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August 2016 CONFIDENTIAL1
Clearing The Air On Airway Clearance
Jeff Marshall MBA, RRT, CPFTPhilips RespironicsMay 6, 2017
August 2016 CONFIDENTIAL2
Objectives
Describe the difference between secretion mobilization and clearance
Describe different types of airway clearance
Describe the clinical advantages of mechanical insufflation-exsufflation
August 2016 CONFIDENTIAL3
1. mobilization
2. removal
Airway
clearance
Airway clearance
Secretion clearance
Mucociliary clearance
(mobilization)
Cough clearance
(removal)
5
Techniques design to loosen and mobilize secretions from the lower airway to the upper airway
Techniques that remove secretions from the lungs
Airway clearance
High-frequency chest-wall compression
Oscillation devices
Positive expiratory pressure
CoughAssist MI-EBreathing techniques
SuctioningManual assisted cough
Chest physiotherapy
5
Secretion clearance
Mucociliary clearance
(mobilization)
Cough clearance
(removal)
August 2016 CONFIDENTIAL6
Mobilization
August 2016 CONFIDENTIAL7
Clearance
• Manual assisted cough
• Suction
• CoughAssist mechanical in-exsufflation
August 2016 CONFIDENTIAL8
Manual assisted cough
• Performed by the respiratory
therapist
• Various positions and
techniques
Manual assisted cough technique can be combined with
the use of CoughAssist
August 2016 CONFIDENTIAL9
Suction
• Standard of care• Low cost• Effective
August 2016 CONFIDENTIAL10
Suctioning
• Invasive procedure
• Misses left main stem bronchus 90% of the time
• Tracheal trauma, suctioning induced hypoxemia, hypertension, cardiac arrhythmias and raised intracranial pressure have all been associated with suctioning
• Patients have reported that suctioning can be a painful and anxiety provoking procedure
Reference: Thompson, L. Suctioning Adults with an Artificial Airway. The Joanna Briggs Institute for Evidence Based Nursing and Midwifery; 2000. Systematic Review No. 9.
August 2016 CONFIDENTIAL11
painful
invasive
uncomfortable
August 2016 CONFIDENTIAL12
hypoxia
infection
tissue trauma
bronchospasm
pulmonary atelectasis
pulmonary bleeding
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a better way?
August 2016 CONFIDENTIAL14
• Noninvasive
• Comfortable
• Effective
Mechanical Insufflator-exsufflator (M I-E)
August 2016 CONFIDENTIAL15
CoughAssist vs. suctioning
• More effective in clearing secretions and better tolerated than endotracheal suctioning1
• Clears airways for longer periods of time than tracheal suctioning1
• 89% of patients preferred CA vs. Suction2
• 29% more mucus1
• 72% patients found it more effective2
1. Sancho J, Servera E, Vergara P, Marin J. Mechanical insufflation exsufflation vs tracheal suctioning via tracheostomy tubes for patients with amyotrophic lateral sclerosis. Am J Phys Med Rehabil 2003;82(10)750-753.
2. Garstang SV et al: Patient preference for in-exsufflation for secretion management with spinal cord injury. J Spinal Cord Med 2000; 23: 80-5.
August 2016 CONFIDENTIAL16
M I-E
• Mechanical insufflator-exsufflator assists patients in clearing retained secretions by applying a positive pressure to the airway, then rapidly shifting to a negative pressure
• This rapid shift in pressure produces a high expiratory flow rate from the lungs
• Proven as effective as a natural cough
August 2016 CONFIDENTIAL17
Introduction to M I-E
• The treatment can be delivered via facemask, mouthpiece, or endotracheal or tracheostomy tube
• It is effective for both invasive and non-invasively ventilated patients
• Cleared for adult and pediatric populations
August 2016 CONFIDENTIAL18
Bullous emphysema
Contraindications
Pneumothorax or pneumo-mediastinum
Acute Lung Injury / Acute Respiratory Distress Syndrome (ARDS)
Acute pulmonary edema
Recent barotrauma
Patients need to be cooperative (unless they have an artificial airway)
August 2016 CONFIDENTIAL19
Non invasive alternative to deep suctioningCan be given via facemask, mouthpiece, endotracheal or tracheostomy tube
What does M I-E do?
Simulates a cough By applying a positive pressure (deep insufflation) to the airway followed by a rapid shift to a negative pressure to produce expiratory flow from the lungs and effectively remove secretions
Assists patients with clearing of retained secretions
Allows Data managementPeak Cough Flow, Tidal Volume, SpO2 on screen and trend review for long titration and long term follow-up
Taking your airway clearance experience to the next level
August 2016 CONFIDENTIAL20
Indications for use of M I-E
• Neuromuscular disorders– ALS– Muscular Dystrophy– SMA– Multiple Sclerosis
• Spinal cord injury
• Tracheostomy
• Low peak cough flows
August 2016 CONFIDENTIAL21
When should M I-E be instituted
Any patient unable to cough or clear secretions effectively due to reduced peak cough expiratory flow
PCF < 160 LPM (Bach JR et Al, Chest 1996)PCF < 240 – 270 LPM (ATS Consensus statement 2004 / Bach JR et Al, Chest 2003)
270 LPM
160 LPM
Flow l/min
Time
Peak flow meter
August 2016 CONFIDENTIAL22
Initiating M I-E
• For new patients – Begin with lower pressures– ±10-15 cmH2O – Low inhale flow
• As they become comfortable– Progressively increase pressures 5-10
cmH2O each cough sequence (4-6 breaths)
Common prescription pressures are generally around ± 35-40 cmH2O*
August 2016 CONFIDENTIAL23
M I-E Procedure
• 1 cough cycle is composed of an inspiratory, expiratory and pause phase
• 4-6 cough cycles composes a sequence• Rest patient 20-30 seconds between
sequences– Make sure you allow enough time for
secretion removal• A treatment is 4-6 cough sequences– Generally performed several times
per day
August 2016 CONFIDENTIAL24
Inhale + Exhale + Pause = Cycle
M I-E treatment
Repeat cycle 4-6 times
Rest 20-30 seconds
Repeat sequence 4-6 times
August 2016 CONFIDENTIAL25
Clinically proven• Increase peak cough expiratory flows more
than fourfold1
• Reduce recurrent respiratory infections in patients with respiratory weakness from neuromuscular disease2,3
• Patients report that it feels “easier to breathe” after the use of CoughAssist3
• Improvement in perceived quality of life due to fewer acute illness-related episodes4
• Patients prefer MI-E to suctioning for comfort and effectiveness and find it less tiring4
1. McCool DF, Rosen MJ. Nonpharmocologic airway clearance therapies: AACP evidence-based clinical practice guidelines. Chest. 2006; 129:250-259. 2. Winck JC, et al. Effects of mechanical insufflation-exsufflation on respiratory parameters for patients with chronic airway secretion encumbrance. Chest. 2004;126:774-7803. Miske LJ. et al. Use of the mechanical in-exsufflator in pediatric patients with neuromuscular disease and impaired cough. Chest. 2004;125:1406-1412.4. Liszner K, et al. CoughAssist Strategy for Pulmonary Toileting in Ventilator-Dependent Spinal Cord Injured Patients. Rehabilitation Nursing 2006;31:218-221.
August 2016 CONFIDENTIAL26
Consideration for critical care
In the critical care environment,
- Any patients that behave like restrictive patients from a muscular strength perspective
- Any intubated patients
Specific attention should be brought to the Neuromuscular Diseases Patients, such as:
– Muscular dystrophy (Duchenne)– Myasthenia gravis– Poliomyelitis– Amyotrophic Lateral Sclerosis (ALS)– Spinal Muscular Atrophy (SMA)
August 2016 CONFIDENTIAL27
Impaired airway clearance in the ICU
27
• Endotracheal intubation prevents the patient from closing the glottis1
• Direct suction clears a small portion of the airway, is ineffective for clearing secretions in the peripheral airways2
• Patient dependent upon mucociliary clearance rather than cough clearance
1. Smina M, Salam A, Khamiees M, Gada P, Amoateng-Adjepong Y, Manthous CA: Cough peak flows and extubation outcomes. Chest 2003, 124:262-268.2. Nakagawa NK, Franchini ML, Driusso P, de Oliveira LR, Saldiva PH, Lorenzi-Filho G: Mucociliary clearance is impaired in acutely ill patients. Chest 2005, 128:2772-2777.
August 2016 CONFIDENTIAL28
Extubation and airway clearance
28
• If the lungs are healthy and ventilation can be fully maintained noninvasively, then the only remaining concern is the effective expulsion of airway secretions.1
• Despite the importance of this factor, no ventilator weaning parameter addresses the ability to cough.2
1. Ferrer M, Bernadich O, Nava S, Torres A: Noninvasive ventilation after intubation and mechanical ventilation. Eur Respir J 2002, 19:959-965.2. Salam A, Tilluckdharry L, Amoateng-Adjepong Y, Manthous CA: Neurologic status, cough, secretions and extubation outcomes. Intensive Care Med 2004, 30:1334-1339.
August 2016 CONFIDENTIAL29
Effects of mechanical insufflation-exsufflation in preventing respiratory failure after extubation: a randomized controlled trialMiguel Gonclaves, Teresa Honrado, Jao Carlos Winck, Jose Artur Paiva
Objective: Assess the efficacy of MI‐E in preventing re‐intubation for patients in whom acute respiratory failure develops after extubation.
August 2016 CONFIDENTIAL30
Patients meeting criteria SBT
Control Group
Conventional extubation protocol
Study Group MI‐E extubation protocol
O2, antibiotics, NIV bronchodilators
Plus CoughAssist
Gonclaves M. et al. Effects of mechanical insufflation-exsufflation in preventing respiratory failure after extubation: a randomized controlled trial
August 2016 CONFIDENTIAL31
Outcome data
Group A (n=40) Group B (n=35) MIE
NIV application, n (%) 20 (50%) 14 (40%)
Patients reintubated (n, %) 19 (48%) 6 (17%)
Causes of reintubation (n)
Respiratory pauses with loss of consciousness 0 1
Respiratory distress after 2-h NIV 6 2
Decreasing level of consciousness 2 0
Intolerance to NIV 2 0
Hypotension (systolic BP < 90 mm Hg for > 30 min. 0 1
Secretion encumbrance associated/severe hypoxemia 9 2
NIV failure rate, n (%) 13 (65%) 2 (14%)
Total ICU length of stay 19.3 + 8.1 16.9 + 11.1
Post extubation ICU length of stay 9.8 + 6.7 3.1 + 2.5
August 2016 CONFIDENTIAL32
M I-E combined with NIV
Reduce re-intubation rates
Reduce post-extubation ICU stay
Goncalves MR. Effects of mechanical insufflation-exsufflation in preventing respiratory failure after extubation. Critical Care 2010.
August 2016 CONFIDENTIAL33
Key points for treating NMD patients
1. Aggressive airway clearance is a key point to manage ARF in NMD
2. Patients with slowly progressive NMD should be extubated directly to NIV combined with assisted coughing1
3. Mechanical insufflation-exsufflation significantly reduces treatment failure in patients with neuromuscular disease, compared conventionally managed with chest physiotherapy alone2
33
1. Sancho J, Servera E. Non-invasive ventilation for patients with neuromuscular disease and acute respiratory failure. Chest. 2008;133(1):314–5.
2. Garuti G, Lusuardi M, Bach JR. Management of cough ineffectiveness in neuromuscular disorders. Shortness of breath. 2013;2(1):28–34.
August 2016 CONFIDENTIAL34
Challenge the status quo
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Bring this technology to your organization
• Improve outcomes
• Reduce ICU days
• Reduce length of stay
• Lower cost of care
• Increase Patient satisfaction
August 2016 CONFIDENTIAL36
Questions
Questions