The Vasopressin Loading for Refractory septic shock (VALOR) study: a prospective observational study.

BACKGROUND: Vasopressin is a second-line vasoactive agent for refractory septic shock. Vasopressin loading is not generally performed because of the lack of evidence for its effects and safety. However, based on our previous findings, we hypothesized it can predict the responsibility to vasopressin infusion with safety, and prospectively examined it in the present study. METHODS: Vasopressin loading was performed via the intravenous administration of a bolus of 1 U, followed by its continuous infusion at 1U/h in patients with septic shock treated with ≥ 0.2 µg/kg/min noradrenaline. An arterial pressure wave analysis was conducted, and endocrinological tests were performed immediately prior to vasopressin loading. We classified patients into responders/non-responders based on mean arterial pressure (MAP) changes after vasopressin loading. Based on our previous findings, the lower tertile of MAP changes was selected as the cut-off. The change in the catecholamine index (CAI) after 6 h was assigned as the primary outcome. Digital ischemia, mesenteric ischemia, and myocardial ischemia during the admission period were prospectively and systematically recorded as adverse events. RESULTS: Ninety-two patients were registered during the study period and examined. Sixty-two patients with a MAP change > 22 mmHg were assigned as responders and the others as non-responders. Blood adrenocorticotropic hormone levels were significantly higher in non-responders. Stroke volume variations were higher in responders before loading, while stroke volume and dP/dtmax were higher in responders after loading. Median CAI changes were - 10 in responders and 0 in non-responders, which was significantly lower in the former (p < 0.0001). AUROC of MAP change with vasopressin loading to predict CAI change < 0 after continuous infusion was 0.843 with sensitivity of 0.92 and specificity of 0.77. Ischemia events were observed in 5 cases (5.4%). CONCLUSIONS: Vasopressin loading may be safely introduced for septic shock. Vasopressin loading may be used to predict responses to its continuous infusion and select appropriate strategies to increase blood pressure.

Adequacy of compression positioning using the feedback device during chest compressions by medical staff in a simulation study.

BACKGROUND: The 2020 American Heart Association guidelines recommend the use of a feedback device during chest compressions (CCs). However, these devices are only placed visually by medical personnel on the lower half of the sternum and do not provide feedback on the adequacy of the pressure-delivery position. In this study, we investigated whether medical staff could deliver CCs at the adequate compression position using a feedback device and identified where the inadequate position was compressed. METHODS: This simulation-based, prospective single-centre study enrolled 44 medical personnel who were assigned to four different groups based on the standing position and the hand in contact with the feedback device as follows: right-left (R-l), right-right (R-r), left-right (L-r), and left-left (L-l), respectively. The sensor position where the maximal average pressure was applied during CCs using the feedback device were ascertained with a flexible capacitive pressure sensor. We determined if this position is the adequate compression position or not. The intergroup differences in the frequency of the adequate compression position, the maximal average pressure, compression rate, depth and recoil were determined. RESULTS: The frequencies of adequate compression positioning were 55, 50, 58, and 60% in the R-l, R-r, L-r, and L-l groups, respectively, with no significant intergroup difference (p = 0.917). Inadequate position occurred in the front, back, hypothenar and thenar sides. The maximal average pressure did not significantly differ among the groups (p = 0.0781). The average compression rate was 100-110 compressions/min in each group, the average depth was 5-6 cm, and the average recoil was 0.1 cm, with no significant intergroup differences (p = 0.0882, 0.9653, and 0.2757, respectively). CONCLUSIONS: We found that only approximately half of the medical staff could deliver CCs using the feedback device at an adequate compression position and the inadequate position occurred in all sides. Resuscitation courses should be designed to educate trainees about the proper placement during CCs using a feedback device while also evaluating the correct compression position.

Structure-Activity Relationship between Thiol Group-Trapping Ability of Morphinan Compounds with a Michael Acceptor and Anti-Plasmodium falciparum Activities.

7-Benzylidenenaltrexone (BNTX) and most of its derivatives showed in vitro antimalarial activities against chloroquine-resistant and -sensitive Plasmodium falciparum strains (K1 and FCR3, respectively). In addition, the time-dependent changes of the addition reactions of the BNTX derivatives with 1-propanethiol were examined by 1H-NMR experiments to estimate their thiol group-trapping ability. The relative chemical reactivity of the BNTX derivatives to trap the thiol group of 1-propanethiol was correlated highly with the antimalarial activity. Therefore, the measurements of the thiol group-trapping ability of the BNTX derivatives with a Michael acceptor is expected to become an alternative method for in vitro malarial activity and related assays.

A night on call or an overnight shift does not reduce residents' empathy: a randomized crossover multicenter survey.

BACKGROUND: Studies have shown that sleep deprivation may reduce empathy among medical students. Yet, little is known about the empathy after a night on call or an overnight shift among resident physicians. Hence, we aimed to examine whether a night on call or an overnight shift reduces the physicians' empathy. METHODS: We conducted a multicenter randomized crossover survey using the Jefferson Scale of Physician Empathy (JSE). A total of 260 physicians who worked at academic hospitals and community hospitals in Japan in 2016 were recruited and randomized into two groups. Group A first completed the JSE prior to a night on call or an overnight shift; then, 8 weeks later, Group A completed the JSE after a night on call or an overnight shift. Group B first completed the JSE after a night on call or an overnight shift; then, 8 weeks later, Group B completed the JSE prior to a night on call or an overnight shift. Statistical analyses were performed to compare the JSE scores of pre- and post-night on call or overnight shifts. RESULTS: A total of 117 Group A physicians and 112 Group B physicians returned a completed JSE. The overall response rate was 88.08%. There was no significant difference in the JSE scores between pre- and post-night on call or overnight shift. (Group A before night vs Group B after night, p = 0.40, Group A after night vs Group B before night, p = 0.68). CONCLUSION: As per our results, a night on call or an overnight shift did not reduce the Japanese physicians' empathy. To the best of our knowledge, this is the first study on physicians' empathy after a night on call or an overnight shift.

Influence of psychiatric or social backgrounds on clinical decision making: a randomized, controlled multi-centre study.

BACKGROUND: Frequent and repeated visits from patients with mental illness or free medical care recipients may elicit physicians' negative emotions and influence their clinical decision making. This study investigated the impact of the psychiatric or social background of such patients on physicians' decision making about whether to offer recommendations for further examinations and whether they expressed an appropriate disposition toward the patient. METHODS: A randomized, controlled multi-centre study of residents in transitional, internal medicine, or emergency medicine was conducted in five hospitals. Upon randomization, participants were stratified by gender and postgraduate year, and they were allocated to scenario set 1 or 2. They answered questions pertaining to decision-making based on eight clinical vignettes. Half of the eight vignettes presented to scenario set 1 included additional patient information, such as that the patient had a past medical history of schizophrenia or that the patient was a recipient of free care who made frequent visits to the doctor (biased vignettes). The other half included no additional information (neutral vignettes). For scenario set 2, the four biased vignettes presented to scenario set 1 were neutralized, and the four neutral vignettes were rendered biased by providing additional information. After reading, participants answered decision-making questions regarding diagnostic examination, interventions, or patient disposition. The primary analysis was a repeated-measures ANOVA on the mean management accuracy score, with patient background information as a within-subject factor (no bias, free care recipients, or history of schizophrenia). RESULTS: A total of 207 questionnaires were collected. Repeated-measures ANOVA showed that additional background information had influence on mean accuracy score (F(7, 206) = 13.84, p <  0.001 partial η2 = 0.063). Post hoc pairwise multiple comparison test, Sidak test, showed a significant difference between schizophrenia and no bias condition (p <  0.05). The ratings for patient likability were lower in the biased vignettes compared to the neutral vignettes, which was associated with the lower utilization of medical resources by the physicians. CONCLUSIONS: Additional background information on past medical history of schizophrenia increased physicians' mistakes in decision making. Patients' psychiatric backgrounds should not bias physicians' decision-making. Based on these findings, physicians are recommended to avoid being influenced by medically unrelated information.

Improving the neurological prognosis following OHCA using real-time evaluation of cerebral tissue oxygenation.

BACKGROUND: The neurological prognosis is poor for patients suffering from out-of-hospital cardiac arrest (OHCA), in the absence of bystander cardio pulmonary resuscitation (CPR), and showing asystole as the initial waveform. However, such patients have the potential of resuming social activity if cerebral tissue oxygen saturation can be preserved. CASE PRESENTATION: We recently encountered a 60-year-old man who had suffered an OHCA in the absence of bystander CPR, and who successfully resumed complete social activity despite initial asystole and requiring at least 75min of chest compressions before return of spontaneous circulation (ROSC). In this case, chest compression was appropriately performed concurrently with real-time evaluation of cerebral tissue oxygenation using near-infrared spectroscopy (NIRS). As a result, the cerebral tissue oxygenation was well maintained, leading to resumption of social activity. CONCLUSIONS: Improved neurological prognoses can be expected if OHCA patients with the potential for social activity resumption are identified, using NIRS, and effective cardiopulmonary and cerebral resuscitation is performed while visually checking CPR quality.

Antitrichomonal activity of δ opioid receptor antagonists, 7-benzylidenenaltrexone derivatives.

The 7-benzylidenenaltrexone (BNTX) derivatives 2a-v, 3a-c, 13a-c, and 14a were synthesized from naltrexone (1) and evaluated for their antitrichomonal activity. The structure-activity-relationship studies found that 4-iodo-BNTX (2g) showed the highest activity (IC50=10.5µM) and the affinity for the opioid receptor was less important for antitrichomonal activity against Trichomonas vaginalis. The morphinan skeleton bearing both the double bond for a Michael acceptor and the phenolic hydroxy group would be a specific template for development of antitrichomonal agents. In addition, the mechanism of the antitrichomonal activity of the BNTX derivatives may differ from that of the standard drug, metronidazole.

ZnCl2-Promoted Intramolecular Hetero-Diels-Alder Reaction of o-Alkynylphenylcarbodiimides for Synthesis of Dihydrodibenzo[b,g][1,8]naphthyridines.

The ZnCl2-promoted intramolecular hetero-Diels-Alder reaction of N-(ortho-propargylphenyl)-N'-arylcarbodiimides, in which the aryl-N=C moiety functioned as a 2-azabuta-1,3-diene, 4π component, has been achieved. By this method, very rare 5,12-dihydrodibenzo[b,g][1,8]naphthyridines and fully aromatized dibenzo[b,g][1,8]naphthyridines were successfully synthesized.

Investigation of 7-benzylidenenaltrexone derivatives as a novel structural antitrichomonal lead compound.

We evaluated antitrichomonal effects of δ opioid receptor (DOR) agonists and antagonists. Although all the agonists were inactive, the DOR antagonists BNTX (2a) and its derivatives 2b-d showed antitrichomonal activity with MIC of 20-40 µM. In addition, the development of a more effective synthetic method for the BNTX derivatives was achieved by using the Knoevenagel condensation.

Efficacy of concomitant use of dexmedetomidine and propofol in tetanus.

Tetanus is an infectious disease caused by Clostridium tetani, which manifests systemic convulsion and autonomic instability associated with high case fatality. Despite proper medical intervention, management of those symptoms is often difficult. We report a case of 67-year-old man with tetanus in which a concomitant use of dexmedetomidine, an adrenaline α-2 receptor agonist, and propofol, a GABA(A) receptor binding agent, was successful in the management of systemic convulsion and autonomic instability without necessitating conventional anticonvulsant, neuromuscular blocking agents, or tracheostomy.

Acute muscle loss assessed using panoramic ultrasound in critically ill adults: a prospective observational study.

PURPOSE: Panoramic ultrasound is one of the recently introduced ultrasound evaluation techniques. We herein examined the relationship between the cross-sectional area of the rectus femoris muscle on panoramic ultrasound and its volume based on the gold standard computed tomography (CT) evaluation. METHODS: This was a single-center prospective observational study. A panoramic ultrasound assessment of the cross-sectional area of the rectus femoris muscle and a simple CT evaluation of its volume were performed on days 1 and 7 of hospitalization. Physical functions were assessed at discharge. RESULTS: Twenty patients were examined. The rate of change in the cross-sectional area of the rectus femoris muscle on panoramic ultrasound correlated with that in its volume on CT (correlation coefficient 0.59, p = 0.0061). In addition, a correlation was observed between the absolute value for the rectus femoris muscle cross-sectional area on panoramic ultrasound and physical functions at discharge. Rectus femoris muscle distances did not correlate with either. CONCLUSION: In the acute phase of critical illness, the cross-sectional area of the rectus femoris muscle on panoramic images correlated with its volume on CT and, thus, it is a valid method for assessing muscle mass.

A new method to detect cerebral blood flow waveform in synchrony with chest compression by near-infrared spectroscopy during CPR.

OBJECTIVE: The objective of the study is to demonstrate the utility of near-infrared spectroscopy (NIRS) in evaluating chest compression (CC) quality in cardiac arrest (CA) patients as well as determine its prognosis predictive value. METHODS: We present a nonconsecutive case series of adult patients with CA whose cardiopulmonary resuscitation (CPR) was monitored with NIRS and collected the total hemoglobin concentration change (ΔcHb), the tissue oxygen index (TOI), and the ΔTOI to assess CC quality in a noninvasive fashion. RESULTS: During CPR, ΔcHb displayed waveforms monitor, which we regarded as a surrogate for CC quality. Total hemoglobin concentration change waveforms responded accurately to variations or cessations of CCs. In addition, a TOI greater than 40% measured upon admission appears to be significant in predicting patient's outcome. Of 15 patients, 6 had a TOI greater than 40% measured upon admission, and 67% of the latter were in return of spontaneous circulation after CPR and were found to be significantly different between return of spontaneous circulation and death (P = .047; P < .05). CONCLUSION: Near-infrared spectroscopy reliably assesses the quality of CCs in patients with CA demonstrated by synchronous waveforms during CPR and possible prognostic predictive value, although further investigation is warranted.

Differences in Cerebral Oxygenation in Cardiogenic and Respiratory Cardiac Arrest Before, During, and After Cardiopulmonary Resuscitation.

We compared the changes in cerebral oxygen saturation (ScO2) levels during cardiac arrest (CA) events using porcine models of ventricular fibrillation CA (VF-CA) and asphyxial CA (A-CA). Twenty female pigs were randomly divided into VF-CA and A-CA groups. We initiated cardiopulmonary resuscitation (CPR) 4 min after CA and measured the cerebral tissue oxygenation index (TOI) using near-infrared spectroscopy (NIRS) before, during, and after CPR. In both groups, the TOI was the lowest at 3-4 min after pre-CPR phase initiation (VF-CA group: 3.4 min [2.8-3.9]; A-CA group: 3.2 min [2.9-4.6]; p = 0.386). The increase in TOI differed between the groups in the CPR phase (p < 0.001); it increased more rapidly in the VF-CA group (16.6 [5.5-32.6] vs. 1.1 [0.6-3.3] %/min; p < 0.001). Seven pigs surviving for 60 min after the return of spontaneous circulation in the VF-CA group recovered limb movement, whereas only one in the A-CA group (p = 0.023) achieved movement recovery. The increase in the TOI did not differ significantly between the groups in the post-CPR phase (p = 0.341). Therefore, it is better to monitor ScO2 concomitantly with CPR initiation using NIRS to assess the responsiveness to CPR in clinical settings.

Impact of Persistent Inflammation, Immunosuppression, and Catabolism Syndrome during Intensive Care Admission on Each Post-Intensive Care Syndrome Component in a PICS Clinic.

BACKGROUND: Persistent inflammation, immunosuppression, and catabolism syndrome (PIICS) is known as a prolonged immunodeficiency that occurs after severe infection. Few studies have demonstrated a direct relationship between PIICS and physical dysfunction in post-intensive care syndrome (PICS). We herein investigated how each component of PICS was affected by the diagnosis of PIICS during hospitalization and examined the relationship between PIICS and PICS using PICS assessments performed at the Hitachi General Hospital PICS Clinic. METHODS: The 273 patients who visited the PICS clinic at one month after discharge from the ICU at Hitachi General Hospital were included in the study. We used the diagnostic criteria for PIICS described in previous studies. At least two of the following blood test values on day 14 of hospitalization had to be met for a diagnosis of PIICS: C-reactive protein (CRP) > 2.0 mg/dL, albumin (Alb) < 3.0 g/dL, and lymphocytes (Lym) < 800/µL. Blood test values closest to day 14 out of 11-17 days of hospitalization were used. The primary outcome was a Barthel Index (BI) < 90, while secondary outcomes were the results of various PICS assessments, including mental and cognitive impairments, performed at the PICS clinic. We supplemented missing data with multiple imputations by chained equations. We performed a nominal logistic regression analysis with age, sex, BMI, SOFA, and the presence of PIICS as variables for BI < 90. RESULTS: Forty-three out of two hundred seventy-three PICS outpatients met the diagnostic criteria for PIICS during hospitalization. In comparisons with non-PIICS patients, significantly higher severity scores for APACHE II and SOFA and a longer hospital stay were observed in PIICS patients, suggesting a higher clinical severity. The primary outcome, BI, was lower in the PIICS group (97.5 (58.5, 100) vs. 100 (95, 100), p = 0.008), as were the secondary outcomes (FSS-ICU: 35 (31, 35) vs. 35 (35, 35), MRC score: 55 (50.25, 58) vs. 58 (53, 60), grip strength: 16.45 (9.2, 25.47) vs. 20.4 (15.3, 27.7)). No significant differences were noted in mental or cognitive function assessments, such as HADS, IES-R, and SMQ. A multivariable analysis supplemented with missing data revealed that PIICS (odds ratio: 1.23 (1.08-1.40 p = 0.001) and age (odds ratio: 1.007 (1.004-1.01), p < 0.001) correlated with BI < 90, independent of clinical severity such as sequential organ failure assessment (SOFA). Similar results were obtained in the sensitivity analysis excluding missing data. CONCLUSIONS: The present study revealed a strong relationship between PIICS and post-discharge PICS physical dysfunction in patients requiring intensive care.

Tracheoarterial fistula in a patient with amyotrophic lateral sclerosis successfully managed by overinflation of the tracheostomy tube cuff alone: a case report.

BACKGROUND: Tracheoarterial fistula is the most devastating complication after tracheostomy, and its mortality, without definitive treatment, approaches 100%. In general, the combination of bedside emergency management, that is, overinflation of the tracheostomy tube cuff, and definitive treatment such as surgical or endovascular intervention is necessary to prevent the poor outcome. Patients with neuromuscular diseases such as amyotrophic lateral sclerosis are susceptible to tracheoarterial fistula because of long-term mechanical ventilation and muscle weakness. CASE PRESENTATION: We describe a case of tracheoarterial fistula in a Japanese 39-year-old patient with amyotrophic lateral sclerosis with long-term ventilator management. The patient was clinically diagnosed with a tracheoarterial fistula because of massive bleeding following sentinel hemorrhage. The massive hemorrhage was controlled by overinflation of the tracheostomy tube cuff alone, without definitive treatment. CONCLUSIONS: This case suggests overinflation of the tracheostomy tube cuff alone plays an important role, semi-permanently, in the management of tracheoarterial fistula, especially in cases where surgical or endovascular intervention is not indicated. Clinicians taking care of patients with tracheostomy undergoing long-term mechanical ventilation should be aware that tracheoarterial fistula might occur following tracheostomy.

Urticaria-like decompression illness in a caisson worker treated successfully in a monoplace chamber.

Background: Although decompression illness is rare for nondivers, it can happen in an environment involving rapid decompression. Recompression is the recommended treatment. We herein report a decompression illness case with cutis marmorata and osteonecrosis in both legs during pneumatic caisson work. Case Presentation: A 59-year-old compressed air worker suffered sudden dyspnea during pneumatic caisson work. He had rash on his trunk and limbs. He was diagnosed with decompression illness, and hyperbaric oxygen therapy was performed twice. He had no neurological dysfunction nor sequalae on discharge, but magnetic resonance imaging follow-up revealed osteonecrosis in both legs. Conclusion: A detailed medical history should be taken when treating patients with dyspnea at work. Cutis marmorata often precedes more severe symptoms. Early introduction of hyperbaric oxygen therapy is desirable.

Association between haemodynamics during cardiopulmonary resuscitation and patient outcomes.

AIM: There is no defined target for blood flow during chest compressions (CC). We previously reported various haemodynamic patterns in which dominant arterial and venous pressures were observed during CC. This study aimed to evaluate arterial and venous perfusion pressures during CC and determine their association with patient outcomes. METHODS: In this prospective observational single-centre study, arterial and venous pressures were recorded continuously on arrival at the emergency department for patients with non-traumatic out-of-hospital cardiac arrest. Parameters included multiple pressure measurements: the arterial systolic (A sys), mean (A mean), and diastolic (A dias); the venous systolic (V sys), mean (V mean), and diastolic (V dias); and the differences between arterial and venous systolic (ΔSys A-V), mean (ΔMean A-V), and diastolic (ΔDias A-V). We compared patients with and without return of spontaneous circulation (ROSC). RESULTS: Among 50 patients, 16 (32%) had ROSC. Of the total measurement time, average A sys, A dias, ΔSys A-V, ΔDias A-V, A mean, and ΔMean A-V were significantly higher in patients with ROSC. When the average ΔMean A-V was stratified, there were 19 (38%) patients with negative average ΔMean A-V values, none of whom had ROSC. As the average ΔMean A-V increased, the ROSC rate also increased (p = 0.00002). CONCLUSIONS: ROSC did not occur in patients with negative average ΔMean A-V values. ROSC may be achieved through individualised resuscitation that places a greater emphasis on differences between mean arterial and venous pressure, rather than through uniform resuscitation.

Adequacy of hand positioning by medical personnel during chest compression in a simulation study.

AIM: During chest compressions (CCs), the hand position at the lower half of the sternum is not strictly maintained, unlike depth or rate. This study was conducted to determine whether medical staff could adequately push at a marked location on the lower half of the sternum, identify where the inappropriate hand position was shifted to, and correct the inappropriate hand position. METHODS: This simulation-based, prospective single-center study enrolled 44 medical personnel. Pressure and hand position during CC were ascertained using a flexible pressure sensor. The participants were divided into four groups by standing position and the hand in contact with the sternum: right-left (R-l), right-right (R-r), left-right (L-r), and left-left (L-l). We compared the groups and the methods: the manual method (MM), the thenar method, and the hypothenar method (HM). RESULTS: Among participants using the MM, 80% did not push adequately at the marked location on the lower half of the sternum; 60%-90% of the inadequate positions were shifted to the hypothenar side. CCs with the HM facilitated stronger pressure, and the position was minimally shifted to the hypothenar side. CONCLUSION: Medical staff could not push at an appropriate position during CCs. Resuscitation courses should be designed to educate personnel on the appropriate position for application of maximal pressure while also evaluating the position during CCs.

Acute mitral valve regurgitation causing severe alveolar hemorrhage.

BACKGROUND: Acute mitral regurgitation could occur without common symptoms like hemodynamic instability, but with dyspnea, hemoptysis, and right-sided infiltration on radiography. We report a case of severe alveolar hemorrhage caused by acute mitral regurgitation, which occurred in the absence of shock. CASE PRESENTATION: A 40-year-old man presented with dyspnea with bloody phlegm and hypoxia, despite being hemodynamically stable. Chest radiography revealed right-sided infiltration, and bronchoscopy showed fresh bloody phlegm in his tracheae. No specific findings were detected with any tests. After treatment with several medications and support with extracorporeal membrane oxygenation, his condition improved, although the etiology of the disease remained unknown. Transthoracic and transesophageal echocardiogram revealed severe mitral valve regurgitation with ruptured mitral chordae tendineae. These suggested that the sudden onset of mitral valve regurgitation had caused severe alveolar hemorrhage. CONCLUSION: Severe alveolar hemorrhage, especially with right-sided infiltration on chest radiography, should be considered a symptom of acute mitral regurgitation.

Effects of Manual Rib Cage Compressions on Mucus Clearance in Mechanically Ventilated Pigs.

BACKGROUND: Manual rib cage compression is a chest physiotherapy technique routinely used in clinical practice. However, scientific evidence remains scarce on the effects of manual rib cage compression on airway clearance and oxygenation in mechanically ventilated patients. METHODS: Anesthetized pigs were intubated via the trachea and mechanically ventilated. To create atelectasis, artificial mucus was infused into the airway. Each pig was randomly assigned to 1 of 2 groups: closed suctioning alone (control group, 7 pigs), or manual rib cage compression combined with closed suctioning (manual rib cage compression group, 8 pigs). Hard and brief rib cage compression synchronized with early expiratory phase was tested. Mucus clearance and oxygenation were assessed after the intervention. Sequential changes of hemodynamics were assessed after the intervention. RESULTS: During hard manual rib cage compression, the mean ± SD peak expiratory flow increased to 44 ± 7 L/min compared with 31 ± 7 L/min without treatment (P < .001). Manual rib cage compression combined with endotracheal suctioning increased mucus clearance compared with closed suctioning alone (mucus amounts, 5.5 [3.4-9.4] g vs 0.7 [0.5-2.0] g; P = .004); however, it did not improve gas exchange and radiologic findings. There were no significant differences in hemodynamic variables between the 2 groups. CONCLUSIONS: Our findings indicated that hard and brief manual rib cage compression combined with closed suctioning was safe and led to improvement of mucus clearance; however, no effectiveness was confirmed with regard to oxygenation and ventilation.