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LetterCorrespondence

Expiratory Rib Cage Compressions to Improve Secretion Clearance During Mechanical Ventilation: Not Only a Matter of Squeezing the Chest

Joan-Daniel Martí, Gianluigi Li Bassi, Talitha Comaru and Antoni Torres
Respiratory Care August 2014, 59 (8) e119-e120; DOI: https://doi.org/10.4187/respcare.03109
Joan-Daniel Martí
Department of Pulmonary and Critical Care Medicine Animal Experimentation Division Thorax Institute Hospital Clínic Barcelona, Spain and Centro de Investigación Biomédica En Red de Enfermedades Respiratorias Mallorca, Spain
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Gianluigi Li Bassi
Department of Pulmonary and Critical Care Medicine Animal Experimentation Division Thorax Institute Hospital Clínic Barcelona, Spain and Centro de Investigación Biomédica En Red de Enfermedades Respiratorias Mallorca, Spain
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Talitha Comaru
Department of Pulmonary and Critical Care Medicine Animal Experimentation Division Thorax Institute Hospital Clínic Barcelona, Spain
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Antoni Torres
Department of Pulmonary and Critical Care Medicine Animal Experimentation Division Thorax Institute Hospital Clínic Barcelona, Spain and Centro de Investigación Biomédica En Red de Enfermedades Respiratorias Mallorca, Spain and Institut d'Investigacions Biomèdiques August Pi i Sunyer Barcelona, Spain
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To the Editor:

We read with interest the manuscript by Guimarães et al,1 who assessed in humans the pulmonary effects of manual rib cage compressions (MRCCs). The authors found a mild increase in the amount of cleared airway secretions with the use of MRCCs and no effects on respiratory mechanics. Some of their results are in line with previous evidence from clinical2 and laboratory3–5 studies; nevertheless, we would like to comment on a few critical methodological aspects of previous works.

First, there is a lack of consistency in the applied methods in previous studies. Unoki et al2–4 applied gentle and gradual rib cage compressions during the expiratory phase and demonstrated marginal effects on mucus clearance and respiratory mechanics, as in the study by Guimarães et al.1 Conversely, in our previous study,5 we applied two different techniques (Fig. 1): (1) soft MRCCs to prolong the late expiratory phase through gentle and gradual chest compressions; and 2) hard MRCCs consisting of brief and strong compressions synchronized with the early expiratory phase to increase peak expiratory flow. Interestingly, soft MRCCs did not influence mucus clearance and worsened the static lung elastance. Conversely, hard MRCCs significantly improved mucus clearance and did not cause any deleterious pulmonary effect. Unfortunately, in the study by Guimarães et al, the applied technique is not fully elucidated. The significant increase in peak expiratory flow (> 16 L/min) indicates that they used a technique comparable to hard MRCCs. Nonetheless, given the expiratory flow limitation found in a limited number of subjects, it is possible that compressions were applied throughout the expiratory phase. Our previous investigation clearly demonstrated that the beneficial effects of MRCCs may vary based on the applied forces, synchronization with the expiratory phase, and the time of application.5 In particular, it seems that very brief compressions synchronized with the early expiratory phase could be the best option to improve mucus clearance during controlled mechanical ventilation.

Fig. 1.
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Fig. 1.

A and D: Flow and pressure waveforms during no treatment. B and E: Soft manual rib cage compressions (MRCCs) prolong the late expiratory phase (arrows in E), leading to a decrease in PEEP (arrows in B). C and F: Hard MRCCs synchronized with the early expiratory phase increase the no-intervention peak expiratory flows (dotted line), with no effects on PEEP.

Second, Guimarães et al1 suggested that the expiratory flow limitation found in their study was probably due to the increased transmural pressure associated with the compressions, which ultimately led to peripheral airway collapse. In our study, we found a significant increase in static elastance, likely related to a decrease in expiratory lung volume, as corroborated by the significant loss of PEEP (∼3 cm H2O) (see Fig. 1). However, this was associated with prolonged compressions only up to the late expiratory phase. Another possible explanation for the findings of Guimarães et al is that the subjects were not fully sedated (3 subjects were not sedated, and 16 presented a Ramsay Sedation Scale score of 2–4). Consequently, the subjects might have modulated the expiratory flow and opposed the thoracic compressions. Thus, uncertainty exists as to the feasibility of the technique in lightly sedated patients on volume controlled continuous mandatory ventilation. Nevertheless, this evidence further supports the use of hard MRCCs rather than a long squeeze of the rib cage. Indeed, a hard MRCC replicates a brief cough and could be safely applied to patients with low PEEP levels or who are not deeply sedated.

To date, scientific evidence on the efficacy and safety of MRCCs during invasive mechanical ventilation is scant, yet the study by Guimarães et al1 and previous studies demonstrate that critical factors (ie, studied population, mode of mechanical ventilation, time of application, expiratory phase synchronization) should be considered when applying this technique. Additional clinical studies are needed to elucidate the role of this physiotherapy technique in the ICU.

Footnotes

  • The authors have disclosed no conflicts of interest.

  • Copyright © 2014 by Daedalus Enterprises

REFERENCES

  1. 1.↵
    1. Guimarães FS,
    2. Lopes AJ,
    3. Constantino SS,
    4. Lima JC,
    5. Canuto P,
    6. Menezes SL
    . Expiratory rib cage compression in mechanically ventilated subjects: a randomized crossover trial. Respir Care 2014;59(5):678-685.
    OpenUrlAbstract/FREE Full Text
  2. 2.↵
    1. Unoki T,
    2. Kawasaki Y,
    3. Mizutani T,
    4. Fujino Y,
    5. Yanagisawa Y,
    6. Ishimatsu S,
    7. et al
    . Effects of expiratory rib-cage compression on oxygenation, ventilation, and airway-secretion removal in patients receiving mechanical ventilation. Respir Care 2005;50(11):1430-1437.
    OpenUrlAbstract/FREE Full Text
  3. 3.↵
    1. Unoki T,
    2. Mizutani T,
    3. Toyooka H
    . Effects of expiratory rib cage compression and/or prone position on oxygenation and ventilation in mechanically ventilated rabbits with induced atelectasis. Respir Care 2003;48(8):754-762.
    OpenUrlAbstract/FREE Full Text
  4. 4.↵
    1. Unoki T,
    2. Mizutani T,
    3. Toyooka H
    . Effects of expiratory rib cage compression combined with endotracheal suctioning on gas exchange in mechanically ventilated rabbits with induced atelectasis. Respir Care 2004;49(8):896-901.
    OpenUrlAbstract/FREE Full Text
  5. 5.↵
    1. Martí JD,
    2. Li Bassi G,
    3. Rigol M,
    4. Saucedo L,
    5. Ranzani OT,
    6. Esperatti M,
    7. et al
    . Effects of manual rib cage compressions on expiratory flow and mucus clearance during mechanical ventilation. Crit Care Med 2013;41(3):850-856.
    OpenUrlPubMed
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Respiratory Care: 59 (8)
Respiratory Care
Vol. 59, Issue 8
1 Aug 2014
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Expiratory Rib Cage Compressions to Improve Secretion Clearance During Mechanical Ventilation: Not Only a Matter of Squeezing the Chest
Joan-Daniel Martí, Gianluigi Li Bassi, Talitha Comaru, Antoni Torres
Respiratory Care Aug 2014, 59 (8) e119-e120; DOI: 10.4187/respcare.03109

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Expiratory Rib Cage Compressions to Improve Secretion Clearance During Mechanical Ventilation: Not Only a Matter of Squeezing the Chest
Joan-Daniel Martí, Gianluigi Li Bassi, Talitha Comaru, Antoni Torres
Respiratory Care Aug 2014, 59 (8) e119-e120; DOI: 10.4187/respcare.03109
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