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Manual hyperinflation (MH), a frequently applied maneuver in critically ill intubated and mechanically ventilated patients, is suggested to mimic a cough so that airway secretions are mobilized toward the larger airways, where they can easily be removed. As such, MH could prevent plugging of the airways. Methods. We performed a search in the databases of Medline, Embase, and the Cochrane Library from January 1. April 2. 01. 2. We systematically reviewed the literature on evidence for postulated benefits and risks of MH in critically ill intubated and mechanically ventilated patients. Results. The search identified 5. We included 1. 3 interventional studies and six observational studies. The number of studies evaluating physiological effects of MH is limited. Trials differed too much to permit meta- analysis. Manual Hyperinflation Icu All patients admitted to Critical Care areas. Abstract Physiotherapists Treating Critical Care. The aims of early mobilisation in the ICU is to maintain impairments present in survivors of critical care and lessening Manual hyperinflation.Manual hyperinflation (MHI) has been shown to improve lung compliance, reduce airway resistance, and enhance secretion removal and peak expiratory flow. The aim. Aims of manual hyperinflation are to optimise alveolar ventilation, to assist with the mobilisation of pulmonary secretions. Use of a pressure manometer enhances student physiotherapists’ performance during manual hyperinflation Manual hyperinflation. Benefits and risks of manual hyperinflation in intubated and mechanically ventilated intensive care unit patients: a systematic review. This systematic review aims to collect the evidence for the suggested benefits and risks of MH in critically ill intubated and. It is uncertain whether MH was applied similarly in the retrieved studies. Finally, most studies are underpowered to show clinical benefit of MH. Use of MH is associated with short- term improvements in lung compliance, oxygenation, and secretion clearance, without changes in outcomes. MH has been reported to be associated with short- term and probably clinically insignificant side effects, including decreases in cardiac output, alterations of heart rates, and increased central venous pressures. Conclusions. Studies have failed to show that MH benefits critically ill intubated and mechanically ventilated patients. MH is infrequently associated with short- term side effects. Introduction. Manual hyperinflation (MH), also known as "bagging" or "bag- squeezing" is a frequently used maneuver in critically ill intubated and mechanically ventilated patients [1,2]. With MH, patients are disconnected from the mechanical ventilator, after which their lungs are temporarily ventilated with a manual ventilation bag. By applying a larger- than- normal volume at a low inspiratory flow followed by an inspiratory pause and expiration with a high expiratory flow, MH is suggested to mimic a normal cough. Propagation of airway secretions from the smaller toward the larger airways then allows for easy removal of airway secretions with airway suction. As such, MH could prevent airway plugging [3,4], and even promote alveolar recruitment [5]. It is far from certain whether MH truly benefits critically ill intubated and mechanically ventilated patients. In addition, disconnection of a critically ill patient from the ventilator could be seen as a rather unsafe intervention [6]. Because MH may cause short- term hyperinflation, one could even consider MH to be dangerous in hemodynamically unstable patients [7,8]. Also, MH could be disadvantageous in patients with respiratory failure. The airway pressures at the end of the MH maneuver are usually much lower than the applied level of positive end- expiratory pressure, which, in combination with airway suctioning, may promote atelectasis. This systematic review aims to collect the evidence for the suggested benefits and risks of MH in critically ill intubated and mechanically ventilated patients. The main research questions were as follows. Does MH benefit critically ill intubated and mechanically ventilated patients with respect to pulmonary compliance, arterial oxygenation, and sputum clearance? Does MH have an effect on the duration of mechanical ventilation, length of stay in the intensive care unit, and incidence of pneumonia? What are reported side effects of MH? The rationale behind manual hyperinflation. ![]() Retained airway secretions may occlude the airways of intubated and mechanically ventilated patients, and, as such, cause atelectasis. This may impair oxygenation by increased intrapulmonary shunting and increase pulmonary vascular resistance. Large atelectasis may even promote development of lung injury [9]. The consequence of large atelectasis is a smaller lung available for ventilation, leading to the concept of "baby lung" ventilation [1. Persistent presence of sputum in the airways may provide an ideal environment for colonizing organisms, finally resulting in pneumonia [1. Frequent removal of sputum from the airways via tracheal suctioning is mandatory in critically ill intubated and mechanically ventilated patients. Under normal conditions, mucociliary transport clears the smaller airways of airway secretions. Objectives Manual hyperinflation (MHI) has been shown to improve lung compliance, reduce airway resistance, and enhance secretion removal and peak expiratory flow. The aims of this study were to investigate whether there is a difference in airflow distribution. Secretions that are transported from the smaller airways into the bronchi and trachea then are removed by coughing. Critically ill patients, however, are frequently sedated and nursed in a supine position, potentially reducing mucociliary transport and promoting retention of airway secretions [1. In addition, the cough reflex can be minimal or even absent in sedated critically ill patients, or they may lack force to cough efficiently. Furthermore, sputum may not be easily transported from the trachea into the translaryngeal tube or trachea cannula, and thus could remain in the larger airways. Unfortunately, with airway suctioning, only the trachea is cleared of secretions, as suction catheters cannot reach sputum in the bronchi and smaller airways. MH, as originally described in the late 1. Description of the MH technique. To enhance the clearance of airway secretions, MH was supposed to include the application of a larger than normal volume (up to one and one half the size of tidal volumes delivered by the ventilator) at a low inspiratory flow (achieved by a slow compression of the ventilation bag), an inspiratory pause (to allow complete distribution of the inflated air among all the ventilated parts of the lung), and a high expiratory flow. In particular, this last element seems important and can be achieved by a complete and rapid release of the ventilation bag [1. As such, MH could resemble a forceful cough, with which a forced and rapid exhalation follows a deep and slow inhalation. It is suggested that the effectiveness of MH is dependent, at least in part, on the ratio between flows with inspiration and expiration [3,4]. With higher expiratory flows (that is, higher than inspiratory flows), sputum could propagate from distal to more proximal areas (that is, from the smaller airways toward the larger airways), where it can be easily removed through endotracheal suctioning [1. It is also suggested that the use of an inspiratory pause maintains the pressure gradient for an appropriate length of time required to overcome the opening pressure of the alveoli [1. Materials and methods. Search methods for identification of manuscripts about MHTwo methods were used to identify relevant manuscripts in the medical literature. First, we performed a search in the databases of Medline, Embase, the Cochrane Library, the Cochrane Database of Systematic Reviews, and the Database of Abstracts on Reviews and Effectiveness (DARE) from January 1. April 2. 01. 2 (Additional file 1). Second, reference lists of identified and selected manuscripts were reviewed to identify additional articles. The following key words (Me. SH and text words) were used: "critical care," "intensive care," "manual hyperinflation," "hyperinflation," "bagging," and "bag squeezing." In addition, we used the key words "hyperoxygenation," "physiotherapy," and "physical therapy." We excluded studies of mechanical hyperinflation by machines, like cough- assist devices. The initial search strategy was designed for maximal retrieval, with no limitation on the type of study design to be identified. We used no restriction on language. Study selection. Two authors (FP and JB) independently reviewed the retrieved articles and abstracts, assessed the eligibility of each study, and resolved disagreement by consensus. Articles were selected if they reported original data from a clinical trial or an observational study. We restricted the selection of articles to those that reported on adult critically ill intubated and mechanically ventilated patients. The same authors made the final selection; we restricted the selection to articles that reported on relevant study end points, including pulmonary compliance, arterial oxygenation, sputum clearance, duration of mechanical ventilation, length of stay in the intensive care unit, and incidence of pneumonia, and only if the main objective concerned the evaluation of the MH procedure. Data- collection process. We extracted data from the included studies by using a data- extraction sheet. We extracted the following data: characteristics of the studies (design, setting), participants, intervention characteristics (MH technique), comparison intervention, and results of all relevant outcomes. Assessment of methodologic quality of individual studies. Two reviewers (FP and JB) assessed the risk of bias of the interventional studies and used the categories randomization, random sequence generation allocation concealment, description of withdrawals and dropouts, the method of and use of intention- to- treat analysis, and standardization of important co- interventions. Synthesis of results. The decision to combine studies in a quantitative analysis was made by assessing clinical heterogeneity (examining types of participants, interventions, and outcomes in each study). Results. Study selection. The search (Figure 1) identified 5. Tables 1, 2, and 3). Number of articles identified at each stage of the review process for potential inclusion in the systematic review. Studies comparing manual hyperinflation (MH) with standard care. Studies comparing manual hyperinflation (MH) with other strategies. Side effects of manual hyperinflation (MH)Study characteristics. We included 1. 3 interventional studies (six randomized controlled trials of MH [5,2. MH with endotracheal suctioning [2. MH with hyperinflation by the mechanical ventilator [2. Physiological end points were respiratory mechanics [2. Clinical end points included duration of mechanical ventilation [2. Critical Care | Home page. Donat R Spahn, Bertil Bouillon, Vladimir Cerny, Timothy J Coats, Jacques Duranteau, Enrique Fern. ГЎndez- Mond. Г©jar, Daniela Filipescu, Beverley J Hunt, Radko Komadina, Giuseppe Nardi, Edmund Neugebauer, Yves Ozier, Louis Riddez, Arthur Schultz, Jean- Louis Vincent and Rolf Rossaint. Published on: 1. 9 April 2. Instruction Manual for Adobe Acrobat Reader Software, Free User Guide in English. DOWNLOAD INFORMATIONS : To download a user guide, please go to the category of your equipment, choose the brand of your equipment, then click on the model which you are looking for. 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