Ventilator hyperinflation (VHI) is a physiotherapy technique used to deliver larger tidal volumes than baseline settings to intubated and mechanically ventilated patients. It aims to improve respiratory function by mobilizing secretions and restoring lung volume. The document outlines the indications, contraindications, procedure and advantages of VHI compared to manual hyperinflation. It also reviews a study that found no significant differences in outcomes between VHI and manual hyperinflation for sputum production, static compliance, oxygenation or cardiovascular stability. In conclusion, VHI is as safe and effective as manual hyperinflation but has advantages of maintaining PEEP and allowing for more accurate control and reproducibility of ventilation parameters.

1. CENTER FOR PHYSIOTHERAPY AND REHABILITATION SCIENCE
JAMIA MILLIA ISLAMIA
Topic: Use Of Ventilator Hyperinflation In ICU
Javid Ahmad Dar
MPT- 3rd Semester
Roll no.- 19MPC0003

2. Introduction
• 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.
• Ventilator hyperinflation (VHI) is a technique used by physiotherapists in intensive care
patients who are receiving mechanical ventilation. The aims of VHI are similar to that of
manual hyperinflation (MHI) and are primarily implemented in order to improve
respiratory function by mobilising secretions and restoring lung volume. Since first being
described in the literature in 2002
• the use of VHI techniques has increased, with recent surveys suggesting they are utilised
within 20% to 40% of tertiary hospitals
• Despite this interest, there has been little research into VHI to guide education and
practice. Clinical studies that have investigated VHI techniques have all utilised different
methods to deliver the technique and there is considerable variability among clinicians in
how VHI is delivered

3. 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

4. ABSOLUTE CONTRAINDICATIONS
• Undrained pneumothorax
• Severe bronchospasm
• Head injury with Intra-Cranial Pressure > 25 mmHg
• Severe hypotension
• Subcutaneous emphysema

5. RELATIVE CONTRAINDICATIONS
• Tumour/obstruction (risk of gas trapping/trauma)
• Emphysematous bullae (risk of pneumothorax)
• Peak inspiratory pressure > 30 cm H2O (won’t be effective due to small change in
tidal volumes before pressure limit reached)
• Recent oesophageal/lung surgery (potential for anastomotic compromise)
• COPD exacerbation (increase of airway inflammation and irritation)
• Bronchospasm (increase of airway inflammation and irritation)
• ARDS (increased risk of pneumothorax/barotrauma)
• Raised ICP (normal = 5 – 15 mmHg) (increased intrathoracic pressure can
compromise MAP and thus CPP)
• Hypotension (risk of reduced venous return)
• CVS instability/arrhythmias (risk of reduced venous return)
• Acute head injury (increased intrathoracic pressure can compromise MAP
and thus CPP)

6. PRE-PROCEDURE ASSESSMENT
• In addition to your standard physiotherapy assessment, you should:
• Assess the suitability for hyperinflation procedure
• Assess for any contraindications
• Calculate desired tidal volume (15ml/kg based on lean body mass). Lean
body mass:
o Calculated as BMI of 25 for those with BMI 25 and above
o Calculated using patient’s actual mass for those with BMI less than 25
• Make note of:
• Current ventilatory setting including mode, specific parameters and alarm parameters
o Minute ventilation
o End-tidal carbon dioxide
o Oxygen saturations
o Peak inspiratory pressure
o Lung compliance (static or dynamic)
o Cardiovascular status of patient (heart rate, rhythm, blood pressure, mean arterial
pressure)

7. LUNG COMPLIANCE … HOW TO CALCULATE?
• Lung compliance is the ease with which the lungs stretch/expand.
• Static compliance is defined as the change in volume for a defined change in pressure in the lungs, and
dynamic compliance is the compliance of the lung tissue during movement of air. Static compliance is
generally deemed to be more accurate as it removes airflow resistance as a variable.
• Normal compliance is 50-100ml/cmH2O.
• Dynamic lung compliance is measured using the following equation:
Exhaled tidal volume/
(Peak inspiratory pressure – PEEP)
• Static lung compliance is measured using the following equation:
Exhaled tidal volume/
(Plateau pressure – PEEP)
• To get a reading of plateau pressure, it is necessary to perform an inspiratory hold at end-inspiration.

8. PROCEDURE
• Simultaneous Intermittent Mandatory Ventilation( SIMV-VC mode.)
• Alarms:
• Increase tidal volume alarm to maximum target volume (15ml/kg) + 300ml
• Change peak pressure alarm to 35 cmH2O
• Parameters:
• FiO2 – no change from pre-treatment parameters
• Inspiratory time – increase to 3 seconds (can increase up to 5 seconds)
• Respiratory rate – decrease to 8 breaths per minute (can decrease to 6
breaths per minute)
• Tidal volume – increase in 200ml increments until target achieved
(ensuring to keep under upper pressure limit of 35 cmH2O)
• Deliver 6-8 breaths at target tidal volume per set, returning to baseline ventilation settings between each set.
• Ensure ventilator settings are returned to baseline after finish of treatment and ask nursing staff to verify settings are
correct

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

10. Pressure Support (PS)
• Maintain the FiO2 at pre-set levels.
• Adjust Vt(ventilation mode) alarm to target Vt plus 300 mls(15ml/kg).
• Change Paw alarm to 35cm/H2O, Change MV alarm to 20L/min.
• Note pre-treatment minute ventilation(Vm) and EtCO2, aim to keep similar
• 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.
• Aim for 8 breaths at target volume, include vibes if indicated.
• 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.
• Aim for 3 sets of 8 VHI breathes.
• Ensure the return of all parameters to pre intervention (PS, Slope, FiO2 Paw & high Vt
alarms) by the Senior Nurse.
• Document settings utilised and outcome measures.
• 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.

11. • Monitor for:
• Minute ventilation (try to maintain as per pre-treatment throughout)
• End-tidal carbon dioxide (try to maintain as per pre-treatment throughout)
• Blood pressure
• Oxygen saturations
• Patient distress
• Peak airway pressures
• Intracranial pressure (if being monitored)
• Inspiratory and Expiratory flow rates
• Troubleshooting:
• Alarms may sound due to changes in inspiratory: expiratory ratio – if so, reduce respiratory
rate and increase inspiratory time more gradually
• If peak pressure is high before target volume reached, increase inspiratory time and reduce
respiratory rate.

12. ADVANTAGES OF VHI WHEN COMPARED TO MHI
• Maintenance of PEEP and thus prevention of ‘derecruitment’ of alveoli
• Accurate control of ventilation parameters
• Reproducibility of technique – remember that MHI has been
demonstrated to have significant inconsistencies in application of technique
• Reduced infection control risk to patient and to staff as no requirement to
• disconnect ventilator circuit
• Only one person is required to administer, compared to two with MHI if using in conjunction with
other techniques (e.g. suctioning or manual techniques)
• Cost savings due to less staff requirements, and also equipment savings, as it uses no extra
equipment

13. • Studies comparing MHI to VHI have found no statistically significant differences between
techniques when comparing for:
• Secretion clearance
• Static and dynamic compliance
• Oxygenation
• Cardiovascular stability
• It appears VHI is as safe and effective as MHI, but with many advantages as detailed above.
• HOWEVER, there are very few studies, with low numbers of subjects (poor power), high
levels of bias (crossover trials rather than RCTs), and no studies looking at any effects longer
than 30 minutes after treatment.
• It is not clear if either VHI or MHI have any long-term positive outcomes, but VHI is safe and
effective in the short-term management of secretions, and can provide short-term gains in lung
compliance.

14. Uses of VHI
• In mechanical ventilation, the ventilator settings have the potential to influence secretion
movement and commonly result in airflow that may result in impaction of secretions in distal
airways.
• For VHI and/or MHI to be utilised to promote secretion mobilisation, inspiratory and/or expiratory
flow rates are modulated in order to bias secretion movement towards proximal airways.
• (VHI) has been shown to be effective in improving respiratory mechanics, and gas exchange in
mechanically ventilated patients;
• VHI has been a safer method to provide therapeutic hyperinflation in mechanically ventilated
patients
• VHI helps in prevention of nosocomial pneumonia

15. S.NO. 1 Title Methodology Result Conclusion
Author ; Berney
and Denehy , 2002
Journal ;
Physiotherapy
Research
International
Imfact factor; 1.3
A comparison of the
effects of manual
and ventilator
hyperinflation on
static lung
compliance and
sputum production
in intubated and
ventilated intensive
care patients
Twenty patients who met the
inclusion criteria were studied.
This was a double crossover
study where all patients were
randomly allocated to one of
two treatment sequences over
two days. The first sequence
involved manual hyperinflation
followed two hours later by
ventilator hyperinflation and the
order was reversed on the
second day. In the second
sequence, ventilator
hyperinflation preceded manual
hyperinflation. The vari- ables
of static pulmonary compliance
and sputum wet weight were
analysed by use of an analysis
of variance (ANOVA) for
repeated measures. Statistical
significance was set at p < 0.05
There was no
significant
difference in sputum
wet weight
production
between either
technique or on
either day of
treatment. Static
pulmonary
compliance
improved with both
hyperinflation
techniques (p <
0.05).
Hyperinflation as
part of a
physiotherapy
treatment can be
performed with
equal benefit using
either a
manual resuscitation
circuit or a
ventilator. Both
methods of
hyperinflation
improve static
pulmonary
compliance and
clear similar
volumes of
pulmonary
secretions.

16. REFERENCES
• Anderson, A., Alexanders, J., Sinani, C., Hayes, S. & Fogarty M. (2015) Effects of
ventilator vs manual hyperinflation in adults receiving mechanical ventilation: a
systematic review of randomised clinical trials. Physiotherapy. 43:103-110
• Berney, S. & Denehy, L. (2002) 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 Research International. 7(2):100-108
• Dennis, D., Jacob, W. & Budgeon, C. (2012) Ventilator versus manual hyperinflation in
clearing sputum in ventilated intensive care unit patients. Anaesthesia and Intensive Care.
40(1):142-149
• Respiratory Physiotherapy Team – St George’s University Hospitals NHS Foundation
Trust (2016) Ventilator Hyperinflation (VHI) – Guidelines for the use of Ventilator
Hyperinflation with adults. Retrieved from:
• Thomas, P. J. (2015) The effect of mechanical ventilator settings during ventilator
hyperinflation techniques: a bench-top analysis. Anaesthesia and Intensive Care. 43(1):
81-87

18. THANK YOU