Tom Lunn

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: 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.