Effects of mechanical insufflation-exsufflation in preventing respiratory failure after extubation: a randomized controlled trial

Miguel R Gonçalves, Teresa Honrado, João Carlos Winck, José Artur Paiva, Miguel R Gonçalves, Teresa Honrado, João Carlos Winck, José Artur Paiva

Abstract

Introduction: Weaning protocols that include noninvasive ventilation (NIV) decrease re-intubation rates and ICU length of stay. However, impaired airway clearance is associated with NIV failure. Mechanical insufflation-exsufflation (MI-E) has been proven to be very effective in patients receiving NIV. We aimed to assess the efficacy of MI-E as part of an extubation protocol.

Method: Patients with mechanical ventilation (MV) for more than 48 hours with specific inclusion criteria, who successfully tolerated a spontaneous breathing trial (SBT), were randomly allocated before extubation, either for (A) a conventional extubation protocol (control group), or (B) the MI-E extubation protocol (study group). During the postextubation period (48 hours), group A patients received standard medical treatment (SMT), including NIV in case of specific indications, whereas group B received the same postextubation approach plus three daily sessions of mechanical in-exsufflation (MI-E). Reintubation rates, ICU length of stay, and NIV failure rates were analyzed.

Results: Seventy-five patients (26 women) with a mean age of 61.8 ± 17.3 years were randomized to a control group (n = 40; mean SAPS II, 47.8 ± 17.7) and to a study group (n = 35; mean SAPS II, 45.0 ± 15.0). MV time before enrollment was 9.4 ± 4.8 and 10.5 ± 4.1 days for the control and the study group, respectively. In the 48 hours after extubation, 20 control patients (50%) and 14 study patients (40%) used NIV. Study group patients had a significant lower reintubation rate than did controls; six patients (17%) versus 19 patients (48%), P < 0.05; respectively, and a significantly lower time under MV; 17.8 ± 6.4 versus 11.7 ± 3.5 days; P < 0.05; respectively. Considering only the subgroup of patients that used NIV, the reintubation rates related to NIV failure were significantly lower in the study group when compared with controls; two patients (6%) versus 13 (33%); P < 0.05, respectively. Mean ICU length of stay after extubation was significantly lower in the study group when compared with controls (3.1 ± 2.5 versus 9.8 ± 6.7 days; P < 0.05). No differences were found in the total ICU length of stay.

Conclusion: Inclusion of MI-E may reduce reintubation rates with consequent reduction in postextubation ICU length of stay. This technique seems to be efficient in improving the efficacy of NIV in this patient population.

References

    1. Boles JM, Bion J, Connors A, Herridge M, Marsh B, Melot C, Pearl R, Silverman H, Stanchina M, Vieillard-Baron A, Welte T. Weaning from mechanical ventilation. Eur Respir J. 2007;16:1033–1056. doi: 10.1183/09031936.00010206.
    1. MacIntyre NR, Cook DJ, Ely EW Jr, Epstein SK, Fink JB, Heffner JE, Hess D, Hubmayer RD, Scheinhorn DJ. Evidence-based guidelines for weaning and discontinuing ventilatory support: a collective task force facilitated by the American College of Chest Physicians; the American Association for Respiratory Care; and the American College of Critical Care Medicine. Chest. 2001;16:375S–395S. doi: 10.1378/chest.120.6_suppl.375S.
    1. Smina M, Salam A, Khamiees M, Gada P, Amoateng-Adjepong Y, Manthous CA. Cough peak flows and extubation outcomes. Chest. 2003;16:262–268. doi: 10.1378/chest.124.1.262.
    1. Nakagawa NK, Franchini ML, Driusso P, de Oliveira LR, Saldiva PH, Lorenzi-Filho G. Mucociliary clearance is impaired in acutely ill patients. Chest. 2005;16:2772–2777. doi: 10.1378/chest.128.4.2772.
    1. Templeton M, Palazzo MG. Chest physiotherapy prolongs duration of ventilation in the critically ill ventilated for more than 48 hours. Intensive Care Med. 2007;16:1938–1945. doi: 10.1007/s00134-007-0762-4.
    1. Rello J, Paiva JA, Baraibar J, Barcenilla F, Bodi M, Castander D, Correa H, Diaz E, Garnacho J, Llorio M, Rios M, Rodrigues A, Sole-Violan J. nternational Conference for the Development of Consensus on the Diagnosis and Treatment of Ventilator-associated Pneumonia. Chest. 2001;16:955–970. doi: 10.1378/chest.120.3.955.
    1. Isakow W, Kollef MH. Preventing ventilator-associated pneumonia: an evidence-based approach of modifiable risk factors. Semin Respir Crit Care Med. 2006;16:5–17. doi: 10.1055/s-2006-933668.
    1. Rello J, Ollendorf DA, Oster G, Vera-Llonch M, Bellm L, Redman R, Kollef MH. Epidemiology and outcomes of ventilator-associated pneumonia in a large US database. Chest. 2002;16:2115–2121. doi: 10.1378/chest.122.6.2115.
    1. Meade M, Guyatt G, Cook D, Griffith L, Sinuff T, Kergl C, Mancebo J, Esteban A, Epstein S. Predicting success in weaning from mechanical ventilation. Chest. 2001;16:400S–424S. doi: 10.1378/chest.120.6_suppl.400S.
    1. Frutos-Vivar F, Ferguson ND, Esteban A, Epstein SK, Arabi Y, Apezteguia C, Gonzalez M, Hill NS, Nava S, D'Empaire G, Anzueto A. Risk factors for extubation failure in patients following a successful spontaneous breathing trial. Chest. 2006;16:1664–1671. doi: 10.1378/chest.130.6.1664.
    1. Capdevila X, Perrigault PF, Ramonatxo M, Roustan JP, Peray P, d'Athis F, Prefaut C. Changes in breathing pattern and respiratory muscle performance parameters during difficult weaning. Crit Care Med. 1998;16:79–87. doi: 10.1097/00003246-199801000-00020.
    1. Ferrer M, Bernadich O, Nava S, Torres A. Noninvasive ventilation after intubation and mechanical ventilation. Eur Respir J. 2002;16:959–965. doi: 10.1183/09031936.02.00299702.
    1. Salam A, Tilluckdharry L, Amoateng-Adjepong Y, Manthous CA. Neurologic status, cough, secretions and extubation outcomes. Intensive Care Med. 2004;16:1334–1339.
    1. Girault C, Daudenthun I, Chevron V, Tamion F, Leroy J, Bonmarchand G. Noninvasive ventilation as a systematic extubation and weaning technique in acute-on-chronic respiratory failure: a prospective, randomized controlled study. Am J Respir Crit Care Med. 1999;16:86–92.
    1. Burns KE, Adhikari NK, Meade MO. Noninvasive positive pressure ventilation as a weaning strategy for intubated adults with respiratory failure. Cochrane Database Syst Rev. 2010.
    1. Nava S, Ambrosino N, Clini E, Prato M, Orlando G, Vitacca M, Brigada P, Fracchia C, Rubini F. Noninvasive mechanical ventilation in the weaning of patients with respiratory failure due to chronic obstructive pulmonary disease: a randomized, controlled trial. Ann Intern Med. 1998;16:721–728.
    1. Girou E, Schortgen F, Delclaux C, Brun-Buisson C, Blot F, Lefort Y, Lemaire F, Brochard L. Association of noninvasive ventilation with nosocomial infections and survival in critically ill patients. JAMA. 2000;16:2361–2367. doi: 10.1001/jama.284.18.2361.
    1. Ferrer M, Esquinas A, Arancibia F, Bauer TT, Gonzalez G, Carrillo A, Rodriguez-Roisin R, Torres A. Noninvasive ventilation during persistent weaning failure: a randomized controlled trial. Am J Respir Crit Care Med. 2003;16:70–76. doi: 10.1164/rccm.200209-1074OC.
    1. Keenan SP, Powers C, McCormack DG, Block G. Noninvasive positive-pressure ventilation for postextubation respiratory distress: a randomized controlled trial. JAMA. 2002;16:3238–3244. doi: 10.1001/jama.287.24.3238.
    1. Esteban A, Frutos-Vivar F, Ferguson ND, Arabi Y, Apezteguia C, Gonzalez M, Epstein SK, Hill NS, Nava S, Soares MA, D'Empaire G, Alia I, Anzueto A. Noninvasive positive-pressure ventilation for respiratory failure after extubation. N Engl J Med. 2004;16:2452–2460. doi: 10.1056/NEJMoa032736.
    1. Hilbert G, Gruson D, Portel L, Gbikpi-Benissan G, Cardinaud JP. Noninvasive pressure support ventilation in COPD patients with postextubation hypercapnic respiratory insufficiency. Eur Respir J. 1998;16:1349–1353. doi: 10.1183/09031936.98.11061349.
    1. Chaisson KM, Walsh S, Simmons Z, Vender RL. A clinical pilot study: high frequency chest wall oscillation airway clearance in patients with amyotrophic lateral sclerosis. Amyotroph Lateral Scler. 2006;16:107–111. doi: 10.1080/14660820600640570.
    1. Bellone A, Spagnolatti L, Massobrio M, Bellei E, Vinciguerra R, Barbieri A, Iori E, Bendinelli S, Nava S. Short-term effects of expiration under positive pressure in patients with acute exacerbation of chronic obstructive pulmonary disease and mild acidosis requiring non-invasive positive pressure ventilation. Intensive Care Med. 2002;16:581–585. doi: 10.1007/s00134-002-1210-0.
    1. Vargas F, Bui HN, Boyer A, Salmi LR, Gbikpi-Benissan G, Guenard H, Gruson D, Hilbert G. Intrapulmonary percussive ventilation in acute exacerbations of COPD patients with mild respiratory acidosis: a randomized controlled trial. Crit Care. 2005;16:382–389.
    1. Winck JC, Goncalves MR, Lourenco C, Viana P, Almeida J, Bach JR. Effects of mechanical insufflation-exsufflation on respiratory parameters for patients with chronic airway secretion encumbrance. Chest. 2004;16:774–780. doi: 10.1378/chest.126.3.774.
    1. Bach JR. Mechanical insufflation-exsufflation: comparison of peak expiratory flows with manually assisted and unassisted coughing techniques. Chest. 1993;16:1553–1562. doi: 10.1378/chest.104.5.1553.
    1. Chatwin M, Ross E, Hart N, Nickol AH, Polkey MI, Simonds AK. Cough augmentation with mechanical insufflation/exsufflation in patients with neuromuscular weakness. Eur Respir J. 2003;16:502–508. doi: 10.1183/09031936.03.00048102.
    1. Vianello A, Corrado A, Arcaro G, Gallan F, Ori C, Minuzzo M, Bevilacqua M. Mechanical insufflation-exsufflation improves outcomes for neuromuscular disease patients with respiratory tract infections. Am J Phys Med Rehabil. 2005;16:83–88. doi: 10.1097/01.PHM.0000151941.97266.96. discussion 89-91.
    1. Esteban A, Alia I, Tobin MJ, Gil A, Gordo F, Vallverdu I, Blanch L, Bonet A, Vazquez A, de Pablo R, Torres A, de La Cal MA, Macias S. Effect of spontaneous breathing trial duration on outcome of attempts to discontinue mechanical ventilation: Spanish Lung Failure Collaborative Group. Am J Respir Crit Care Med. 1999;16:512–518.
    1. Agarwal R, Aggarwal AN, Gupta D, Jindal SK. Role of noninvasive positive-pressure ventilation in postextubation respiratory failure: a meta-analysis. Respir Care. 2007;16:1472–1479.
    1. Nava S, Gregoretti C, Fanfulla F, Squadrone E, Grassi M, Carlucci A, Beltrame F, Navalesi P. Noninvasive ventilation to prevent respiratory failure after extubation in high-risk patients. Crit Care Med. 2005;16:2465–2470. doi: 10.1097/01.CCM.0000186416.44752.72.
    1. Ferrer M, Valencia M, Nicolas JM, Bernadich O, Badia JR, Torres A. Early noninvasive ventilation averts extubation failure in patients at risk: a randomized trial. Am J Respir Crit Care Med. 2006;16:164–170.
    1. Epstein SK, Ciubotaru RL. Independent effects of etiology of failure and time to reintubation on outcome for patients failing extubation. Am J Respir Crit Care Med. 1998;16:489–493.
    1. Khamiees M, Raju P, DeGirolamo A, Amoateng-Adjepong Y, Manthous CA. Predictors of extubation outcome in patients who have successfully completed a spontaneous breathing trial. Chest. 2001;16:1262–1270. doi: 10.1378/chest.120.4.1262.
    1. Servera E, Sancho J, Zafra MJ, Catala A, Vergara P, Marin J. Alternatives to endotracheal intubation for patients with neuromuscular diseases. Am J Phys Med Rehabil. 2005;16:851–857. doi: 10.1097/01.phm.0000184097.17189.93.
    1. Bach JR, Goncalves M. Ventilator weaning by lung expansion and decannulation. Am J Phys Med Rehabil. 2004;16:560–568. doi: 10.1097/01.PHM.0000130027.80861.B8.
    1. Bach JR, Saporito LR. Criteria for extubation and tracheostomy tube removal for patients with ventilatory failure: a different approach to weaning. Chest. 1996;16:1566–1571. doi: 10.1378/chest.110.6.1566.
    1. Bach JR. Inappropriate weaning and late onset ventilatory failure of individuals with traumatic spinal cord injury. Paraplegia. 1993;16:430–438. doi: 10.1038/sc.1993.72.
    1. Bach JR, Goncalves MR, Hamdani I, Winck JC. Extubation of patients with neuromuscular weakness: a new management paradigm. Chest. 2010;16:1033–1039. doi: 10.1378/chest.09-2144.
    1. Antonelli M, Conti G, Moro ML, Esquinas A, Gonzalez-Diaz G, Confalonieri M, Pelaia P, Principi T, Gregoretti C, Beltrame F, Pennisi MA, Arcangeli A, Proietti R, Passariello M, Meduri GU. Predictors of failure of noninvasive positive pressure ventilation in patients with acute hypoxemic respiratory failure: a multi-center study. Intensive Care Med. 2001;16:1718–1728. doi: 10.1007/s00134-001-1114-4.

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