Manual Hyperinflation Versus Diaphragmatic Proprioceptive Neuromuscular Facilitation on Pulmonary Functions in Mechanically Ventilated Patients

C- reactive protein analysis

时间窗: immediately after the intervention

Each patient will be informed about the purpose of the test and how it will be done with keeping the explanation brief and in simple terms. Each patient will be instructed to assume a relaxed comfortable position with loose clothes. Initial step, phlebotomist will secure a snug rubber band around patient's upper arm, and the patient will be asked to pump his fist several times. Then phlebotomist will palpate the vein, and will cleanse with an alcohol prep pad. Then practitioner will introduce a needle into the vein, and will draw a vial of blood. After that the practitioner will remove the band, then remove the needle and apply pressure to venipuncture site up to one minute. A bandage will be applied over the site. The test will be conducted for all patients pre and post the treatment program duration. Normal finding for C-reactive protein (CRP) is \< 1.0 mg/dL or \<10.0 mg/L (SI units) (\< 3 mg/L for high-sensitivity CRP \[hs-CRP\]),

Blood gases analysis

时间窗: immediately after the intervention

Each patient will be informed about the purpose of the test and how it will be done with keeping the explanation brief and in simple terms. Each patient will be informed to assume a relaxed comfortable position with loose clothes. Arterial blood samples will be taken via arterial line which is accessible and less painful. The collected arterial blood sample will be sent for laboratory investigation according to ICU department laboratory communication protocol of Gamal Abdel Nasser Hospital. The test will be conducted for all patients pre and post the treatment program duration.

Assessment of chest expansion

时间窗: immediately after the intervention

Each patient will be informed about the purpose of the test and how it will be done with keeping the explanation brief and in simple terms. Each patient will assume a comfortable half lying suping position. Marking will be done at 3 levels; axillary, nipple and xiphisterna. Patient will be asked to first take some normal breaths as a breath control technique for relaxation. Then will be asked to exhale completely and then inhale maximally as much as he can and hold breath for a second. The difference between maximum exhalation and inhalation will be recorded during holding breath using a measuring tape at all three-level mentioned above. This procedure will be repeated three times and then the best value will be recorded The chest expansion will be measured for all patients pre and post the treatment program duration

Assessment of weaning parameters

时间窗: during the assessment time

The weaning process will be indicated according to the following criteria; Adequate oxygenation" PaO2/FIO2 ratio ≥ 200, FIO2≤ 0.40, PaO2 ≥ 60, PaCO2 and PEEP ≤ 5 cmH2O", PH ≥ 7.30, Respiratory rate ≤ 45 bpm, Heart rate ≤ 140 bpm, RSBI ≤ 8 breaths/min/ml/kg body weight, Hemodynamic stability" no or minimal vasopressors or inotropes", Appropriate level of conscious, No continuous sedation infusion nor neuromuscular blocking agents, Afebrile, Adequate hemoglobin ≥8 g/dl and/or no evidence of hemorrhage

Oxygenation Index

时间窗: immediately after the intervention

Oxygenation index is the better indicator for defining of lung injury compared to the PaO2/FiO2 ratio as it includes mean airway pressure (MAP), also it is an important determinant of oxygenation of acute respiratory failure, which evaluated according the following equation (PaO2/ FiO2) \<300 mmHg with or without elevated arterial carbon dioxide tension (PaCO2) (Liu et al., 2015). OI is a commonly used to assess the severity of hypoxic respiratory failure (HRF) and persistent pulmonary hypertension OI = mean airway pressure MAP (in cmH2O) × FiO2 × 100 ÷ PaO2 . Where FiO2: Fraction of inspired oxygen in percent. MAP: Mean airway pressure in mmHg. FiO2: Fraction of inspired oxygen. PaO2: Partial pressure of oxygen in arterial blood in mmHg. The oxygenation index will be recorded for all patients pre and post the treatment program duration.