Management of the Artificial AirwayDiscussion

Branson, Richard D.; Gomaa, Dina; Rodriquez, Dario

doi:10.4187/respcare.03246

Cited by 21 publications

(29 citation statements)

References 127 publications

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“…There is no evidence in the literature that airway secretions – even when considered as “excessive” – are an indication for on-call bronchoscopy [13, 38]. The preferred techniques to manage airway secretions in mechanically ventilated patients are chest physiotherapy, postural drainage, high-frequency chest-wall devices, humidification, and repeated suctioning [39]. Olopade and Prakash [40] demonstrated that 81% of bronchoscopies due to retained secretions did not result in clinical improvement.…”

Section: Discussion/conclusionmentioning

confidence: 99%

A Before-and-After Study of Evidence-Based Recommendations for On-Call Bronchoscopy

et al. 2021

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Background: Bronchoscopy is widely used and regarded as standard of care in most intensive care units (ICUs). Data concerning recommendations for on-call bronchoscopy are lacking. Objectives: Evaluation of recommendations, complications, and outcome of on-call bronchoscopies. Method: A retrospective single-centre analysis was conducted in a large university hospital. All on-call bronchoscopies performed outside normal working hours in the year before (period 1) and after (period 2) establishing a catalogue of recommendations for indications of on-call bronchoscopy on November 1, 2016, were included. Results: Overall, 924 bronchoscopies in 538 patients were analysed. A relative reduction of 83.6% from 794 bronchoscopies in 432 patients (1.84 per patient) during period 1 to 130 in 107 patients (1.21 per patient) during period 2 was observed. Most bronchoscopies (812/924, 87.9%) were performed in ICUs, and 416 patients (77.3%) were intubated. Bronchoscopies for excessive secretions decreased significantly during period 2. Fifty-three of 130 bronchoscopies (40.8%) fulfilled the specified recommendations during period 2, in comparison with 16.8% in period 1 (p < 0.001). Complications were recorded in 58 of 924 procedures (6.3%) and were more frequent in period 2, especially moderate bleeding. In-hospital mortality of patients undergoing on-call bronchoscopy did not differ between periods and was 28.7 and 30.2% in periods 1 and 2, respectively. Conclusion: The introduction of recommendations for on-call bronchoscopy led to a significant decline of on-call bronchoscopies without negatively affecting outcome. More evidence is needed in on-call bronchoscopy, especially for ICU patients with intrinsic higher complication rates.

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Section: Discussion/conclusionmentioning

confidence: 99%

A Before-and-After Study of Evidence-Based Recommendations for On-Call Bronchoscopy

et al. 2021

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“…The Mechanical ventilation delivered through a tracheal tube (ETT) to critically ill patients, requires appropriate heating, moistening and filtering of the airway in order to counteract bypassing of the upper respiratory tract due to the use of an ETT [ 37 ]. Any moisture deficit must be offset by the large airways of the tracheobronchial tree, which are poorly suited for this task, the gas with low RH rapidly absorbs moisture from the tracheobronchial mucosa and secretions in the airway, this can result in dry secretions, plugging with mucus, and obstruction of the airways [ 38 ]. The heating and humidifying of inspiratory gas, with different devices, can prevent complications associated with dryness of the respiratory mucosa, which can lead to the occlusion of the ETT [ 39 ].…”

Section: Humidification In Imv Which Device Can We Use?mentioning

confidence: 99%

Humidification on Ventilated Patients: Heated Humidifications or Heat and Moisture Exchangers?

Cerpa¹,

Cáceres²,

Romero-Dapueto³

et al. 2015

TORMJ

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The normal physiology of conditioning of inspired gases is altered when the patient requires an artificial airway access and an invasive mechanical ventilation (IMV). The endotracheal tube (ETT) removes the natural mechanisms of filtration, humidification and warming of inspired air. Despite the noninvasive ventilation (NIMV) in the upper airways, humidification of inspired gas may not be optimal mainly due to the high flow that is being created by the leakage compensation, among other aspects. Any moisture and heating deficit is compensated by the large airways of the tracheobronchial tree, these are poorly suited for this task, which alters mucociliary function, quality of secretions, and homeostasis gas exchange system. To avoid the occurrence of these events, external devices that provide humidification, heating and filtration have been developed, with different degrees of evidence that support their use.

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“…1,2 These include ventilator-induced lung injury and ventilator-associated pneumonia. 3 Mechanically ventilated patients may receive endotracheal suctioning, which aims to maintain a patent airway and remove accumulated secretions. 4 However, endotracheal suctioning can also contribute to hypoxia, atelectasis, tissue trauma, and pain and distress for the patient.…”

Section: Introductionmentioning

confidence: 99%

Avoidance of Routine Endotracheal Suction in Subjects Ventilated for ≤ 12 h Following Elective Cardiac Surgery

et al. 2020

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BACKGROUND: Mechanical ventilation requires an endotracheal tube. Airway management includes endotracheal suctioning, a frequent procedure for patients in the ICU. Associated risks of endotracheal suctioning include hypoxia, atelectasis, and infection. There is currently no evidence about the safety of avoiding endotracheal suction. We aimed to assess the safety of avoiding endotracheal suction, including at extubation, in cardiac surgical patients who were mechanically ventilated for^12 h. METHODS: We conducted a single-center, noninferiority, randomized controlled trial in a cardiac ICU in a metropolitan tertiary teaching hospital. Subjects were assigned to either avoidance of endotracheal suction or to usual care including endotracheal suctioning during mechanical ventilation. In total, we screened 468 patients and randomized 249 subjects (usual care, n 5 125; intervention, n 5 124). Subjects were elective cardiac surgical patients anticipated to receive^12 h of mechanical ventilation. The primary outcome was the P aO 2 /F IO 2 on room air 6 h after extubation, with a noninferiority margin of 10% (lower bound of one-sided 95% CI to be < 30). RESULTS: There were no differences in group characteristics at baseline. The primary analysis was a per-protocol analysis performed on 154 subjects. The median P aO 2 /F IO 2 was 323 for the intervention group and 311 for the standard care group (median difference 5 12, one-sided 95% CI-14.3). The results were consistent when using an intention-to-treat analysis and a 97.5% CI. There were no differences between groups in complications or safety measures, including the escalation of oxygen therapy. CONCLUSIONS: Endotracheal suctioning can be safely minimized or avoided in low-risk patients who have had cardiac surgery and are expected to be ventilated for < 12 h after surgery.

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Management of the Artificial AirwayDiscussion

Cited by 21 publications

References 127 publications

A Before-and-After Study of Evidence-Based Recommendations for On-Call Bronchoscopy

A Before-and-After Study of Evidence-Based Recommendations for On-Call Bronchoscopy

Humidification on Ventilated Patients: Heated Humidifications or Heat and Moisture Exchangers?

Avoidance of Routine Endotracheal Suction in Subjects Ventilated for ≤ 12 h Following Elective Cardiac Surgery

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