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Terapias no farmacológicas de aclaramiento de la vía aérea y soporte respiratorio muscular en
el paciente ventilado: Estado del arteel paciente ventilado: Estado del arteJoão Carlos Winck, MD, PhD
Coordinator of the Respiratory Medicine Unit
Respiratory Rehabilitation Consultant
Affiliated Professor
Agenda
• Introduction• Mechanical Techniques for secretion
clearance– PEP, OPEP– IPV– IPV– HFCWO– MI-E
• Conclusions
Secretions and morbidity in Respiratory failure
• Secretion encumbrance is the main cause of Respiratory failure in NMD-Tzeng A, Chest 2000
• Cough strenght and secretions amount predict extubation outcome- Khamiees M, Chest 2001
• Excessive bronchial secretions are a cause of failure of • Excessive bronchial secretions are a cause of failure of NIV during acute exacerbations of COPD-Plant P, Thorax 2001
Cough dysfunction and secretion encumbrance in PMV
Med Intensiva. 2012;36(8):531-539
23% of patients have thick secretions
Intensive Care Med (2004) 30:1334–1339
41% of the Cough PEF ≤60 L/min
PCF and Survival in ALS
How to measure CPF
A PCF> 160L/min at the mouth or >60L/min through ET tube suggest readiness to
decannulation and extubationWinck JC, Rev Port Pneumol 2015: 94-98
PCF: high risk levels
7
< 160L/min Decannulationfailure
<270L/min Ineffective cough during respiratory infection
«Secretions paradigms» that need to change!
• Bronchoscopy is the method of choice for atelectasis resolution (in the ICU)
• (Mini)Tracheostomy is indicated in NMD patients with ineffective cough
• Endotracheal suctioning is the method of choice for secretion management
Components of Airway Clearance
The mucociliary escalator
Cough mechanics
Conditions the benefit from secretion clearance
• Conditions where mucociliary clerance is disrupted but cough is intact- CF, COPD
• Conditions where muco-ciliary clearance is OK but cough is ineffective-NMD
Secretion clearance therapy
• Hydration of secretions• Mucolysis (dornase alpha)• Reducing inflammatory cells (AB)• Maximizing airway caliber (BD)• Manual airway clearance techniques• Manual airway clearance techniques• Mechanical airway clearance techniques
Chest physical therapy techniques
• Positioning• Breathing control techniques
– Active cycle of breathing technique (ACBT)(ACBT)
– Autogenic drainage– Forced exhalation technique
• Manual chest percussion• Manuel chest vibration
Other non-mechanical techniques for mucus mobilization
• Manual assisted coughing techniques
• Glossopharyngeal breathing
PEP and Oscillatory PEP
PEP and OPEP do not have proven superiority to othe rairway-clearance strategies, but may be more conven ient for the
patient and less time-consuming
Myers TR, Respir Care 2007
Mechanical techniques for mucus mobilization
• IPV• HFCWO• MI-E
High-Frequency Oscillation of the Airway and Chest Wall
• Intermittent Percussive Ventilation The Percussionator (1.7-5Hz) Breas IMP2 (1-6Hz)Breas IMP2 (1-6Hz)
• High-Frequency External Chest Wall Compression
The Vest (2-25Hz, 5-20cmH20)The Hayek Oscillator (1-17Hz, -70+70cmH20)
Mechanisms of IPV
Breas IMP2
IPV devices
IMP2, Breas (Hospital version)
Impulsator, Percussionaire Pegaso, Dima
Different applications of IPV
Studies using IPV (1994-2010)
Critical Care 2006; R382
In intubated and MV children, a RCT, showed that atelectasis scores after treatment were unchanged in the CPT group but improved significantly in the IPV group Treatment lasted an average of 6.2 days in the CPT group and 2.1 days in the IPV group
Patients recovered normal SpO2 and 3 in 4 improved atelectasis score
92
92,5
93
93,5
94
94,5
95
95,5
Baseline Day 5
SpO2
atelectasis score
p=0.002
Hypersecretive patients
Mean weight of secretions was significantly higher after IPV
IPV (10-15min twice daily) for 7 months in 9 IPV (10-15min twice daily) for 7 months in 9
NMD children (vs 9 controls) with a mean FVC 35%
reduced days of antibiotic use and
hospitalization for respiratory illness
Reardon CC et al Arch Pediatr Adolesc Med 2005: 526
This technique is effective in mobilizing mucus but does not assist mobilizing mucus but does not assist
in removing it!
Before IPV After IPV
Addition of IPV to the usual CPT in tracheostomized patientsimproves gas exchange and expiratory muscle performance improves gas exchange and expiratory muscle performance and reduces the incidence of pneumonia.
Addition of IPV to the usual CPT in tracheostomized patientsimproves gas exchange and expiratory muscle performance improves gas exchange and expiratory muscle performance and reduces the incidence of pneumonia.
High-Frequency Oscillation of the Airway and Chest Wall
• Intermittent Percussive Ventilation The Percussionator (1.7-5Hz) Breas IMP2 (1-6Hz)Breas IMP2 (1-6Hz)
• High-Frequency External Chest Wall Compression
The Vest (2-25Hz, 5-20cmH20)The Hayek Oscillator (1-17Hz, -70+70cmH20)
Hansen LG et al, Biomed Instrum Technol 1990: 289
HFCWO (10-15min twice daily) for 3 months in 22 ALS patients (vs 24 controls) with a mean FVC 66+-14% improved breathlessness and increased cough at night
Lange DJ et al Neurology 2006: 991
After extubation, patients on HFCWO had greater numberof sputum suctions and higher CRx improvement
The mechanism of mucus clearance during MI-E
In-exsufflator models
COMFORT COUGH (KOREA)
COFFLATOR (USA 1953)
IN-EXSUFFLATOR
COUGH ASSIST 2001 E70 2012NIPPY CLEARWAY (UK)
PEGASO (ITALY)IN-EXSUFFLATOR
USA 1993
Settings during MI-E
Pressures < 30 to – 30 cmH20 do not achieve minimall y clinically effective PCF (2,7 L/s); Increasing insufflation time from 2 to 3 sec improves I-E volumes
Gómez-Merino, Am J Phys Med Rehabil 2002
Settings during MI-E
Insp Time
Exp Time
Each application:
6 cycles of +-40cmH20, 3sec insufflation, 4 sec exs ufflation, 2 sec pause
Winck JC, Chest 2004
Exp Time
Pause
Pressure
Efficacy of MI-E in Neuromuscular Patients
Study Year Subjects Improvement of PCF
Bach 1993 21 (non ALS) 313%
Sivasothy 2001 12 (7 ALS) 39%
Chatwin 2003 22 39%
Mustfa 2003 47 ALS 26-28%
Sancho 2004 26 ALS (15 bulbar)
-19%
Winck 2004 20 (13 ALS) 17-22%
Use of MI-E in Neuromuscular Patients
Chatwin M, ERJ 2003
MI-E (Mean:+40-24cmH20) increased significantly PCF in nonbulbar (n=26) as
well as bulbar patients (n=21)
DOENÇA= ALS100
98
96
13
8
500
400
300
Physiologic Effects of MI-E
ALS GroupSpO2SpO2 PCFPCF
**
1313N =
94
92
90
88
SPO2BAS
SPO2POS
13
1313N =
300
200
100
0
PCEFB
PCEFPOS
**PIFMF significantly increased with pressures at 40 to -40
cmH20
P < 0.005P < 0.005 P < 0.005P < 0.005
Baseline MIBaseline MI--E40E40Baseline MIBaseline MI--E40E40
Winck, Chest 2004
MI-E (Mean:+40-24cmH20) increased significantly PCF in nonbulbar (n=26) as
well as bulbar patients (n=21)
Use of MI-E in ALS Patients
• In stable patients with PCF MIC ≤ 160 L/s or PCF MIC>240 MI-E is not warranted
• MI-E in patients with severe bulbar dysfunction-cau se of UA collapse?
Sancho, Chest 2004
How to use MI-E in Bulbar ALS
Andersen T, Thorax 2016
New featuresCoughAssist E70
• During therapy:• updated at each cycle during therapy• latest measurement displayed at rest
Monitoring – Peak cough flow and tidal volume
E70
�Use monitoring to help monitor lack of efficiency in therapy
Low PCF could mean:
� exhale flow blocked (patient tongue)
� lack of synchronization (holding breath during exsuflation)
Mechanism of action
Oscillation feature
Pressure (cmH2O)
•Oscillations assist in releasing mucus from the bronchial
walls, increasing mobilization improving bronchial drainage
E70
Exhale Pressure set
Inhale pressure setamplitude
____1____frequency
Time (s)
Respir Care 2016;61(8): 1051—1058
CPF generated by mechanical in-exsufflation,
Respir Care 2016;61(8): 1051—1058
CPF generated by mechanical in-exsufflation, independent of the severity of bulbar
dysfunction, does not change despite the addition of high-frequency oscillations.
Improve synchronisation: Cough -Trak™
It will only trigger upon inhale ,initiating an inspiration for the setinhale time, automatically switch toexhale for the set exhale time, and
E70
exhale for the set exhale time, andthen wait for the next patientinitiated inhale
What for:
Cough-Trak will help synchronize the therapy with the patient thus improving the comfort and making it easier for the caregiver to administer
Longterm effects of MI-E in survival
Improves outcomes in Duchenne Muscular Distrophy
Gomez-Merino, Am J Phys Med Rehabil 2002
Ten patients (9 ALS) used MI-E daily. Eleven patients Ten patients (9 ALS) used MI-E daily. Eleven patients used MI-E intermittently, during exacerbations, and in 8
patients early application of MI-E (guided by oximetry feed-back) avoided hospitalization
TIV users required MI-E twice as many days per month as NIV
users. On-demand MI-E compared with standard continuous users. On-demand MI-E compared with standard continuous
saves €108,758.
Home Cough augmentationtechniques: Carer strain Index
Effects of mechanical insufflation-exsufflation in preventing
respiratory failure after extubation.
A randomized controlled trial.
M Gonçalves et al. Crit Care 2012
Daily Post – extubation MI-E application (pressures- IN: 40cmH2O; Ex: -40cmH2O)through a oronasal mask in a patient with NIV indication
Use of MI-E in patients with artificial airway
Sancho J, Am J Phys Med Rehabil 2003
MI-E in tracheostomized patients
Preference for suctioning or MI-E in SCI
Garstang S, J Spinal Cord Med 2000
MI-E in tracheostomized patients
• Higher expiratory pressures are needed with narrower tubes (with 6
• In patients with endotracheal tube or tracheostomy inflation pressure may be higher than 40-40
Guerin C et al Repir Care 2011 Aug;56(8):1108-14
(with 6 tracheostomy tube, pressure of 60cmh20 may be needed). Cuffs should be inflated to prevent leaks
higher than 40-40 cmH20 to overcome the resistance of the tube or cannula.
WHAT ABOUT COMBININGTECHNIQUES?
What about combining techniques?
Pre-tx Post-tx
Stable C6 tetraplegia ASIA A
Conclusions
• IPV can be useful for tracheostomized, or intubated patients (improves secretion clearance and atelectasis) but can be dangerous in SB patients (if cough is not assisted).
• HFCWO-may not be beneficial alone• HFCWO-may not be beneficial alone• MI-E-is beneficial for atelectasis or secretion
clearance in NMD (both in tracheostomized and SB patients). Caution in ALS Bulbar patients. Longterm results seem promising
• Adding MI-E to NIV in the post-extubation phase may increase success rates and ICU LOS
