Effect of ERCC and/or PEEP-ZEEP Maneuver on Oxygenation, Ventilation, and Airway Secretions Removal in MV Patients

Study Overview
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Brief Summary
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Mechanical ventilation (MV) is crucial in managing respiratory insufficiency. However, prolonged use can cause complications. Various strategies have been explored to optimize patient outcomes. Patients receiving IMV face multiple challenges in clearing lung secretions, such as inadequate humidification, high oxygen fractions, use of sedatives/analgesics, basal lung disease, and mechanical interference with secretion elimination near the trachea. Airway suctioning may not be sufficient in clearing the airway of mechanically ventilated patients, especially if they are paralyzed or lack a preserved cough reflex. This can lead to secretion retention, which may cause hypoxemia, atelectasis, ventilator-associated pneumonia, and delay weaning from MV. Bronchial hygiene is believed to improve respiratory system compliance by increasing Cdyn and Cst. Airway clearance techniques are commonly used in the treatment of patients with IMV to improve their pulmonary function through bronchial clearance, expansion of collapsed lung areas, and balancing of the ventilation/perfusion ratio. Physiotherapy methods including postural drainage, manual rib-cage compression (MRC), manual hyperinflation, positive end-expiratory pressure-zero end-expiratory pressure (PEEP-ZEEP) maneuver, and tracheal suctioning can alleviate atelectasis and improve bronchial hygiene. Two effective techniques for improving lung function and gas exchange are Expiratory Rib Cage Compression (ERCC) and the PEEP-ZEEP maneuver. ERCC applies external pressure during expiration, and PEEP-ZEEP temporarily reduces Positive End-Expiratory Pressure (PEEP) to 0 cmH2O, followed by a rapid return to the original PEEP level during expiration. Both techniques help to mobilize and remove airway secretions, ultimately improving lung function and gas exchange.

Detailed Description
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Expiratory rib cage compression is a form of chest physiotherapy that involves squeezing the chest with the hands during expiration and releasing it at the end of expiration to aid in the mobilization of lung secretions, facilitate comfortable inspiration, and promote alveolar ventilation. The concept of manual chest compression was first explored in the 1950s, when Opie et al. proposed that local chest compression produces a toothpaste effect, which helps to expel the retained material through the bronchus. This phenomenon piqued the interest of other researchers, leading to a better understanding of the functioning of the mucous layer and the development of therapeutic strategies to improve it. This technique increases forced expiratory volume by 30% and leads to the resting of the expiratory muscles. Most of all, the technique is quite safe, as it has been employed in some patients for more than 3 years with no complications. Therefore, this technique can be used before the patients' endotracheal suctioning interventions, and it is widely used with mechanically ventilated patients to prevent and/or to treat atelectasis. In addition, removing secretion is essential because accumulated secretions intervene in gas exchange and may delay recovery; coughing can be initiated voluntarily or by reflex. The positive end-expiratory pressure-zero end-expiratory pressure maneuver considers that by raising PEEP to 15 cmH2O during five cycles, followed by an abrupt reduction of PEEP to 0 cmH2O, gas redistribution occurs through collateral ventilation. Subsequently, small airways are opened, and the adhered mucus is displaced. With the reduction of PEEP, the expiratory flow pattern is modified, causing the secretions located in smaller airways to be transported to the central airways. While many studies have looked at the effects of rib cage compression (RCC) or the PEEP-ZEEP maneuver individually, there is a need for comparative studies that directly compare these two techniques. Understanding the different effects of these interventions on oxygenation, ventilation, and airway-secretion removal can help critical care nurses (CCNs) choose the most effective strategy for mechanically ventilated patients. Therefore, the purpose of this study is to compare the effects of RCC and the PEEP-ZEEP maneuver on oxygenation, ventilation, and airway-secretion removal in mechanically ventilated patients. By evaluating these outcomes, we can gain insights into the potential benefits and limitations of each technique, ultimately contributing to the optimization of respiratory support strategies in critically ill patients. The findings of this study can have important implications for CCN clinical practice as they can inform CCNs about the efficacy and safety of RCC and the PEEP-ZEEP maneuver. Improving oxygenation, ventilation, and airway-secretion removal in mechanically ventilated patients can lead to enhanced patient outcomes, reduced complications, and potentially shorter durations of mechanical ventilation and intensive care unit stays.

Official Title
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Effect of Expiratory Rib Cage Compression and/or PEEP-ZEEP Maneuver on Oxygenation, Ventilation, and Airway Secretions Removal in Mechanically Ventilated Patients

Conditions
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Mechanically Ventilated Patients

Intervention / Treatment
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* Other: Expiratory Rib Cage Compression
* Other: PEEP-ZEEP Maneuver
* Other: ERCC + PEEP-ZEEP maneuver


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Patients who are aged ≥18 years. Patients who have tracheal intubation and are likely to require MV for ≥72 hours. Patients who are hemodynamically stable: Heart rate (HR): ≥ 60 b or ≤100 b/min, mean arterial pressure (MAP) ≥ 90 mmHg, central venous pressure ≥ 3 or ≤ 8 cmH2O. Exclusion Criteria: Patients with pneumothorax, rib fracture, and subcutaneous emphysema. Patients with traumatic brain injuries and spinal cord injuries. Patients with ARDS who require high PEEP levels (>10 cmH2O). Patients admitted with pneumonia. Pregnant patients.

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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Accepts Healthy Volunteers

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Supportive Care
Allocation: Randomized
Intervention Model: Parallel Assignment
Interventional Model Description: A randomized controlled trial with four parallel groups will be used in the current study.
Masking: Quadruple


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Group (1) : ERCC Group<br>- The researcher will implement the ERCC technique for 10 minutes as follows: the researcher will use both hands bilaterally to gradually squeeze the rib cage (on the anterolateral region of the chest at the level of the last six ribs) in conjunction with chest-wall vibration during the expiratory phase of the ventilatory cycle. From the end of inspiration to the end of expiration, an attempt will be made to compress the rib cage over the region of the lungs that is most affected and the force will be applied every 2 breaths only during the expiration, synchronizing the maneuver rate with the breathing frequency of the subject. At the end of each expiratory phase, rib-cage compression is interrupted to permit free manual hyperinflation-induced inspiration. The ERCC technique will be implemented twice per day. | Other: Expiratory Rib Cage Compression<br>* Expiratory rib cage compression (ERCC) In this study, ERCC is a technique consisting of bilateral manual compression of the lower rib cage (anterolateral region of the chest at the level of the six last ribs) gradually during the expiratory phase of the ventilatory cycle and release from the compression at the end of the expiration.<br>|
| Experimental: Group (2) : PEEP-ZEEP Group<br>The researcher in the presence of the attending physician will apply the PEEP-ZEEP maneuver in the following manner: During the inspiration phase of the ventilatory cycle, it is proposed to increase PEEP to 15 cmH2O, while maintaining a PIP of 40 cmH2O. Following the completion of five ventilatory cycles, PEEP will be abruptly decreased to 0 cmH2O during the expiration phase, referred to as ZEEP. Subsequently, during the subsequent inspiration phase, PEEP will be restored to the previously established levels. The maneuver will be repeated for a duration of 10 minutes, with a gap of two ventilatory cycles between every repetition.The PEEP-ZEEP maneuver will be implemented twice per day. At the end of the PEEP-ZEEP maneuver, the patient will receive tracheal suction as mentioned before. The patients will be monitored continuously, and the maneuver will be interrupted if the patients become hemodynamically unstable or develop psychomotor agitation. | Other: PEEP-ZEEP Maneuver<br>* PEEP-ZEEP maneuver In this study, PEEP-ZEEP maneuver refers to PEEP which stands for positive end-expiratory pressure, and ZEEP which stands for zero end-expiratory pressure. In this maneuver PEEP will be incremented to 15 cmH2O throughout five consecutive respiratory cycles, then immediately after the inspiratory phase of the fifth cycle has been ended ZEEP should be done by abruptly reducing PEEP value to 0 cmH2O. The PEEP-ZEEP maneuver should be performed in two sets, consisting of a total of 10 consecutive breathing cycles. Subsequently, the patient is ventilated according to his/her baseline ventilator parameters.<br>|
| Experimental: Group (3) : ERCC + PEEP-ZEEP Group<br>The ERCC technique will be applied as mentioned above, followed by PEEP-ZEEP maneuvers according to the standard steps mentioned before. Also, the patients will be monitored continuously, and the maneuver will be interrupted if the patients become hemodynamically unstable or develop psychomotor agitation. | Other: ERCC + PEEP-ZEEP maneuver<br>* - The ERCC technique will be applied as mentioned above, then followed by PEEP-ZEEP maneuvers according to the standard steps mentioned before.<br>|
| No Intervention: Group (4) : control Group<br>The researcher will observe the conventional nursing care provided by CCNs in the study settings which may affect oxygenation, ventilation, and airway clearance for 30 minutes twice daily for five consecutive days. These conventional nursing practices may include enteral feeding, changing patients' positions, routine suctioning, and other traditional physiotherapies such as chest percussion and vibration. Part II of tool one will be used to assess physiological parameters, and tool two will be used to assess oxygenation, ventilation parameters, and airway clearance indicators for patients in the control group twice per day from the 1st day to the 5th day of the study pre and post-conventional nursing care. | |

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| oxygenation | partial pressure of oxygen tension (PaO2). (mmHg) Arterial oxygen saturation (SaO2). (100%) PaO2/FiO2 ratio, and oxygenation index (OI). (mmHg) | (T0) pre-intervention, (T1) immediately after the intervention, and (T3) up to 30 minutes | 
| ventilation | The partial pressure of carbon dioxide (PaCO2). (mmHg) Tidal volume (Vt). (ml) Positive end-expiratory pressure (PEEP). (CmH2O) Peak inspiratory pressure (PIP). (CmH2O) Minute ventilation (Mv). (L/m) Inspiratory: Expiratory Ratio (I: E ratio). Friction of inspired Oxygen (FIO2). (100%) Pressure Support (PS). (CmH2O) Plateau Pressure (Ppt). (CmH2O) Oxygen flow rate. (L/m) Static compliance (Cst) and dynamic compliance (Cdyn). (L/CmH2O) Respiratory system resistance (Rsr). (CmH2O/L /Sec) Rapid shallow breathing index (RSBI). (Breath /m/L) | (T0) pre-intervention, (T1) immediately after the intervention, and (T3) up to 30 minutes | 
| airway-secretion removal | Oxygenic parameters for airway clearance, such as SpO2 (100%) and end tidal carbon dioxide (ETCO2) (mmHg). Sputum parameters that include volume (ml), colour, consistency of respiratory secretions cleared from the airways, and frequency of sputum suctioning. Lung function parameters such as peak inspiratory flow (PIF) (L/m), peak expiratory flow (PEF) (L/m): PIF ratio, peak airway pressure-plateau pressure gradient during constant flow ventilation (CmH2O), respiratory rate (RR) (b/m), maximum airway pressure (CmH2O), and vital capacity (L). Ventilator graphs, especially flow-volume loops. Lung sound auscultation (presence or absence of chest crepitations). | (T0) pre-intervention, (T1) immediately after the intervention, and (T3) up to 30 minutes | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| duration of mechanical ventilation (days) | effect of ERCC and/or PEEP-ZEEP maneuvers on duration of mechanical ventilation (days) | 5 days | 
| length of ICU stay (days) | effect of ERCC and/or PEEP-ZEEP maneuvers on length of ICU stay (days). | from day 1 till discharge |