Analysis of different levels of positive end-expiratory pressure during lung retrieval for transplantation: an experimental study.

Atelectasis and inadequate oxygenation in lung donors is a common problem during the retrieval of these organs. Nevertheless, the use of high positive end-expiratory pressure (PEEP) is not habitual during procedures of lung retrieval. Twenty-one Sprague-Dawley male consanguineous rats were used in the study. The animals were divided into 3 groups according to the level of PEEP used: low (2 cmH2O), moderate (5 cmH2O), and high (10 cmH2O). Animals were ventilated with a tidal volume of 6 mL/kg. Before lung removal, the lungs were inspected for the presence of atelectasis. When atelectasis was detected, alveolar recruitment maneuvers were performed. Blood gasometric analysis was performed immediately. Finally, the lungs were retrieved, weighed, and submitted to histological analysis. The animals submitted to higher PEEP showed higher levels of oxygenation with the same tidal volumes PO2=262.14 (PEEP 2), 382.4 (PEEP 5), and 477.0 (PEEP 10). The occurrence of atelectasis was rare in animals with a PEEP of 10 cmH2O, which therefore required less frequent recruitment maneuvers (need for recruitment: PEEP 2=100%, PEEP 5 =100%, and PEEP 10=14.3%). There was no change in hemodynamic stability, occurrence of pulmonary edema, or other histological injuries with the use of high PEEP. The use of high PEEP (10 cmH2O) was feasible and probably a beneficial strategy for the prevention of atelectasis and the optimization of oxygenation during lung retrieval. Clinical studies should be performed to confirm this hypothesis.

Analysis of different levels of positive end-expiratory pressure during lung retrieval for transplantation: an experimental study

Atelectasis and inadequate oxygenation in lung donors is a common problem during the retrieval of these organs. Nevertheless, the use of high positive end-expiratory pressure (PEEP) is not habitual during procedures of lung retrieval. Twenty-one Sprague-Dawley male consanguineous rats were used in the study. The animals were divided into 3 groups according to the level of PEEP used: low (2 cmH2O), moderate (5 cmH2O), and high (10 cmH2O). Animals were ventilated with a tidal volume of 6 mL/kg. Before lung removal, the lungs were inspected for the presence of atelectasis. When atelectasis was detected, alveolar recruitment maneuvers were performed. Blood gasometric analysis was performed immediately. Finally, the lungs were retrieved, weighed, and submitted to histological analysis. The animals submitted to higher PEEP showed higher levels of oxygenation with the same tidal volumes PO2=262.14 (PEEP 2), 382.4 (PEEP 5), and 477.0 (PEEP 10). The occurrence of atelectasis was rare in animals with a PEEP of 10 cmH2O, which therefore required less frequent recruitment maneuvers (need for recruitment: PEEP 2=100%, PEEP 5 =100%, and PEEP 10=14.3%). There was no change in hemodynamic stability, occurrence of pulmonary edema, or other histological injuries with the use of high PEEP. The use of high PEEP (10 cmH2O) was feasible and probably a beneficial strategy for the prevention of atelectasis and the optimization of oxygenation during lung retrieval. Clinical studies should be performed to confirm this hypothesis.

Recomendaciones sobre rehabilitación en la cirugía de resección pulmonar de la Sociedad Española de Rehabilitación Cardio-Respiratoria (SORECAR) / Recommendations of the Spanish Society of Cardio-Respiratory Rehabilitation (SORECAR) on rehabilitation after lung resection surgery

La cirugía de resección pulmonar es la única opción curativa en las fases tempranas del cáncer de pulmón, pero sigue presentando una alta morbimortalidad perioperatoria. Una correcta estratificación del riesgo quirúrgico y una optimización de la situación general del paciente precirugía son elementos claves para disminuir el riesgo de complicaciones postoperatorias. Por otro lado, la cirugía junto a las posibles terapias adyuvantes impactan de manera negativa en la capacidad funcional y en la calidad de vida de muchos pacientes. Un grupo de expertos fue nombrado por la Sociedad Española de Rehabilitación Cardio-Respiratoria (SORECAR) para que realizaran una revisión de todas las evidencias disponibles sobre la evaluación funcional en la estratificación del riesgo quirúrgico y sobre la rehabilitación pre- y poscirugía de resección pulmonar y para que elaboraran un documento aplicándolas a la práctica clínica. Así se ha diseñado un protocolo de actuación en rehabilitación durante la fase pre- y poscirugía de resección pulmonar, con instrucciones o recomendaciones a modo de resumen. Con esto se pretende potenciar el papel de la rehabilitación en la cirugía de resección pulmonar y consensuar el modo de actuar en este campo (AU)

Lung resection surgery is the only curative option in the early stages of lung cancer but carries a high risk of perioperative morbidity and mortality. Proper surgical risk stratification and pre-surgical optimization of the patient's overall situation are key elements to reduce the risk of postoperative complications. Surgery, together with possible adjuvant therapies, may impact negatively on functional capacity and quality of life in many patients. Consequently, a group of experts was appointed by the Spanish Society of Cardio-Respiratory Rehabilitation (SORECAR) to review all the available evidence on functional assessment in surgical risk stratification and on pre- and postsurgery rehabilitation in order to create a document that applied their findings to clinical practice. As a result, an action plan has been defined for rehabilitation during the pre- and postsurgical stages of lung resection with instructions or recommendations presented as a checklist. The aim of creating this document was to enhance the role of rehabilitation after lung resection surgery and to agree on interventions in this area (AU)

Laser photocoagulation in patients with retinopathy of prematurity undergoing chest physiotherapy.

The authors report the correlation between chest physiotherapy and increased risk of vitreous hemorrhage after laser photocoagulation therapy in patients with retinopathy of prematurity (ROP). Two premature neonates, the first born at 26 weeks and the second at 31 weeks gestational age, both underwent chest physiotherapy, the first for congenital cystic fibrosis and bronchopulmonary dysplasia and the second for premature alveolar atelectasis. Both were diagnosed as having ROP that necessitated laser photocoagulation treatment at 34 and 37 weeks, respectively. The first patient developed bilateral vitreous hemorrhage and bilateral cataracts. The second patient developed vitreous hemorrhage in one eye. Chest physiotherapy in neonates with ROP significantly increases the risk of hemorrhage after laser photocoagulation in an otherwise fragile retinal vasculature.

Consequences of bed rest.

Bed rest is frequently prescribed for critically ill patients because it is assumed to be beneficial for preventing complications, for conserving scarce metabolic resources, and for providing patient comfort. Furthermore, higher levels of physical activity in critically ill patients have been assumed to be impractical or not feasible. Bed rest has been prescribed in the past for several other clinical conditions including acute flares of rheumatoid arthritis, cavitary tuberculosis, acute myocardial infarction, and acute low back pain. However, randomized, controlled, clinical trials failed to demonstrate beneficial effects of bed rest in most of these conditions. Bed rest can cause several complications that may delay or prevent recovery from critical illnesses including disuse muscle atrophy, joint contractures, thromboembolic disease, and insulin resistance. Recent studies demonstrated the feasibility and safety of physical medicine programs in critically ill patients including those with acute respiratory failure requiring mechanical ventilation. Other physical medicine tools, such as neuromuscular electrical stimulation and passive stretching of muscles, may also reduce some complications of bed rest.

Inalação de solução salina hipertônica como coadjuvante da fisioterapia respiratória para reversão de atelectasia no pós-operatório de cirurgia cardíaca pediátrica / Inhalation of hypertonic saline solution as coadjuvant in respiratory physiotherapy to reverse atelectasis in the postoperative of pediatric heart surgery

Criança de 11 meses, sexo feminino, submetida à operação de fechamento de comunicação interventricular, comunicação interatrial e ligadura de canal arterial. Evoluiu no pós-operatório com atelectasia persistente em base pulmonar à direita, não respondendo às manobras fisioterapêuticas convencionais, efetuadas seis vezes ao dia. Após associação, como coadjuvante, da inalação de solução salina hipertônica com NaCl a 6 por cento, imediatamente antes e após o atendimento fisioterápico, observou-se crises de tosse produtiva, com maior indução do escarro e resolução completa da atelectasia, com três dias de tratamento.

The case of an eleven-month-old female child is presented diagnosed as having congenital heart disease with pulmonary hyperflow, who was submitted to a surgery to close an interventricular communication, interatrial communication and arterial canal ligature. The infant evolved with persistent atelectasis at the right lung base in the postoperative period which did not respond to conventional physiotherapeutic measures. Inhalation of hypertonic saline solution with 6 percent NaCl was associated as a coadjuvant therapy, giving a total cure of the atelectasis after three days of treatment.

The effects of three manual hyperinflation techniques on pattern of ventilation in a test lung model.

Manual hyperinflation (MHI) is used by physiotherapists as a treatment technique in intubated patients. This study investigated the effect of three different MHI techniques using a Mapleson-C circuit configuration with a CIG Medishield valve on volume delivered (Vt), peak inspiratory (PIFR) and expiratory flow rates (PEFR), and peak airway pressure (PAP) in a test lung model. The protocols differed in the degree of valve closure and inclusion of an inspiratory pause. For protocols 1, 2 and 3 the measures were Vt-1.33 (0.21), 2.74 (0.13), 3.55 (0.12) litres; PAP-14.30 (0.82), 24.00 (0.47), 30.20 (0.92) cmH2O and PIFR-1.13 (0.05), 1.51 (0.15), 1.32 (0.09) l/s respectively. All pair comparisons were statistically significant except for PEFR (l/s), which was significantly lower for protocol 1 [1.62 (0.06)], compared to protocols 2 [2.01 (0.25)] and 3 [2.10 (0.19)] but not between protocols 2 and 3. Circuit and technique choice should be considered in relation to the specific therapeutic aim of treatment.

Manual hyperinflation: consistency and modification of the technique by physiotherapists.

BACKGROUND AND PURPOSE: The present study aimed to evaluate the consistency with which physiotherapists apply manual hyperinflation to a test lung using the Air-Viva-2 or Mapleson-B resuscitation circuit, and their ability to modify the technique as pulmonary characteristics change. METHOD: A quasi-experimental, randomized, repeated-measures design was used to study 16 volunteer physiotherapists performing manual hyperinflation to a test lung simulating three clinical situations. Each subject applied manual hyperinflation to the test lung for each simulation three times in one day using the resuscitation circuit that they would normally use in their clinical practice. Eight subjects used the Air-Viva-2 circuit and eight used the Mapleson-B circuit. Measurements of tidal volume (Vp), peak airway pressure (Paw) and fraction of delivered oxygen (FDO2) were recorded during each testing period. Inflation rate and minute volume were calculated. RESULTS: As compliance decreased and airway resistance increased, VT decreased and Paw increased. Of the eight subjects using the Air-Viva-2 circuit, only three subjects delivered greater than 0.80 FDO2. All subjects using the Mapleson-B circuit delivered greater than 0.85 FDO2. CONCLUSIONS: Subjects demonstrated good consistency in the application of manual hyperinflation for all three simulations and modified their technique appropriately as simulated pulmonary characteristics changed.

Prevention of postoperative pulmonary complications through respiratory rehabilitation: a controlled clinical study.

OBJECTIVE: To investigate the efficacy of respiratory rehabilitation in preventing postoperative pulmonary complications (PPC) and to define which patients can benefit. DESIGN: A randomized clinical trial. SETTING: A public hospital. PATIENTS: Eighty-one patients who had upper abdominal surgery were distributed into two homogeneous groups: control (n = 41) and rehabilitation (n = 40). INTERVENTION: Breathing exercises in the rehabilitation group. MAIN OUTCOME MEASURES: Preoperative and postoperative clinical evaluation, spirometry, arterial gasometry, and simple chest X-rays. RESULTS: The incidence of PPC was 7.5% in the rehabilitation group and 19.5% in the control group; the control group also had more radiologic alterations (p = .01). Stratified PPC analysis did not reveal significant differences between groups. However, high- and moderate-risk patients in the rehabilitation group had fewer PPC. Multivariate analysis showed a greater PPC risk associated with pulmonary history (p = .02) and duration of surgery longer than 120 min (p = .03), while rehabilitation exerted a protective effect (p = .06). Significant postoperative decreases in pulmonary volumes and arterial gas values were recorded in both groups, without significant differences. CONCLUSIONS: Respiratory rehabilitation protects against PPC and is more effective in moderate- and high-risk patients, but does not affect surgery-induced functional alterations.

Chest physical therapy to the patient with multiple trauma. Two case studies.

Chest physical therapy is the preferred treatment in the MIEMSS for both preventing and treating pulmonary complications caused by retained secretions. The beneficial results of chest physical therapy in our facility, including improvement in chest roentgenogram appearance, arterial blood gases, and lung compliance, have been documented. The cases presented illustrate the successful use of chest physical therapy despite the presence of severe trauma and possible contraindications. The potential benefits of chest physical therapy may outweigh the existing possible contraindications.