Bedside Detection of Retained Tracheobronchial Secretions in Patients Receiving Mechanical Ventilation

Guglielminotti, Jean; Alzieu, Marc; Maury, Éric; Guidet, Bertrand

doi:10.1378/chest.118.4.1095

Cited by 60 publications

(57 citation statements)

References 10 publications

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“…These contradictory results highlight the need for standardization of ventilator waveform analysis through education, particularly because the sawtooth pattern is currently considered one of the 2 best objective markers indicating the presence of retained airway secretions in patients who are mechanically ventilated. [28][29][30][31] We also found that the level of training of the research and ICU clinician did not influence the consistency of percentage agreement for all assessment techniques. This is in accordance with a study by Brooks and Thomas 23 in which inter-rater agreement varied depending on the breath sound heard but was not affected by level of clinical experience.…”

Section: Discussionmentioning

confidence: 54%

“…27 As with lung sounds, ventilator waveforms also have specific signature patterns that represent certain lung disorders, such as obstructive lung disease and retained airway secretions. 27 Studies by Jubran and Tobin 28 and Guglielminotti et al 29 found that a sawtooth pattern on a flow-volume loop had a high likelihood ratio of retained secretions in ventilator-dependent subjects. They also found excellent inter-rater agreement when assessing for the sawtooth pattern.…”

Section: What This Paper Contributes To Our Knowledgementioning

confidence: 99%

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Inter-Rater Agreement of Auscultation, Palpable Fremitus, and Ventilator Waveform Sawtooth Patterns Between Clinicians

2016

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BACKGROUND: Clinicians often use numerous bedside assessments for secretion retention in participants who are receiving invasive mechanical ventilation. This study aimed to evaluate interrater agreement between clinicians when using standard clinical assessments of secretion retention and whether differences in clinician experience influenced inter-rater agreement. METHODS: Seventy-one mechanically ventilated participants were assessed by a research clinician and by one of 13 ICU clinicians. Each clinician conducted a standardized assessment of lung auscultation, palpation for chest-wall (rhonchal) fremitus, and ventilator inspiratory/expiratory flow-time waveforms for the sawtooth pattern. RESULTS: On the presence of breath sounds, agreement ranged from absolute to moderate in the upper zones and the lower zones, respectively. Kappa values for abnormal and adventitious lung sounds achieved moderate agreement in the upper zones, less than chance agreement to substantial agreement in the middle zones, and moderate agreement to almost perfect agreement in the lower zones. Moderate to almost perfect agreement was established for palpable fremitus in the upper zones, moderate to substantial agreement in the middle zones, and less than chance to moderate agreement in the lower zones. Inter-rater agreement on the presence of expiratory sawtooth pattern identification showed moderate agreement. The level of percentage agreement between the research and ICU clinicians for each respiratory assessment studied did not relate directly to level of clinical experience. CONCLUSIONS: Inter-rater agreement for all assessments showed variability between lung regions but maintained reasonable percentage agreement in mechanically ventilated participants. The level of percentage agreement achieved between clinicians did not directly relate to clinical experience for all respiratory assessments. Therefore, these respiratory assessments should not necessarily be viewed in isolation but interpreted within the context of a full clinical assessment.

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Section: Discussionmentioning

confidence: 54%

Section: What This Paper Contributes To Our Knowledgementioning

confidence: 99%

Inter-Rater Agreement of Auscultation, Palpable Fremitus, and Ventilator Waveform Sawtooth Patterns Between Clinicians

2016

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“…Most studies concerning airway suctioning have been dedicated to its mechanics and complications. [15][16][17][18][19] While the question of when to suction remains unanswered, [20][21][22] some authors 8,9 have suggested that analysis of ventilator curves might predict the presence of retained secretions, whereas Branson, in a review on secretion management, highlighted the need for more reliable detection methods. 20 In a recent editorial, Marini referred to acoustic monitoring of airway sounds to improve the timing of suctioning and to avoid unnecessary suctioning and the related risks.…”

Section: Discussionmentioning

confidence: 99%

“…Even though it is routinely performed several times a day, clear indications for suctioning are lacking, and the available indications are based on deterioration of the patient's condition due to secretion retention. 7,8 TBA Care seems to provide reliable indication of the need for suctioning. Its continuous airway monitoring allows suctioning prior to clinical deterioration caused by secretion retention, reduces unnecessary suctionings, and reduces the number of suctioning passes.…”

Section: Discussionmentioning

confidence: 99%

“…[7][8][9] To the best of our knowledge, this is the first prospective randomized trial to compare different indications for endotracheal suctioning. We compared the efficacy of TBA Care in detecting the presence of secretions in the airways to standard indications, and we tested the hypothesis that different suctioning indications could impact the incidence of VAP 2,10-12 and extubation rate.…”

Section: Introductionmentioning

confidence: 99%

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Tracheal Secretion Management in the Mechanically Ventilated Patient: Comparison of Standard Assessment and an Acoustic Secretion Detector

et al. 2011

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BACKGROUND: Standard indications for endotracheal suctioning are often based on clinical judgment on the deterioration of the patient's condition, and/or routine suctioning. TBA Care is a secretion detector that analyses airway sounds and indicates the need for suctioning. OBJECTIVE: To determine the efficacy of TBA Care in detecting retained secretions, compared to standard indications. METHODS: We conducted a prospective randomized trial with 72 general intensive care unit patients randomized at intubation into 2 groups, differing only in suctioning indications. The control group indications were at least 3 scheduled suctionings per day or were clinically driven. The secretion-detector group indications were device signal or clinically driven. At each suctioning session we recorded the indication for suctioning and the amount of secretions removed. Patients were followed until intensive care unit discharge or extubation. Diagnosis of ventilatorassociated pneumonia was confirmed via microbiological analysis of suctioned secretions. RE-SULTS: We analyzed 1,705 suctionings in the control group and 1,354 in the secretion-detector group. The secretion-detector group had fewer suctionings per day (3.9 ؎ 2.3 vs 4.8 ؎ 1.2, P ‫؍‬ .002) and a lower rate of unnecessary suctionings (4% vs 12%, P < .001). In the secretion-detector group, 97% of the suctionings were performed following the signal from the TBA Care device. In the control group, clinical deterioration (65%) was the most frequent indication for suctioning. The incidence of ventilator-associated pneumonia was similar in the groups. CONCLUSIONS: TBA Care seems to give valid and timely indications for suctioning, anticipating clinical deterioration due to secretion retention and reducing unnecessary suctionings. (ClinicalTrials.gov registration NCT00932776.)

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Managing Secretions in the Ventilated Patient: The Role of Humidification, Suction, Physiotherapy, Mucolytics and Airway Adjuncts

Ntoumenopoulos

2009

Respiratory Disease and Its Management

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Bedside Detection of Retained Tracheobronchial Secretions in Patients Receiving Mechanical Ventilation

Cited by 60 publications

References 10 publications

Inter-Rater Agreement of Auscultation, Palpable Fremitus, and Ventilator Waveform Sawtooth Patterns Between Clinicians

Inter-Rater Agreement of Auscultation, Palpable Fremitus, and Ventilator Waveform Sawtooth Patterns Between Clinicians

Tracheal Secretion Management in the Mechanically Ventilated Patient: Comparison of Standard Assessment and an Acoustic Secretion Detector

Managing Secretions in the Ventilated Patient: The Role of Humidification, Suction, Physiotherapy, Mucolytics and Airway Adjuncts

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