Mechanical Insufflator-exsufflator to Control Mucus Hypersecretion in Patients in Palliative Care - A Feasibility Study

Mechanical Insufflator-exsufflator to Manage Respiratory Secretion in Patients in Palliative Care - A Feasibility Study

Patients with advanced chronic diseases may suffer with respiratory secretion and available therapies to control this condition are uncomfortable or little effective in palliative care patients. Therefore, alternative therapies should be tested, assessing clinically relevant outcomes in palliative care, such as comfort during therapy and the number of interventions required in a day. Mechanical Insufflation-Exsufflation is an option that presents advantages, since it can be used in patients with minimum cooperation and is non-invasive, which may lead to higher comfort during therapy.

The aim of the study is to verify the feasibility of a clinical trial comparing the effects of Mechanical Insufflation-Exsufflation with usual care in hospitalized palliative care patients that are suffering with respiratory secretion. Patients allocation will follow a "fast-track allocation design", in which included patients will be randomized in two groups:

1. Receive Mechanical Insufflation-Exsufflation therapy in the moment that is assigned to this group;
2. will receive 24h of usual care and after that will be allowed to choose between usual care or Mechanical Insufflation-Exsufflation Therapy.

The assessments will be: Time from the first intervention until the need of a following intervention, discomfort due therapy, discomfort due respiratory secretion, palliative outcome scale, number of adverse events and number of interventions during 24h period. The primary outcome is to verify the feasibility of developing a future larger clinical trial to assess the effects of the use of Mechanical Insufflation-Exsufflation to control respiratory secretions in patients in palliative care.

Study Overview

• Status: Unknown
• Conditions: Palliative Care; Mucus Hypersecretion
• Intervention / Treatment: Device: Mechanical Insufflation-Exsufflation; Other: Usual Care

Detailed Description

Investigators will conduct a feasibility study for a future fast track randomized trial, which will be carried out in the Américo Brasiliense State Hospital and conducted by the Spirometry and Respiratory Physiotherapy Laboratory from the Federal University of São Carlos, Brazil.

The concept of feasibility is defined as "capable of being done or carried out" and studies which aim is to verify the feasibility intends to verify if a larger clinical trial would have a acceptable probability of success in proving the efficacy of an intervention 24. The importance of feasibility studies has been discussed since health research resources are frequently wasted in large clinical trials with interventions with small impact, studies with insufficient power, or even using measures and outcomes that do not reflect the expected changes caused by the interventions. Furthermore, these studies are essential when dealing with populations that usually lead to an increased chance of losing the follow-up or a high number of missing data, such as palliative care.

Both groups will receive the therapy with the mechanical insufflators-exsufflator, however, the Mechanical insufflation-exsufflation group will receive it as in a fast track way, while the usual care, will receive the usual care for more 24 hours, and then they will receive one session of Mechanical Insufflation-Exsufflation. After this 24 hours period, the patients will be asked what therapy they would like to receive each time they need help to deal with hypersecretion until the end of the hospitalization, or until the physician responsible for the patient consider the hypersecretion was controlled.

The allocation through fast track has been used due to ethical reasons, in order to maintain the randomized and controlled aspects of the research, and yet provide the opportunity to all patients to be benefited of the new intervention before the end of the study. Furthermore, an increase in the acceptability and retention of the participants is expected, since they are going to receive the new therapy in some moment of the study, which may be during or after the follow-up 28. The cross-over design was not chosen, since the wash-out period necessary to this model of study might lead to a period without treatment for vulnerable patients, with expected short life time.

Usual Care The patients will receive the treatment according to the hospital protocol to deal with hypersecretive patients (suctioning that can be preceded by respiratory physiotherapy and nebulisation). A trained member of the nurse staff or a physiotherapist will be responsible for providing the therapy. A member of the research team will collect in the patients' records all the therapies provided by the staff to control hypersecretions.

Mechanical Insufflation-Exsufflation The settings used in the Mechanical Insufflator-Exsufflator will be the same of a previous study, where were used: six assisted cough cycles with pressures of 40 to -40cmH2O; the inspiratory time of 3s; the expiratory time 4s and a pause between cycles of 4s. The patients will be instructed to cough alongside the exsufflation phase, with exception of Chronic Obstructive Pulmonary Disease patients which will be instructed to exhale slowly. An oral-nasal mask will be used as interface, but in patients with tracheotomy, the device will be connected to it.

• Study Type: Interventional
• Enrollment (Anticipated): 50
• Phase: Not Applicable

Contacts and Locations

Study Locations

• Brazil
  • São Paulo
    • São Carlos, São Paulo, Brazil
      • Recruiting
      • Hospital Estadual Américo Brasiliense
      • Contact: Juliano F Arcuri, MSc; Phone Number: +55 16 33518343; Email: julianoarcuri@gmail.com

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

• Prognosis:

  • Less than one year assessed by the responsible physician, with a negative answer of the to the "surprise question" - Would you be surprised if this patient died in the following year?
  • Higher than 3 months, assessed by the same physician

• Patients with problems to deal with secretions, which could be one or both of the following problems:

  • Hypersecretion
  • Cough inefficiency (peak cough flow <250L/min)
• Karnofsky Performance Status Scale higher or equal to 30%;
• Ability to give written informed consent or presence of a person who is responsable for the patient

Exclusion Criteria:

• Patients with conditions considered as contra-indication for the use of Mechanical Insufflator-Exsufflator:

  • Bullous emphysema history
  • Known susceptibility for pneumothorax or pneumo-mediastinum
  • Known to have had any recent barotrauma.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Supportive Care
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Single

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Mechanical Insufflation-Exsufflation Group; Patients will receive usual care except suctioning or cough augmentation techniques+Mechanical Insufflation-Exsufflation	Device: Mechanical Insufflation-Exsufflation; Mechanical Insufflator-Exsufflator (MI-E): 6 assisted cough with expiratory pressure of -40cmH2O and inspiratory pressure defined by the therapist as the maximum pressure defined as comfortable; inspiratory time 3s and expiratory time 4s, using a manual cycle. Patients will be instructed to cough during exsufflation phase, with exception of Chronic obstructive pulmonary disease patients which will be instructed to exhale slowly. An oral-nasal mask will be used as interface, but in patients with tracheotomy, the device will be connected to it. A trained physiotherapist will conduct the therapy. During the night and weekends, patients will not start this therapy, however, if they have already started the therapy in MI-E group, or if they have already finished the period of follow-up they will be able to request this therapy, which will be provided by hospital staff . The equipment (Cough Assist®, Respironics, Phillips), will be available in the ward for the interventions.; Other Names: Cough Assist (Philips Respironics)
Active Comparator: Usual Care Group; Patients will receive the usual care provided by the hospital, all interventions to control respiratory secretion will be verified in patient chart	Device: Mechanical Insufflation-Exsufflation; Mechanical Insufflator-Exsufflator (MI-E): 6 assisted cough with expiratory pressure of -40cmH2O and inspiratory pressure defined by the therapist as the maximum pressure defined as comfortable; inspiratory time 3s and expiratory time 4s, using a manual cycle. Patients will be instructed to cough during exsufflation phase, with exception of Chronic obstructive pulmonary disease patients which will be instructed to exhale slowly. An oral-nasal mask will be used as interface, but in patients with tracheotomy, the device will be connected to it. A trained physiotherapist will conduct the therapy. During the night and weekends, patients will not start this therapy, however, if they have already started the therapy in MI-E group, or if they have already finished the period of follow-up they will be able to request this therapy, which will be provided by hospital staff . The equipment (Cough Assist®, Respironics, Phillips), will be available in the ward for the interventions.; Other Names: Cough Assist (Philips Respironics); Other: Usual Care; The patients will receive the treatment according to the hospital protocol to deal with hypersecretive patients (suctioning that can be preceded by respiratory physiotherapy and nebulisation). A trained member of the nurse staff or a physiotherapist will be responsible for providing the therapy. A member of the research team will collect in the patients' records all the therapies provided by the staff to control hypersecretions.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Study Feasibility assessed by verifying the recruitment rates, acceptability of the patients and hospital	The feasibility of the study will be the primary outcome, and it will be assessed by verifying the recruitment rates, acceptability of the patients and hospital, and if the assessments were suitable to the study	Through the completion of the study, up to one year

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Incidence of Treatment-Emergent Adverse Events (Safety and Tolerability)	Assessed by the number of times an event with change in physiological parameters occurred during the intervention (Heart Rate>150bpm or <50bpm; Systolic Blood Pressure>200mmHg or <80mmHg; decrease of 5% or higher in the pulse oxymetry; hemoptysis).	Assessed in the period between the start of the intervention until 30min after the end of the intervention
Effect size of Palliative Outcome Scale	This is a quality of life multidimensional scale in patients in palliative care. With this scale, we intend to see the effects of the therapy over the general perceived health of the patients.	Immediately after the inclusion and in the final assessment (24 hours after the inclusion).
Effect size of discomfort due to the hypersecretion	Assessed using a numeric scale (0-10). This assessment will be conducted in order to evaluate how much the hypersecretion bothers the patient, and if the therapy is capable of changing this perception of discomfort.	Immediately before the first intervention and ten minutes after the first intervention.
Effect size of discomfort due to the therapy	Assessed using a numeric scale (0-10), this assessment will provide information to the decision of the viability the therapy in palliative care, since uncomfortable therapies are often discouraged since usually they may not cure the cause of the problem.	Ten minutes after the first intervention
Effect size of time until the next intervention	The moment immediately after the first intervention until the time a new intervention is required. It will be verified in the patient's records. The therapies to control hypersecretions may lead to discomfort due to the stimulation of the cough and the change in the respiratory pattern, a therapy with a more lasting effect may be preferable, since it can provide a longer period without the discomfort of another intervention.	In the end of the 24 hours period.
Effect size of number of interventions during 24 hours	The number of interventions will be verified in the patient's records. Therapies that may lead to a lasting effect, can be performed less times during a day, this reflects in a longer period of comfort, and smaller health expenses.	In the end of the 24 hours period

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
Percentage of patients using pharmacological agents to control respiratory secretions	Patient's chart will be revised to verify the percentage of patients that received pharmacological interventions to control respiratory secretions, prescribed by the hospital team.	In the completion of the study, an average of one year

Collaborators and Investigators

• Sponsor: Universidade Federal de Sao Carlos
• Collaborators: Philips Respironics; Hospital Estadual Américo Brasiliense

Publications and helpful links

General Publications

• Bach JR. Mechanical insufflation-exsufflation. Comparison of peak expiratory flows with manually assisted and unassisted coughing techniques. Chest. 1993 Nov;104(5):1553-62. doi: 10.1378/chest.104.5.1553.
• Bach JR. Amyotrophic lateral sclerosis: prolongation of life by noninvasive respiratory AIDS. Chest. 2002 Jul;122(1):92-8. doi: 10.1378/chest.122.1.92.

Study record dates

Study Major Dates

• Study Start (Actual): February 1, 2016
• Primary Completion (Anticipated): July 30, 2017
• Study Completion (Anticipated): July 30, 2017

Study Registration Dates

• First Submitted: December 16, 2015
• First Submitted That Met QC Criteria: January 7, 2016
• First Posted (Estimate): January 11, 2016

Study Record Updates

• Last Update Posted (Actual): July 18, 2017
• Last Update Submitted That Met QC Criteria: July 13, 2017
• Last Verified: July 1, 2017

More Information

Terms related to this study

• Keywords: Palliative Care; Respiratory Secretion
• Other Study ID Numbers: MIE-Palliative

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: Undecided