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R. Kuroiwa1, T. Inagaki1, S. Furukawa1, Y. Takeuchi1, Y. Kawasaki2, A. Murata1
1Chiba University Hospital, Division of Rehabilitation Medicine, Chiba, Japan, 2Chiba University Hospital, Biostatistics Section, Clinical Research Center, Chiba, Japan
Background: Mechanical insufflation-exsufflation (MI-E) is an effective airway clearance device for impaired cough associated with neuromuscular disease. However, the adverse events of MI-E are not well reported in critically ill patients.
Purpose: The purpose of this study was to report on the adverse events of MI-E and the factors associated with these adverse events in critically ill patients.
Methods: This retrospective study was conducted at the Chiba University Hospital intensive care unit (ICU) between January 2015 and September 2017. Data were collected from the electronic medical records, which routinely report the patient’s premorbid condition. MI-E was used in patients who had difficulty in clearing airway secretions with usual care; this included airway suctioning in patients with impaired coughing (e.g., loss of cough reflex, cough weakness) and/or increased airway secretions. Inclusion criteria were patients with invasive mechanical ventilation in ICU and using the MI-E device. Exclusion criteria were pneumothorax, pneumomediastinum, pulmonary bullae, severe cardiovascular and active alveolar hemorrhage due to the risk of adverse events with MI-E.
Patients received MI-E (Cough Assist E70, Philips Japan, Tokyo) through an endotracheal or tracheostomy tube. MI-E was performed by a physical therapist with experience in the use of MI-E . For first-time users, low insufflation and exsufflation pressures were initially used (15–20 cm H2O), which were increased as needed by monitoring for resolution of added sounds on auscultation and improvements in oxygen saturation.
Safety of MI-E was assessed by noting the occurrence of adverse events associated with use of the MI-E. Other outcome measures were insufflation and exsufflation pressure of MI-E at the time of adverse events, diagnosis and disease-related complications.
Patients received MI-E (Cough Assist E70, Philips Japan, Tokyo) through an endotracheal or tracheostomy tube. MI-E was performed by a physical therapist with experience in the use of MI-E . For first-time users, low insufflation and exsufflation pressures were initially used (15–20 cm H2O), which were increased as needed by monitoring for resolution of added sounds on auscultation and improvements in oxygen saturation.
Safety of MI-E was assessed by noting the occurrence of adverse events associated with use of the MI-E. Other outcome measures were insufflation and exsufflation pressure of MI-E at the time of adverse events, diagnosis and disease-related complications.
Results: We studied 11 patients who received MI-E. Diagnoses included the following: myasthenia gravis (n=3), cervical spinal cord injury (n=3), Guillain-Barré syndrome (GBS, n=2), brain tumor surgery, hypoxic encephalopathy and traumatic brain injury (one patient respectively). We identified adverse events in two patients: one patient had a transient asystole (at the time of the episode's appearance, insufflation/exsufflation pressure of the MI-E was +30/-30 cm H2O), the other patient had events with fluctuation of blood pressure and fatigue (insufflation/exsufflation pressure of the MI-E was +15/-15 cm H2O). These episodes occurred during the use of MI-E and both patients had acute phase of GBS with autonomic dysfunction. One patient who had a transient asystole during MI-E therapy temporarily discontinued the MI-E, and after receiving a temporary pacemaker, could continue to receive MI-E therapy. The other patient could continue to receive MI-E therapy with monitoring of their vital signs. MI-E was effective for airway clearance in both patients. In addition, no other adverse events after MI-E were observed.
Conclusion(s): We report that several adverse events occurred during the use of MI-E in critically ill patients. These adverse events are associated with autonomic dysfunction in the acute phase of GBS.
Implications: The present study was clinically important because there have not been any previous reports of autonomic dysfunction associated with use of MI-E.
Funding, acknowledgements: The MI-E device was provided by Philips Japan, Ltd.
Keywords: Mechanical insufflation-exsufflation, Adverse events, Critically ill patients
Topic: Critical care
Did this work require ethics approval? Yes
Institution: Chiba university
Committee: The Chiba University Ethics Committee
Ethics number: 3089
All authors, affiliations and abstracts have been published as submitted.
