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INTRODUCTION

Pneumonia remains one of the most prevalent respiratory illnesses seen in clinical practice and is quite common in people around the world,^[1] and it is one of the most common nosocomial infections among patients in intensive care units. (ICU).^[2] It is a potentially lethal disease brought on by inhaled bacteria and viruses, inflammation of the lower respiratory tract, and infection of the bronchioles and alveoli. Usually, the illness manifests as excruciating chest pain and a persistent cough that produces large volumes of mucus.^[3] Hospital acquired pneumonia (HAP), community-acquired pneumonia (CAP), and ventilator-associated pneumonia (VAP) are the three primary categories.^[1]

Ventilator-associated pneumonia (VAP), characterized as parenchyma lung infection which manifests in mechanically ventilation patient which develops 48-72 hours post-endotracheal insertion, is the most prevalent hospital-acquired illness in the intensive care unit (ICU).^[2,4] Starting from the late 1950s, VAP has been recognized as a serious consequence in the ICU.^[5] VAP raises hospital and ICU stays, morbidity, and mortality, which raises healthcare costs.^[6] It has been demonstrated that it is crucial to divide VAP patients into groups in order to classify them as early- or late-onset. Endotracheal intubation and reduced awareness are the main risk factors for pneumonia of early onset, or VAP occurring within or in 5 days, usually brought on by various community-acquired bacteria such Haemophilus influenzae, Streptococcus pneumoniae, and Staphylococcus aureus. Late-onset pneumonia is usually indicated by the aspiration of stomach or oropharyngeal contents containing multidrug-resistant nosocomial pathogens, defined as VAP which occurs in more than 5 days. ^[2]

Several risk factors, including the use of positive end expiratory pressure (PEEP), supine patient positioning, airway intubation, decreased consciousness, intracranial monitoring, and airway re-intubation, have been associated with VAP. For example, artificial ventilation and airway intubation impair the natural removal of airway secretions, raising the risk of ventilator-associated pneumonia.^[2] Other risk factors for VAP include a range of therapies (e.g., Low endotracheal tube cuff pressure, supine head position, re-intubation, and H2 blockers), as well as underlying severe illness (aspiration gastric colonization, acute lung injury, or coma).^[5]

VAP PATHOPHYSIOLOGY

VAP usually occurs 48-72 hours after the patient is intubated or mechanically ventilated and is caused by microorganisms.^[7] There are four usual methods for the microorganism to infiltrate the lungs: through a pool of secretions surrounding the tube, a biofilm of gram-negative bacteria inside the tube, or micro-aspirations, which typically occur during tube insertion or when mucociliary clearance is insufficient to secrete the mucus flow, especially when the patient is supine. Endogenic aerobic gram-negative bacteria with high pathogenicity overgrow the flora of intensive care unit patients, frequently leading to lung infections. ^[6]

CHEST PT FOR PREVENTION OF VAP

Figure 2: Different chest physiotherapy therapy interventions used in ICU and pneumonia patients

To effectively treat prevention and battle VAP, care procedures involving the entire health team in hygienic care, appropriate clinical follow-up, and physical therapy must be developed as soon as possible.^[9] Simple and affordable preventive measures can reduce a number of VAP risk factors. One popular preventive measure is chest physical therapy, in which physiotherapists treat intensive care unit (ICU) patients using a variety of techniques including high-frequency chest wall oscillation, suctioning, patient positioning, and chest vibrations.^[1] chest percussions, early mobilization, respiratory physical therapy^[9], and different coughing techniques, either alone or in combination, to avoid pulmonary complications like ventilator-associated pneumonia (VAP).^[2] In critical care settings, chest physical therapy is a crucial part of the multidisciplinary approach,^[10] and the physiotherapist enhances the patient's functional and respiratory conditions as a team member, possibly shortening the patient's stay in the critical care unit.^[9]

Breathing Exercises: One of the first techniques used in chest physical therapy at the start of the 20th century was deep breathing exercises and since then has been acknowledged as a crucial component of a successful ventilator weaning process and is one of the most commonly used therapies in critical care units.^[4] The main purpose of breathing exercises is to increase ventilation and lung expansion, which in turn increases tissue ventilation perfusion and decreases hypoventilation and hypoxic damage uin tissues.^[11]

Diaphragmatic Breathing: It enhances the lung's vertical vital capacity by relaxing the diaphragm and abdominal muscles. This technique is claimed to be beneficial for COPD, thoracic abdominal surgery, ICD or rhyles tube, and anxious hospital stays. It is important to note that excessive training can increase the risk of barotraumas and hyperventilation. ^[11]

Pursed Lip Breathing Exercises: This breathing exercises is beneficial for those with COPD and other small airway illnesses where back pressure is thought to control airway collapsibility. ^[11]

Active Cycle of Breathing Techniques: Consists of forceful expiration, thoracic expansion exercises, active breathing regulation, and occasionally chest clapping and postural drainage. ^[1]

Positioning: Moving the patient so that the atelectatic side of the lung is up is known as postural drainage, in order to increase the ventilation-perfusion ratio. This permits secretions to go along major bronchus by gravity thus reducing the possibility of aspirating gastric and upper aero digestive tract secretions. Using an X-ray of the chest and/or physical examination, locate the atelectasis and secretion. Then, shift your body posture till the atelectasis is up, and use gravity to help you release any respiratory secretions. ^{[2, 12]}

Expiratory Rib Cage Compression (ERCC) or Squeezing: In an effort to improve expiratory flows and ease airway clearance in patients on mechanical ventilation, respiratory therapists and physiotherapists have empirically employed it.^[10] Two sequential actions make up expiratory rib cage Compression: squeezing the patient's chest wall during expiration lowers the end-expiratory reserve volume. At the start of inspiration, the patient's rib cage is released, increasing the end-inspiratory reserve volume. This methods raise tidal volume, decrease dead-space ventilation, and encourage sputum expectoration. ^[12]

High-Frequency Chest Wall Oscillation: Usually, the chest wall is compressed using an inflatable jacket that is coupled to an air pulse generator. At different frequencies, the chest wall can be squeezed and released by introducing an erratic flow of air into the jacket. It has been demonstrated that both central and peripheral mucus clearance is facilitated by high-frequency oscillation of the chest wall. ^[1]

Chest Vibration: Secretions can be released and mobilized by applying a gentle oscillatory motion and compression to the patient's chest wall.^[7]

Mechanical Techniques: Executed by providing biofeedback or visual incentive for lung expansion and airway clearance through intraoral oscillation, as well as by using an incentive spirometer, inspiratory muscle training devices, positive airway pressure devices (EzPAP and acapella), and a lung flute. ^[11]

OBJECTIVE

This review article's primary goal is to investigate the effect of physical therapy in lowering the prevalence of ventilator-associated pneumonia.

REVIEW OF LITERATURE

1. Renu B et al., through the randomized clinical trial evaluated the impact of multimodal chest physiotherapy on preventing ventilator-associated pneumonia in 101 intubatedand mechanically ventilated ICU patients who were split up into study and control groups, each of which had therapy twice a day. Both groups' clinical lung infection scores significantly decreased, according to the results, but the study group's mortality rate significantly decreased as well. Multimodal chest physical therapy was linked to a notable reduction in the incidence of VAP and maybe an effective strategy in preventing VAP and reducing mortality. ^[5]
2. Arti Y et al., through their study assessed how multimodal chest physical therapy reduced the overall mortality rate and ventilator-associated pneumonia. in 90 intubated and mechanically ventilated patients in the ICU, which were separated into research groups (which got placement and vibrations of the chest wall) and control groups (who underwent manual hyperinflation and suctioning). The study group experienced a substantial reduction in clinical lung infection score, which decreased the development of VAP and suggests that physiotherapy may be helpful in preventing VAP. ^[13]
3. Guimaraes F et al., carried out a crossover trial to look at the sputum clearance and acute mechanical effects of expiratory rib cage compression (ERCC) in patients with lung infections who were on mechanical ventilation. Although ERCC boosted expiratory flow, it had no clinically significant impact on respiratory mechanics or sputum output. The maneuver promoted a small increase in static and effective compliance only after a hyperinflation maneuver. Additionally, they identified that ERCC could cause expiratory flow limitation in some patients. The authors came to the conclusion that although ERCC causes an increase in expiratory flow, it does not appreciably enhance respiratory mechanics or sputum output in patients on mechanical ventilation and may result in EFL in certain people. ^[10]
4. Shahrokhi M et al., through their RCT study compared the impact of respiratory physiotherapy and increased positive end-expiratory pressure on capnography results in 60 adult patients with ventilator associated pneumonia in the ICU. Both methods significantly differed in the excreted pCO2, with respiratory physiotherapy and PEEP intervention resulting in higher amounts of excreted pCO2 compared to PEEP alone. Also, the CO2 excretion increased after respiratory physiotherapy. ^[13]
5. Marques A et al., The study looked into the effects of respiratory physiotherapy, which included exercise training, education, and procedures for clearing the airways and breathing, when added to standard pharmacological care in 97 outpatients with lower respiratory tract infections. Even while both groups made progress, the experimental group's improvement was larger, demonstrating that combining respiratory physical therapy with medication results in a better recovery in terms of symptoms and functional metrics. ^[14]
6. Jose A et al., investigated if an exercise-based rehabilitation program inpatient program is superior to a respiratory physiotherapy regimen for improving functional outcomes, symptoms, quality of life, and length of hospital stay in 49 patients with community-acquired pneumonia. An inpatient exercise-based rehabilitation program was found to significantly enhance patients' functional ability, peripheral muscle strength, dyspnea, and quality of life when compared to a standard respiratory physiotherapy regimen thus, concluding that Inpatient exercise rehabilitation was seen to be more beneficial than standard respiratory physiotherapy for improving functional outcomes. ^[15]
7. Phillips J et al., carried out a survey to find out what physiotherapists think about the efficacy of airway clearance techniques and what clinical practice consists of for adults and children during an acute exacerbation of bronchiectasis. For Adults it was found that physical exercise, oscillating positive expiratory pressure devices, directed huffing, the active cycle of breathing technique, and positive expiratory pressure were the most effective techniques while for pediatric patients, the most effective techniques were percussion, positive expiratory pressure through a mask or mouthpiece, and directed huffing. ^[16]
8. Lemes D et al., conducted a randomized crossover trial to determine if side lying with pressure support ventilation during ventilator-induced hyperinflation is superior to side lying alone in terms of clearing secretions and enhancing respiratory mechanics in 30 ventilated patients suffering from lung infections. The experimental intervention cleared significantly more secretions than the control intervention. Additionally, respiratory compliance increased significantly more after ventilator-induced hyperinflation in side lying. ^[17]
9. Leemans G et al., conducted a study to evaluate a mobile high-frequency chest wall oscillation (mHFCWO) device's efficacy compared to a standard nonmobile HFCWO (sHFCWO) device in individuals suffering from cystic fibrosis(CF). The mHFCWO device provided airway clearance comparable to the sHFCWO device. Sputum production was similar between the two devices however, Specific airway volume significantly decreased and specific airway resistance increased as a result of the mHFCWO therapy. They concluded that the mHFCWO device is a practical choice for airway clearance in CF patients, promoting the movement of mucus from the peripheral to the central airways, potentially improving adherence to therapy due to its mobility. ^[18]
10. Ryrso C et al., investigated the impact of exercise training on the prognosis of 186 individuals with community-acquired pneumonia through a randomized controlled experiment. They were randomized to booklet exercises, in-bed cycling, or normal care. Length of stay (LOS) was the main endpoint, whereas 90-day readmission and 180-day death were the secondary outcomes. Exercise training did not lower LOS or death, according to the study. It did, however, raise the possibility of lowering readmission risk and readmission days.^[19]

METHODOLOGY

The literature search was conducted using three well-established academic databases: Google Scholar, PubMed, and Web of Science. These platforms were chosen to ensure a comprehensive and credible collection of relevant studies. Following an extensive search process, a total of 28 articles were identified as meeting the inclusion criteria. Each of these selected papers underwent a detailed examination to extract key insights, methodologies, and findings that contributed significantly to the foundation of this narrative review.

Inclusion Criteria:

• Randomized controlled trials
• Interventional studies
• Cross-sectional studies
• Survey reports

Exclusion Criteria:

• Case studies
• Studies before the year
• Studies in language other than English

RESULT

From the above review of literature, a result was derived that addition of chest physiotherapy treatment to the care routine of critically ill and pneumonia patients has notable potential. Moreover, other studies stress the need for synergy among multiple interventions rather than isolationism of one particular physiotherapy technique.

CONCLUSION

Multimodal chest physiotherapy appears to be a powerful method in mitigating the occurrence of ventilator associated pneumonia (VAP) and lowering mortality in patients on mechanical ventilation. A consistent reduction in the Clinical Pulmonary Infection Score (CPIS) indicates a decrease in infection severity. Techniques such as chest wall vibrations, optimal positioning, and manual hyperinflation demonstrate notable clinical benefits. While Expiratory Rib Cage Compression (ERCC) may enhance expiratory airflow, its impact on the actual clearance of secretions remains limited.

Rehabilitation through structured exercise has shown to surpass traditional physiotherapy in improving functional capacity, quality of life, and overall outcomes in pneumonia patients. Additionally, the use of mobile high-frequency chest wall oscillation (HFCWO) devices may enhance patient adherence while maintaining therapeutic efficacy. Respiratory-focused physiotherapy, both in the ICU and outpatient settings, significantly contributes to symptom management and respiratory function enhancement. However, the choice of intervention must always be tailored to the patient’s condition, tolerance level, and specific clinical goals.

Future research should focus on large-scale randomized controlled trials comparing specific physiotherapy modalities, exploring the long-term impact of early rehabilitation, and investigating personalized, protocol- driven interventions to optimize outcomes in ventilated patients.

CONFLICT OF INETEREST

There was no conflict of interest for the study "Exploring the Impact of physiotherapy in reducing the incidences of ventilator-associated pneumonia: A narrative review."

ACKNOWLEDGEMENT

I would like to express my deepest gratitude to all those who have supported me throughout the journey of writing this review paper.

First and foremost, I would like to thank my Guide, [Dr. Shivpriya Sharma], for her invaluable guidance, encouragement, and insightful feedback. Your expertise and patience have been instrumental in shaping this research and helping me navigate the complexities of my topic.

I would also like to extend my heartfelt thanks to my parents and friends, whose unwavering love, patience, and support have been my greatest strength.

Thank you all for your contributions and support.

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