Mechanical insufflation-exsufflation in prevention of post-extubation acute respiratory failure: most welcome but must be used cautiously in critically ill patients

Preliminary experience on the safety and tolerability of mechanical “insufflation-exsufflation” in subjects with artificial airway

“…The effect of the short 3-s + 50-cmH 2 O “recruitment maneuver” is supported by the observed increase of arterial oxygenation from 5 to 60 min after MIE. Thus, in our short series of critically ill intubated patients, disconnection did not result in loss of positive pressure, alveolar collapse, and desaturation [ 19 , 20 ]. Conversely, conventional suctioning implies disconnection and drop of airway pressure, as well as interruption of ventilation and oxygenation.…”

“…On the other hand, however, the short “recruitment” maneuver during the positive pressure phase may increase the risk of respiratory and hemodynamic complications [ 6 , 13 – 15 ]. The few published experiences reporting on its use in intensive care do not report complications associated with the use of MIE [ 10 , 16 – 18 ], although concerns about the safety of the technique in critically ill patients have been voiced [ 19 , 20 ]. The technique has been introduced in clinical practice in our department to support respiratory tract secretion suctioning in subjects needing frequent suctioning, to facilitate weaning and/or to reduce the risk of reintubation.…”

Glucose Concentration Affects Fibrin Clot Structure and Morphology as Evidenced by Fluorescence Imaging and Molecular Simulations

“…Therefore, d f measurements from confocal microscopy studies where a dye percentage is applied may better explain fibrin fiber density and clotting rate rather than changes in mass. Examining the relationship between thrombin concentration and d f with constant fibrinogen concentration, Hawkins et al (2012) 68 found that clots imaged using confocal microscopy were qualitatively different in clot architecture, d f increased with increasing thrombin concentration (ie, reaction rate) and were densest at the highest thrombin concentration. 69 Compared to our findings, this trend suggests increased glucose concentration actually slows clotting time as (1) the lowest d f was measured for the 10.0 mmol/L glucose condition, (2) the 10.0 mmol/L condition produced the densest formed fibers (highest porosity reading), and (3) limited change in d f and fibrinogen glycation was observed between the 0.0 mmol/L (1.754; 0.0308 mol glucose /mol fibrinogen ) and 6.0 mmol/L (1.736; 0.743 mol glucose /mol fibrinogen ) glucose conditions.…”