The Use of Mechanical Insufflation-Exsufflation in Invasively Ventilated Critically Ill Adults

Abstract

Mechanical insufflation-exsufflation (MI-E) is traditionally used in the neuromuscular population. There is growing interest of MI-E use in invasively ventilated critically ill adults. We aimed to map current evidence on MI-E use in invasively ventilated critically ill adults. Two authors independently searched electronic databases MEDLINE, Embase, and CINAHL via the Ovid platform; PROSPERO; Cochrane Library; ISI Web of Science; and International Clinical Trials Registry Platform between January 1990-April 2021. Inclusion criteria were (1) adult critically ill invasively ventilated subjects, (2) use of MI-E, (3) study design with original data, and (4) published from 1990 onward. Data were extracted by 2 authors independently using a bespoke extraction form. We used Mixed Methods Appraisal Tool to appraise risk of bias. Theoretical Domains Framework was used to interpret qualitative data. Of 3,090 citations identified, 28 citations were taken forward for data extraction. Main indications for MI-E use during invasive ventilation were presence of secretions and mucus plugging (13/28, 46%). Perceived contraindications related to use of high levels of positive pressure (18/28, 68%). Protocolized MI-E settings with a pressure of 640 cm H 2 O were most commonly used, with detail on timing, flow, and frequency of prescription infrequently reported. Various outcomes were re-intubation rate, wet sputum weight, and pulmonary mechanics. Only 3 studies reported the occurrence of adverse events. From qualitative data, the main barrier to MI-E use in this subject group was lack of knowledge and skills. We concluded that there is little consistency in how MI-E is used and reported, and therefore, recommendations about best practices are not possible.

Mechanical Insufflation-Exsufflation: Considerations for Improving Clinical Practice

“…These contraindications and precautions are listed in the instructions for use of the Clearway 2 [ 15 ] (Breas Medical, Mölnlycke, Sweden) and E70 [ 16 ] (Philips Respironics, Murrysville, PA, USA) and by Swingwood and coworkers [ 17 ].…”

“…Interestingly, they reported that clinicians were more likely to use MI-E in the patient without an artificial airway [ 47 ]. Swingwood and colleagues [ 17 ] also reviewed all the papers where MI-E was used in the ICU. From these papers, perceived lack of skills and knowledge and resources were also identified as a barrier; however, they also identified enabling features to utilizing MI-E, in that if they had a positive clinical response to MI-E, then they would be more likely to use it.…”

“…Initial settings should be reviewed and adapted for continual effectiveness and patients may need higher settings when unwell due to an increase in their respiratory muscle weakness [7]. These contraindications and precautions are listed in the instructions for use of the Clearway 2 [15] (Breas Medical, Mölnlycke, Sweden) and E70 [16] (Philips Respironics, Murrysville, PA, USA) and by Swingwood and coworkers [17].…”

Mechanical insufflation‐exsufflation for invasively ventilated critically ill patients—A focus group study

“…[22][23][24] The interview guide was also informed by previous work and clinical experience of the research group. 12,14,15,21,25 The interview guide (See Table S1) included questions about actual knowledge, skills, environmental context, (inter)professional role and beliefs regarding MI-E in invasively ventilated patients and was reviewed by health care professionals external to the research team prior to use.…”

“…8,9 It is conventionally used as a non-invasive device with rapid alternation between positivepressure to optimize tidal volume (VT) and lung recruitment followed by negative pressure that augments gas flows, improves sputum mobilization, and ultimately stimulates a cough. 10 Until now, MI-E is used extensively to promote cough and prevent secretion retention in non-critically ill patients, like patients with neuromuscular disease or spinal cord injury, that do or do not receive ventilatory support. 8 Recent intensive care unit (ICU) practice surveys suggest increased use of MI-E as an additional intervention in airway clearance during mechanical ventilation of critically ill patients.…”