1
|
Sánchez-García M, Álvarez-González M, Domingo-Marín S, Pino-Ramírez ÁD, Martínez-Sagasti F, González-Arenas P, Cardenal-Sánchez C, Velasco-López E, Núñez-Reiz A. Comparison of Mechanical Insufflation-Exsufflation and Hypertonic Saline and Hyaluronic Acid With Conventional Open Catheter Suctioning in Intubated Patients. Respir Care 2024; 69:575-585. [PMID: 38307525 PMCID: PMC11147607 DOI: 10.4187/respcare.11566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 12/06/2023] [Indexed: 02/04/2024]
Abstract
BACKGROUND Open respiratory secretion suctioning with a catheter causes pain and tracheobronchial mucosal injury in intubated patients. The goal of mechanical insufflation-exsufflation (MI-E) is to move secretions proximally and noninvasively by generating a high peak expiratory air flow. Nebulized hypertonic saline with hyaluronic acid (HS-HA) may facilitate suctioning by hydration. We assessed the safety and tolerance of a single session of airway clearance with MI-E and HS-HA in critically ill intubated patients. METHODS Adults with a cuffed artificial airway were randomized to (1) open suctioning, (2) open suctioning after HS-HA, (3) MI-E, or (4) MI-E with HS-HA. Adverse events, pain and sedation/agitation scores, and respiratory and hemodynamic variables were collected before, during, and 5-min and 60-min post intervention. RESULTS One-hundred twenty subjects were enrolled and completed the study. Median (interquartile range [IQR]) Acute Physiology and Chronic Health Evaluation II (APACHE II) score was 22 (16-28); median (IQR) age was 69.0 (57.0-75.7) y, and 90 (75%) were male. Baseline respiratory and hemodynamic variables were comparable. Adverse events occurred in 30 subjects (25%), with no between-group differences. Behavioral pain equivalents and Richmond Agitation-Sedation Scale were higher during suctioning in groups 1 (P < .001) and 2 (P < .001). Independent predictive variables for higher pain and agitation/sedation scores were study groups 1 and 2 and simultaneous analgosedation, respectively. Noradrenaline infusion rates were lower at 60 min in groups 2 and 4. PaO2 /FIO2 had decreased at 5 min after open suctioning in group 1 and increased at 60 min in group 3. CONCLUSIONS We observed no difference in adverse events. MI-E avoids pain and agitation.
Collapse
|
2
|
Seipp A, Klausen A, Timmer A, Grimm T, Groß M, Summ O, Otto-Sobotka F. Effect of mechanical insufflation-exsufflation for ineffective cough on weaning duration in diseases of the peripheral or central nervous system (MEDINE): study protocol for a randomised controlled trial in a neurological weaning centre. BMJ Open 2023; 13:e071273. [PMID: 37460261 DOI: 10.1136/bmjopen-2022-071273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/20/2023] Open
Abstract
INTRODUCTION Patients with neurological or neurosurgical disease can suffer from impaired cough, which may result in life-threatening retention of tracheobronchial secretions, atelectasis, pneumonia and finally death. Due to a lack of alternatives and pathophysiological plausibility, the application of mechanical insufflation-exsufflation (MI-E) has already become international standard care in neuromuscular disease and spinal cord injury although a lack of evidence for efficacy. High-quality studies to support the use of MI-E in neurological and neurosurgical patients during weaning from mechanical ventilation are missing. The goal of this exploratory study is to display the effect size of MI-E intervention on the duration of mechanical ventilation and additional outcomes. METHODS AND ANALYSIS One hundred adult patients with a cough deficiency or retention of secretion admitted to a neurological intensive care unit (ICU) are planned to be recruited for this randomised controlled trial. Patients are randomised 1:1 to receive either MI-E or best standard care. Observation will take place until discharge from the hospital, death or end of the study period. The primary endpoint of this trial is the duration of mechanical ventilation from randomisation until successful weaning. The outcome will be analysed with Kaplan-Meier estimation and competing risks analyses. Secondary endpoint is the proportion of patients with successful weaning. Further outcomes will include the incidence of hospital-acquired pneumonia, mortality, decannulation rate, length of stay on the ICU and the total score of the Glasgow Coma Scale. ETHICS AND DISSEMINATION The study was approved by the Medical Ethics Committee of the University of Oldenburg. The findings of this study will be submitted for publication in a peer-reviewed journal. TRIAL REGISTRATION NUMBER DRKS00020981.
Collapse
Affiliation(s)
- Alexander Seipp
- Epidemiology and Biometry, Carl von Ossietzky University of Oldenburg Faculty VI Medicine and Health Sciences, Oldenburg, Germany
| | - Andreas Klausen
- Big Data in Medicine, Carl von Ossietzky University of Oldenburg Faculty VI Medicine and Health Sciences, Oldenburg, Germany
- Oldenburg Research Network Emergency and Intensive Care Medicine (OFNI), Carl von Ossietzky University of Oldenburg Faculty VI Medicine and Health Sciences, Oldenburg, Germany
| | - Antje Timmer
- Epidemiology and Biometry, Carl von Ossietzky University of Oldenburg Faculty VI Medicine and Health Sciences, Oldenburg, Germany
| | - Teresa Grimm
- Department of Neurological Intensive Care and Rehabilitation, Evangelisches Krankenhaus Oldenburg, Oldenburg, Germany
- Carl von Ossietzky University of Oldenburg Faculty VI Medicine and Health Sciences, Oldenburg, Germany
| | - Martin Groß
- Department of Neurological Intensive Care and Rehabilitation, Evangelisches Krankenhaus Oldenburg, Oldenburg, Germany
- Carl von Ossietzky University of Oldenburg Faculty VI Medicine and Health Sciences, Oldenburg, Germany
| | - Oliver Summ
- Department of Neurological Intensive Care and Rehabilitation, Evangelisches Krankenhaus Oldenburg, Oldenburg, Germany
- Carl von Ossietzky University of Oldenburg Faculty VI Medicine and Health Sciences, Oldenburg, Germany
| | - Fabian Otto-Sobotka
- Epidemiology and Biometry, Carl von Ossietzky University of Oldenburg Faculty VI Medicine and Health Sciences, Oldenburg, Germany
| |
Collapse
|
3
|
Swingwood EL, Stilma W, Tume LN, Cramp F, Voss S, Bewley J, Ntoumenopoulos G, Schultz MJ, Scholte Op Reimer W, Paulus F, Rose L. The Use of Mechanical Insufflation-Exsufflation in Invasively Ventilated Critically Ill Adults. Respir Care 2022; 67:1043-1057. [PMID: 35610033 PMCID: PMC9994141 DOI: 10.4187/respcare.09704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Mechanical insufflation-exsufflation (MI-E) is traditionally used in the neuromuscular population. There is growing interest of MI-E use in invasively ventilated critically ill adults. We aimed to map current evidence on MI-E use in invasively ventilated critically ill adults. Two authors independently searched electronic databases MEDLINE, Embase, and CINAHL via the Ovid platform; PROSPERO; Cochrane Library; ISI Web of Science; and International Clinical Trials Registry Platform between January 1990-April 2021. Inclusion criteria were (1) adult critically ill invasively ventilated subjects, (2) use of MI-E, (3) study design with original data, and (4) published from 1990 onward. Data were extracted by 2 authors independently using a bespoke extraction form. We used Mixed Methods Appraisal Tool to appraise risk of bias. Theoretical Domains Framework was used to interpret qualitative data. Of 3,090 citations identified, 28 citations were taken forward for data extraction. Main indications for MI-E use during invasive ventilation were presence of secretions and mucus plugging (13/28, 46%). Perceived contraindications related to use of high levels of positive pressure (18/28, 68%). Protocolized MI-E settings with a pressure of ±40 cm H2O were most commonly used, with detail on timing, flow, and frequency of prescription infrequently reported. Various outcomes were re-intubation rate, wet sputum weight, and pulmonary mechanics. Only 3 studies reported the occurrence of adverse events. From qualitative data, the main barrier to MI-E use in this subject group was lack of knowledge and skills. We concluded that there is little consistency in how MI-E is used and reported, and therefore, recommendations about best practices are not possible.
Collapse
Affiliation(s)
- Ema L Swingwood
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, United Kingdom; and Adult Therapy Services, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, United Kingdom.
| | - Willemke Stilma
- Faculty of Health, Urban Vitality, Centre of Expertise, Amsterdam University of Applied Sciences, Amsterdam, the Netherlands; and Department of Intensive Care Medicine, Amsterdam University Medical Centers, location AMC, Amsterdam, the Netherlands
| | - Lyvonne N Tume
- School of Health and Society, University of Salford, Manchester, United Kingdom; and Alder Hey Children's NHS Foundation Trust, Liverpool, United Kingdom
| | - Fiona Cramp
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, United Kingdom
| | - Sarah Voss
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, United Kingdom
| | - Jeremy Bewley
- Department of Intensive Care, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, United Kingdom
| | | | - Marcus J Schultz
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location AMC, Amsterdam, the Netherlands; Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam University Medical Centers, location AMC, Amsterdam, the Netherlands; Mahidol Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand; and Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Wilma Scholte Op Reimer
- Department of Cardiolo-gy, Amsterdam University Medical Centers, AMC, location AMC, Amsterdam, the Netherlands
| | - Frederique Paulus
- Faculty of Health, Urban Vitality, Centre of Expertise, Amsterdam University of Applied Sciences, Amsterdam, the Netherlands; and Department of Intensive Care Medicine, Amsterdam University Medical Centers, location AMC, Amsterdam, the Netherlands
| | - Louise Rose
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, United Kingdom; and Department of Critical Care and Lane Fox Respiratory Unit, Guy's and St Thomas' Foundation NHS Hospital Trust, London, United Kingdom
| |
Collapse
|
4
|
Arias-Rivera S, Jam-Gatell R, Nuvials-Casals X, Vázquez-Calatayud M. [Update of the recommendations of the Pneumonia Zero project]. ENFERMERIA INTENSIVA 2022; 33:S17-S30. [PMID: 35911624 PMCID: PMC9326456 DOI: 10.1016/j.enfi.2022.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
La pandemia por el SARS-Cov-2 ha impactado negativamente en la aplicación de las recomendaciones de Neumonía Zero y se ha acompañado de un incremento de las tasas de Neumonía asociada a ventilación mecánica (NAVM) en las unidades de cuidados intensivos de España. Con el objetivo de disminuir las tasas actuales a 7 episodios por 1000 días de VM, se han actualizado las recomendaciones del proyecto inicial. Se identificaron, 27 medidas que se clasificaron en 12 medidas funcionales (posición semisentada, higiene estricta de manos, entrenamiento para manipular la vía aérea, valoración diaria de posible extubación, protocolización del destete, traqueostomía precoz, ventilación no invasiva, vigilancia microbiológica, cambio de tubuladuras, humidificación, fisioterapia respiratoria, nutrición enteral postpilórica), 7 mecánicas (control de la presión del neumotaponamiento, tubos con aspiración subglótica, nutrición con sondas de bajo calibre/en intestino delgado, aspiración de secreciones con circuitos cerrados/abiertos, filtros respiratorios, cepillado de dientes, técnicas de presión negativa en la aspiración de secreciones) y 8 farmacológicas (descontaminación selectiva digestiva, descontaminación orofaríngea, ciclo corto de antibióticos, higiene de boca con clorhexidina, antibióticos inhalados, rotación de antibióticos, probióticos, anticuerpos monoclonales). Cada medida se analizó de forma independiente, por al menos dos miembros del grupo de trabajo, mediante una revisión sistemática de la literatura y una revisión iterativa de las recomendaciones de las sociedades científicas y/o grupos de expertos. Para la clasificación de la calidad de la evidencia y fuerza de las recomendaciones se siguió la propuesta del grupo GRADE. Para determinar el grado de recomendación, cada medida fue puntuada por todos los miembros del grupo de trabajo en relación con su efectividad, tolerabilidad y aplicabilidad en las UCI españolas a corto plazo de tiempo. Se solicitó el apoyo de expertos externos en alguna de las medidas que se revisaron. Se seleccionaron aquellas medidas que alcanzaron la máxima puntuación.
Collapse
Affiliation(s)
- S Arias-Rivera
- Investigación de enfermería. Hospital Universitario de Getafe, Getafe. CIBER Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, España
| | - R Jam-Gatell
- Área de críticos. Hospital Universitari Parc Taulí, Sabadell, Barcelona, España
| | - X Nuvials-Casals
- Área de Desarrollo Profesional e investigación de Enfermería, Clínica Universidad de Navarra. Universidad de Navarra. IdisNA, Instituto de Investigación Sanitaria de Navarra, Navarra, España
| | | | | |
Collapse
|
5
|
Funo K, Negishi Y, Akamine C, Takeuchi R, Uzawa Y. Setting Mechanical Insufflation-Exsufflation (MI-E) Pressures for Amyotrophic Lateral Sclerosis (ALS) Patients to Improve Atelectasis and Reduce Risk of Pneumothorax: A Case Report. Cureus 2022; 14:e25786. [PMID: 35812619 PMCID: PMC9270190 DOI: 10.7759/cureus.25786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/08/2022] [Indexed: 12/04/2022] Open
Abstract
Mechanical insufflation-exsufflation (MI-E) has been used to supplement the ability to cough and expel pulmonary secretions in patients with neuromuscular disease who have a reduced ability to cough. The manufacturer's guidelines for MI-E recommend a setting of inspiratory pressure of +40 cmH2O and expiratory pressure of -40 cmH2O. However, patients with small stature and restricted ventilatory impairment are prone to pneumothorax, so the manufacturer's recommendations are not used as is, and should be adjusted for the physical and pulmonary characteristics of each patient. Here, we report a case in which MI-E was used for an amyotrophic lateral sclerosis (ALS) patient with short height, low BMI, and restricted lung capacity at inspiratory and expiratory pressures lower than the manufacturer's recommendations. In adjusting MI-E pressure, physical observations such as chest auscultation, visual chest dilation, and observation of secretion movement toward the tracheal tube were performed to avoid unnecessary pressure. As a result, the pressure level set was lower than the manufacturer's recommendation (25 cmH2O) but sufficient to improve atelectasis and no pneumothorax occurred. The method we practiced in this study is feasible in any clinical setting. We also believe that MI-E, when performed in conjunction with treatment response observation, can be expected to improve at lower pressures than generally recommended, thereby reducing the risk of lung injury and providing safer treatment.
Collapse
|
6
|
Kumar M, Kataria S, Rajni E, Thandi P, Kulhari G. Role of aminoglycosides in management of ventilator-associated pneumonia caused by Klebsiella pneumoniae: A report from a tertiary care hospital in Jaipur. ARCHIVES OF MEDICINE AND HEALTH SCIENCES 2022. [DOI: 10.4103/amhs.amhs_202_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
|