Intensive Care - manual and ventilator hyperinflation
SEE ALSO – ICU – Physiotherapy Overview

Ahmed F, Shafeeq AM, Moiz JA et al (2010) Comparison of effects of manual versus ventilator hyperinflation on respiratory compliance and arterial blood gases in patients undergoing mitral valve replacement. Heart Lung; 39(5):437-43. doi: 10.1016/j.hrtlng.2009.10.006
• manual hyperinflation appears to produce longer lasting improvements in oxygenation than ventilator hyperinflation

Allen GB, Suratt BT, Rinaldi L, Petty JM, Bates JH (2006) Choosing the frequency of deep inflation in mice: balancing recruitment against ventilator-induced lung injury. Am J Physiol Lung Cell Mol Physiol, 291, L710–L717
www.ncbi.nlm.nih.gov/pubmed/16698851
• low tidal volume ventilation protects against ventilator-induced lung injury but can promote atelectasis
• periodic deep inflation can open alveoli, but if delivered too frequently may cause damage by repeated overdistention
frequent ventilator deep breaths can safely improve gas exchange and lung mechanics and may confer protection from biotraum

Anderson A, Alexanders J, Sinani C et al (2015) Effects of ventilator vs manual hyperinflation in adults receiving mechanical ventilation: a systematic review of randomised clinical trials. Physiotherapy; 101(2):103-110. doi:10.1016/j.physio.2014.07.006
• MH and VH have similar effects on secretion clearance, oxygenation and cardiovascular stability

Anning L, Paratz J, Wong WP et al (2003) Effect of manual hyperinflation on haemodynamics in an animal modal. Respir Care, 8, 3, 155-63
www3.interscience.wiley.com/cgi-bin/abstract/112510534/ABSTRACT
• mechanism of effect on manual hyperinflation on cardiac output

Barke M, Eales CJ (1994) Ambubagging as a therapeutic technique. S.African J.Phys, 50, 26-7

Barker M, Adams S (2002) An evaluation of a single chest physiotherapy treatment on mechanically ventilated patients with acute lung injury. Physiother Res Int, 7, 3, 157-69
www3.interscience.wiley.com/journal/112501201/abstract
• PaO2:FiO2 ratio did not alter significantly with (a) suction, (b) positioning and suction, (c) positioning, MH and suction.

Berney S, Denehy L (2002) A comparison of the effects of manual and ventilator hyperinflation on static lung compliance and sputum production. Physiother Res Internat, 7, 100-108
• both methods improve lung compliance and clear secretions

Berney S, Denehy L (2003) The effect of physiotherapy on oxygen consumption and haemodynamics in patients who are critically ill. Austr J Physiother, 49, 99-105
ajp.physiotherapy.asn.au/AJP/vol_49/2/AustJPhysiotherv49i2Berney.pdf
• Sensible physiotherapy does not upset metabolic or haemodynamic variables;
• MHI increases compliance, resolves atelectasis and clear secretions
• Corrects other articles mistakenly asserting that PT can be dangerous:

Berney S, Denehy L, Pretto J (2004) Head-down tilt and manual hyperinflation enhance sputum clearance in patients who are intubated and ventilated. Aust J Physiother, 50, 9–14
www.physiotherapy.asn.au/AJP/50-1/AustJPhysiotherv50i1Berney.pdf
• during manual hyperinflation, a head-down tilt increases sputum production

Bowman TA, Paget-Brown A, Carrol J (2012) Sensing and responding to compliance changes during manual ventilation using a lung model: can we teach healthcare providers to improve? J Pediatrics, 160, 3, 372–376

Choi JS-P, Jones A Y-M (2005) Effects of manual hyperinflation and suctioning on respiratory mechanics in mechanically ventilated patients with ventilator-associated pneumonia. Austr J Physiother, 51, 25-30
www.physiotherapy.asn.au/AJP/vol_51/1/AustJPhysiotherv51i1Choi.pdf
• manual hyperinflation improves lung compliance in people with ventilator-associated pneumonia

Clapham L, Harrison J, Raybould T (1995) A multidisciplinary audit of manual hyperinflation. Int Crit Care Nurs, 11, 265-71
www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6WGN-4DK6DNY-N&_user=10&_handle=V-WA-A-W-AE-MsSAYVA-UUW-U-AAVWCVBYEC-AAVUAWVZEC-ZCYCZZZVY-AE-U&_fmt=summary&_coverDate=10%2F31%2F1995&_rdoc=5&_orig=browse&_srch=%23toc%236827%231995%23999889994%23567056!&_cdi=6827&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=3cb88e001e92e2738f31b220c875dc88
• audit leading to a standardised technique

Claxton BA, Morgan P, Mckeague H (2003) Alveolar recruitment strategy improves arterial oxygenation after cardiopulmonary bypass. Anaesthesia, 58, 111-16

Constantin JM, Futier E (2010) A recruitment maneuver increases oxygenation after intubation of hypoxemic intensive care unit
patients. Crit Care, 14:R76
www.biomedcentral.com/content/pdf/cc8989.pdf
• randomised controlled study showing how a recruitment maneuver (CPAP of 40 cmH2O over 30 seconds) following intubation in hypoxemic patients improved oxygenation, without adverse effects.

Corley M et al (1993) The myth of 100% oxygen delivery through manual resuscitation bags. J Emerg Nurs, 19, 45-4
• different bags have different FIO2

Das A, Cole O, Chikhani M et al (2015) Evaluation of lung recruitment maneuvers in acute respiratory distress syndrome using computer simulation. Crit Care, 19:8. doi:10.1186/s13054-014-0723-6

Davies N, Igo S (2004) Manual hyperinflation: a survey investigating the use of current best evidence. ACPRC Journal, 36, 8-17
• a manometer in the circuit should be mandatory

Denehy L (1999) The use of manual hyperinflation in airways clearance. Eur Resp J, 14, 958-65
erj.ersjournals.com/cgi/reprint/14/4/958?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&andorexactfulltext=and&searchid=1140033961325_2670&FIRSTINDEX=0&sortspec=relevance&volume=14&firstpage=958&resourcetype=1&journalcode=erj
• includes a further exhortation to use a manometer

Dueck R (2006) Alveolar recruitment versus hyperinflation: A balancing act. Curr Opin Anaesthesiol, 19, 6, 650-4.
www.ncbi.nlm.nih.gov/pubmed/17093370?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_SingleItemSupl.Pubmed_Discovery_RA&linkpos=4&log$=relatedreviews&logdbfrom=pubmed
• PEEP levels must be high enough to minimise recruitment/derecruitment cycling.
• balancing recruitment versus overdistension may require thoracic tomography.

Dyhr T et al (2002) Effects of lung recruitment maneuvre and PEEP on lung volume, respiratory mechanics and alveolar gas mixing in patients ventilated after cardiac surgery. Acta Anaesthesiol Scand, 46, 717-25
www.blackwell-synergy.com/doi/abs/10.1034/j.1399-6576.2002.460615.x
• maintenance of PEEP with manual hyperinflation

Dyhr T et al (2003) Lung recruitment manoeuvres are effective in regaining lung volume and oxygenation after open endotracheal suctioning in acute respiratory distress syndrome. Crit Care, 7(1): 55–62
ccforum.com/content/7/1/55
• MH is effective in regaining lung volume after suction

Eaton JM (1984) Adult manual resuscitators. Br J Hosp Med, 31, 67-70
• max safe pressure is 70 cmH2O in normal lungs

Ellis ER, Redfern J, Rusterholtz B (1999) The effects of feedback on the performance of manual hyperinflation by physiotherapists. WCPT Proc. p.31
• manometer ensures effective and safe pressures

Gammon RB (1991) Pulmonary interstitial emphysema in mechanically ventilated patients. Am Rev Resp Dis, 143, 4, A693
• barotrauma on x-ray - mediastinal emphysema, interstitial emphysema

Gammon RB (1992) Pulmonary barotrauma in IPPV. Chest, 102, 568-72
www.chestjournal.org/cgi/content/abstract/102/2/568
• incidence and risk factors for pneumothorax and pneumomediastinum

Garcνa-Fernαndez J, Canfrαn S, de Segura IA et al (2013) Pressure safety range of barotrauma with lung recruitment manoeuvres: a randomised experimental study in a healthy animal model. Eur J Anaesthesiol; 30(9):567-74. doi: 10.1097/EJA.0b013e3283607875

Gattinoni L (2016) Ultra-protective ventilation and hypoxemia Crit Care; 20:130. doi: 10.1186/s13054-016-1310-9
ccforum.biomedcentral.com/articles/10.1186/s13054-016-1310-9

Griffiths R (2000) Breathing circuits and their uses. Br J Periop Nurs, 10, 55-9

Halter JM (2003) Positive End-Expiratory Pressure after a recruitment maneuver prevents both alveolar collapse and recruitment/derecruitment. Am J Respir Crit Care Med, 167, 1620-26
ajrccm.atsjournals.org/cgi/content/full/167/12/1620
• effect of recruitment maneuver using peak pressure of 45 cmH2O and PEEP of 35 cmH2O for 1 minute, followed by PEEP of 5 or 10 cmH2O

Hartland BL, Newell TJ, Damico N (2015) Alveolar recruitment maneuvers under general anesthesia: a systematic review of the literature. Respir Care; 60(4):609-620

Hess DR, Bigatello LM (2002) Lung recruitment: the role of recruitment maneuvers. Respir Care, 47, 308-17
www.rcjournal.com/contents/03.02/03.02.0308.asp
• ‘open lung strategies’ by extra PEEP, sustained inflation, stepwise inflation, sighs & spontaneous breathing

Hicky J (2006) Manually ventilating & suctioning in-line with a SensorMedics 3100B high frequency oscillatory ventilator bench test. AARC Conference, Texas
www.cardinal.com/mps/focus/respiratory/abstracts/abstracts/ab2006/OF-06-157.asp
• method for manual hyperinflation and suction without losing airway pressure with HFO

Hila J, Ellis E (2002) Feedback withdrawal and changing compliance during manual hyperinflaiton. Physiother Res Internat, 7, 53-64
• pressure manometer recommended for safe and effective practice

Hodgson C, Ntoumenopoulos G, Dawson H (2007) The Mapleson C circuit clears more secretions than the Laerdal circuit during manual hyperinflation in mechanically-ventilated patients: a randomised cross-over trial. Austr J Physiother, 53, 1, 33-8

Jantz MA (1994) Pneumothorax and barotrauma. Clin Chest Med, 15, 1, 75-92
• identification of early barotrauma on x-ray

Jellema WT et al (2000) Haemodynamic effects of intermittent manual hyperinflation in patients with septic shock. Heart Lung, 29, 356-66
• risk of haemodynamic compromise with MH is relatively small

Jones A et al (1992) Peak expiratory flow rates produced with the Laerdal and Mapleson-C bagging circuits. Austr Physiotherapy J, 38, 211-15

Jones A, Hutchinson RC (1992) Effects of bagging and percussion on total static compliance of the respiratory system. Physiotherapy, 78, 661-66
• percussion/vibs/suction increases heart rate and BP, MH increases lung compliance

Kaul TK, Mittal G (2013) Mapleson's breathing systems. Indian J Anaesth; 57(5): 507–515. doi: 10.4103/0019-5049.120148

Khemani R (2016) Recruitment maneuvers to the extreme. Respir Care; 61(2):260-261
• safety concerns regarding hemodynamic stability and the risk of barotrauma during recruitment maneuvres.

Lapinsky SE et al (1997) Safety and efficacy of a sustained inflation maneuver for alveolar recruitment. Chest, 112, 126S
• sustained inflations at 30-40 cmH2O for 20 secs are safe through ventilator

Lapinsky SE (2003) Recruitment and retention of lung volume. Crit Care, 7, 9-10
ccforum.com/content/7/1/9
• editorial relating to Dyhr et al (2003), above

Lemes DA, Zin WA, Guimaraes FS (2009) Hyperinflation using pressure support ventilation improves secretion clearance and respiratory mechanics in ventilated patients with pulmonary infection: a randomised crossover trial. Aust J Physiother; 55(4):249-54
• ventilator hyperinflation improves secretion clearance

Lowhagen K, Lindgren S, Odenstedt H et al (2011) Prolonged moderate pressure recruitment manoeuvre results in lower optimal positive end-expiratory pressure and plateau pressure. Acta Anaesthesiol Scand; 55(2):175-84. doi: 10.1111/j.1399-6576.2010.02366.x

Maa S-H, Hung T-J, Hsu K-H (2005) Manual hyperinflation improves alveolar recruitment in difficult-to-wean patients. Chest, 128, 2714-21.
chestjournal.chestpubs.org/content/128/4/2714.full?sid=c3f28d99-318b-4fa9-b66e-916a84952698
• manual hyperinflation significantly recruits collapsed alveoli

Maxwell L, Ellis E (1998) Secretion clearance by manual hyperinflation. Physiother Th Pract, 14, 89-97

Maxwell LJ, Ellis ER (2003) The effect of circuit type, volume delivered and rapid release on flow rates during manual hyperinflation. Austr J Physiother, 49, 31-8
• assessment of different bags and different techniques

Maxwell LJ, Ellis ER (2004) Effect of maintaining bag compression during manual hyperinflation. Austr J Physiother, 50, 49
www.physiotherapy.asn.au/AJP/50-1/AustJPhysiotherv50i1Maxwell.pdf

McCarren B (1998) Description of manual hyperinflation in intubated patients with atelectasis. Physiother Theory Pract, 14, 199-210

Nielsen J (2006) Central hemodynamics during lung recruitment maneuvers at hypovolemia, normovolemia and hypervolemia. Int Care Med, 32, 4, 585-94
www.springerlink.com/(accux3esn5ttldic1i3hpc55)/app/home/contribution.asp?referrer=parent&backto=issue,16,37;journal,4,297;linkingpublicationresults,1:100428,1
• lung recruitment maneuvers significantly decreased cardiac output at hypovolemia; hypervolemia partly counteracted this compromise. Also a marked right-ventricular dysfunction was found

Ntoumenopoulos G (2005) Indications for manual lung hyperinflation in the mechanically ventilated patient with COPD. Chron Respir Dis, 2: 199-207

Ntoumenopoulos G, Gild A (1998) The effect of manual lung hyperinflation and postural drainage on pulmonary complications. Anaesth Int Care, 26, 492-6
www.aaic.net.au/ (summary available)
• trend towards reduced nosocomial pneumonia in patients receiving manual hyperinflation and postural drainage

Paratz et al (2002) Effect of manual hyperinflation on hemodynamics, gas exchange, and respiratory mechanics in ventilated patients. J Int Care Med, 17, 317-324
jic.sagepub.com/cgi/content/abstract/17/6/317?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&andorexactfulltext=and&searchid=1&FIRSTINDEX=0&sortspec=relevance&volume=17&firstpage=317&resourcetype=HWCITMHI improves lung mechanics and gas exchange without impairing the cardiovascular system

Patman S, Jenkins S, Smith K (2001) Manual hyperinflation: consistency and modification of the technique by physiotherapists. Phys Res Int, 6, 106-17

Patman S, Jenkins S (1998) Cardiovascular responses to manual hyperinflation in postoperative coronary artery surgery. Physiother Theory Pract, 14, 5-12

Patman S, Jenkins S, Stiller K (2000) Manual hyperinflation: effects on respiratory parameters. Physiother Res Internat, 5(3), 157-71
• MH improves lung compliance, (A-a)PO2, PaO2/FiO2

Paulus F, Binnekade JM, Vroom MB et al (2012) Benefits and risks of manual hyperinflation in intubated and mechanically ventilated intensive care unit-patients: a systematic review. Crit Care, 16, R145

Redfern J, Ellis E, Holmes W (2001) The use of a pressure manometer enhances students physiotherapists performance during manual hyperinflation. Austr J Physiother, 47, 121-31
ajp.physiotherapy.asn.au/AJP/vol_47/2/AustJPhysiotherv47i2Redfern.pdf
• manometer provides effective feedback

Reick CW (1996) Auto-PEEP associated with excessive oxygen flow through five manual resuscitators. Respir Care, 41, 1009-12
• advice for MH with slow flow rate to avoid intrinsic PEEP

Robson WP (1998) To bag or not to bag? Int Crit Care Nurs. 14, 239-43
www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6WGN-4DHNT8N-5S&_user=10&_handle=V-WA-A-W-E-MsSAYZA-UUA-U-AAVWEZBUBA-AAVUCVBYBA-ZZEUEBEUE-E-U&_fmt=summary&_coverDate=10%2F31%2F1998&_rdoc=5&_orig=browse&_srch=%23toc%236827%231998%23999859994%23540603!&_cdi=6827&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=7e8b20d0d97301ecbc59ea21082170d3
• literature review

Rothen HU, Neumann P, Berglund JE et al (1999) Dynamics of re-expansion of atelectasis during general anaesthesia. Br J Anaesth, 82, 551-6
• pressure of 40 cmH2O (i.e. to vital capacity) eliminates atelectasis

Rusterholz B, Ellis D (1998) The effect of lung compliance and experience on manual hyperinflation. Austr J Physiother, 44, 23-8

Silbergleit R et al (1996) Sudden severe barotrauma from self-inflating bag-valve devices. J Trauma, 40, 320-2
www.jtrauma.com/pt/re/jtrauma/abstract.00005373-199602000-00031.htm;jsessionid=D4ysC2SXIab2U16fBKL0MjvTvi0Y9gDgOBs1XPUoObXLcAYn1ve4!-477899252!-949856144!9001!-1
• bag with reservoir may push up pressures if valve blocked

Singer M, Vermaat J (1994) Hemodynamic effects of manual hyperinflation in critically ill patients. Chest, 106, 1182-7
chestjournal.chestpubs.org/content/106/4/1182.full.pdf+html?sid=8887ec47-ee48-4fb9-acb3-b621a795883b
• MH can increase or decrease BP, but cardiac output is consistently reduced and takes up to 15 mins to recover

Stone KS et al (1991) The effect of lung hyperinflation and endotracheal suctioning on cardiopulmonary haemodynamics. Nurs Res, 40, 76-80
• mechanism of how MH can increase BP

Thomas PJ (2015) The effect of mechanical ventilator settings during ventilator hyperinflation techniques: a bench-top analysis. Anaesth Intensive Care; 43(1):81-7

Tusman G, Bohm SH, Tempra A et al (2003) Effects of recruitment maneuver on atelectasis in anesthetized children. Anesthiol, 98, 14-22
www.anesthesiology.org/pt/re/anes/fulltext.00000542-200301000-00006.htm;jsessionid=D4zrItG5sPaPQCx2FEttl6IefE6ttfsZtLZ3K1bXSCdbMe62SfjW!-477899252!-949856144!9001!-1
• atelectasis was reduced in children given manual hyperinflation with peak pressure of 40 cmH2O and PEEP of 15 cmH2O for 10 breaths


ACPRC = Association of Chartered Physiotherapists in Respiratory Care
ARDS = acute respiratory distress syndrome
CPAP = continuous positive airways pressure
FIO2 = fraction of inspired oxygen
MH = manual hyperinflation
PaO2:FiO2 = arterial oxygen to fraction of inspired oxygen ratio
PEEP = positive end-expiratory pressure
VH = ventilator hyperinflation
WCPT = World Confederation of Physical Therapy