clearing the air on airway clearance -...

August 2016 CONFIDENTIAL1

Clearing The Air On Airway Clearance

Jeff Marshall MBA, RRT, CPFTPhilips RespironicsMay 6, 2017


Objectives

Describe the difference between secretion mobilization and clearance

Describe different types of airway clearance

Describe the clinical advantages of mechanical insufflation-exsufflation


1. mobilization

2. removal

Airway

clearance

Airway clearance

Secretion clearance

Mucociliary clearance

(mobilization)

Cough clearance

(removal)

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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

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Secretion clearance

Mucociliary clearance

(mobilization)

Cough clearance

(removal)


Mobilization


Clearance

• Manual assisted cough

• Suction

• CoughAssist mechanical in-exsufflation


Manual assisted cough

• Performed by the respiratory

therapist

• Various positions and

techniques

Manual assisted cough technique can be combined with

the use of CoughAssist


Suction

• Standard of care• Low cost• Effective


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.


painful

invasive

uncomfortable


hypoxia

infection

tissue trauma

bronchospasm

pulmonary atelectasis

pulmonary bleeding


a better way?


• Noninvasive

• Comfortable

• Effective

Mechanical Insufflator-exsufflator (M I-E)


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.


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


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


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)


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


Indications for use of M I-E

• Neuromuscular disorders– ALS– Muscular Dystrophy– SMA– Multiple Sclerosis

• Spinal cord injury

• Tracheostomy

• Low peak cough flows


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


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*


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


Inhale + Exhale + Pause = Cycle

M I-E treatment

Repeat cycle 4-6 times

Rest 20-30 seconds

Repeat sequence 4-6 times


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.


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)


Impaired airway clearance in the ICU

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• 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.


Extubation and airway clearance

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• 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.


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.


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


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


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.


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

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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.


Challenge the status quo


Bring this technology to your organization

• Improve outcomes

• Reduce ICU days

• Reduce length of stay

• Lower cost of care

• Increase Patient satisfaction


Questions

Questions

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