Airway Clearance With an Optimized Mechanical Insufflation-Exsufflation Maneuver

Volpe, Márcia Souza; Naves, Juliane Moreira; Ribeiro, Gabriel G.; Ruas, Gualberto; Amato, Marcelo Britto Passos

doi:10.4187/respcare.05965

Cited by 33 publications

(36 citation statements)

References 31 publications

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“…A recent study found that mucus transport could be further enhanced by applying a slow insufflation, which created a greater expiratory flow bias. 10 Despite this evidence base, some centers reported an increase in CPF with low pressures, [11][12][13][14] whereas others have reported efficacy with high pressures. [15][16][17][18][19][20] Hov and coworkers 21 surveyed centers in Europe and found that younger children were set up with lower MI-E pressures than older children and that there was wide variation in settings prescribed.…”

Section: See the Related Editorial On Page 265mentioning

confidence: 99%

“…This is also likely to contribute to an expiratory air-flow bias because our exsufflation pressures were greater than our insufflation pressure. However, with new evidence emerging from both a bench study, 10 and flexible transnasal fiber-optic laryngoscopy during MI-E, 29,30 it is clear that more attention needs to be paid to insufflation flow and insufflation pressures. A key implication for clinicians is that some bulbar ALS patients are unlikely to benefit from high pressures and flows and may not tolerate MI-E if they have spasticity of the upper airway.…”

Section: Significance Of Findingsmentioning

confidence: 99%

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Long-Term Mechanical Insufflation-Exsufflation Cough Assistance in Neuromuscular Disease: Patterns of Use and Lessons for Application

Chatwin

Simonds

2019

Respir Care

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BACKGROUND: Mechanical insufflation-exsufflation (MI-E) devices increase expiratory air flow and thereby promote increased cough peak flow (CPF) in conjunction with a cough. There is little research looking at long-term use of MI-E in subjects with neuromuscular disease (NMD), and no long-term study has reported CPF, MI-E device settings, and adherence. METHODS: We evaluated 181 patient records (130 adults, 51 children) of individuals who received a MI-E device from our center between February 2014 and February 2018. Median age (interquartile range [IQR]) was 27 (14-51) y. Duchenne muscular dystrophy (DMD), spinal muscular atrophy (SMA), and amyotrophic lateral sclerosis (ALS) were the 3 most common diagnoses. RESULTS: MI-E devices were provided to the weakest subjects with a CPF < 160 L/min. Median (IQR) settings were insufflation, 25 (23-30) cm H 2 O, exsufflation ؊35 (؊30 to ؊40) cm H 2 O, insufflation time 1.5 (1.3-1.7) s, exsufflation time 1.8 (1.5-2.0) s, and pause 1.5 (1.3-2.0) s. The inspiratory flow profile was set to high in all subjects, and no subject used supplemental oxygen with the MI-E device. When comparing insufflation pressures to exsufflation pressures, a greater negative pressure was used relative to positive pressure (P < .001). When comparing insufflation to exsufflation time, there was a significantly longer exsufflation duration (P < .001). Median (IQR) CPF at the start of MI-E was 60 (10-100) L/min. There was no correlation between either insufflation or exsufflation pressures and CPF. Median (IQR) usage for the group was 60% (13.5-100%) of days for the total days. Subjects with tracheostomies or SMA type I had the greatest adherence to treatment. Median (IQR) duration of MI-E use was 17 (8.5-32) months. Ninety-six percent of subjects were receiving ventilatory support. CONCLUSIONS: Greater exsufflation pressures than insufflation pressures, together with a shorter insufflation time than exsufflation time, were used. Predicting good adherence among the subjects was difficult. Subjects who produced daily secretions were more likely to use MI-E every day.

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Section: See the Related Editorial On Page 265mentioning

confidence: 99%

Section: Significance Of Findingsmentioning

confidence: 99%

Long-Term Mechanical Insufflation-Exsufflation Cough Assistance in Neuromuscular Disease: Patterns of Use and Lessons for Application

Chatwin

Simonds

2019

Respir Care

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“…However, adjusting high inspiratory flow might not be indicated in mechanically ventilated patients because it might reduce the expiratory flow bias and, consequently, the efficacy of clearing secretion. This likelihood was demonstrated by Volpe et al 74 in a bench study with a lung model simulating a patient on mechanical ventilation. The authors reported that the MI-E maneuver was optimized by applying slow lung insufflation, which reduced the PIF and, consequently, increased the expiratory flow bias (Fig.…”

Section: Mechanical Insufflation-exsufflationmentioning

confidence: 72%

“…Moreover, the authors noted that the expiratory flow bias (PEF -PIF difference) and MI-E pressure gradient were significantly correlated with mucus displacement, whereas the PEF was not. 74 These results indicate that, to optimize airway Time (s) A B Fig. 4.…”

Section: Mechanical Insufflation-exsufflationmentioning

confidence: 85%

Airway Clearance Techniques for Mechanically Ventilated Patients: Insights for Optimization

2020

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Secretion management in mechanically ventilated patients is a paramount task for clinicians. A better understanding of the mechanisms of flow bias and airway dynamic compression during airway clearance therapy may enable a more effective approach for this population. Ventilator hyperinflation, expiratory rib cage compression, a PEEP-ZEEP maneuver, and mechanical insufflation-exsufflation are examples of techniques that can be optimized according to such mechanisms. In addition, novel technologies, such as electric impedance tomography, may help improve airway clearance therapy by monitoring the consequences of regional secretion displacement on lung aeration and regional lung mechanics.

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“…There are some practical limitations in the study by Volpe et al 5 The reproducibility to achieve the low insufflation flow manually has not been evaluated. It could be speculated as being low in the daily practice according to the way that the authors changed the insufflation flow with the model CM-3200 (Philips Respironics, Murrysville, Pennsylvania).…”

Section: Mechanical Insufflation-exsufflation: Room For Improvementmentioning

confidence: 99%

Mechanical Insufflation-Exsufflation: Room for Improvement

et al. 2018

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Airway Clearance With an Optimized Mechanical Insufflation-Exsufflation Maneuver

Abstract: The optimized MI-E maneuver, applied with slow insufflation, resulted in a higher expiratory flow bias, which made the therapy more effective at moving mucus outward, compared with the standard MI-E maneuver, typically applied with fast insufflation.

Cited by 33 publications

References 31 publications

Long-Term Mechanical Insufflation-Exsufflation Cough Assistance in Neuromuscular Disease: Patterns of Use and Lessons for Application

Long-Term Mechanical Insufflation-Exsufflation Cough Assistance in Neuromuscular Disease: Patterns of Use and Lessons for Application

Airway Clearance Techniques for Mechanically Ventilated Patients: Insights for Optimization

Mechanical Insufflation-Exsufflation: Room for Improvement

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