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

Abstract

BackgroundCatheter suctioning of respiratory secretions in intubated subjects is limited to the proximal airway and associated with traumatic lesions to the mucosa and poor tolerance. “Mechanical insufflation-exsufflation” exerts positive pressure, followed by an abrupt drop to negative pressure. Potential advantages of this technique are aspiration of distal airway secretions, avoiding trauma, and improving tolerance.MethodsWe applied insufflation of 50 cmH2O for 3 s and exsufflation of − 45 cmH2O for 4 s in patients with an endotracheal tube or tracheostomy cannula requiring secretion suctioning. Cycles of 10 to 12 insufflations-exsufflations were performed and repeated if secretions were aspirated and visible in the proximal artificial airway. Clinical and laboratory parameters were collected before and 5 and 60 min after the procedure. Subjects were followed during their ICU stay until discharge or death.ResultsMechanical insufflation-exsufflation was applied 26 times to 7 male and 6 female subjects requiring suctioning. Mean age was 62.6 ± 20 years and mean Apache II score 23.3 ± 7.4 points. At each session, a median of 2 (IQR 1; 2) cycles on median day of intubation 11.5 (IQR 6.25; 25.75) were performed. Mean insufflation tidal volume was 1043.6 ± 649.9 ml. No statistically significant differences were identified between baseline and post-procedure time points. Barotrauma, desaturation, atelectasis, hemoptysis, or other airway complication and hemodynamic complications were not detected. All, except one, of the mechanical insufflation-exsufflation sessions were productive, showing secretions in the proximal artificial airway, and were well tolerated.ConclusionsOur preliminary data suggest that mechanical insufflation-exsufflation may be safe and effective in patients with artificial airway. Safety and efficacy need to be confirmed in larger studies with different patient populations.Trial registrationEudraCT 2017-005201-13 (EU Clinical Trials Register).

Effects Of Mechanical In-Exsufflation On Mucus Clearance In Critically Ill Patients On Invasive Mechanical Ventilation

“…In this randomized cross-over trial, when inspiratory/expiratory pressures of 50 cmH 2 O were applied, lung compliance improved immediately after the intervention, and 10 minutes thereafter. Despite these encouraging previous results, other publications have consistently failed to nd bene ts (15,16,18). In our study, compliance of the respiratory system increased immediately after CPT + MI-E intervention.…”

“…Nunes et al observed an improvement in SpO 2 after either endotracheal suctioning or MI-E (18), while other publications failed to corroborate these results (15,16). Sanchez-Garcia et al demonstrated an improvement in PaO 2 following MI-E (15).…”

“…Theoretically, the high PEF and NEP work alongside to drive mucus outward. To date, only a few studies have evaluated the e cacy and safety of MI-E in ventilated critically ill patients, reporting promising gures on the removal of airway secretions (15)(16)(17)(18), and safety (16)(17)(18). Encouraging results have also been reported in spontaneously-breathing patients with neuromuscular diseases, unable to produce an e cient cough (19).…”

ERS International Congress, Madrid, 2019: highlights from the Respiratory Intensive Care Assembly

“…More recently the safety of MI-E has been examined in endotracheally intubated patients. An observational study [120] reported no adverse events during MI-E use in these patients. The study authors concluded that MI-E may be safe and effective in the intubated population, but further work is required [120].…”

Effects of Mechanical Insufflation-Exsufflation on the Breathing Pattern in Stable Subjects With Duchenne Muscular Dystrophy: “A Step Into New Knowledge”

“…Only 2 papers in the literature report pressures of 50 cm H 2 O: Sánchez-García et al, 11 who applied insufflation of 50 cm H 2 O and exsufflation of Ϫ45 cm H 2 O in subjects with an endotracheal tube or tracheostomy cannula; and Guerin et al, 10 who used this setting of MI-E in a bench study performed on a lung model with different sizes of endotracheal and tracheostomy tubes. Both studies considered the presence of endotracheal and tracheostomy tubes, which are known to offer high air-flow resistances that therefore require higher pressures.…”