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Manual Hyperinflation

Presented by: Karishma H. Keswani Moderated by: Mr. A. Gopal Krishna

Definition Breathing systems Non-rebreathing systems Manual hyperinflation Rebreathing systems Summary References

Inflating the lungs using oxygen and manual compression to provide a tidal volume (Vt) of 1.0l, requiring a peak inspiratory pressure of from 20 to 40 cm H2O. Using Vt exceeding baseline Vt Using a Vt that is 50% greater than that delivered by the ventilator

Breathing systems
A gas pathway connected to the patient, through which gas flows occur at respiratory pressures, and into which a controlled composition of a gas mixture is dispensed. Extends from the point of fresh gas inlet to the point at which gas escapes to the atmosphere or a scavenging system.

Classification of breathing systems

1. Non-rebreathing systems 2. Rebreathing systems

Non-rebreathing system: equipment

Air Viva

Laerdal bag

Non-rebreathing system: equipment

Laerdal bag

1. Reservoir bag 2. Non-rebreathing valve OR Adjustable pressure limiting (APL) valve OR PEEP valve 3. Schimmelbusch mask

Reservoir bag

Reservoir bag
composed of rubber or plastic ellipsoidal in shape so that they can be grasped easily with one hand Neck connects with breathing system Tail is the opposite end

Volume of the bag

OD bag Length Weight Bag volume 135(mm) 320(mm) 360g 1600(ml)

95 255 220 500

70 243 170 280


Mechanism of MHI

Mechanism of MHI
Slow deep inspiration: Recruits collateral ventilation Enhances interdependence to aid re-expansion of atelectatic segments Improves gaseous exchange Assesses and potentially improves compliance Inspiratory hold (at full inspiration): Further utilizes collateral ventilation and interdependence; therefore maximizes pressure distribution

Mechanism of MHI
Fast expiratory release: Mimics a forced expiration (huff or cough) Stimulates a cough Hand-held PEEP By grasping and holding the end of a semi-filled bag throughout inspiration and expiration it is possible to maintain a low level of PEEP.

To improve oxygenation pre- and postsuctioning. To mobilize excess bronchial secretions. To reinflate areas of the collapsed lung.

Large emphysematous bullae, subcutaneous emphysema Open bronchopulmonary fistula Inverse ratio ventilation Systolic BP less than 80mmHg Hypovolemia. Agitation / aggression Acute head injury, raised intracranial pressure Large air leak Peak airway pressures > 40-50cmH2O

Unstable cardiovascular system, arrhythmias or frequent ectopics Undrained pneumothorax Severe bronchospasm High peak inspiratory pressure (PIP) Positive end-expiratory pressure (PEEP) >10 cmH2O Acute pulmonary oedema

Unexplained haemoptysis Recent pneumonectomy Rib fracture During renal dialysis, which tends to destabilize BP. Hyperinflated lungs with intrinsic PEEP. During weaning if patients with hypercapnic COPD are dependent on their hypoxic drive to breathe. Severe hypoxaemia with PEEP above 10 mm of Hg

Procedure guidelines
Follow universal safety precautions Assessment indications / precautions for MHI. Ensure optimal fluid status and cardiovascular stability. Consent. The two caregivers providing the treatment should be positioned on opposite sides of the bed. Patient position: well-forward sidelying. If a different area is to be targeted, it is placed uppermost.

Observe chest expansion. Tell the patient that s/he will feel a deep breath. They should be free of distractions or nursing interventions. A PEEP valve may be used when the patient is on a PEEP > 10cmH2O and shows clinical signs of desaturation. Disconnect patient from the ventilator, attach the bagging circuit to the catheter mount, attach the reservoir bag to the ventilator tubing and mute the alarm or switch the ventilator to standby as per local policy in the Unit.

Co-ordinate the delivery of the breaths with any respiratory efforts of the patient. Allow the patient to acclimatise by using small TVs initially. Minimise movement of the endotracheal or tracheostomy tube during MHI. Perform slow deep inspiration aiming to achieve a peak inspiratory pressure of 40 cmH2O.

Hold the breath for 3s at the end of inspiration followed by rapid release of the bag. If the patient remains stable, use 6-8 MHI breaths and suction when indicated. Repeat the cycle of MHI. Reconnect the patient to the ventilator if the ventilator has been turned off ensure it has been switched on.

Document that the patient is reconnected to the ventilator as above and handover has been given to nursing staff The sidelying position should be continued so long as it is comfortable for the patient and convenient for the nursing procedures.

Paediatric MHI
use 500ml bag Turn the O2 flow rate to 4 6 liters Bag squeeze using fingers rather than whole hand interspersing one hyperinflation with 3 or 4 tidal breaths Pressure not more than 10 cm of H2O above the peak airway pressure for term babies and 5cm for preterm babies.

Preterm neonates Hypovolemia Low cardiac output

Raised intra cranial pressure

Emphysematous bullae

Multiple cysts
Undrained pneumothorax

Termination Assessment of efficacy Infection control Instillation of saline

Perceived benefits
Removal of secretions Re-inflation of atelectasis Improved oxygenation Stimulation of a cough reflex Improved lung volumes Improved lung compliance Prevent nosocomial pneumonia

Reduced blood pressure Reduced saturation Increased intracranial pressure Reduced respiratory drive

Rebreathing systems
Allow the to-and-fro movement of inspiratory and expiratory gases within the breathing system. Carbon dioxide elimination is achieved by the flushing action of fresh gas introduced into this breathing system.

Rebreathing system: equipment

Magill rebreathing bag

Mapleson C

Adult Pediatric Neonatal Bag volume 2000 ml 1000 ml 500 ml

Mapleson systesms

Mechanism of Mapleson systems

Mapleson system

Non-rebreathing system

Simple, inexpensive, lightweight, easy to use, disassemble & reassemble Administration of 100% oxygen Heat & humidity loss Tracheal tube kinking/displacement Fresh gas flow Used in Malignant hyperthermia



No No No Variable No

Yes Yes Yes High Yes

Dead space & rebreathing

Used in Emergency situations




1. 2. 3. 4. 5. Denehy L. The use of manual hyperinflation in airway clearance. Eur Respir J. 1999; 14: 958-65 Critical care network Northern Ireland. Northern health and social care trust. Manual hyperinflation of adult patients in critical care. Apr 2010. Ehrenwerth J, Eisenkraft J. Anaesthesia Equipment: Principles and applications. Elseiver; 1993 Davey AJ, Diba A. Wards Anaesthetic Equipment. 5th ed. Philadelphia: Elsevier Saunders; 2005 Sosis MB. Anaesthesia equipment manual. Philadelphia: Lippincott Williams and Wilkins; 1997 Dorsch JA, Dorsch SE. Understanding anaesthesia equipment. 5th ed. Philadelphia: Lippincott Williams and Wilkins; 2008


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