Concurrent Trigger Sensitivity Adjustment And Diaphragmatic Facilitation On Weaning From Mechanical Ventilation
Condition: Acute Respiratory Failure; Mechanically Ventilated Patients
MeSH terms: Respiratory Insufficiency; Hypersensitivity
Study type: Interventional

Summary: 
      As Acute respiratory failure (ARF) is a challenging serious condition especially when it
      necessitates intubation to deliver mechanical ventilation which is a fundamental strategy for
      supporting the respiratory function when the patient can't bear all work of breathing. Even
      if it represents a life-saving procedure, mechanical ventilation (MV) is associated to
      life-threatening complications as respiratory muscle dysfunction, and atrophy that lead to
      long stay in intensive care unit (ICU) and higher mortality. Weaning difficulty is
      experienced in nearly 30 percent of critically ill patients.

      The decision to extubate mechanically ventilated patients should be aimed at preventing both
      the risk of premature liberation from MV which is associated with poor outcome and the risk
      of delayed extubation which increases the complications of prolonged MV and there is
      increasing evidence that MV itself may adversely affect the diaphragm's structure and
      function, which has been termed ventilator-induced diaphragmatic dysfunction (VIDD). The
      combination of positive pressure ventilation and positive end-expiratory pressure may unload
      the diaphragm which leads to changes in myofibril length and rapid atrophy that occurs within
      hours of MV, caused by an imbalance between protein synthesis and proteolysis, lead to a
      large reduction in the inspiratory pressure generated by the diaphragm.
    

Detailed description: 
      Physiotherapist is a key member of multidisciplinary team and plays an vital role in ICU in
      improving the patient's quality of life, Inspiratory muscle training (IMT) applies a load to
      the diaphragm and accessory inspiratory muscles to increase their strength and endurance.
      Adjustment of ventilator sensitivity provides resistance and hence a pressure load to the
      inspiratory muscles, and proprioceptive neuromuscular facilitation (PNF) of respiration is
      newly introduced in ICU for patients who are ventilator dependent by use of external
      proprioceptive and tactile stimuli to assist respiration. PNF techniques improve inspiration
      and expiration in next cycle that shows improvement with active initiation or more
      participation in respiration to alter the rate and depth of breathing, facilitate respiratory
      muscles, improve breathing pattern and increase tidal volume So the purpose of this study is
      to determine the concurrent effect of trigger sensitivity adjustment and diaphragmatic
      facilitation on weaning of patients from mechanical ventilation. As the patients may gain a
      more benefit from the combination of trigger sensitivity adjustment and manual diaphragmatic
      facilitation (PNF) techniques than from each one alone. Therefore, a concurrent trigger
      sensitivity adjustment and manual diaphragmatic facilitation (PNF) techniques must likely be
      started within 24 to 48 hours of initiating MV to protect diaphragm from atrophy, facilitate
      faster weaning, minimize ICU stay and cost of treatment, and decrease the morbidity and
      mortality rate of those patients admitted to ICU.

      Study Hypothesis:

      It will be hypothesized that there is no effect of diaphragmatic facilitation on weaning of
      patients from mechanical ventilation.

      It will be hypothesized that there is no effect of trigger sensitivity adjustment on weaning
      of patients from mechanical ventilation.

      It will be hypothesized that there is no effect of a concurrent trigger sensitivity
      adjustment and diaphragmatic facilitation on weaning of patients from mechanical ventilation.
    

Intervention name(s): Manual diaphragmatic facilitation (PNF) technique; Trigger sensitivity adjustment on mechanical ventilation; concurrent trigger sensitivity adjustment and manual diaphragmatic facilitation (PNF) technique
Intervention type(s): Procedure; Procedure; Procedure
Intervention description(s): Diaphragmatic PNF is a facilitator technique used to improve chest expansion, increase epigastric excursion, promote breathing frequency and depth, by applying external proprioceptive tactile stimuli over diaphragm. The therapist places the thumbs toward the xiphoid process and the fingers along the costal margins of the lower ribs and pushing deep to stimulate the diaphragm During inspiration, the patient will be instructed "take a deep breath breathe in" and the therapist assists the movement to promote the subject's respiratory pattern in downward movement. At the maximum inspiration, therapist will say "hold your breath for 5 seconds". The therapist gives mild resistance to the inferior movement of the contracting diaphragm during inspiration while pushing diaphragm superiorly. During expiration, therapist says "breathe out" and pushed under lower ribs on both sides upward to assist the discharge of air remaining in the lungs.; The pressure trigger sensitivity will be adjusted to 20% of the first recorded MIP at the start of training by decreasing trigger sensitivity towards negative pressure. In the first session, inspiratory muscle training (IMT) will be limited to 5 min; afterwards the duration will be increased by 5 min at every session until it reaches 30 min. If a patient tolerates 30 min of IMT, The next session will be performed with increasing negative pressure of the trigger sensitivity by 10% of the initial MIP. The maximal acceptable intensity is 40% of MIP, Patients who can't tolerate IMT with 20% of MIP for 5 min will be trained with 10% of MIP; Diaphragmatic PNF technique will be applied synchronously in the same time, on each breath with trigger sensitivity adjustment on mechanical ventilation in same manner as discussed before
Other intervention name(s): Diaphragmatic PNF; Trigger sensitivity
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Single (Participant)
Primary purpose: Treatment
Keywords: Acute Respiratory Failure; Mechanical ventilation; Ventilator Induced diaphragmatic dysfunction; Proprioceptive neuromuscular training; Diaphragmatic facilitation; Diaphragmatic PNF; Inspiratory Muscle training; Trigger sensitivity