Ema Swingwood

Background: Invasively ventilated, critically ill children are at risk of retained respiratory secretions, which can obstruct airways, impair gas exchange, and cause lung collapse or ventilator-acquired pneumonia. Endotracheal suctioning partially removes secretions, but additional airway clearance interventions may be required. Mechanical insufflation-exsufflation (MI-E), is a cough augmentation device used to improve secretion clearance in adult intensive care, however it is not well characterised in paediatrics. Aim: To explore MI-E use in invasively ventilated, critically ill children. Method: This multi-methods study used an anonymous, electronic survey of UK-based paediatric physiotherapists. A scoping review searched seven electronic databases (1995–2025), using key terms (“airway clearance technique*”) OR (“mechanical insufflation exsufflation”) AND (“mechanical ventilation”) OR (“invasive ventilation”). Data were analysed descriptively for both methods, with content analysis for free text survey responses. Mixed-evidence, narrative integration compared and contrasted survey and scoping review findings. Results: Twenty-nine physiotherapists from across the UK completed the survey, 76% ( n = 22/29) were advanced specialists, and all reported access to an MI-E device. Six studies (2010–2024), one prospective, the remaining retrospective or case studies, were identified. Both data sources indicated MI-E was most frequently used with acutely unwell neuromuscular patients, though survey responses described a broader clinical application, including children with complex neurological conditions, general respiratory illnesses, trauma, and post-operative surgical or orthopaedic needs. MI-E settings and outcomes were inconsistently reported. Contraindications aligned across sources. Conclusions: MI-E appears increasingly accessible within paediatric critical care. Future research should assess MI-E safety in intubated patients and investigate broader critically ill populations.

Mechanical Insufflation-Exsufflation in the Intensive Care Unit - a case report series

Background: Lung ultrasound (LUS) is a non-invasive, point-of-care imaging modality increasingly used by physiotherapists to support diagnosis and guide intervention in critically ill patients. Evidence describing its impact on physiotherapy assessment, management, and resource utilisation remains limited. Objectives: To describe physiotherapy-led LUS practice, including scan indications, scan findings, influence on physiotherapy intervention selection, and potential implications for resource utilisation. Methods: A single-centre, prospective service evaluation was conducted between September 2024 and May 2025. Data were collected for all patients receiving physiotherapy-led LUS capturing patient demographics, scan indications and findings, intervention changes, and predicted resource implications. Descriptive statistics were used to summarise outcomes. Results: 117 scans were completed. Patients were predominantly post-cardiac surgery in intensive care (43/117, 37%). Acute deterioration was the most common indication (41%). LUS most frequently identified lobar collapse and pleural effusion. Physiotherapists reported reduced diagnostic uncertainty (97%), modified interventions (76% of cases) and the prevention of physiotherapy intervention that would otherwise have been ineffective (85/117, 73%). Predicted reductions in imaging and treatment duration were noted in 39% of assessments. Conclusions: Physiotherapy-led LUS appears feasible and may enhance assessment accuracy, guide targeted interventions, and optimise resource utilisation across respiratory care.

Background: Occupational Therapy (OT) in the Intensive Care Unit (ICU) supports recovery in physical, cognitive, emotional domains, and activities of daily living (ADL), yet. Provision across the UK remains inconsistent, with variable staffing and role integration and no data illustrating the potential impact from such roles. Method: A retrospective service evaluation was undertaken in a UK NHS adult ICU to examine the association of increased OT staffing with changes in rehabilitation activity and functional status. Patients with ICU stays over 7 days were included in line with NICE CG83 high rehabilitation risk criteria. Three 1-month timepoints were compared. Data included delivery of OT interventions, functional outcomes (Modified Barthel Index), and discharge destination. Results: Ninety-nine patients were included. Increased OT staffing was associated with a greater proportion of patients receiving OT assessments, upper limb rehabilitation, personal activities of daily living retraining, cognitive screening, delirium management, and therapy handover. Modified Barthel index scores at hospital discharge increased across timepoints 1, 2 and 3 (55, 71.5 and 82, respectively ( p = 0.02)). Discharge destination patterns varied and could not be attributed solely to staffing changes. Discussion: Increased OT staffing was associated with greater delivery of rehabilitation interventions and potential improvements in functional outcomes. However, differences in patient clinical complexity across timepoints may also have influenced these results. Further evaluation is required to establish causal relationships.

Introduction: Post-intensive care syndrome affects up to 70% of adult intensive care unit (ICU) survivors, with ICU-acquired weakness contributing substantially to long-term disability. Despite evidence supporting early and structured rehabilitation to enhance physical recovery, targeted upper-limb rehabilitation approaches in the ICU remain comparatively underexplored. This scoping review will map and summarise existing evidence on upper-limb weakness and rehabilitation strategies delivered by healthcare professionals for critically ill adults. Methods and analysis: This scoping review protocol has been developed in accordance with the Joanna Briggs Institute methodology for scoping reviews and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews, ensuring transparent and comprehensive reporting. Searches will be conducted in MEDLINE (Ovid), CINAHL (EBSCO), Embase, Scopus and the Cochrane Central Register of Controlled Trials (CENTRAL). The search will include studies published between March 2009 and August 2025, aligning with National Institute of Clinical Excellence (NICE) Guideline CG83 (2009), which marked a major policy shift in ICU rehabilitation practice. Quantitative data will be summarised descriptively (eg, frequencies and proportions), while qualitative data will undergo thematic synthesis to identify patterns in experiences, perceptions and implementation of upper-limb rehabilitation. Grey literature (eg, OpenGrey and relevant conference proceedings) will also be screened to reduce publication bias. Rayyan AI software will be used to manage citation screening and reviewer collaboration; no artificial intelligence-assisted decision tools will be used to determine study inclusion. Ethics and dissemination: As this review will synthesise previously published data, ethical approval is not required. Results will be disseminated through peer-reviewed publication, conference presentations and open-access platforms. Findings from this review will inform the development of evidence-based ICU rehabilitation guidelines and highlight priorities for future research to improve upper-limb recovery in critically ill adults. Study registration: Open Science Framework (osf.io/j86nf).

Background: Airway clearance is a vital aspect of respiratory care in patients with severe acute respiratory failure receiving veno-venous extracorporeal membrane oxygenation (VV-ECMO). These patients often receive high levels of sedation alongside ultra-lung protective invasive mechanical ventilation, which, while reducing ventilator-induced lung injury, significantly impairs physiological mechanisms essential for secretion clearance, such as expiratory flow bias, mucociliary transport, and effective cough. Objectives: This commentary explores the multifaceted challenges to airway clearance in the VV-ECMO population, evaluating current physiotherapeutic interventions, and identifying critical areas for future research. Discussion: Ultra-lung protective ventilation settings reduce airflow and expiratory shear forces necessary for secretion mobilisation. Concurrent sedation and neuromuscular blockade suppress cough reflexes and promote secretion stasis, while reduced airflow impairs the two-phase gas-liquid flow critical for airway hygiene. Additionally, increased secretion viscosity and altered lung mechanics further limit clearance. Current physiotherapy strategies such as suctioning, hyperinflation, cough augmentation, and manual techniques are often adapted from non-ECMO settings and lack validation in this population. Diagnostic challenges, such as reduced auscultation efficacy, highlight the growing importance of tools like lung ultrasound. Pharmacological adjuncts, including mucolytics and saline lavage, are used despite limited supporting evidence. Conclusion: Airway clearance in patients receiving VV-ECMO is hampered by a convergence of physiological, mechanical, and clinical factors. Existing literature remains scarce and largely extrapolated from conventional invasive mechanical ventilation populations. There is an urgent need for targeted research to define evidence-based interventions tailored to the unique pathophysiology of this complex group.

Introduction Patients receiving extracorporeal membrane oxygenation (ECMO) for severe acute respiratory failure (SARF) often experience significant challenges with airway clearance due to disease severity, ultra-protective ventilation strategies and suppression of mucociliary and cough mechanisms. Extremely low tidal volumes and minimal flow rates further hinder secretion mobilisation. Despite increasing global use of ECMO, there is currently no synthesis of evidence describing airway clearance practices, their physiological rationale or outcomes in this population. This scoping review aims to explore the extent and nature of evidence on airway clearance interventions in invasively ventilated adult patients receiving ECMO for SARF. Specific objectives include mapping the types of interventions described and specific parameters, their intended physiological effects, reported outcomes and safety considerations. Methods and analysis This scoping review will be conducted in accordance with the Joanna Briggs Institute methodology and reported using Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidelines. A comprehensive search will be undertaken across Embase, Ovid Emcare, Ovid Medline, CINAHL and grey literature sources including TRIP and Google Scholar. Eligible studies will include original data on airway clearance interventions in adult patients (≥16 years) receiving ECMO for SARF. Studies focused on paediatric populations, extracorporeal carbon dioxide removal, or solely cardiac ECMO will be excluded. Two independent reviewers will screen titles, abstracts and full texts, extract data using a piloted tool and summarise findings using descriptive statistics and narrative synthesis. Basic qualitative content analysis will support mapping of interventions including parameters, their physiological and clinical rationale, and reported outcomes including adverse effects. Ethics and dissemination As this study involves a review of existing literature and does not include collection of primary data, ethical approval is not required. Findings will be disseminated through publication in a peer-reviewed journal and presentation at relevant academic and professional meetings. The results are expected to highlight variations in practice and provide a foundation for future research aimed at optimising respiratory care and improving outcomes for patients receiving ECMO for SARF. Registration osf.io/ptfr7.

Background Acute respiratory deterioration in hospitalised patients requires timely intervention to prevent further clinical decline. Out-of-hours respiratory care is typically provided through on-call physiotherapy rotas, extended hour cover, or 24/7 on-site services. However, models of care vary widely internationally, and little is known about how these services are structured, delivered, and evaluated for acutely deteriorating respiratory patients. Objectives To map and describe international models of care for out-of-hours services for acutely deteriorating respiratory patients, including key model characteristics, workforce configurations, referral processes, reported barriers and facilitators, and associated outcomes. Methods A scoping review was undertaken following the Joanna Briggs Institute and PRISMA-ScR guidance. This included a comprehensive search of electronic databases and grey literature. Papers were included if they reported models of out-of-hours care relevant to respiratory physiotherapy or multidisciplinary care for patients with acute respiratory deterioration. Data were extracted independently by four reviewers and synthesised descriptively using a narrative approach. Results Thirteen international papers published between 2002 and 2023 were included. The majority (77%) described out-of-hours physiotherapy models; others reported extended hours or multidisciplinary rapid response teams. Operating hours, referral processes, and protocols varied widely, with many services relying on non-specialist physiotherapists for out-of-hours provision. Barriers to service provision included staffing limitations, variability in competence, and organisational challenges. Facilitators included presence of senior support, structured training, protocols, and institution support for extended hours models. Evidence on clinical outcomes was limited and heterogeneous. Conclusions Out-of-hours care for acutely deteriorating respiratory patients is delivered through a range of models internationally, with considerable variation in structure and workforce configuration. Further research is needed to evaluate model effectiveness, impact on staff well-being, and relevance to evolving workforce demands.