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

Authors:
Fernando S Guimaraes at Federal University of Rio de Janeiro
Fernando S Guimaraes
Sara L S Menezes at Federal University of Rio de Janeiro
Sara L S Menezes
Agnaldo José Lopes at Hospital Universitario Pedro Ernesto
Agnaldo José Lopes
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Abstract

In Reply : We thank Dr Marti and his colleagues for their comments on our study. The different methods used to investigate the clinical and physiological repercussions of airway clearance techniques make comparison between studies difficult. Animal studies like those from Unoki et al[1][1],[2][2]
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Expiratory Rib Cage
Compressions to Improve
Secretion Clearance During
Mechanical Ventilation: Not Only
a Matter of Squeezing the Chest—
Reply
In Reply:
We thank Dr Martí and his colleagues
for their comments on our study. The dif-
ferent methods used to investigate the clin-
ical and physiological repercussions of air-
way clearance techniques make comparison
between studies difficult. Animal studies
like those from Unoki et al
1,2
and Martí
et al
3
are important to elucidate mechanisms
and raise insights into safety and efficacy of
clinical studies with human participants.
However, compared with animal models,
most mechanically ventilated patients are
not paralyzed and present with diverse clin-
ical conditions and respiratory mechanics
profiles.
The rational of chest physiotherapy is to
displace secretions from the periphery to
more central airways, where they can be
removed by coughing.
4
In our study, simi-
lar to the forced expiratory technique, we
used prolonged strong manual compression
aimed at improving the 2-phase gas-liquid
flowinlungperiphery.
4,5
Ourresultsshowed
that, according to expiratory flow-volume
loop monitoring, this maneuver increased
not only the peak expiratory flow but also
the air flow throughout the entire expiratory
phaseinmostsubjects.
6
Conversely,because
the brief strong expiratory maneuver in the
study by Martí et al
3
increased the peak
expiratory flow, it was considered an exog-
enouscough.
7
Moreover,theincrease in mu-
cus displacement velocity in the central air-
ways (trachea) observed in their study is an
expected result and does not reflect mobi-
lization of secretions from the lung periph-
ery.
In conceptual terms, a distinction has to
bemadebetweenanyabruptexpiratoryman-
ual compressive maneuver, which mimics
the attributes of an effective spontaneous
cough, and prolonged expiratory rib cage
compression as a technique to remove se-
cretions from the lung periphery. The first,
also called directed cough or manually as-
sistedcough,consists of “assisting the cough
effort with abdominal or thoracic compres-
sion during exhalation”
4
and has been indi-
cated to improve the peak expiratory flow
in patients with weak cough.
8,9
Because the
hard manual rib cage compressions in the
study by Martí et al
3
were applied only in
the early expiratory phase, we question
whether it can be compared with a directed
cough maneuver or an exogenous cough.
To date, the literature has not shown any
benefit in mobilizing peripheral secretions
by rapidly squeezing out air with prolonged
strong compressions (manually assisted
cough), brief strong manual compressions
synchronizedwiththeearlyexpiratoryphase
(hardmanualribcage compressions), or pro-
longed strong and slow manual compres-
sions throughout the entire expiration phase
(expiratory rib cage compression) in me-
chanically ventilated patients.
Fernando S Guimara˜esPTPhD
Sara Lucia Silveira de Menezes
PT PhD
Rehabilitation Sciences Master’s Program
Augusto Motta University Center
and
School of Physiotherapy
Federal University of Rio de Janeiro
Rio de Janeiro, Brazil
Agnaldo J Lopes MD PhD
Rehabilitation Sciences Master’s Program
Augusto Motta University Center
and
Pedro Ernesto Hospital
Rio de Janeiro State University
Rio de Janeiro, Brazil
The authors have disclosed no conflicts of in-
terest.
REFERENCES
1. Unoki T, Mizutani T, Toyooka H. Effects
of expiratory rib cage compression and/or
prone position on oxygenation and ventila-
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2. Unoki T, Mizutani T, Toyooka H. Effects
of expiratory rib cage compression com-
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exchange in mechanically ventilated rab-
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2004;49(8):896-901.
3. Martí JD, Li Bassi G, Rigol M, Saucedo L,
Ranzani OT, Esperatti M, et al. Effects of
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41(3):850-856.
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6. Guimara˜es FS, Lopes AJ, Constantino SS,
Lima JC, Canuto P, de Menezes SL. Expi-
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RESPIRATORY CARE •AUGUST 2014 VOL 59 NO8 e121
... Regarding its objectives, ERRC is usually applied either to assist with secretion movement from distal to proximal airways, or to remove secretion from large airways. 45,46 In theory, if ERRC is applied with gradual intensity (from gentle to strong) to prolong exhalation after the onset of the expiratory phase, it removes secretions from distal airways. On the other hand, if ERRC is applied with hard compressions to increase PEF and synchronized with the onset of expiration, it removes secretions from proximal airways. ...
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