Physiotherapy Research Intemational 213

10(4)213-221(2005)
DOI: 101002/pri.l5

Effect of expiratory flow increase

technique on pulmonary function of
infants on mechanical ventilation
CELIZE CB ALMEIDA Department of Pediatrics, State University of Campinas Medical
School, Campinas, Sao Paulo, Brazil
JOSE D RIBEIRO Department of Pediatrics and Center for Investigation in Pediatrics,
State University of Campinas Medical School, Campinas, Sao Paulo, Brazil
ARMANDO A ALMEIDA-JUNIOR Pediatric Intensive Care Unit, State University of
Campinas Medical School, Campinas, Sao Paulo, Brazil
ANGELICA MB ZEFERINO Department of Pediatrics, State University of Campinas
Medical School, Campinas, Sao Paulo, Brazil.
ABSTRACT Background and Purpose. Although chest physiotherapy techniques are
commonly used in the treatment of respiratory diseases, there are, however, few studies in
the literature on the effectiveness of these techniques in paediatric patients. The purpose of
the present study was to evaluate the ejfect ofthe expiratory flow increase technique (EFIT)
on the pulmonary function of infants on invasive mechanical pulmonary ventilation.
Method. A prospective, non-randomized study design was used, with consecutive enrol-
ment conducted in the paediatric intensive care unit (PICU) ofa university hospital. All
infants with acute obstructive respiratory failure who were on invasive mechanical
pulmonary ventilation between April 2001 and April 2003 were included in this study.
Respiratory rate, PaO^, PaCO^, SatO^, PaO/FiO^, P(A-a)O^/PaO^, PaO/PAO^, VDA^T,
dynamic compliance, inspiratory and expiratory resistance values were compared before
and after application ofthe EFIT. Results. Blood gas and pulmonary function measure-
ments were recorded before and after EFIT. Repeated-measures analysis of variance
(ANOVA) was used. The results were considered statistically significant when p values were
<0.05. Twenty-two infants were enrolled. There was a significant increase in respiratory
rate, SatO^znd PaO^/PAO^and a significant decrease in P(A-a)O^/PaO^ after application
ofthe EFIT. Conclusion. There was a short-term improvement in the oxygenation of infants
who were submitted to the EFIT. Additional studies are necessary to establish the efficacy
and effectiveness of this technique. Copyright © 2005 John Wiley & Sons, Ltd.

Key words: critical care, expiratory flow increase technique (EFIT), paediatrics

INTRODUCTION the prevention or reduction of the conse-

quences of invasive mechanical pulmonary
Conventional chest physiotherapy tech- ventilation, such as the accumulation of
niques are indicated as a treatment for acute secretion, atelectasis, inadequate distribu-
or chronic respiratory diseases as well as for tion of ventilation, ventilation or perfusion

Copyright © 2005 John Wiley & Sons, Ltd 10: 213-221 (2005)
214 Almeida et al.
mismatch and increased work of breathing
(Oberwaldner, 2000). Several techniques
can be used for the above-mentioned disor-
ders and an extensive search of the relevant
literature reveals various studies on their
effectiveness. However, few studies refer to
patients on invasive mechanical pulmonary
ventilation and there is no consensus about
the best technique indicated for this condi-
tion.
In the 1970s Barthe described a new
technique for removing secretion that is
referred to as the expiratory flow increase
technique (EFIT). It has been described as a
thoraco-abdominal movement performed
manually by the physiotherapist to clear
airway obstructions. EFIT is used in the
paediatric intensive care unit (PICU) at the
State University of Campinas Medical
School, Brazil, as it does not require the
patient's collaboration and can easily be
applied to infants and young children or to
intubated patients. Although there are no
scientific studies validating this technique,
it is currently the most commonly used tech-
nique of this kind in France (Conference de
Consensus sur la Kinesitherapie Respira-
toire, 1995). Nevertheless, among the
studies mentioning the use of EFIT in paedi-
atric patients (Grosdemanche et al., 1972;
Demont et al., 1991; Postiaux et al., 1991a;
Postiaux et al, 1991b; Postiaux et al., 1995;
Ribeiro et al., 2001), only two refer to its use
in patients on invasive mechanical
pulmonary ventilation (Demont et al., 1996;
Bemard-Narbonne et al., 2003).
Studies have been published on the effect
of other techniques in adult patients on inva-
sive mechanical pulmonary ventilation for
the following conditions: acute lobar atelec-
tasis (Stiller et al., 1990); after cardiac
surgery (Horiuchi et al., 1997); acute respi-
ratory distress syndrome (Davis et al.,
2001); respiratory failure (Brock-Utne et al..
Copyright © 2005 John Wiley & Sons, Ltd
1975; Winning et al., 1975; Mackenzie et
al., 1980); and all diseases that required
invasive mechanical pulmonary ventilation
(Mackenzie et al., 1978; Ruiz et al., 1999;
Arellano, 2001). These studies analysed
postural drainage, vibration, percussion,
cough stimulation and suction, comparing
pulmonary function before and after appli-
cation of the techniques. Recently, some
studies have also evaluated the use of
manual hyperinflation in adult patients on
invasive mechanical pulmonary ventilation
(Clarke et al., 1999; Hodgson et al., 2000;
Patman et al., 2000; Barker and Adams,
2002; Bemey and Denehy, 2002).
Very few studies discuss the effects of
chest physiotherapy techniques in children
on invasive mechanical pulmonary ventila-
tion, and most of them refer to neonates
(Fox et al., 1978; Zach et al., 1981; Reines
et al., 1982; Flenady and Gray, 2001; Main
et al., 2004; Main and Stocks, 2004). These
studies suggest that beneficial effects can be
achieved with the use of chest physiotherapy
but, since they were conducted in children
with different diseases, an overall analysis
was impossible. The studies conducted by
Fox et al (1978), by Main et al (2004) and by
Main and Stocks (2004) measured
pulmonary function with the objective of
evaluating the effect of chest physiotherapy
techniques.
Chest physiotherapy has been carried out
in infants with respiratory diseases but some
authors do not recommend its use in cases
of acute viral bronchiolitis (Perlstein et al.,
1999; Oberwaldner, 2000; Kotagal et al.,
2002). However, chest physiotherapy tech-
niques have not yet been studied in patients
with acute viral bronchiolitis on invasive
mechanical pulmonary ventilation. The
study carried out by Webb et al (1985), in
infants with acute viral bronchiolitis, found
no significant difference in the hospitaliza-
10:213-221(2005)
 Effect of EFIT on pulmonary function of infants on IMPV 215

tion period between the group in which Exclusion criteria consisted of:
postural drainage, percussion and suction
were applied and the control group without • patients paralysed by curare
invasive mechanical pulmonary ventilation. • patients with haemodynamic instability,
Since the effectiveness of chest physio- neuromuscular diseases, cardiac
therapy techniques has not yet been scientif- diseases, post-operative patients, patients
ically proven in paediatric patients on with chronic pneumopathies, severe
invasive mechanical pulmonary ventilation, protein-caloric malnutrition or acute
studies need to be conducted in this popula- respiratory failure due to upper respira-
tion. The purpose of the present study was tory diseases
to evaluate the effect of EFIT on the • patients with chest radiography indi-
pulmonary function of infants on invasive cating atelectasis of more than one-third
mechanical pulmonary ventilation because ofthe lung
of acute obstructive respiratory failure. • patients with a positive end expiratory
pressure (PEEP) >10 cm H^^
METHOD
Materials and procedure
Study design
This was a prospective, non-randomized, Expiratory flow increase technique
non-controlled. Phase II study of infants The EFIT consisted of a passive expiration
who were intubated and ventilated. It was performed using the increase in expiratory
conducted in the PICU of the University flow to move the peripheral secretions of the
Hospital, State University of Campinas, bronchial tree towards the trachea. It was
Brazil, from April 2001 to April 2003. EFIT carried out with one hand on the child's chest
was carried out in all eligible patients. between the sternal furcula and an imaginary
The study was approved by the Institu- inter-mammary line. The hand was
tional Review Board prior to initiation and supported on its outer edge but the contact
the parents gave their written, informed surface varied according to the size of the
consent before their infants were enrolled inchild's chest. The other hand supported the
the study. abdominal region with the thumb and first
finger reaching the lower ribs. The physio-
Subjects therapist carried out EFIT by placing one
Subjects were included in the study if they hand on the patient's chest and applying
were: pressure symmetrically from top to bottom
and from front to back, while the other hand
• between 28 days and 12 months of age supported the upper abdominal region
• intubated and ventilated during the expiratory phase. The manoeuvre
• had a diagnosis of obstructive acute was repeated 40 times in all patients and was
respiratory failure made on the basis of followed by suction.
the following clinical and radiological
criteria: history of wheezing and
coughing; diffuse wheezes or prolonged Procedure
expiration during pulmonary ausculta- The patients were intubated using a non-
tion; and chest radiography with signs of cuffed tracheal tube with an internal diam-
air trapping. eter of 3.5-4.5 mm. The mechanical

Copyright © 2005 John Wiley & Sons, Ltd 10:213-221(2005)

216 Almeida et al.
ventilators were time-cycled, pressure-
limited and adjusted for sjmchronized inter-
mittent mandatory ventilation. Data were
collected after the patients had been on inva-
sive mechanical pulmonary ventilation for
24-72 hours and at least 12 hours after the
last chest physiotherapy technique had taken
place.
The patients were placed in the supine
position with the upper portion of the bed
placed at an angle of 30° and suction of the
endotracheal tube was performed. They
were then sedated with midazolam and
diazepam, injected intravenously. The
following measures were taken immediately
before and 30 minutes after EFIT:
• respiratory rate (RR)
• expired tidal volume (VTexp)
• alveolar tidal volume (VTalv)
• minute ventilation (VE)
• alveolar ventilation (VA)
• airway dead space volume (VDaw)
• alveolar dead space volume (VDalv)
• total dead space volume (VD)
• dead space volume/tidal volume ratio
(VDA^T)
• dynamic inspiratory resistance (Rinsp)
• dynamic expiratory resistance (Rexp)
• dynamic compliance (Cdyn).
Measurements were calculated using volu-
metric capnography (CO^SMO Plusr
monitor manufactured by Dixtal Inc., Sao
Paulo, Brazil); PaO^, PaCO^, SatO^,
PaO^/FiOj, P(A-a)O/PaO2 ^nd PaO/PAO^
were measured by blood gas analysis,
calculated as:
inspiratory pressure -
PEEP/inspiratory flow
R^^p was calculated as:
Rjjp = peak inspiratory pressure -
PEEP/expiratory flow
Copyright © 2005 John Wiley & Sons, Ltd
j was calculated as:
~ VT/peak inspiratory pressure - PEEP.
While the data were being collected, the
invasive mechanical pulmonary ventilation
parameters remained unaltered and the
patients remained in the same position.
Statistical analysis
Analysis of variance (ANOVA) was applied
to compare the measurements obtained at
the two time periods. This statistical
analysis was considered the most adequate
for testing the effects of EFIT in infants of
different weights since it eliminates weight
as a cause of variation. The results were
considered statistically significant when p
values were <0.05 (Montgomery, 1991).
The statistical program used was Statistical
Analysis System (SAS), Version 8.2 (SAS
System for Windows, 1999-2001).
RESULTS
Twenty-two infants, 18 males, aged 1-11
months (mean age 3.1 months) and
weighing 3.4-8.9 kg (mean 5.64 kg) were
enrolled in this trial. The characteristics of
these infants are shown in Table 1.
The mean parameters used for invasive
mechanical pulmonary ventilation were:
• peak inspiratory pressure of 27.8 cm
• PEEP of 4 cm HjO
• mechanical respiratory rate of 24.1
breaths/minute
• inspiratory period of 0.56 seconds
• inspired oxygen fraction (FiO^) of 0.41.
EFIT was performed for a mean of 12
minutes, and measurements were collected
10: 213-221(2005)
 Effect of EFIT on pulmonary function of infants on IMPV 217
TABLE 1: General and clinical characteristics of 22 infants on invasive mechanical pulmonary ventilation at
the paediatric intensive care unit

Patient Six Age Weight Premature Episode of Month

(months) (kg) wheezing of data Atelectasis" Pneumonia""

1 M 2 6.8 No First April No No

2 M 3 6.4 No First April No No
3 M 6 6.5 No Second April No No
4 F 2 4.1 Yes First April Yes Yes
5 F 5 8.2 No First July No Yes
6 M 3 5.5 No First August No No
7 M 7 8.9 No Fourth February No No
g M 11 6.7 Yes First March No No
9 M 1 4.7 No First April No No
10 F 1 3.4 No First May Yes No
11 M 8 8.0 No First May No Yes
12 F 2 3.8 Yes First May No Yes
13 M 3 6.0 No Fist May No No
14 M 1 5.2 No First June No Yes
15 M 1 5.3 No First July No No
16 M 2 6.3 No First July Yes No
17 M 1 3.6 Yes First March Yes Yes
18 M 1 3.6 Yes First March No Yes
19 M 2 4.3 No First April No No
20 M 1 4.8 No First April No Yes
21 M 4 6.0 No Second April No No
22 M 3 6.0 No First April No No

"Presence of associated atelectasis; 'Presence of associated pneumonia.

M = male; F = female.

at a mean of five minutes before and after During EFIT, patients showed no signs
the technique. of respiratory distress (retractions, nasal
The mean, standard deviation (SD) and flaring) decrease in oxygen saturation by
p values of the variables analysed in the pulse oximetry, bradycardia, tachycardia,
study are presented in Table 2. pneumothorax or bone fractures. All
patients evolved to extubation and were
A statistically significant increase was dischargedfromPICU.
observed in RR, SatO^and PaO/PAO^
values and a statistically significant DISCUSSION
decrease in P(A-a)O2/PaO2 after EFIT
(p<0.05). Similarly, no statistically signifi- In the present study there was no change in
cant difference was found in the mean PaOj or PaOj/FiO^ however, an improve-
values of PaO^, PaCO^, PaO/FiO^, VT • ment was observed in SatO^, V{K-a)0J?&0.^
VT^,^, VE, VA, VD^^, VD^,^, VD, VD/VT, and PaOj/PAOj following EFIT (p<0.05).
This suggests that EFIT improves certain

Copyright © 2005 John Wiley & Sons, Ltd 10: 213-221 (2005)
218 Almeida etal.

TABLE 2: Position and distribution measurements (mean 6 SD) of pulmonary function variables and compar-
ison of two evaluation times of 22 infants on invasive mechanical pulmonary ventilation, using analysis of vari-
ance corrected for weight

Pulmonary function variable Mean (± standard deviation) (SD) p value

Before After

RR (breaths/minute) 34.36 (±12.73) 40.45 (±21.92) 0.04*

PaOjCmmHg) 104.70 (±37.3) 111.91 (±35.29) 0.10
PaCOj (mmHg) 42.04 (±9.10) 41.72 (±8.20) 0.68
PaOj/FiOj 261.31 (±93.92) 282.57 (±95.43) 0.07
P(A-a)O,/PaO2 1.242 (±0.721) 1.114 (±0.744) 0.03*
PaOj/PAOj 0.494 (±0.169) 0.534 (±0.185) 0.03*
SatOj (%) 97.31 (±2.56) 98.37 (±1.29) 0.04*
VT,p(mL) 39.92 (±14.88) 39.05 (±17.37) 0.13
VT^JmL) 30.14 (±12.96) 30.05 (±12.94) 0.55
VA(L) 0.89 (±0.39) 0.82 (±0.45) 0.12
VE(L) 1.20 (±0.49) 1.22 (±0.54) 0.89
VDJmL) 7.14 (±1.64) 7.50 (±2.09) 0.65
VD,,(mL) 8.24 (±3.23) 8.44 (±4.27) 0.11
VD (mL) 15.38 (±4.01) 15.94 (±5.38) 0.11
VDA'T 0.46 (±0.12) 0.49 (±0.13) 0.06
120.82 (±54.05) 115.64 (±55.47) 0.11
R^p (cm Hfi/L/s) 129.74 (±58.84) 128.09 (±58.56) 0.29
C,^ (mL/cm HP) 2.96 (±1.41) 3.24 (±1.67) 0.19

RR = respiratory rate; PaOj = arterial pressure of oxygen; PaCOj = arterial pressure of carbon dioxide;
PaOjFiOj = arterial pressure of oxygen/inspired fraction of oxygen ratio; P(A-a)Oj/PaO2 = alveolar-arterial
pressure difference of oxygen/arterial pressure of oxygen; PaO2/PAO2 = arterial pressure of oxygen/alveolar
pressure of oxygen; SatO^ = aterial saturation of oxygen; VT^^^ = expiratory tidal volume; VT^j^ = alveolar tidal
volume; VA = alveolar ventilation; VE = minute ventilation; VD^^ = airway dead space volume; VD , = alve-
olar dead space volume; VD = total dead space volume; VD/VT = dead space volume/tidal volume ratio; Rj__ =
inspiratory resistance; R^^^ = expiratory resistance; C^^^ = dynamic compliance.
*Level of significance <0.05.

variahles with respect to oxygenation. diverse (Brock-Utine et al., 1975;

Nevertheless, differences between measure-
ments taken before and after EFIT, although
statistically significant, are not clinically
significant. In our experience, patients on
invasive mechanical pulmonary ventilation,
who have acute obstruction, are usually have
copious secretions and by removing
bronchial secretion, EFIT may therefore
improve gas exchange.
Some studies that analysed chest physio-
therapy in adults and children also evaluated
oxygenation. However, results have been
contradictory and the techniques used are
Mackenzie et al., 1978; Fox et al., 1978;
Davis et al., 2001; Main et al., 2004). Since
the chest physiotherapy techniques were
applied together in these studies, it was
impossible to analyse each individual tech-
nique separately.
The increase in RR (p<0.05) observed in
the present study may have been due to the
physical effort made by the patient during
EFIT. However, no significant increase in
minute ventilation occurred.
Our results confirm the need to carry out
more studies to evaluate VD/VT after chest

Copyright © 2005 John Wiley & Sons, Ltd 10:213-221(2005)

 Effect of EFIT on pulmonary function of infants on IMPV 219
physiotherapy in patients on invasive
mechanical pulmonary ventilation, since
results published in the literature up to this
time are controversial (Davis et al., 2001;
Main and Stocks, 2004).
No statistically significant difference in
PaCOj was found in our study, and this may
have occurred because there was no signifi-
cant improvement in VA, as shown by our
results. This is in agreement with the find-
ings published by Clarke et al. (1999), in
which manual hyperinflation was used, and
by Main and Stocks (2004), in which vibra-
tion, percussion or compression and
postural drainage were used.
The fact that R^^ exceeded the value of
R. in infants on invasive mechanical
pulmonary ventilation is considered a
consequence of the characteristics of the
ventilator (American Thoracic Society/
European Respiratory Society, 1993) a
result confirmed both in our study and in
that of Fox et al. (1978). Similarly, no statis-
tically significant difference in C^^^^ was
found in our study. Fox et al. (1978) and
Demont et al. (1996) found no statistically
significant difference in C^ following chest
physiotherapy in neonates.
The present study was carried out in 22
patients: 18 males and four females. Nine-
teen patients were less than six months old
and 18 were hospitalized during autumn or
winter. These data illustrate the principal
risk factors for acute viral bronchiolitis:
greater risk for males aged <6 months, and
season (American Thoracic Society/Euro-
pean Respiratory Society, 1993). Although
the aetiological agent was not identified,
patient history, as well as clinical and radio-
logical data, support a diagnosis of acute
viral bronchiolitis and indicate clinical
uniformity.
Very few assessments of the effective-
ness of chest physiotherapy techniques in
Copyright © 2005 John Wiley & Sons, Ltd
patients on invasive mechanical pulmonary
ventilation have been conducted because the
patients are usually in a critical condition
and very often have either ventilatory or
haemodynamic instability that may interfere
with the analyses of the variables being
studied. Randolph et al. (2003), in a review
of children in nine PICUs over a period of
six months, reported the difficulty encoun-
tered in conducting a study in this popula-
tion because of the small number of cases
with the same disease and with no other
associated diseases.
IMPLICATIONS
Few studies on the application of EFIT in
the pulmonary function of infants on inva-
sive mechanical pulmonary ventilation have
been found in the literature. Further studies
are needed to establish the efficacy and
effectiveness of EFIT on the parameters of
pulmonary function in infants on invasive
mechanical pulmonary ventilation, as well
as to identify the diseases for which this
technique would be most beneficial. It
should be emphasized that EFIT causes no
complications that could contraindicate its
use in these patients.
ACKNOWLEDGMENTS
The authors would like to thank Glaucy Cruz Bres-
ciani Baptista for reviewing the article, as well as the
physicians, physiotherapists and nursing staff of the
PICU for their co-operation. This study was supported
by the 'Fundagao de Amparo a Pesquisa do Estado de
Sao Paulo' (FAPESP), GRANT #00/04046-5.
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Address correspondence to: Celize Cruz Bresciani
Almeida, Department of Pediatrics, State University
of Campinas Medical School, Rua Jasmim, n. 750,
Torre 1, Apt. 84, Zip Code 13087-460, Campinas,
Sao Paulo, Brazil (E-mail: celize@directnet.com.br).
(Submitted January 2005; accepted July 2005)
10: 213-221 (2005)