Effective: XXX

Effective: 07 September 2020

Ventilator Hyperinflation by Physiotherapists Guideline – Bunbury

Hospital

1. Guiding Principles

Ventilator Hyperinflation (VHI) is a physiotherapy intervention that enables the

deliverance of larger than baseline tidal volumes (Vt) via adjustment of the ventilator
in the intubated and ventilated patient.

Competency must be achieved prior to performing the technique.

2. Guideline

2.1 Purpose
To improve the respiratory status of intubated, ventilated patients by the deliverance of
larger than normal tidal volume breaths, utilising safe peak inspiratory pressure (PIP),
without interruption to the desired positive end expiratory pressure (PEEP) and the
oxygen supply. This enables recruitment of collapsed alveoli and clearance of
secretions from the bronchi, thereby improving gas exchange.

2.2 Indications:
VHI is indicated in the stable ventilated patient who:
 Secretion retention that does not respond to suction and positioning
 Patients who are PEEP dependent
 Prior / post endotracheal suctioning
 Segmental/lobar atelectasis
 Poor cough mechanism

2.3 Aims of VHI

 To aid in the resolution of atelectasis in the ventilated patient
 To mobilise and assist removal of excessive bronchial secretions
 To improve lung compliance
 To assist with prevention of nosocomial pneumonia

2.4 Contraindications

Any concerns about performing VHI on a patient should be discussed with the
Senior Physiotherapist, Senior Medical Officer and or Senior Nursing Staff prior to
commencing VHI

2.5 Absolute Contraindications

Condition Rationale
Patients requiring nitric oxygen or Patient too unstable
prostaglandin infusion

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Increased airway pressure will increase

Severe bronchospasm airway irritation and inflammatory
response
Unexplained frank haemoptysis May be indicative of acute trauma to the
lung parenchyma
Broncho pleural fistula May exacerbate air leak
Undrained pneumothorax or May increase size of pneumothorax
intercostal catheter with an air leak /
subcutaneous emphysema of
unknown cause
Documented cystic lung changes Increases risk of pneumothorax
(bullae/blebs)such as in severe
chronic obstructive pulmonary
disease with large emphysematous
bullae or cavitating lung pathology
Peak airway pressure(Paw)>30cm High risk of barotrauma
H 2O
Mean arterial blood Increased positive pressure in thoracic
pressure(MAP)<60mm Hg or Systolic cavity compromises venous return –
<80mm Hg reduces cardiac output
Inotropic requirement equivalent to Increased positive pressure in thoracic
15-20mls/hr total of adrenaline and cavity compromises venous return –
noradrenalin (dilution 4mg/50ml} or a reduces cardiac output.
sudden increase in inotropes
Head injury with intracranial pressure Increasing intra-thoracic pressure can
(ICP) > 20mmHG compromise mean arterial pressure and
compromise cerebral perfusion pressure

2.6 Relative Contraindications

Obstructing airway tumour or lung Risk of gas trapping or causing trauma

tumour at risk of cavitation
Recent oesophageal or lung surgery High airway pressure may compromise
e.g. oesophagectomy, the anastomosis. Check with surgeons
lobectomy/pneumonectomy, long regarding stump pressure.
volume reduction surgery,
diaphragmatic repair
Acute pulmonary oedema Technique not indicated, will not be
beneficial
Large undrained pleural effusion High risk of barotrauma
Acute respiratory distress syndrome ( Increased risk of barotrauma /
ARDS) / large contusions pneumothorax
Fractional oxygen(FiO2)>0.7 Pt may be too unstable to do VHI

High positive end expiratory Generally if the pt. requires a PEEP > 10
pressure(PEEP)>10cm H2O to maintain PaO2, they may be too
unstable to do VHI. Also with high PEEP
there is a lower expiratory flow therefore
less effective for airway clearance.

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Unexplained increase in respiratory High respiratory rate makes it hard to co-

rate ordinate breaths

CVS instability/arrhythmias Compromised venous return - further

increases effort required to maintain
adequate tissue perfusion

Delivery of VHI in patients with any identified relative contraindications requires

approval of ICU Consultant prior to initiating treatment

Other:
Take care and monitor Paw (airway pressures) closely with patients who are
coughing vigorously on the ventilator as this generates high intrapulmonary
pressures.

2.7 Competencies
Refer to Competency assessment documents accessed via the Bunbury Hospital
Physiotherapy Department. Contact via Sally Barrett, ICU Physiotherapist,
Bunbury Hospital.

2.8 Procedural Guidelines

 Assess the patient’s suitability and need for hyperinflation.

 Check for any contraindications.
 Discuss current status of patient with nurse caring for patient in all instances
(for handover and to review current status of patient). In instances where
patients have relative contraindications or where concerns exist discuss
suitability for VHI with relevant duty Consultant prior to delivering VHI.
 Apply personal protective equipment as per WACHS Infection Prevention
and Control Policy.
 Explain the procedure to the patient if appropriate.
 Position the patient optimally for sputum drainage.
 Measure the height of the patient, and take note of body weight on
admission.
 Calculate Body Mass Index (BMI)=Mass/Height2 ; In the event that BMI is
greater than 25, Vt is to be calculated using the ideal weight at a BMI of 25
for their height. When BMI is less than 25 then the calculation is adjusted to
the patient’s weight. Determine target tidal volume of 15ml/kg Take note of
pre intervention ventilator mode, settings, alarm parameters, Vt, PIP and lung
compliance over 3 ventilator cycles using the form located in: A ventilator
competent Senior RN competent to adjust parameters on the ventilator under
the guidance of the Senior Physiotherapist.

2.9 Simultaneous Intermittent Mandatory Ventilation (SIMV) auto flow

1. Maintain the FiO2 at pre-set levels.
2. Adjust Vt alarm to target Vt plus 300 mls(15ml/kg).
3. Change Paw alarm to 35cm/H2O.
4. Note pre-treatment minute ventilation(Vm) and EtCO2, aim to keep similar.

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5. Reduce RR(respiratory Rate) to 8/min. and then increase Ti 3sec, if I:E ratio
alarms decrease RR and increase Ti,increase incrementally until RR 8 and Ti
3 achieved.
6. Increase Vt by 150-300mls increments until target volume achieved.
7. If Paw increase too high then increase Ti (3-5sec) and if necessary decrease
RR minimum 6/min.
8. Aim for 8 breaths at target volume, include vibes if indicated.
9. A manual inspiratory hold (3-5 seconds) may be added if indicated and
patient does not have any evidence of Chronic Obstructive Pulmonary
Disease (COPD) related hyperinflation.
10. Aim for 3 sets of 8 VHI breathes.
11. Senior Nurse to return ventilator to pre-treatment parameters (ventilation
mode, Vt, RR and Ti) and Senior Physiotherapist to suction as required
following pre-oxygenation. This may occur following interruption of the VHI
breaths or at the end of the cycle of breaths.
12. Ensure the return of all parameters to pre intervention (Ventilation mode, Vt,
RR Ti FiO2 Paw & high Vt alarms) by the Senior Nurse.
13. Document settings utilised and outcome measures.

2.10 Pressure Control + (PCV+)/ Mandatory minute ventilation (MMV)

1. Change ventilation mode to SIMV auto flow
2. Set Vt to that being achieved on the PCV+ mode
3. Follow steps 1-13 above returning the ventilator parameters to PCV+ between
each cycle. Check after each cycle that the PC setting is correct
4. Ensure the return of all parameters to pre intervention settings (PCV+/PC
level/FiO2/RR/Tinsp/Paw alarm/Vt alarm) by the Senior Nurse
5. Document settings utilised and outcome measures

2.11 Pressure Support (PS)

1. Maintain the FiO2 at pre-set levels.
2. Adjust Vt alarm to target Vt plus 300 mls(15ml/kg).
3. Change Paw alarm to 35cm/H2O, Change MV alarm to 20L/min.
4. Note pre-treatment minute ventilation(Vm) and EtCO2, aim to keep similar
5. Change Slope time from 0.2 to 0.7, then gradually increase PS in 2cm/H2O
increments until either Target Vt or maximum Paw (35 cm/H2O ) reached.
6. Aim for 8 breaths at target volume, include vibes if indicated.
7. Senior Nurse to return ventilator settings to pre-treatment parameters (PS,
and Slope) between cycles and Senior Physiotherapist to suction as required
following pre-oxygenation if required. This may occur following interruption of
the VHI breaths or at the end of the cycle of breaths.
8. Aim for 3 sets of 8 VHI breathes.
9. Ensure the return of all parameters to pre intervention (PS, Slope, FiO2 Paw &
high Vt alarms) by the Senior Nurse.
10. Document settings utilised and outcome measures.
11. Ensure patient is breathing at an adequate minute ventilation when returned
to pre VHI PSV setting and if necessary get Senior RN to return to SIMV
settings.

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2.12 Monitoring During VHI

It is very important to closely observe throughout the intervention the following:
 Blood Pressure (BP)
 Heart Rate (HR)
 Saturations
 ETCO2/Vm
 Signs of patient distress
 Peak airway pressure
 Intracranial Pressure (ICP)if indicated

2.13 Potential Negative Responses to VHI

 If I:E ratio alarms when establishing larger Vt in SIMV then decrease RR
and increase T insp , incrementally until RR 8 and Ti 3 achieved.
 If Peak airway increases too high> 33 when establishing larger Vt in SIMV,
increase Ti(3-5sec) and if necessary decrease RR minimum 6/min.
 Patient may become stressed during the intervention (tachycardia,
hypertension); if observed check if bolus sedation can be delivered and
provide reassurance. Reduce Vt or PS if necessary to see if VHI is better
tolerated, proceed with slower incremental rises in Vt or PS, modify T
insp/RR to achieve better synchrony in SIMV. Accept Vt at a lower level
than target Vt and reassess tolerance in subsequent sets of VHI.
 Haemodynamic Instability: Hyperinflation may potentially increase intra-
thoracic pressure and reduce venous return and cardiac output. It is
important to recognise CVS instability prior to commencing treatment and
to be vigilant during intervention ceasing if instability noted.
 If there is marked deterioration in SpO2/HR/BP discontinue VHI and
assess for reasons it has occurred.
 If the intracranial pressure increases >20 mmHg during application of VHI
in the Head Injury Patient monitor Vm and ETCO2 and ensure they are
closely matching pre treatment levels (fluctuating levels and inadequate
ventilation can influence ICP).

2.14 Documentation
Documentation should include:
 Ventilator mode
 Patients position
 Number of breaths delivered
 Maximum volumes reached and Target volume
 Inspiratory time/plateau time
 Patients response to treatment (static lung compliance, gas exchange,
SpO2, sputum clearance, CXR/auscultation findings, wave forms,
ICP/ETCO2 where indicated, CVS)
 Any changes to medication management throughout
 Adverse responses and action taken
 Plan for frequency and dosage of treatment

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3. Definitions

H 2O Water
Hg Mercury
FiO2 Fraction of Inspired Oxygen
PaO2 Partial pressure of Oxygen
ICU Intensive Care Unit
CVS Cardiovascular system
EtCO2 End tidal Carbon Dioxide
Ti Inspiratory Time
SIMV Synchronized Intermittent mandatory ventilation

4. Roles and Responsibilities

The ICU Physiotherapist will review the relevant guidelines every year or earlier as
appropriate. Prior to releasing the guidelines they will be endorsed by the Director of
ICU

All Physiotherapists must complete a supervised training program and competency

based assessment with a senior Intensive Care Physiotherapist. Competency will be
observed and assessed over a number of sessions before unsupervised practice is
allowed.

The Physiotherapist, Medical team, and ICU Nurse must be in partnership for the
delivery of the intervention, which will be congruous with the agreed team care of the
patient

5. Compliance

Failure to comply with this policy document may constitute a breach of the WA Health
Code of Conduct (Code). The Code is part of the Integrity Policy Framework issued
pursuant to section 26 of the Health Services Act 2016 (WA) and is binding on all
WACHS staff which for this purpose includes trainees, students, volunteers,
researchers, contractors for service (including all visiting health professionals and
agency staff) and persons delivering training or education within WACHS.
WACHS staff are reminded that compliance with all policies is mandatory.

6. Records Management

All WACHS clinical records must be managed in accordance with Health Record
Management Policy.

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7. Evaluation

Monitoring of compliance with this document is to be carried out by the Senior ICU
Physiotherapist, every 2 years using Evidence Based research in conjunction with
other ICU Senior Physiotherapists in W.A.

8. Standards

National Safety and Quality Health Service Standards 1.27

9. Legislation

Health Services Act 2016 (WA)

10. References

1. Patman S, Jenkins S, Stiller K. Manual hyperinflation – effects on respiratory

parameters. Physiotherapy Res Int 2000; 5:157-171.
2. Hodgson C, Carroll S, Denehy L. A survey of manual hyperinfla¬tion in Australian
hospitals. Aust J Physiotherapy 1999; 45:185-193.
3. Berney S, Denehy L. A comparison of the effects of manual and ventilator
hyperinflation on static lung compliance and sputum production in intubated and
ventilated intensive care patients. Physiotherapy Res Int 2002; 7:100-108.
4. Savian C, Paratz J, Davies A. Comparison of the effectiveness of manual and
ventilator hyperinflation at different levels of positive end-expiratory pressure in
artificially ventilated and intubated intensive care patients. Heart Lung 2006;
35:334-341.
5. Lemes DA, Zin WA, Guimaraes FS. Hyperinflation using pressure support
ventilation improves secretion clearance and respiratory mechanics in ventilated
patients with pulmonary infection: a randomised crossover trial. Aust J
Physiotherapy 2009; 55:249-254.
6. Dennis DM, Jacob WJ, Samuel FD. A survey of the use of ven¬tilator hyperinflation
in Australian tertiary intensive care units. Crit Care Resusc 2010; 12:262-268.
7. 7. Hodgson C, Denehy L, Ntoumenopoulos G, Santamaria J, Carroll S. An
investigation of the early effects of manual lung hyperinflation in critically ill
patients. Anaesth Intensive Care 2000; 28:255-261.
8. Hodgson C, Ntoumenopoulos G, Dawson H, Paratz J. The Mapleson C circuit
clears more secretions than the Laerdal circuit during manual hyperinflation in
mechanically-ventilated patients: a randomised cross-over trial. Aust J
Physiotherapy 2007; 53:33-38.
9. Choi JS, Jones AY. Effects of manual hyperinflation and suctioning in respiratory
mechanics in mechanically ventilated patients with ventilator-associated
pneumonia. Aust J Physiotherapy 2005; 51:25-30.
10. Hodgson CL, Tuxen DV, Davies AR, Bailey MJ, Higgins AM, Holland AE et al. A
randomised controlled trial of an open lung strategy with staircase recruitment,
titrated PEEP and targeted low airway pressures in patients with acute respiratory
distress syndrome. Crit Care 2011; 15:R133.
11. Paulus F, Binnekade JM, Middelhoek P, Schuitz MJ, Vroom MB. Manual
hyperinflation of intubated and mechanically ventilated patients in Dutch intensive

Printed or saved electronic copies of this policy document are considered uncontrolled.
Always source the current version from WACHS HealthPoint Policies.

Date of Last Review: July 2020 Page 7 of 8 Date Next Review: June 2023
WACHS South West Ventilator Hyperinflation by Physiotherapists – Bunbury Hospital

care units--a survey into current practice and knowledge. Intensive Crit Care Nurs
2009; 25:199-207.
12. Paulus F, Binnekade JM, Middelhoek P, Vroom MB, Schultz MJ. Performance of
manual hyperinflation: a skills lab study among trained intensive care unit nurses.
Med Sci Monit 2009; 15:CR418-242.
13. Dennis DM, Jacob WJ, Budgeon C. Ventilator versus manual hyperinflation in
clearing sputum in ventilated intensive care unit patients. Anaesth Intensive Care
2012; 40: 142-149
14. Hayes K, Seller D, Webb M, Hodgson CL, Holland AE. Ventilator Hyperinflation: a
survey of current physiotherapy practise in Australia and New Zealand. New
Zealand Journal of Physiotherapy 2011; 39:124-30
15. SCGH Ventilator Hyperinflation Clinical Guidelines 2016
16. St George University, NHS V.H.I Guidelines 2016
17. Government of Western Australia East Metropolitan Health Service. Ventilation
Hyperinflation Procedure (2017) Armadale Health Service, Perth, Western Australia
18. Government of Western Australia South Metropolitan Health Service.
Physiotherapy Management of Organ Donors (Acute) Guideline (2018)
Rockingham Peel Group, Rockingham, Western Australia

11. Related Forms

Nil

12. Related Policy Documents

WACHS Ventilation (Non-Invasive and Invasive Mechanical) – Clinical Practice

Standard

13. Related WA Health System Policies

Nil

14. Policy Framework

Clinical Services Planning and Programs

This document can be made available in alternative formats

on request for a person with a disability
Contact: A/Senior Physiotherapist (S. Barrett)
Directorate: WACHS South West – Bunbury Hospital EDRMS Record # ED-CO-20-67381
Version: 1.00 Date Published: 08 September 2020
Copyright to this material is vested in the State of Western Australia unless otherwise indicated. Apart from
any fair dealing for the purposes of private study, research, criticism or review, as permitted under the
provisions of the Copyright Act 1968, no part may be reproduced or re-used for any purposes whatsoever
without written permission of the State of Western Australia.

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