Preliminary experience on the safety and tolerability of mechanical "insufflation-exsufflation" in subjects with artificial airway

Abstract

Background: Catheter suctioning of respiratory secretions in intubated subjects is limited to the proximal airway and associated with traumatic lesions to the mucosa and poor tolerance. "Mechanical insufflation-exsufflation" exerts positive pressure, followed by an abrupt drop to negative pressure. Potential advantages of this technique are aspiration of distal airway secretions, avoiding trauma, and improving tolerance.

Methods: We applied insufflation of 50 cmH2O for 3 s and exsufflation of - 45 cmH2O for 4 s in patients with an endotracheal tube or tracheostomy cannula requiring secretion suctioning. Cycles of 10 to 12 insufflations-exsufflations were performed and repeated if secretions were aspirated and visible in the proximal artificial airway. Clinical and laboratory parameters were collected before and 5 and 60 min after the procedure. Subjects were followed during their ICU stay until discharge or death.

Results: Mechanical insufflation-exsufflation was applied 26 times to 7 male and 6 female subjects requiring suctioning. Mean age was 62.6 ± 20 years and mean Apache II score 23.3 ± 7.4 points. At each session, a median of 2 (IQR 1; 2) cycles on median day of intubation 11.5 (IQR 6.25; 25.75) were performed. Mean insufflation tidal volume was 1043.6 ± 649.9 ml. No statistically significant differences were identified between baseline and post-procedure time points. Barotrauma, desaturation, atelectasis, hemoptysis, or other airway complication and hemodynamic complications were not detected. All, except one, of the mechanical insufflation-exsufflation sessions were productive, showing secretions in the proximal artificial airway, and were well tolerated.

Conclusions: Our preliminary data suggest that mechanical insufflation-exsufflation may be safe and effective in patients with artificial airway. Safety and efficacy need to be confirmed in larger studies with different patient populations.

Trial registration: EudraCT 2017-005201-13 (EU Clinical Trials Register).

Keywords: Airway clearance; Artificial airway; Endotracheal aspiration; Endotracheal intubation; Mechanical insufflation-exsufflation; Respiratory tract secretions; Safety; Secretion suctioning.

Conflict of interest statement

Ethics approval and consent to participate

The study was evaluated and approved by the institutional Ethics Review Board (Comité de Ética e Investigación Clínica. Ref 17/395-E_P) for publication, with a waiver for informed consent.

Consent for publication

The Ethics Review Board approved the study protocol and the publication of the collected anonymized patient data.

Competing interests

The authors declare that they have no competing interests.

Quick look

Current knowledge

Current practice of respiratory secretion suctioning in subjects with endotracheal tubes or tracheostomy cannulas consists of insertion of a sterile catheter. This maneuver is frequently associated with pain and agitation and traumatic injury to the tracheobronchial mucosa and occasionally causes more severe, life-threatening complications. It is also relatively inefficient, because it only aspirates proximal airway secretions.

What this paper contributes to our knowledge

This paper provides the first set of data about the safety of an alternative technique, called mechanical insufflation-exsufflation (MIE), with the potential of being well tolerated and more effective. The device applies positive pressure followed by an abrupt fall to negative pressure, thereby imitating cough and generating outward flow. We did not detect any adverse event in the present small study, in which we attempted airway secretion clearance with MIE. MIE was well tolerated and produced respiratory secretions in all except one of the suctioning attempts.

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Figures

Fig. 1

Schematic of the setup of the mechanical insufflation-exsufflation procedure