Department of Neuroanaesthesiology and Critical Care, Neuroscience Centre, All India Institute of Medical Sciences, New Delhi, Delhi 110029, India.
Department of Neuroanaesthesiology and Critical Care, Neuroscience Centre, All India Institute of Medical Sciences.
Phys Ther. 2019 Apr 1;99(4):388-395. doi: 10.1093/ptj/pzy141.
Physical therapist intervention can play a significant role in the prevention of mechanical and infectious complications in patients with traumatic brain injury (TBI) who are mechanically ventilated.
The objective of this study was to observe and compare the effects of manual and mechanical airway clearance techniques on intracranial pressure (ICP) and hemodynamics in patients with severe TBI.
The design was a prospective, randomized, crossover trial.
The setting was a neurointensive care unit at a level 1 trauma center.
Forty-six adult patients aged 18 to 75 years, of either sex, with severe TBI, receiving mechanical ventilatory support with continuous ICP monitoring, and undergoing regular airway clearance techniques participated in this study.
Two techniques were performed by a single trained physical therapist. Treatment A was a manual chest percussion technique and treatment B used a mechanical chest wall vibrator. Each treatment was applied for 10 minutes alternately, separated by an interval of 4 hours.
ICP was measured from the start of intervention to 10 minutes postintervention. Secondary measurements included cerebral perfusion pressure, heart rate, mean arterial pressure (each from the start of the intervention until 10 minutes postintervention at 1-minute intervals), and arterial blood gas parameters (from just before the start of the intervention and 10 minutes postintervention).
The increases in mean (95% CI) intracranial pressure of 2.4 (1.4-3.4) and 1.0 (0.2-1.8) mmHg, during and after the intervention with treatment A, respectively, were statistically significantly higher than for treatment B, irrespective of sequence. In contrast, a mean heart rate rise of 6.4 (3.3-9.5) beats/min and mean arterial pressure rise of 5.3 (2.0-8.6) mmHg were significantly higher only during the intervention phase of treatment A compared with treatment B. Peak mean values of ICP, heart rate, and arterial pressure were also significantly higher during treatment A. However, mean values of cerebral perfusion pressure or its degree of change were statistically comparable in both treatment groups.
Patients with high baseline ICP values (>20 mmHg) were excluded, and, because of the crossover design, the effect of individual technique on final (long-term) neurological or respiratory outcomes could not be studied.
Manual chest percussion technique in patients with severe TBI was associated with statistically significant transient increases in ICP and hemodynamics, compared with the mechanical method. However, such transient increases in ICP by either technique were not clinically relevant in patients with moderate-to-severe TBI without intracranial hypertension on a mechanical ventilator.
物理治疗师的干预可以在预防机械和感染并发症方面发挥重要作用，对于机械通气的创伤性脑损伤（TBI）患者。
本研究的目的是观察和比较手动和机械气道清除技术对严重 TBI 患者颅内压（ICP）和血液动力学的影响。
这是一项前瞻性、随机、交叉试验。
设置在一级创伤中心的神经重症监护病房。
46 名年龄在 18 至 75 岁之间的成年患者，无论性别如何，均患有严重的 TBI，接受机械通气支持和持续 ICP 监测，并进行常规气道清除技术。
由一名经过培训的物理治疗师进行两种技术。治疗 A 是手动胸部叩击技术，治疗 B 使用机械胸壁振动器。每种治疗方法交替进行 10 分钟，间隔 4 小时。
从干预开始到干预后 10 分钟测量 ICP。次要测量包括脑灌注压、心率、平均动脉压（从干预开始到 10 分钟后每隔 1 分钟测量一次）和动脉血气参数（从干预开始前和干预后 10 分钟测量）。
治疗 A 期间和之后颅内压升高的平均值（95%CI）分别为 2.4（1.4-3.4）和 1.0（0.2-1.8）mmHg，与治疗 B 相比，分别统计学上显著更高，与顺序无关。相比之下，治疗 A 期间的平均心率升高 6.4（3.3-9.5）次/分钟和平均动脉压升高 5.3（2.0-8.6）mmHg，与治疗 B 相比，仅在干预阶段显著更高。治疗 A 期间 ICP、心率和动脉压的峰值平均值也明显更高。然而，两组的脑灌注压平均值或其变化程度在统计学上是可比的。
排除了基线 ICP 值较高（>20mmHg）的患者，并且由于交叉设计，无法研究单个技术对最终（长期）神经或呼吸结果的影响。
与机械方法相比，严重 TBI 患者的手动胸部叩击技术与统计学上显著的 ICP 和血液动力学一过性升高相关。然而，在机械通气的中度至重度 TBI 患者中，没有颅内压升高的情况下，两种技术引起的 ICP 一过性升高在临床上并不相关。
