of the finding couls be questioned
VAP

CPT PREVENTION STRATEGY: Routine twice daily CPT physiotherapy to all patients in ICU to prevent VAP is NOT RECOMMENDED at this time. MOTIVATION: Two studies investigated the effect of a routine twice daily physiotherapy package (position; suction; MHI or vibrations) on the incidence of VAP (Ntoumenopoulos et al 1998; Ntoumenopoulos et al 2002) with conflicting results. The physiotherapeutic package of care provided in two RCT’s (Ntoumenopoulos et al 1998; Ntoumenopoulos et al 2002) did not affect TOV; ICU LOS or mortality. It showed a tendency to reduce the incidence of VAP (diagnosed by CPIS) in one study. The quality of evidence is downgraded to low due to imprecision of sample and poor methodological quality

POSTED COMMENTS:

  • THE STUDY BY NTOUMENOPOULOS et al 20002 only ENROLLED PATIENTS WITH CLEAR CXR ON ADMISSION hence no evidecne of pnerumonia. It was also a requirement that they have been intubated and ventilated for at least 48 hours. Treatment was initiated upon admission to the ICU (treatment or control), we did not wait for 48 hours before the start of physiotherapy!!!

  • Disagree The first study by Ntoumenopoulos was underpowered but the 2nd is still an RCT. It is impossible to control all variables, and would be difficult to do a study more tightly controlled than this. I was disappointed it wasn't even mentioned in the recent review in ICM, pointing to the fact that narrative review is dangerous as it reflects the bias of the authors .


PATIENT POSITION:
All intubated patients (that do not present with contra indications) should be nursed in a semi-recumbent position with the goal of 45 degrees head up to prevent the development of VAP. STRENGTH OF RECOMMENDATION: Strong recommendation This positioning resulted in a decrease in the incidence of VAP in one clinical guideline (Dodek et al 2004) and one systematc review (Gastmeier et al (2007). The cost and burden of implementing a basic nursing position for all intubated patients in ICU is very low compared to the possibility of preventing the development of VAP.
QUALITY OF EVIDENCE:
moderate quality evidence: One well developed clinical guideline (Dodek et al 2004) scoring above 75 for all the domains of the AGREE instrument and a systematic review updating the evidence (Gastmeier et al 2007). Evidence is downgraded due to imprecision of data

POSTED COMMENTS:

  • Agree but evidence not strong

SUCTION SYSTEM : No suction system (open or closed) is superior in the prevention of VAP in intubated patients. The choice of which system to use must be based on availability. STRENGTH OF RECOMMENDATION: Strong recommendation None of the systems (OSS or CSS) reported a decrease in the incidence of VAP. Intubated patients are suctioned regularly in ICU and claims have been made to the effectiveness of CSS over OSS. It is therefore important to recognize that no system is superior QUALITY OF EVIDENCE: based on high quality evidence from one meta analysis evaluating 9 RCT’s.

POSTED COMMENTS:

  • No preference for VAP, but in patients on PEEP > 10 subject to de-recruitment - closed should be perferred
EXESSIVE SECRETIONS

PATIENT POSITION: When excessive secretions are identified in intubated and ventilated patient the patient might be placed in a gravity assisted drainage position for at least 15 minutes twice daily.

STRENGTH OF RECOMMENDATION: Weak recommendation The addition of a gravity assisted drainage position to MHI and suction significantly increased the wet weight of sputum in one randomized cross over design study (Berney et al 2004). No harm was reported but whether this increased volume of secretions removed will affect LOS or TOV is not clear. QUALITY OF EVIDENCE: based on moderate quality evidence one randomized crossover design downgraded due to imprecision of the data (Berney et al 2004).

POSTED COMMENTS:

  • Agree in selected patients. More invasive haemodynamic data required in order to determine effect on work of heart

EXTUBATION: The patient's ability to cough effectively should be assessed prior to extubation.The patient might be extubated when the therapist is available to assist the patient in secretion clearance through FET or directed coughing following extubation. MOTIVATION: The therapist is the member of the interdisciplinary team concerned with the patient's ability to effectively clear his/her airway and should therefor be part of the team management of the extubation process. The proposed statement is vague enough to make the potential link between extubation failure and therapist involvement without current available evidence evaluating this. We do have evidence that poor cough response and exessive secretions are independently associated with extubation failure. Salam et al (2004) reported CPF (cough peak flow) 60 l/min or less were nearly five times as likely to fail extubation compared to those with CPF higher than 60 l/min (risk ratio [RR]=4.8; 95% CI=1.4–16.2). Patients with secretions of more than 2.5 ml/h were three times as likely to fail (RR=3.0; 95% CI=1.0–8.8) as those with fewer secretions.

POSTED COMMENTS:

  • I would be happier to accept a combination of the two phrases, rather than acceptance of one over the other. I think there is merit in both elements. eg: "The patient's ability to cough effectively should be assessed prior to extubation and they should be clear of secretions before extubation is attempted.
  • The therapist does not always have to be preset, but should be part of the team advsing on extbation. The amount of secretions are not as important as ability to handle secretions, sp peak flow is important
  • I agree it si certainly iodeal if the therapist is present particularly when there is a high suspicion of extubation failure - given the independent variables of failure are known
  • I am not sure what is being asked here. I would agree that a patient can be extubated if an assessment of the patients ability to cough and clear secretions has been made. The role of the therapist is important in assisting the patient - although the evidence for this is admittedly lacking.

 


MANUAL TECHNIQUES: There is a lack and poor quality evidence to make any recommendations with regards to the use of manual techniques at this time. One randomized cross over design study (Unoki et al 2005) failed to report any improvement to outcome when adding manual vibrations to treatment consisting of sidelying and suction. There were however limitations identified in methodological quality and the directness of evidence. Both the duration and the skill of application are questionable. Expert opinion (Branson 2007) discourages routine application

POSTED COMMENTS:

  • Chest wall vibrations can increase expiratory flow rates, Maclean 1989 and May. Be of se in patients who are heavily or have poor couch response to suctioning, Ntoumenopoulos and Shipsides2007
RECRUITMENT MANOUVRE

HYPERINFLATION (Ventilator or manual) might be included in the management of intubated and ventilated adult patients on evidence of CxR infiltrates; volume loss; excessive secretions or decreased oxygenation. STRENGTH OF RECOMMENDATION: Weak recommendation Hyperinflation resulted in improvement in pulmonary compliance and secretion production in one randomized cross over design study (Hodgson et al 2000) when compared to a no intervention control. No adverse effects were recorded. The effect on LOS or TOV is not clear. QUALITY OF EVIDENCE: Based on moderate quality evidence downgraded due to imprecision of data and sample


Ventilator Hyperinflation:VHI is the prefered method of hyperinflation in patients that are ventilated on PEEP levels of >7.5cmH20. Patients ventilated at these levels of PEEP should not be disconnected for hyperinflation as there is no clinical advantage in using MHI to clear secretions. In patients with PEEP levels <7.5cmH20 either VHI or MHI can be used. If MHI is used include a PEEP valve and set at the same level as the ventilator. STRENGTH OF RECOMMENDATION: Weak recommendation A greater improvement in pulmonary compliance when comparing VHI to MHI was observed in one randomized crossover design study (Savian et al 2006) while there was no difference in the volume of wet weight sputum removed in two studies comparing VH to MHI (Berney et al 2002; Savian et al 2006). No harm was reported with adherence to strict criteria, but effect on LOS and TOV has not been established. QUALITY OF EVIDENCE: Based on moderate quality evidence provided by two crossover design studies (Berney et al 2002; Savian et al 2006). The quality of the evidence is downgraded to moderate quality due to the imprecision of data

POSTED COMMENTS:

  • If PEEP is < 7.5 I don't think it is essential to use a PEEP valve
  • Agree with the caveat that in patients on PEEP subject to de-recruitment - VHI is safer




REBREATHING BAG is the preferred choice of equipment when considering manual hyperinflation to remove secretions. STRENGTH OF RECOMMENDATION: Weak recommendation Rebreathing bag cleared more secretions when compared to a self inflating bag in one randomized crossover design study (Hodgson et al 2007). No difference was observed in the pulmonary compliance or oxygenation. Although no harm was observed the effect of this outcome on LOS and TOV has not been established. QUALITY OF EVIDENCE: based on moderate quality evidence from one randomized crossover design study downgraded for imprecision of sample.

POSTED COMMENTS:

  • Disagree - the volume and pressure are important - how they are achieved is not
 
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