Intensive Care Med
DOI 10.1007/s00134-016-4315-6
LETTER
Effects of chest physiotherapy
by expiratory flow increase on secretion
removal and lung mechanics in ventilated
patients: a randomized crossover study
Anne Freynet1, Guillaume Gobaille1, Olivier Joannes‑Boyau2, Pierre Grandet1, Catherine Fleureau2,
Jean Ripoche3, Antoine Dewitte2,3* and Alexandre Ouattara2,4
© 2016 Springer-Verlag Berlin Heidelberg and ESICM
Dear Editor,
A recent study published in this journal evaluated
the effects of manually assisting a cough using a strong
expiratory manual compressive manoeuver in mechani-
cally ventilated patients [1]. The authors showed signifi-
cant removal of sputum with no effect on gas exchange or
lung mechanics. However, the benefits and safety of chest
physiotherapy in ICUs remain controversial, especially
when there is diffuse alveolar damage [2]. We proposed
in this crossover study conducted at the Bordeaux Uni-
versity Hospital (France) to assess the effects of another
physiotherapy technique to assist mechanically ventilated
patients.
After approval from our ethics committee (Comité
de Protection des Personnes Sud-Ouest et Outre Mer
III, Agreement number DC 2012/114), 16 consecutive
patients presenting a ventilator-associated pneumonia
and requiring a neuromuscular blockade were prospec-
tively included between March 2013 and January 2014.
Non-inclusion criteria were hemodynamic instability and
chest trauma. All treatments were left to the discretion
of the attending physicians according to international
recommendations. The expiratory flow increase (EFI)
technique consisted of prolonged slow manual chest and
abdomen compressions throughout an entire expiration
*Correspondence: antoine.dewitte@chu‑bordeaux.fr
2
CHU de Bordeaux, Service d’Anesthésie-Réanimation II, 33000 Bordeaux,
France
Full author information is available at the end of the article
This study was presented at the 2015 ERS International Congress in
Amsterdam, The Netherlands.
phase. Patients were randomly divided into two groups:
a group receiving an endotracheal suction (ETS) fol-
lowed, 4  h later, by a respiratory physiotherapy session
concluded by an ETS (EFI  +  ETS) and the other group
receiving first the EFI + ETS, followed 4 h later by ETS
alone (Fig. S1).
Respiratory mechanics were continuously recorded
using SERVO-i RCR v3.7 software (Maquet Critical Care,
Solna, Sweden); measurements were the average of all
respiratory cycles during 1  min before treatment (t0),
immediately after treatment (t1), 20  min later (t2), and
1  h later (t3). The first minute of all physiotherapy ses-
sions was also recorded. The weight of bronchial secre-
tions was measured at t1 for each group.
The demographic characteristics of included patients
are shown in Table  S1. There was a significant decrease
in peak pressure and plateau pressure during and imme-
diately after the EFI sessions (Fig.  1). The amount of
secretions collected was significantly increased after
EFI  +  ETS as compared to ETS alone (120 [40–255] vs
210 [80–545] mg, P  =  0.02). A transient improvement
in static lung compliance was also observed at t1 and t2
after EFI + ETS (Table S2).
The rational of chest physiotherapy is to displace secre-
tions from the peripheral to the more central airways,
where they can be removed. However, the literature is
conflicting regarding the benefits of mobilizing periph-
eral secretions by rapidly squeezing air out using pro-
longed strong compressions (manually assisted cough),
by brief strong manual expiratory compressions (hard
manual ribcage compressions), or by using prolonged

Fig. 1  Effect of chest physiotherapy on respiratory mechanics
(*P < 0.05; versus before expiratory flow increase [EFI])
strong and slow manual compressions throughout the
entire expiration phase (expiratory ribcage compres-
sion). Some authors report that static lung elastance is
made even worse, expiratory flow is limited, or there can
be higher inflation pressures in patients with susceptible
lungs during soft manual ribcage compressions [3–5].
This study, although including patients with moderate
acute respiratory distress syndrome, confirms that EFI
enabled efficient and safe bronchial sputum removal with
decreased pulmonary pressure and provided transient
improvement in static compliance immediately after EFI.
Electronic supplementary material
The online version of this article (doi:10.1007/s00134-016-4315-6) contains
supplementary material, which is available to authorized users.
Author details
1
 CHU de Bordeaux, Service de Kinésithérapie, 33000 Bordeaux, France. 2 CHU
de Bordeaux, Service d’Anesthésie-Réanimation II, 33000 Bordeaux, France.
3
 University of Bordeaux, Bioingénierie tissulaire, U1026, 33000 Bordeaux,
France. 4 University of Bordeaux, Adaptation cardiovasculaire à l’ischémie,
U1034, 33600 Pessac, France.
Compliance with ethical standards
Conflicts of interest 
The authors have no conflicts of interest to disclose. The authors thank Erwan
Floch (Newmed Publishing Services) for revising the English.
Accepted: 8 March 2016
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