Kuroiwa R1, Tateishi Y2, Inagaki T1, Furukawa S1, Takemura R3, Kawasaki Y3, Murata A1
1Chiba University Hospital, Rehabilitation Medicine, Chiba, Japan, 2Chiba University, Emergency and Critical Care Medicine, Chiba, Japan, 3Chiba University Hospital, Biostatistics Section, Clinical Research Center, Chiba, Japan
Background: Ventilator-associated pneumonia (VAP) is the most common ICU-acquired infection and is associated with increased mortality. Mechanical in-exsufflation (MI-E) is an effective airway clearance strategy for impaired cough, especially in those with neuromuscular disease. However, evidence for use of MI-E in critically ill patients is insufficient.
Purpose: This study aimed to assess the efficacy of MI-E in preventing VAP in critically ill patients.
Methods: This retrospective cohort study was undertaken at a University Teaching Hospital ICU investigating admissions between January 2014 and September 2017. Information was drawn from electronic medical records.
Inclusion criteria were any patients requiring invasive mechanical ventilation ≥ 48 hours and received rehabilitation including chest physiotherapy (CPT). Exclusion criteria were community-acquired pneumonia, pneumothorax and bulla, severe cardiovascular failure, alveolar hemorrhage, patients who had sustained any injury or developed any complication that did not allow provision of CPT. Those who received rehabilitation 5 days and patients 7 years old were also excluded.
Use of MI-E for patients with impaired cough began at study institution in 2015. From January - December 2014 those receiving CPT acted as a historical control group, with the intervention group being those receiving MI-E from January 2015 to September 2017. Patients received the MI-E (Cough-Assist E70, Philips Respironics) intervention through the endotracheal tube or tracheostomy tube with in/exsufflation pressures set at range 15 to 40 cm H2O, with 5-10 cycles applied in every session with a chest wall thrust (manually assisted coughing) by a physiotherapist timed to the exsufflation cycle. This was repeated several times or until secretions were sufficiently expelled. Daily treatment frequency was 1-3 session, provided by a physiotherapist experienced with using MI-E. Positioning was determined via assessment, with the most affected lung on auscultation or chest imaging positioned uppermost facilitating gravity-assisted drainage. Nurses performed airway suctioning at the end of each cycle and as needed during each rest period.
The primary outcome of the study was VAP incidence [as defined by a clinical pulmonary infection score (CPIS) > 6]. Data analysis, via Fisher exact test and Mann Whitney U-tests, was undertaken by JMP (version 13; https://www.jmp.com/en_dk/home.html).
Results: Of 169 patients screened during Jan - Dec 2014 19 patients received CPT; across Jan 2015 - Sept 2017 520 patients were screened, of which 11 patients received MI-E. There were no significant differences between the groups for demographic parameters, admission severity, or length of ventilation.The incidence of VAP was significantly different between groups [CPT group 84.2% (16/19) vs MI-E group 26.4% (3/11) (p=0.0045)]. Adjusting for potential confounders (including age, mechanical ventilation duration, APACHE II and SOFA scores) in multivariable logistic regression analysis indicated that the confounders were not associated with the incidence of VAP.
Conclusion(s): In this retrospective cohort study, MI-E in ventilated critically ill patients was independently associated with a reduction in VAP. Confirmation of benefits of MI-E in prevention of VAP via a larger prospective randomized controlled trial is required.
Implications: This study found that the MI-E was effective in critically ill patients.;MI-E may reduce mortality, length of stay in ICU, and cost of therapy.
Keywords: Mechanical in-exsufflation, Ventilated-associated pneumonia, Critically ill patients
Funding acknowledgements: The MI-E device was provided rental free of charge from Philips Respironics.
Purpose: This study aimed to assess the efficacy of MI-E in preventing VAP in critically ill patients.
Methods: This retrospective cohort study was undertaken at a University Teaching Hospital ICU investigating admissions between January 2014 and September 2017. Information was drawn from electronic medical records.
Inclusion criteria were any patients requiring invasive mechanical ventilation ≥ 48 hours and received rehabilitation including chest physiotherapy (CPT). Exclusion criteria were community-acquired pneumonia, pneumothorax and bulla, severe cardiovascular failure, alveolar hemorrhage, patients who had sustained any injury or developed any complication that did not allow provision of CPT. Those who received rehabilitation 5 days and patients 7 years old were also excluded.
Use of MI-E for patients with impaired cough began at study institution in 2015. From January - December 2014 those receiving CPT acted as a historical control group, with the intervention group being those receiving MI-E from January 2015 to September 2017. Patients received the MI-E (Cough-Assist E70, Philips Respironics) intervention through the endotracheal tube or tracheostomy tube with in/exsufflation pressures set at range 15 to 40 cm H2O, with 5-10 cycles applied in every session with a chest wall thrust (manually assisted coughing) by a physiotherapist timed to the exsufflation cycle. This was repeated several times or until secretions were sufficiently expelled. Daily treatment frequency was 1-3 session, provided by a physiotherapist experienced with using MI-E. Positioning was determined via assessment, with the most affected lung on auscultation or chest imaging positioned uppermost facilitating gravity-assisted drainage. Nurses performed airway suctioning at the end of each cycle and as needed during each rest period.
The primary outcome of the study was VAP incidence [as defined by a clinical pulmonary infection score (CPIS) > 6]. Data analysis, via Fisher exact test and Mann Whitney U-tests, was undertaken by JMP (version 13; https://www.jmp.com/en_dk/home.html).
Results: Of 169 patients screened during Jan - Dec 2014 19 patients received CPT; across Jan 2015 - Sept 2017 520 patients were screened, of which 11 patients received MI-E. There were no significant differences between the groups for demographic parameters, admission severity, or length of ventilation.The incidence of VAP was significantly different between groups [CPT group 84.2% (16/19) vs MI-E group 26.4% (3/11) (p=0.0045)]. Adjusting for potential confounders (including age, mechanical ventilation duration, APACHE II and SOFA scores) in multivariable logistic regression analysis indicated that the confounders were not associated with the incidence of VAP.
Conclusion(s): In this retrospective cohort study, MI-E in ventilated critically ill patients was independently associated with a reduction in VAP. Confirmation of benefits of MI-E in prevention of VAP via a larger prospective randomized controlled trial is required.
Implications: This study found that the MI-E was effective in critically ill patients.;MI-E may reduce mortality, length of stay in ICU, and cost of therapy.
Keywords: Mechanical in-exsufflation, Ventilated-associated pneumonia, Critically ill patients
Funding acknowledgements: The MI-E device was provided rental free of charge from Philips Respironics.
Topic: Critical care; Cardiorespiratory; Neurology
Ethics approval required: Yes
Institution: Chiba University
Ethics committee: The Chiba University Ethics review Committees
Ethics number: 3089
All authors, affiliations and abstracts have been published as submitted.
