1. Airway Secretion Clearance in the
ICU
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Olu Albert, MPH, RRT
Clinical Manager
Home Respiratory Care- Asia Pacific
International Group
Home Healthcare Solutions

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 A review of Airway Clearance Techniques
Mechanical Insufflation Exsufflation Timeline
Case Study: Post-Op Myothonic Dysthrophy
Cough Assist E-70
Literature review of Cough Assist Use in the ICU
Take Home Message
Agenda

3. Airway Clearance Techniques: What’s New?
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4. 4
Airway Clearance Techniques

5. Manual Assisted Cough
 Performed by the
physiotherapist
 Various positions and
techniques
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6. Substitutes: Suction
Cons
• Invasive procedure
• Misses left main stem bronchus
90% of the time
• Tracheal trauma, suctioning
induced hypoxemia, hypertension,
cardiac arrhythmias and raised
intracranial pressure have all been
associated with suctioning
• Patients have reported that
suctioning can be a painful and
anxiety provoking procedure
Thompson, L. Suctioning Adults with an Artificial Airway. The Joanna Briggs Institute for Evidence
Based Nursing and Midwifery; 2000. Systematic Review No. 9.
Pros
• Costs
• Training
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http://www.youtube.com/watch?v=VqLwGXgm8_M&feature=related

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Cufflator
1950’s
Cough Assist
1993
E-70
2012
Cough Assist Time-Line

8. Case Study
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Case Study
Clinical findings
 VC – 0.69 L
 PCF – 175 LPM
 PaO2 – 57.3 mm Hg
 SpO2 – 88%
 RR – 45 bpm
Goncalves, MR. Commentary: Exploring the potential of mechanical insufflation-exsufflation. Breathe 2008; 4:326-329.
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18-year-old male with myotonic dystrophy in
respiratory failure following a surgical procedure to
repair a pectus excavatum

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2nd Day Post-op Pectus Excavatum Repair
Goncalves, MR. Commentary: Exploring the potential of mechanical insufflation-exsufflation. Breathe 2008; 4:326-329.
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After 8 sessions of MI-E via Face Mask
X-ray 24h
Goncalves, MR. Commentary: Exploring the potential of mechanical insufflation-exsufflation. Breathe 2008; 4:326-329.
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Case Study: Day 3
Clinical Findings
 SpO2 – 97% (FiO2 21%)
 RR – 18
 PCF – 350 L/m
 FVC – 1.71
Patient avoided Intubation and Bronchoscopy
Goncalves, MR. Commentary: Exploring the potential of mechanical insufflation-exsufflation. Breathe 2008; 4:326-329.
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13. Treatment Protocol
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16. Therapy Plan:
 Cough cycle = Inhale + Exhale + Pause
 1Sequence = 4 to 6 cough cycles given in rapid succession
 Resting time = Patient rests for 20 – 30 seconds
 During rest, clear secretions that are visible in the mouth,
throat or tracheostomy tube
 Therapy = Repeat above sequence 4 – 6 times or until
secretion expelled
Typical CoughAssist
Treatment
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17. Typical Treatment
Example of settings:
Pressures (positive and negative)
 Start low, 10 to 15 cm H2O while oscillations set at patient comfort
 Get patient familiar with the device
 Increase pressures as tolerated, 35 to 45 cm H2O ideally*
 The goal of expiratory pressure is to replace a good expiratory cough flow
 Possibility to use abdominal and chest compression during expiration (ie. Set
with automatic mode or use foot pedal in Manual mode)
 Higher pressures are often required when compliance decreases or resistance
increases (small tracheal tubes, obesity, scoliosis)
* Studies have shown that therapeutic PCF may not be reached with MI-E expiratory pressures less
than -40 cm H2O
Winck JC, et al. Effects of mechanical insufflation-exsufflation on respiratory parameters for patients
with chronic airway secretion encumbrance. Chest. 2004;126:774-780.
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18. Typical Treatment
Hints:
 Therapy can be adjusted to the need of each
individual patient:
Use presets for different needs of therapy
 Best before meals and at bedtime
 Frequency of sessions according to case history
 Necessary adaptation for invasive use
Possible higher pressure needed
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20. Clinical Evidence: ICU & Cough
Assist
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22. Methods
• Retrospective Chart Review from Jan 2009 through 2013
• Inclusion: Restrictive Lung Disease willing to be extubated to CNVS
• Extubation Criteria: Reversal Acute Illness with normal physiological
parameters
• Insufflation and Exsufflation Pressures of 60-70 cmH2O
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23. Results
98 successive patients were extubated CNVS
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Conclusion:
Many unweanable restrictive patients can be extubated to MIE and
CNVS

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28. Conclusion
• Noninvasive Respiratory Management using NIV and MIE has been
shown to reduce hospitalizations and tracheostomy for patients with
NMDs and SCI who have functioning bulbar musculature and can be
used to extubate and deccanulate patients

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30. Results
• There is good tolerance and physiologic
improvements in both restrictive and pulmonary
disease
• There was improvements in PCF and SpO2 for
both NMD and COPD patients at pressures of
40cmH2O to -40cmH2O
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31. Take Home Message
The new Cough Assist (E-70) can be used noninvasively to mobilize
and remove airway secretion
Insufflation Techniques using the MIE can be an effective lung
recruitment strategies
Current evidence in the medical literature suggests that MIE is safe in
cases obstructive and restrictive diseases
Clinical Data suggests that MIE is safe to use and there is no
correlation between MIE use and Pneumothorax
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