airway secretion clearance in the icu

Airway Secretion Clearance in the

ICU

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Olu Albert, MPH, RRT

Clinical Manager

Home Respiratory Care- Asia Pacific

International Group

Home Healthcare Solutions

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A review of Airway Clearance Techniques

Mechanical Insufflation Exsufflation Timeline

Case Study: Post-Op Myothonic Dysthrophy

Cough Assist E-70

Literature review of Cough Assist Use in the ICU

Take Home Message

Agenda

Airway Clearance Techniques: What’s New?

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Airway Clearance Techniques

Manual Assisted Cough

Performed by the

physiotherapist

Various positions and

techniques

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Substitutes: Suction

Cons

• 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

Thompson, L. Suctioning Adults with an Artificial Airway. The Joanna Briggs Institute for Evidence

Based Nursing and Midwifery; 2000. Systematic Review No. 9.

Pros

• Costs

• Training

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http://www.youtube.com/watch?v=VqLwGXgm8_M&feature=related



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Cufflator

1950’s

Cough Assist

1993

E-70

2012

Cough Assist Time-Line

Case Study

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Case Study

Clinical findings

VC – 0.69 L

PCF – 175 LPM

PaO2 – 57.3 mm Hg

SpO2 – 88%

RR – 45 bpm

Goncalves, MR. Commentary: Exploring the potential of mechanical insufflation-exsufflation. Breathe 2008; 4:326-329.

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18-year-old male with myotonic dystrophy in

respiratory failure following a surgical procedure to

repair a pectus excavatum

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2nd Day Post-op Pectus Excavatum Repair


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After 8 sessions of MI-E via Face Mask

X-ray 24h

Goncalves, MR. Commentary: Exploring the potential of mechanical insufflation-exsufflation. Breathe 2008; 4:326-329.16

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Case Study: Day 3

Clinical Findings

SpO2 – 97% (FiO2 21%)

RR – 18

PCF – 350 L/m

FVC – 1.71

Patient avoided Intubation and Bronchoscopy


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Treatment Protocol

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Therapy Plan: Cough cycle = Inhale + Exhale + Pause

1Sequence = 4 to 6 cough cycles given in rapid succession

Resting time = Patient rests for 20 – 30 seconds

During rest, clear secretions that are visible in the mouth,

throat or tracheostomy tube

Therapy = Repeat above sequence 4 – 6 times or until

secretion expelled

Typical CoughAssist

Treatment

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Typical Treatment

Example of settings:

Pressures (positive and negative)

Start low, 10 to 15 cm H2O while oscillations set at patient comfort

Get patient familiar with the device

Increase pressures as tolerated, 35 to 45 cm H2O ideally*

The goal of expiratory pressure is to replace a good expiratory cough flow

Possibility to use abdominal and chest compression during expiration (ie. Set

with automatic mode or use foot pedal in Manual mode)

Higher pressures are often required when compliance decreases or resistance

increases (small tracheal tubes, obesity, scoliosis)

* Studies have shown that therapeutic PCF may not be reached with MI-E expiratory pressures less

than -40 cm H2O

Winck JC, et al. Effects of mechanical insufflation-exsufflation on respiratory parameters for patients

with chronic airway secretion encumbrance. Chest. 2004;126:774-780.17

Typical Treatment

Hints:

Therapy can be adjusted to the need of each

individual patient:

Use presets for different needs of therapy

Best before meals and at bedtime

Frequency of sessions according to case history

Necessary adaptation for invasive use

Possible higher pressure needed

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Clinical Evidence: ICU & Cough

Assist

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Methods

• Retrospective Chart Review from Jan 2009 through 2013

• Inclusion: Restrictive Lung Disease willing to be extubated to CNVS

• Extubation Criteria: Reversal Acute Illness with normal physiological

parameters

• Insufflation and Exsufflation Pressures of 60-70 cmH2O

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Results

98 successive patients were extubated CNVS

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Conclusion:

Many unweanable restrictive patients can be extubated to MIE and

CNVS

Conclusion

• Noninvasive Respiratory Management using NIV and MIE has been

shown to reduce hospitalizations and tracheostomy for patients with

NMDs and SCI who have functioning bulbar musculature and can be

used to extubate and deccanulate patients

Results

• There is good tolerance and physiologic

improvements in both restrictive and pulmonary

disease

• There was improvements in PCF and SpO2 for

both NMD and COPD patients at pressures of

40cmH2O to -40cmH2O

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Take Home Message

The new Cough Assist (E-70) can be used noninvasively to mobilize

and remove airway secretion

Insufflation Techniques using the MIE can be an effective lung

recruitment strategies

Current evidence in the medical literature suggests that MIE is safe in

cases obstructive and restrictive diseases

Clinical Data suggests that MIE is safe to use and there is no

correlation between MIE use and Pneumothorax

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airway secretion clearance in the icu

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