Review paper|Articles in Press

Benefits and risks of ventilator hyperinflation in mechanically ventilated intensive care patients: A systematic review and meta-analysis

Published:February 21, 2023DOI:



      Patients requiring mechanical ventilation in the intensive care unit (ICU) have diminished respiratory defences and are at high risk of respiratory compromise, leading to an increased risk of pulmonary infection and prolonged ventilation. Ventilator hyperinflation (VHI) is an airway clearance technique used by physiotherapists and is suggested to improve respiratory mechanics. The objective of this study was to review the evidence for the benefits and risks of VHI in intubated and mechanically ventilated patients in the ICU.

      Review method used

      We conducted a systematic review.

      Data sources

      We searched PubMed, Embase, CINAHL, CENTRAL, and Scopus from inception to 31st May 2022 for all randomised control trials evaluating VHI in intubated and mechanically ventilated adults in the ICU.

      Review methods

      Two authors independently performed study selection and data extraction. Individual study risk of bias was assessed using the Physiotherapy Evidence Database scale, and certainty in outcomes was assessed using the Grading of Recommendations, Assessment, Development and Evaluations framework.


      We included 10 studies enrolling 394 patients. Compared to standard care, VHI had significant effects on sputum clearance (Standardise mean difference: 0.36, 95% confidence interval [CI]: 0.12 to 0.61; very low certainty), static pulmonary compliance (mean difference [MD]: 4.77, 95% CI: 2.40 to 7.14; low certainty), dynamic pulmonary compliance (MD: 1.59, 95% CI: 0.82 to 2.36; low certainty) and oxygenation (MD: 0.28, 95% CI: 0.01 to 0.55; low certainty). No significant adverse events or immediate side effects relating to VHI were reported. There is a paucity of data available on the effects of VHI on clinical outcomes including mechanical ventilation duration, ICU length of stay, and mortality.


      Our findings suggest VHI has potential short-term respiratory benefits including increased secretion clearance, pulmonary compliance, and oxygenation, with no immediate adverse effects in intubated and mechanically ventilated ICU patients. However, there remains limited data on the longer term influence of VHI on clinical outcomes, and further research to inform clinical practice is needed.


      This study is registered with the International Prospective Register of Systematic Reviews (PROSPERO; CRD42022341421).


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Australian Critical Care
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Volpe M.S.
        • Guimarães F.S.
        • Morais C.C.
        Airway clearance techniques for mechanically ventilated patients: insights for optimization.
        Respir Care. 2020; 65: 1174-1188
        • Branson R.D.
        Secretion management in the mechanically ventilated patient.
        Respir Care. 2007; 52: 1328-1347
        • Goetz R.L.
        • Vijaykumar K.
        • Solomon G.M.
        Mucus clearance strategies in mechanically ventilated patients.
        Front Physiol. 2022; 13834716
        • Spapen H.D.
        • De Regt J.
        • Honoré P.M.
        Chest physiotherapy in mechanically ventilated patients without pneumonia-a narrative review.
        J Thorac Dis. 2017; 9: E44-E49
        • Hess D.R.
        Airway clearance: physiology, pharmacology, techniques, and practice.
        Respir Care. 2007; 52: 1392-1396
        • Pneumatikos I.A.
        • Dragoumanis C.K.
        • Bouros D.E.
        Ventilator-associated pneumonia or endotracheal tube-associated pneumonia? An approach to the pathogenesis and preventive strategies emphasizing the importance of endotracheal tube.
        Anesthesiology. 2009; 110: 673-680
        • Bassi G.L.
        Causes of secretion retention: patient factors, ventilation, devices, drugs.
        Curr Respir Med Rev. 2014; 10: 143-150
        • Restrepo R.D.
        • Walsh B.K.
        Humidification during invasive and noninvasive mechanical ventilation.
        Respir Care. 2012; 57: 782-788
        • Paratz J.
        • Ntoumenopoulos G.
        Detection of secretion retention in the ventilated patient.
        Curr Respir Med Rev. 2014; 10: 151-157
        • Berney S.
        • Denehy L.
        A comparison of the effects of manual and ventilator hyperinflation on static lung compliance and sputum production in intubated and ventilated intensive care patients.
        Physiother Res Int. 2002; 7: 100-108
        • Berney S.
        • Haines K.
        • Denehy L.
        Physiotherapy in critical care in Australia.
        Cardiopulm Phys Ther J. 2012; 23: 19-25
        • Savian C.
        • Paratz J.
        • Davies A.
        Comparison of the effectiveness of manual and ventilator hyperinflation at different levels of positive end-expiratory pressure in artificially ventilated and intubated intensive care patients.
        Heart Lung. 2006; 35: 334-341
        • Ahmed F.
        • Shafeeq A.M.
        • Moiz J.A.
        • Geelani M.A.
        Comparison of effects of manual versus ventilator hyperinflation on respiratory compliance and arterial blood gases in patients undergoing mitral valve replacement.
        Heart Lung. 2010; 39: 437-443
        • Dennis D.
        • Jacob W.
        • Budgeon C.
        Ventilator versus manual hyperinflation in clearing sputum in ventilated intensive care unit patients.
        Anaesth Intensive Care. 2012; 40: 142-149
        • Anderson A.
        • Alexanders J.
        • Sinani C.
        • Hayes S.
        • Fogarty M.
        Effects of ventilator vs manual hyperinflation in adults receiving mechanical ventilation: a systematic review of randomised clinical trials.
        Physiotherapy. 2015; : 101103-101110
        • Martinez B.P.
        • Lobo L.L.
        • de Queiroz R.S.
        • Saquetto M.B.
        • Júnior L.A.F.
        • Correia H.F.
        • et al.
        Effects of ventilator hyperinflation on pulmonary function and secretion clearance in adults receiving mechanical ventilation: a systematic review with meta-analysis.
        Heart Lung. 2022; 56: 8-23
        • Page M.J.
        • McKenzie J.E.
        • Bossuyt P.M.
        • Boutron I.
        • Hoffmann T.C.
        • Mulrow C.D.
        • et al.
        The PRISMA 2020 statement: an updated guideline for reporting systematic reviews.
        BMJ. 2021; 372: n71
        • Hoffmann T.C.
        • Glasziou P.P.
        • Boutron I.
        • Milne R.
        • Perera R.
        • Moher D.
        • et al.
        Better reporting of interventions: template for intervention description and replication (TIDieR) checklist and guide.
        BMJ. 2014; 348: g1687
        • Higgins J.P.T.
        • Li T.
        • Deeks J.J.
        Chapter 6: Choosing effect measures and computing estimates of effect.
        in: Higgins J.P.T. Thomas J. Chandler J. Cumpston M. Li T. Page M.J. Cochrane handbook for systematic reviews of interventions version 6.3 (updated February 2022). Cochrane, 2022 (Available from)
        Date accessed: July 16, 2022
        • Macedo L.G.
        • Elkins M.R.
        • Maher C.G.
        • Moseley A.M.
        • Herbert R.D.
        • Sherrington C.
        There was evidence of convergent and construct validity of Physiotherapy Evidence Database quality scale for physiotherapy trials.
        J Clin Epidemiol. 2010; 63: 920-925
        • Maher C.G.
        • Sherrington C.
        • Herbert R.D.
        • Moseley A.M.
        • Elkins M.
        Reliability of the PEDro scale for rating quality of randomized controlled trials.
        Phys Ther. 2003; 83: 713-721
        • Schunemann H.
        • Brozek J.
        • Guyatt G.
        • Oxman A.
        Chapter 5. Quality of evidence.
        in: Schunemann H. Brozek J. Guyatt G. Oxman A. Handbook for grading the quality of evidence and the strength of recommendations using the GRADE approach (updated October 2013). GRADE Working Group, 2013
        • Berney S.
        • Denehy L.
        The effect of physiotherapy treatment on oxygen consumption and haemodynamics in patients who are critically ill.
        Aust J Physiother. 2003; 49: 99-105
        • Lemes D.A.
        • Zin W.A.
        • Guimaraes F.S.
        Hyperinflation using pressure support ventilation improves secretion clearance and respiratory mechanics in ventilated patients with pulmonary infection: a randomised crossover trial.
        Aust J Physiother. 2009; 55: 249-254
        • Naue Wda S.
        • da Silva A.C.
        • Güntzel A.M.
        • Condessa R.L.
        • de Oliveira R.P.
        • Rios Vieira S.R.
        Increasing pressure support does not enhance secretion clearance if applied during manual chest wall vibration in intubated patients: a randomised trial.
        J Physiother. 2011; 57: 21-26
        • Guimarães F.S.
        • Lopes A.J.
        • Constantino S.S.
        • Lima J.C.
        • Canuto P.
        • de Menezes S.L.
        Expiratory rib cage Compression in mechanically ventilated subjects: a randomized crossover trial [corrected].
        Respir Care. 2014; 59: 678-685
        • Naue Wda S.
        • Forgiarini Junior L.A.
        • Dias A.S.
        • Vieira S.R.
        Chest compression with a higher level of pressure support ventilation: effects on secretion removal, hemodynamics, and respiratory mechanics in patients on mechanical ventilation.
        J Bras Pneumol. 2014; 40: 55-60
        • Assmann C.B.
        • Vieira P.J.
        • Kutchak F.
        • Rieder Mde M.
        • Forgiarini S.G.
        • Forgiarini Junior L.A.
        Lung hyperinflation by mechanical ventilation versus isolated tracheal aspiration in the bronchial hygiene of patients undergoing mechanical ventilation.
        Rev Bras Ter Intensiva. 2016; 28: 27-32
        • Adorna E.L.
        • Vieira F.N.
        • Naue W.S.
        • Dias A.S.
        • Vieira S.R.
        Hyperinflation with mechanical ventilation as a bronchial hygiene maneuver.
        Clin Biomed Res. 2016; 36: 242-247
        • Ribeiro B.S.
        • Lopes A.J.
        • Menezes S.L.S.
        • Guimarães F.S.
        Selecting the best ventilator hyperinflation technique based on physiologic markers: a randomized controlled crossover study.
        Heart Lung. 2019; 48: 39-45
        • Naue Wda S.
        • Herve B.B.
        • Vieira F.N.
        • Deponti G.N.
        • Martins L.F.
        • Dias A.S.
        • et al.
        Comparison of bronchial hygiene techniques in mechanically ventilated patients: a randomized clinical trial.
        Rev Bras Ter Intensiva. 2019; 31: 39-46
        • Chicayban L.M.
        Acute effects of ventilator hyperinflation with increased inspiratory time on respiratory mechanics: randomized crossover clinical trial.
        Rev Bras Ter Intensiva. 2019; 31: 289-295
        • Paulus F.
        • Binnekade J.M.
        • Vroom M.B.
        • Schultz M.J.
        Benefits and risks of manual hyperinflation in intubated and mechanically ventilated intensive care unit patients: a systematic review.
        Crit Care. 2012; 16: R145
        • Maa S.H.
        • Hung T.J.
        • Hsu K.H.
        • Hsieh Y.I.
        • Wang K.Y.
        • Wang C.H.
        • et al.
        Manual hyperinflation improves alveolar recruitment in difficult-to-wean patients.
        Chest. 2005; 128: 2714-2721
        • Paulus F.
        • Binnekade J.M.
        • Middelhoek P.
        • Vroom M.B.
        • Schultz M.J.
        Performance of manual hyperinflation: a skills lab study among trained intensive care unit nurses.
        Med Sci Monit. 2009; 15: CR418-CR422
        • Dennis D.M.
        • Jacob W.J.
        • Samuel F.D.
        A survey of the use of ventilator hyperinflation in Australian tertiary intensive care units.
        Crit Care Resusc. 2010; 12: 262-268
        • Davies J.D.
        • Senussi M.H.
        • Mireles-Cabodevila E.
        Should a tidal volume of 6 mL/kg be used in all patients?.
        Respir Care. 2016; 61: 774-790
        • Jackson M.
        • Cairns T.
        Care of the critically ill patient.
        Surgery (Oxf). 2021; 39: 29-36
        • Acute Respiratory Distress Syndrome Network
        • Brower R.G.
        • Matthay M.A.
        • Morris A.
        • Schoenfeld D.
        • Thompson B.T.
        • Wheeler A.
        Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome.
        N Engl J Med. 2000; 342: 1301-1308
        • Fan E.
        • Del Sorbo L.
        • Goligher E.C.
        • Hodgson C.L.
        • Munshi L.
        • Walkey A.J.
        • et al.
        An official American Thoracic Society/European Society of Intensive Care Medicine/Society of Critical Care Medicine clinical practice guideline: mechanical ventilation in adult patients with acute respiratory distress syndrome.
        Am J Respir Crit Care Med. 2017; 195: 1253-1263
        • Sahetya S.K.
        • Mallow C.
        • Sevransky J.E.
        • Martin G.S.
        • Girard T.D.
        • Brower R.G.
        • et al.
        Association between hospital mortality and inspiratory airway pressures in mechanically ventilated patients without acute respiratory distress syndrome: a prospective cohort study.
        Crit Care. 2019; 23: 367
        • Neto A.S.
        • Simonis F.D.
        • Barbas C.S.
        • Biehl M.
        • Determann R.M.
        • Elmer J.
        • et al.
        Lung-protective ventilation with low tidal volumes and the occurrence of pulmonary complications in patients without acute respiratory distress syndrome: a systematic review and individual patient data analysis.
        Crit Care Med. 2015; 43: 2155-2163
        • Lipes J.
        • Bojmehrani A.
        • Lellouche F.
        Low tidal volume ventilation in patients without acute respiratory distress syndrome: a paradigm shift in mechanical ventilation.
        Crit Care Res Pract. 2012; 2012416862
        • Serpa Neto A.
        • Cardoso S.O.
        • Manetta J.A.
        • Pereira V.G.
        • Espósito D.C.
        • Pasqualucci Mde O.
        • et al.
        Association between use of lung-protective ventilation with lower tidal volumes and clinical outcomes among patients without acute respiratory distress syndrome: a meta-analysis.
        JAMA. 2012; 308: 1651-1659
        • Simonis F.D.
        • Serpa Neto A.
        • Binnekade J.M.
        • Braber A.
        • Bruin K.C.M.
        • Determann R.M.
        • et al.
        • Writing Group for the PReVENT Investigators
        Effect of a low vs intermediate tidal volume strategy on ventilator-free days in intensive care unit patients without ARDS: a randomized clinical trial.
        JAMA. 2018; 320: 1872-1880
        • Jacob W.
        • Dennis D.
        • Jacques A.
        • Marsh L.
        • Woods P.
        • Hebden-Todd T.
        Ventilator hyperinflation determined by peak airway pressure delivered: a randomized crossover trial.
        Nurs Crit Care. 2021; 26: 14-19