Comparison of Mechanical Insufflation-Exsufflation and Hypertonic Saline and Hyaluronic Acid With Conventional Open Catheter Suctioning in Intubated Patients
Restricted accessResearch articleFirst published online May, 2024
Comparison of Mechanical Insufflation-Exsufflation and Hypertonic Saline and Hyaluronic Acid With Conventional Open Catheter Suctioning in Intubated Patients
Open respiratory secretion suctioning with a catheter causes pain and tracheobronchial mucosal injury in intubated patients. The goal of mechanical insufflation-exsufflation (MI-E) is to move secretions proximally and noninvasively by generating a high peak expiratory air flow. Nebulized hypertonic saline with hyaluronic acid (HS-HA) may facilitate suctioning by hydration. We assessed the safety and tolerance of a single session of airway clearance with MI-E and HS-HA in critically ill intubated patients.
METHODS:
Adults with a cuffed artificial airway were randomized to (1) open suctioning, (2) open suctioning after HS-HA, (3) MI-E, or (4) MI-E with HS-HA. Adverse events, pain and sedation/agitation scores, and respiratory and hemodynamic variables were collected before, during, and 5-min and 60-min post intervention.
RESULTS:
One-hundred twenty subjects were enrolled and completed the study. Median (interquartile range [IQR]) Acute Physiology and Chronic Health Evaluation II (APACHE II) score was 22 (16–28); median (IQR) age was 69.0 (57.0–75.7) y, and 90 (75%) were male. Baseline respiratory and hemodynamic variables were comparable. Adverse events occurred in 30 subjects (25%), with no between-group differences. Behavioral pain equivalents and Richmond Agitation-Sedation Scale were higher during suctioning in groups 1 (P < .001) and 2 (P < .001). Independent predictive variables for higher pain and agitation/sedation scores were study groups 1 and 2 and simultaneous analgosedation, respectively. Noradrenaline infusion rates were lower at 60 min in groups 2 and 4. PaO2/FIO2 had decreased at 5 min after open suctioning in group 1 and increased at 60 min in group 3.
CONCLUSIONS:
We observed no difference in adverse events. MI-E avoids pain and agitation.
American Association for Respiratory Care. AARC clinical practice guidelines. Endotracheal suctioning of mechanically ventilated patients with artificial airways 2010. Respir Care, 2010; 55(6):758-764.
2.
PuntilloKA, MorrisAB, ThompsonCL, Stanik-HuttJ, WhiteCA, WildLR. Pain behaviors observed during six common procedures: results from Thunder Project II. Crit Care Med, 2004; 32(2):421-427.
3.
RobledaG, Roche-CampoF, Membrilla-MartinezL, Fernandez-LucioA, Villamor-VazquezM, MertenA, et al. [Evaluation of pain during mobilization and endotracheal aspiration in critical patients]. Med Intensiva, 2016; 40(2):96-104.
4.
BarachAL, BeckGJ. Exsufflation with negative pressure; physiologic and clinical studies in poliomyelitis, bronchial asthma, pulmonary emphysema, and bronchiectasis. AMA Arch Intern Med, 1954; 93(6):825-841.
5.
BickermanHA. Exsufflation with negative pressure (E.W.N.P.); elimination of radiopaque material and foreign bodies from bronchi of anesthetized dogs. AMA Arch Intern Med, 1954; 93(5):698-704.
6.
Ferreira de CamillisML, SaviA, Goulart RosaR, FigueiredoM, WickertR, BorgesLGA, et al. Effects of mechanical insufflation-exsufflation on airway mucus clearance among mechanically ventilated ICU subjects. Respir Care, 2018; 63(12):1471-1477.
7.
SanchoJ, ServeraE, VergaraP, MarinJ. Mechanical insufflation-exsufflation vs tracheal suctioning via tracheostomy tubes for patients with amyotrophic lateral sclerosis: a pilot study. Am J Phys Med Rehabil, 2003; 82(10):750-753.
8.
TerziN, GuerinC, GoncalvesMR. What’s new in management and clearing of airway secretions in ICU patients? It is time to focus on cough augmentation. Intensive Care Med, 2019; 45(6):865-868.
9.
Herrero-CortinaB, AlcarazV, VilaroJ, TorresA, PolverinoE. Impact of hypertonic saline solutions on sputum expectoration and their safety profile in patients with bronchiectasis: a randomized crossover trial. J Aerosol Med Pulm Drug Deliv, 2018; 31(5):281-289.
10.
DonaldsonSH, BennettWD, ZemanKL, KnowlesMR, TarranR, BoucherRC. Mucus clearance and lung function in cystic fibrosis with hypertonic saline. N Engl J Med, 2006; 354(3):241-250.
11.
MichonAL, Jumas-BilakE, ChironR, LamyB, MarchandinH. Advances toward the elucidation of hypertonic saline effects on Pseudomonas aeruginosa from cystic fibrosis patients. PLoS One, 2014; 9(2):e90164.
12.
WohlauerM, MooreEE, SillimanCC, FragosoM, GamboniF, HarrJ, et al. Nebulized hypertonic saline attenuates acute lung injury following trauma and hemorrhagic shock via inhibition of matrix metalloproteinase-13. Crit Care Med, 2012; 40(9):2647-2653.
13.
BuonpensieroP, De GregorioF, SepeA, Di PasquaA, FerriP, SianoM, et al. Hyaluronic acid improves “pleasantness” and tolerability of nebulized hypertonic saline in a cohort of patients with cystic fibrosis. Adv Ther, 2010; 27(11):870-878.
14.
MaizL, GironRM, PratsE, ClementeMG, PolverinoE, CanoS, et al. Addition of hyaluronic acid improves tolerance to 7% hypertonic saline solution in bronchiectasis patients. Ther Adv Respir Dis, 2018; 12:1753466618787385.
15.
FurnariML, TerminiL, TraversoG, BarraleS, BonaccorsoMR, DamianiG, et al. Nebulized hypertonic saline containing hyaluronic acid improves tolerability in patients with cystic fibrosis and lung disease compared with nebulized hypertonic saline alone: a prospective, randomized, double-blind, controlled study. Ther Adv Respir Dis, 2012; 6(6):315-322.
16.
RosM, CasciaroR, LuccaF, TroianiP, SaloniniE, FavilliF, et al. Hyaluronic acid improves the tolerability of hypertonic saline in the chronic treatment of cystic fibrosis patients: a multi-center, randomized controlled clinical trial. J Aerosol Med Pulm Drug Deliv, 2014; 27(2):133-137.
17.
Sanchez-GarciaM, SantosP, Rodriguez-TrigoG, Martinez-SagastiF, Farina-GonzalezT, Del Pino-RamirezA, et al. Preliminary experience on the safety and tolerability of mechanical “insufflation-exsufflation” in subjects with artificial airway. Intensive Care Med Exp, 2018; 6(1):8.
18.
Sanchez GarciaM, AlvarezM, DomingoS, Del PinoA, MartínezF, GonzálezP, et al. Safety and tolerability of mechanical insufflation-exsufflation (MIE) and hypertonic saline with hyaluronic acid (HS-HA) for respiratory secretion suctioning (RSS) in intubated patients. Intensive Care Med Exp, 2019; 7(3):533.
19.
JakiT, VasileiouD. Factorial versus multi-arm multi-stage designs for clinical trials with multiple treatments. Stat Med, 2017; 36(4):563-580.
20.
ButcherNJ, MonsourA, MewEJ, ChanAW, MoherD, Mayo-WilsonE, et al. Guidelines for reporting outcomes in trial reports: the CONSORT-Outcomes 2022 Extension. JAMA, 2022; 328(22):2252-2264.
21.
SchulzKF, AltmanDG, MoherD. Group C. CONSORT 2010 statement: updated guidelines for reporting parallel group randomized trials. J Clin Epidemiol, 2010; 63(8):834-840.
22.
CorregerE, MuriasG, ChaconE, EstrugaA, SalesB, Lopez-AguilarJ, et al. [Interpretation of ventilator curves in patients with acute respiratory failure]. Med Intensiva, 2012; 36(4):294-306.
23.
Alvarez-LermaF, Palomar-MartinezM, Sanchez-GarciaM, Martinez-AlonsoM, Alvarez-RodriguezJ, LorenteL, et al. Prevention of ventilator-associated pneumonia: the multimodal approach of the Spanish ICU “Pneumonia Zero” Program. Crit Care Med, 2018; 46(2):181-188.
24.
GuerinC, BourdinG, LerayV, DelannoyB, BayleF, GermainM, et al. Performance of the CoughAssist insufflation-exsufflation device in the presence of an endotracheal tube or tracheostomy tube: a bench study. Respir Care, 2011; 56(8):1108-1114.
Van de LeurJP, ZwavelingJH, LoefBG, Van der SchansCP. Endotracheal suctioning versus minimally invasive airway suctioning in intubated patients: a prospective randomized controlled trial. Intensive Care Med, 2003; 29(3):426-432.
27.
van MeenenDMP, van der HoevenSM, BinnekadeJM, de BorgieC, MerkusMP, BoschFH, et al. Effect of on-demand vs routine nebulization of acetylcysteine with salbutamol on ventilator-free days in intensive care unit patients receiving invasive ventilation: a randomized clinical trial. JAMA, 2018; 319(10):993-1001.
28.
Latorre-MarcoI, Acevedo-NuevoM, Solis-MunozM, Hernandez-SanchezL, Lopez-LopezC, Sanchez-SanchezMM, et al. Psychometric validation of the behavioral indicators of pain scale for the assessment of pain in mechanically ventilated and unable to self-report critical care patients. Med Intensiva, 2016; 40(8):463-473.
29.
SesslerCN, GosnellMS, GrapMJ, BrophyGM, O’NealPV, KeaneKA, et al. The Richmond Agitation-Sedation Scale: validity and reliability in adult intensive care unit patients. Am J Respir Crit Care Med, 2002; 166(10):1338-1344.
30.
GoncalvesMR, HonradoT, WinckJC, PaivaJA. Effects of mechanical insufflation-exsufflation in preventing respiratory failure after extubation: a randomized controlled trial. Crit Care, 2012; 16(2):R48.
31.
KuroiwaR, TateishiY, OshimaT, InagakiT, FurukawaS, TakemuraR, et al. Mechanical insufflation-exsufflation for the prevention of ventilator-associated pneumonia in intensive care units: a retrospective cohort study. Indian J Crit Care Med, 2021; 25(1):62-66.
32.
WuMF, WangTY, ChenDS, HsiaoHF, HuHC, ChungFT, et al. The effects of mechanical insufflation-exsufflation on lung function and complications in cardiac surgery patients: a pilot study. J Cardiothorac Surg, 2021; 16(1):350.
33.
BachJR, MartinezD. Duchenne muscular dystrophy: continuous noninvasive ventilatory support prolongs survival. Respir Care, 2011; 56(6):744-750.
34.
ChatwinM, SimondsAK. Long-term mechanical insufflation-exsufflation cough assistance in neuromuscular disease: patterns of use and lessons for application. Respir Care, 2020; 65(2):135-143.
35.
LacombeM, Del Amo CastrilloL, BoreA, ChapeauD, HorvatE, VaugierI, et al. Comparison of three cough-augmentation techniques in neuromuscular patients: mechanical insufflation combined with manually assisted cough, insufflation-exsufflation alone, and insufflation-exsufflation combined with manually assisted cough. Respiration, 2014; 88(3):215-222.
36.
SiriwatR, DeerojanawongJ, SritippayawanS, HantragoolS, CheanprapaiP. Mechanical insufflation-exsufflation versus conventional chest physiotherapy in children with cerebral palsy. Respir Care, 2018; 63(2):187-193.
37.
CoutinhoWM, VieiraPJC, KutchakFM, DiasAS, RiederMM, ForgiariniLAJr.. Comparison of mechanical insufflation-exsufflation and endotracheal suctioning in mechanically ventilated patients: effects on respiratory mechanics, hemodynamics, and volume of secretions. Indian J Crit Care Med, 2018; 22(7):485-490.
38.
Martinez-AlejosR, MartiJD, Li BassiG, Gonzalez-AntonD, Pilar-DiazX, ReginaultT, et al. Effects of mechanical insufflation-exsufflation on sputum volume in mechanically ventilated critically ill subjects. Respir Care, 2021; 66(9):1371-1379.
39.
SuriP, BurnsSP, BachJR. Pneumothorax associated with mechanical insufflation-exsufflation and related factors. Am J Phys Med Rehabil, 2008; 87(11):951-955.
40.
McDonaldLA, BerlowitzDJ, HowardME, RautelaL, ChaoC, SheersN. Pneumothorax in neuromuscular disease associated with lung volume recruitment and mechanical insufflation-exsufflation. Respirol Case Rep, 2019; 7(6):e00447.
41.
YasokawaN, TanakaH, KuroseK, AbeM, OgaT. Mechanical insufflation-exsufflation–related bilateral pneumothorax. Respir Med Case Rep, 2020; 29:101017.
42.
GarstangSV, KirshblumSC, WoodKE. Patient preference for in-exsufflation for secretion management with spinal cord injury. J Spinal Cord Med, 2000; 23(2):80-85.
43.
PuntilloKA, MaxA, TimsitJF, VignoudL, ChanquesG, RobledaG, et al. Determinants of procedural pain intensity in the intensive care unit. The Europain(R) study. Am J Respir Crit Care Med, 2014; 189(1):39-47.
44.
MorrowB, ZampoliM, van AswegenH, ArgentA. Mechanical insufflation-exsufflation for people with neuromuscular disorders. Cochrane Database Syst Rev, 2013(12):CD010044.
45.
ChanquesG, GelinasC. Monitoring pain in the intensive care unit (ICU). Intensive Care Med, 2022; 48(10):1508-1511.
46.
ChanquesG, TarriT, RideA, PradesA, De JongA, CarrJ, et al. Analgesia nociception index for the assessment of pain in critically ill patients: a diagnostic accuracy study. Br J Anaesth, 2017; 119(4):812-820.
47.
PayenJF, BruO, BossonJL, LagrastaA, NovelE, DeschauxI, et al. Assessing pain in critically ill sedated patients by using a behavioral pain scale. Crit Care Med, 2001; 29(12):2258-2263.
48.
RahuMA, GrapMJ, FergusonP, JosephP, ShermanS, ElswickRKJr.. Validity and sensitivity of 6 pain scales in critically ill, intubated adults. Am J Crit Care, 2015; 24(6):514-523.
