Clinical application of intrapulmonary percussive ventilation: A scoping review.

Impaired respiratory function secondary to acute or chronic respiratory disease poses a significant clinical and healthcare burden. Intrapulmonary percussive ventilation (IPV) is used in various clinical settings to treat excessive airway secretions, pulmonary atelectasis, and impaired gas exchange. Despite IPV's wide use, there is a lack of clinical guidance on IPV application which may lead to inconsistency in clinical practice. This scoping review aimed to summarise the clinical application methods and dosage of IPV used by clinicians and researchers to provide guidance. A two-staged systematic search was conducted to retrieve studies that used IPV in inpatient and outpatient settings. MEDLINE, EMBASE, CINAHL, Scopus, and Google scholar were searched from January 1979 till 2022. Studies with patients aged ≥16 years and published in any language were included. Two reviewers independently screened the title and abstract, reviewed full text articles, and extracted data. Search yielded 514 studies. After removing duplicates and irrelevant studies, 25 studies with 905 participants met the inclusion criteria. This is the first scoping review to summarise IPV application methods and dosages from the available studies in intensive care unit (ICU), acute inpatient (non-ICU), and outpatient settings. Some variations in clinical applications and prescribed dosages of IPV were noted. Despite variations, common trends in clinical application and prescription of IPV dosages were observed and summarised to assist clinicians with IPV intervention. Although an evidence-based clinical guideline could not be provided, this review provides detailed information on IPV application and dosages in order to provide clinical guidance and lays a foundation towards developing a clinical practice guideline in the future.

Remi-fent 1-A pragmatic randomised controlled study to evaluate the feasibility of using remifentanil or fentanyl as sedation adjuncts in mechanically ventilated patients.

Objective: To evaluate the feasibility of conducting a prospective randomised controlled trial (pRCT) comparing remifentanil and fentanyl as adjuncts to sedate mechanically ventilated patients. Design: Single-center, open-labelled, pRCT with blinded analysis. Setting: Australian tertiary intensive care unit (ICU). Participants: Consecutive adults between June 2020 and August 2021 expected to receive invasive ventilation beyond the next day and requiring opioid infusion were included. Exclusion criteria were pregnant/lactating women, intubation >12 h, or study-drug hypersensitivity. Interventions: Open-label fentanyl and remifentanil infusions per existing ICU protocols. Outcomes: Primary outcomes were feasibility of recruiting ≥1 patient/week and >90 % compliance, namely no other opioid infusion used during the study period. Secondary outcomes included complications, ICU-, ventilator- and hospital-free days, and mortality (ICU, hospital). Blinded intention-to-treat analysis was performed concealing the allocation group. Results: 208 patients were enrolled (mean 3.7 patients/week). Compliance was 80.6 %. More patients developed complications with fentanyl than remifentanil: bradycardia (n = 44 versus n = 21; p < 0.001); hypotension (n = 78 versus n = 53; p < 0.01); delirium (n = 28 versus n = 15; p = 0.001). No differences were seen in ICU (24.3 % versus 27.6 %,p = 0.60) and hospital mortalities (26.2 % versus 30.5 %; p = 0.50). Ventilator-free days were higher with remifentanil (p = 0.01). Conclusions: We demonstrated the feasibility of enrolling patients for a pRCT comparing remifentanil and fentanyl as sedation adjuncts in mechanically ventilated patients. We failed to attain the study-opioid compliance target, likely because of patients with complex sedative/analgesic requirements. Secondary outcomes suggest that remifentanil may reduce mechanical ventilation duration and decrease the incidence of complications. An adequately powered multicentric phase 2 study is required to evaluate these results.

Effect of intrapulmonary percussive ventilation on intensive care unit length of stay, the incidence of pneumonia and gas exchange in critically ill patients: A systematic review.

BACKGROUND: Pulmonary complications such as pneumonia, pulmonary atelectasis, and subsequent respiratory failure leading to ventilatory support are a common occurrence in critically ill patients. Intrapulmonary percussive ventilation (IPV) is used to improve gas exchange and promote airway clearance in these patients. The current evidence regarding the effectiveness of intrapulmonary percussive ventilation in critical care settings remains unclear. This systematic review aims to summarise the evidence of the effectiveness of intrapulmonary percussive ventilation on intensive care unit length of stay (ICU-LOS) and respiratory outcomes in critically ill patients. RESEARCH QUESTION: In critically ill patients, is intrapulmonary percussive ventilation effective in improving respiratory outcomes and reducing intensive care unit length of stay. METHODS: A systematic search of intrapulmonary percussive ventilation in intensive care unit (ICU) was performed on five databases from 1979 to 2021. Studies were considered for inclusion if they evaluated the effectiveness of IPV in patients aged ≥16 years receiving invasive or non-invasive ventilation or breathing spontaneously in critical care or high dependency units. Study titles and abstracts were screened, followed by data extraction by a full-text review. Due to a small number of studies and observed heterogeneities in the study methodology and patient population, a meta-analysis could not be included in this review. Outcomes of interest were summarised narratively. RESULTS: Out of 306 identified abstracts, seven studies (630 patients) met the eligibility criteria. Results of the included studies provide weak evidence to support the effectiveness of intrapulmonary percussive ventilation in reducing ICU-LOS, improving gas exchange, and reducing respiratory rate. INTERPRETATION: Based on the findings of this review, the evidence to support the role of IPV in reducing ICU-LOS, improving gas exchange, and reducing respiratory rate is weak. The therapeutic value of IPV in airway clearance, preventing pneumonia, and treating pulmonary atelectasis requires further investigation.

Feasibility and safety of intrapulmonary percussive ventilation in spontaneously breathing, non-ventilated patients in critical care: A retrospective pilot study.

BACKGROUND: Intrapulmonary percussive ventilation is used in various clinical settings to promote secretion clearance, reverse or treat atelectasis and improve gas exchange. Despite a few studies reporting the use of intrapulmonary percussive ventilation in critical care, the available data remain insufficient, contributing to weaker evidence toward its effectiveness. Also, there is a paucity of studies evaluating the safety and feasibility of intrapulmonary percussive ventilation application in critical care. This retrospective pilot study has evaluated the safety and feasibility of intrapulmonary percussive ventilation intervention in non-intubated patients admitted to an intensive care unit. METHODS: The medical records of 35 subjects were reviewed, including 22 subjects who received intrapulmonary percussive ventilation intervention and 13 subjects matched for age, sex, and primary diagnosis who received chest physiotherapy. The records were audited for feasibility, safety, changes in oxygen saturation, chest X-ray changes, and intensive care unit length of stay. RESULTS: A total of 104 treatment sessions (IPV 65 and CPT 39) were delivered to subjects admitted with a range of respiratory conditions in critical care. Subjects completed 97% of IPV sessions. No major adverse events were reported with intrapulmonary percussive ventilation intervention. Intensive care unit length of stay in the intrapulmonary percussive ventilation group was 9.6 ± 6 days, and in the CPT group, it was 11 ± 9 days (p = 0.59). Peripheral oxygen saturation pre to post intervention was 92% ± 4 to 96% ± 4 in IPV group and 95% ± 4 to 95% ± 3 in the CPT group. CONCLUSION: Application of intrapulmonary percussive ventilation intervention was feasible and safe in non-ventilated adult patients in critical care.

Trend of complementary therapies in paediatric age group.

OBJECTIVE: To assess the knowledge of mothers regarding commonly used Complimentary alternative medicines, their usage and various therapeutic choices for common ailments. METHODS: A cross-sectional Survey on a predesigned proforma was done from July 2007- August 2007 in the out patient department of a tertiary care hospital. Consent was taken from the participants and 375 complete proformas were included in the study out of 500 interviewed. RESULTS: Of the 375 mothers who were interviewed, 237 (63.2%) believed in alternative medicine whereas 138 (36.8%) did not believe in it. Complimentary alternative medicines (CAM) was used most often in children with respiratory tract and gastro intestinal symptoms, the most frequently used therapy was Honey 58.9% and Joshanda 31.2%, followed by Heeng 11.3% and brandy being used in 2.8% for respiratory complaints. Gastrointestinal symptoms were treated with Saunf water 28.4%, mint 20.6% and ajwain 17.7%. Higher education level was associated with more complementary medicine use. Majority of mothers used it for gastrointestinal problems and respiratory problems 24% and 22.2% respectively. CONCLUSIONS: Mothers are aware of various available CAM and are using them for different ailments like honey for respiratory illnesses, Saunf and Ajwain for gastrointestinal problems as they have been found to have linctus and antispasmodic effects respectively. It has also been observed that the CAM was used in combination with other therapeutic modalities and not alone.

Is serum total IgE levels a good predictor of allergies in children?

OBJECTIVE: To study the role of Serum Total IgE levels as a marker of allergy and to see its association with different host and environmental factors, its association with different systemic allergies and with the increased allergic systemic involvement. METHODS: A cross sectional comparative study was conducted at Liaquat National Hospital Paediatric Medicine Unit and Outpatient Clinic, from December 2007 to October 2008. Two hundred and fifty eight children in the age group 6 months to 12 years meeting the inclusion criteria, were enrolled for the study. Complete blood count and serum total IgE levels were done in all patients. Data was collected and tabulated. Chi-square was applied to test the association of serum Total IgE levels with different variables using SPSS and p-value of <0.05 was taken as statistically significant. RESULTS: Out of 258 patients 166(64.37%) had raised serum total IgE levels (108 males and 92 females). Among host factors there was no significant association of serum total IgE levels with age, sex, height of the patient, positive family history of allergy or age at which symptoms developed (p =or> 0.05), though the correlation of serum total IgE levels was seen with weight of the patient (p < 0.049), early weaning (p < 0.01) and bottle feeding (p < 0.01) in children. Among environmental factors serum total IgE levels had a strong association with exposure to passive smoking (p < 0.01), pollen (p < 0.01), cold (p < 0.01), and pets (p < 0.01). Blood eosinophilia was another factor that had positive association with allergy and raised serum total IgE levels (p < 0.01). However association of serum IgE levels was not statistically significant for any systemic allergies, skin allergy (0.608), food allergy (p < 0.210), allergic sinusitis (p < 0.113), allergic rhinitis (p < 0.358), allergic conjunctivitis (p < 0.507) except for bronchial asthma (p =or<0.01) where serum total IgE levels was also associated with severity of bronchial asthma (p < 0.01). Interestingly there was no significant relationship of increased number of systemic allergies with serum IgE levels. CONCLUSION: Serum total IgE level is a good predictor of allergy in children. It is influenced by early weaning, early bottle feeding, exposure to passive smoking, pollen, cold, and pets and is associated with blood eosinophilia. Also serum total IgE level is a strong predictor of allergy in asthmatic children.

The MOVIN' project (Mobilisation Of Ventilated Intensive care patients at Nepean): A quality improvement project based on the principles of knowledge translation to promote nurse-led mobilisation of critically ill ventilated patients.

OBJECTIVE: Prospective quality improvement project to evaluate the impact of a training programme to promote nurse-led mobilisation of intubated critically ill patients. METHODS: This project involved an educational programme to upskill nurses and overcome the barriers/challenges to nurse-led mobilisation. Initial strategies focused on educating and upskilling nurses to attain competency in active mobilisation. Subsequent strategies focused on positive reinforcement to achieve a culture shift. A pre- and post-intervention audit was used to evaluate its effectiveness. RESULTS: A baseline audit showed that ∼9% of ventilated patients were mobilised. Several barriers were identified. Twenty-three nurses underwent training in actively mobilising ventilated patients. This increased their confidence levels and there was reduction in reported barriers. However, the rate of active mobilisation remained low (9.7%). Subsequently, a programme of positive reinforcement with rewards and visual reminders was introduced, which saw an increase in the number of nurse-led mobilisations of both ventilated patients (from 9.7% to 34.8%; p=0.0003), and non-ventilated patients (29.5% versus 62.9%; p=<0.0001). CONCLUSION: It is safe and feasible to train nurses to perform active mobilisation of ventilated patients. However, to promote a culture change, training and competency must be combined with a multi-pronged approach including reminders, positive reinforcement and rewards.

A Laplacian based image filtering using switching noise detector.

This paper presents a Laplacian-based image filtering method. Using a local noise estimator function in an energy functional minimizing scheme we show that Laplacian that has been known as an edge detection function can be used for noise removal applications. The algorithm can be implemented on a 3x3 window and easily tuned by number of iterations. Image denoising is simplified to the reduction of the pixels value with their related Laplacian value weighted by local noise estimator. The only parameter which controls smoothness is the number of iterations. Noise reduction quality of the introduced method is evaluated and compared with some classic algorithms like Wiener and Total Variation based filters for Gaussian noise. And also the method compared with the state-of-the-art method BM3D for some images. The algorithm appears to be easy, fast and comparable with many classic denoising algorithms for Gaussian noise.

A study of the effect of Nigella sativa (Black seeds) in isoniazid (INH)-induced hepatotoxicity in rabbits.

OBJECTIVE: To investigate the possibility of hepatoprotective effect of Nigella sativa (NS) in INH-induced hepatotoxicity. MATERIALS AND METHODS: The experiments were carried out on 24 male rabbits. They were divided into 4 groups (6 each); rabbits in group 1 were treated with INH following a standard protocol to induce hepatotoxicity. Rabbits in group 2 received starch. Group 3 received NS 1 g/kg/day before INH treatment. Group 4 rabbits were treated with NS only. Phenobarbital sodium (IP) was given to induce metabolism of INH. INH and NS were given orally. The experiment continued for 12 days; at day 13, animals were sacrificed. Liver function tests, malondialdehyde (MDA) were estimated in serum and in liver homogenates. Liver histopathological examinations were performed. RESULTS: Histopathological changes of hepatotoxicity were found in all INH-treated rabbits. The histopathological findings were normal in three rabbits treated with NS before INH, very mild in two, and with moderate changes in one rabbit. Serum alanine aminotransferase (S.ALT) was elevated after INH treatment and returned back to the control value when NS was given before INH. Similar pattern of effect was noticed with serum aspartate aminotransferase (S.AST), S. total bilirubin, S. MDA, and Serum alkaline phosphatase.In liver homogenate, AST, ALT, and MDA were increased with INH treatment compared to the control, then decreased with NS treatment given before INH CONCLUSIONS: NS has hepatoprotective effects against INH-induced hepatotoxicity in rabbits. NS 1 g/kg proved safe, no adverse effects; no histopathological or biological abnormalities were seen.