Measuring lung aeration change with lung ultrasound in response to physiotherapy breathing techniques

TIDieR Criterion Intervention 1 Name: Incentive spirometry (IS) Rationale: Facilitates a patient to perform a slow sustained inspiration, producing a sustained maximal inspiration to aid the re-expansion of collapsed alveoli in the setting of atelectasis. When breathing in through an incentive spirometer, a piston rises inside the device and measures the volume of the inspired air. It encourages the patient to perform a slow and deep inspiration through visual feedback.46 Goal: The patient is verbally informed of their risk of postoperative pulmonary complications following surgery and the benefit that IS can have on increasing lung volumes, improving gas exchange, assisting secretion removal and preventing postoperative atelectasis and other complications. A single page handout will also reinforce verbal information, and provide step-by-step instructions on how to complete IS. Materials: A single page handout will be given to participants to reinforce verbal education about PPC risk and the role of IS in reducing this risk. Intervention providers: Familiarisation with protocol prior to treating participants. The IS device used will be the Voldyne 4000 Volumetric Exerciser from Medline. Procedure: The IS exercises will be taught to and performed by the participant in a single physiotherapy session. The participant will be positioned in a semi-recumbent position in bed. IS exercises will consist of 4 sets of 5 slow breaths to maximal inspiratory capacity, as instructed below: (1) hold the device in front of your mouth with relaxed elbows; (2) breathe out; (3) place lips around mouthpiece and seal; (4) inhale slowly and deeply through the mouth and see how high you can raise the yellow float here; (5) once you have reached your capacity to breathe in, hold the breath for 3-5 seconds; (6) take the mouthpiece out of your mouth and breathe out slowly. Each set of 5 breaths are followed by three coughs, or a forced expiratory technique with an open glottis called a “huff”, with a small firm pillow pressed over the abdominal incision to support the wound and to encourage greater expiratory force. It is at the treating physiotherapist’s discretion to place hands on the patient’s chest wall during the coaching sessions to provide tactile feedback of performance. Who: Research or clinical physiotherapists will deliver the intervention How: Face-to-face, a single physiotherapy session with an individual participant Where: The study will take place in the inpatient hospital setting, in the intensive care unit/HDU or surgical step down unit of three participating government funded public hospitals. The hospital delivering IS will be a 357-bed tertiary referral hospital in northern Tasmania, with a 13-bed Level III general ICU. Intervention 2 Name: Bubble positive expiratory pressure (PEP) Rationale: A slow, sustained expiration into a water filled chamber produces positive pressure to splint open collapsed alveoli, with the oscillation of water in the chamber producing vibration in the airways to help shear secretions for expectoration. Goal: The patient is verbally informed of their risk of postoperative pulmonary complications following surgery and the benefit that bubble PEP can have on promoting secretion clearance, increasing lung volumes, improving gas exchange and preventing postoperative atelectasis and other complications. A single page handout will also reinforce verbal information, and provide step-by-step instructions on how to complete bubble PEP. Materials: A single page handout will be given to participants to reinforce verbal education about PPC risk and the role of bubble PEP in reducing this risk. Intervention providers: Familiarisation with protocol prior to treating participants. The bubble PEP device consists of a bottle of water for irrigation measuring 21cm in height and 10cm in width. The bottle will be filled with 10cm of water, to ensure positive expiratory pressure generated by the device remains between 11-13cmH20. The suction tubing used will have an internal diameter of 1cm, and a length of 30cm. The bottom of the suction tubing will rest on the bottom of the bottle. The bottle will be filled with water to a height of 10cm.47 Procedure: Bubble PEP will be taught to and performed by the participant in a single physiotherapy session. The participant will be positioned in a semi-recumbent position in bed. Bubble PEP exercises will consist of 5 slow sustained expirations in to a chamber of water as instructed below. (1) hold the bottle in front of your mouth with relaxed elbows; (2) inhale slowly, slightly deeper than a normal breath; (3) place lips around the tubing and seal; (4) exhale slowly through your mouth for 3-5 seconds, you should see steady bubbling in the water bottle; (5) take the mouthpiece out of your mouth and inhale slowly, slightly deeper than normal. Each set of 5 breaths are followed by three coughs, or a forced expiratory technique with an open glottis called a “huff”, with a small firm pillow pressed over the abdominal incision to support the wound and to encourage greater expiratory force. It is at the treating physiotherapist’s discretion to place hands on the patient’s chest wall during the coaching sessions to provide tactile feedback of performance. Who: Research or clinical physiotherapists will deliver the intervention How: Face-to-face, a single physiotherapy session with an individual participant Where: The study will take place in the inpatient hospital setting, in the intensive care unit/HDU or surgical step down unit of three participating government funded public hospitals. The hospital delivering bubble PEP will be a 600-bed tertiary referral hospital in Northern Sydney Australia, with a 58-bed Level III general (including major trauma, burns, spinal cord injuries), cardiothoracic and neurosurgical ICU. Participants will receive only one of the three listed treatments above as part of their participation in the study. Each study site will be delivering one type of technique. RNSH will deliver bubble PEP, Royal Perth Hospital will deliver deep breathing exercises and Launceston General Hospital will deliver incentive spirometry. Participants will still also receive respiratory physiotherapy treatment techniques as part of standard care regardless of their involvement in the study.