Terapias no farmacológicas de aclaramiento de la vía aérea y soporte respiratorio muscular en

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1 Terapias no farmacológicas de aclaramiento de la vía aérea y soporte respiratorio muscular en el paciente ventilado: Estado del arte João Carlos Winck, MD, PhD Coordinator of the Respiratory Medicine Unit Respiratory Rehabilitation Consultant Affiliated Professor

2 Agenda Introduction Mechanical Techniques for secretion clearance PEP, OPEP IPV HFCWO MI-E Conclusions

amount predict extubation outcome- Khamiees M, Chest 2001 Excessive bronchial

3 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 NIV during acute exacerbations of COPD-Plant P, Thorax 2001

4 Cough dysfunction and secretion encumbrance in PMV 41% of the Cough PEF 60 L/min 23% of patients have thick secretions Intensive Care Med (2004) 30: Med Intensiva. 2012;36(8):

5 PCF and Survival in ALS

6 How to measure CPF A PCF> 160L/min at the mouth or >60L/min through ET tube suggest readiness to decannulation and extubation Winck JC, Rev Port Pneumol 2015: 94-98

7 PCF: high risk levels < 160L/min Decannulation failure <270L/min Ineffective cough during respiratory infection 7

8 «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

9 Components of Airway Clearance The mucociliary escalator Cough mechanics

10 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

11 Secretion clearance therapy Hydration of secretions Mucolysis (dornase alpha) Reducing inflammatory cells (AB) Maximizing airway caliber (BD) Manual airway clearance techniques Mechanical airway clearance techniques

12 Chest physical therapy techniques Positioning Breathing control techniques Active cycle of breathing technique (ACBT) Autogenic drainage Forced exhalation technique Manual chest percussion Manuel chest vibration

13 Other non-mechanical techniques for mucus mobilization Manual assisted coughing techniques Glossopharyngeal breathing

14 PEP and Oscillatory PEP PEP and OPEP do not have proven superiority to other airway-clearance strategies, but may be more convenient for the patient and less time-consuming Myers TR, Respir Care 2007

16 IPV HFCWO MI-E Mechanical techniques for mucus mobilization

17 High-Frequency Oscillation of the Airway and Chest Wall Intermittent Percussive Ventilation The Percussionator (1.7-5Hz) Breas IMP2 (1-6Hz) High-Frequency External Chest Wall Compression The Vest (2-25Hz, 5-20cmH20) The Hayek Oscillator (1-17Hz, cmH20)

18 Breas IMP2 Mechanisms of IPV

19 IPV devices IMP2, Breas (Hospital version) Impulsator, Percussionaire Pegaso, Dima

21 Different applications of IPV

22 Studies using IPV ( )

25 Critical Care 2006; R382

28 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

29 Patients recovered normal SpO2 and 3 in 4 improved atelectasis score 95, , , ,5 92 p=0.002 Baseline Day 5 SpO2

30 Mean weight of secretions was significantly higher after IPV Hypersecretive patients

31 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

32 This technique is effective in mobilizing mucus but does not assist in removing it!

35 Before IPV After IPV

36 Addition of IPV to the usual CPT in tracheostomized patients improves gas exchange and expiratory muscle performance and reduces the incidence of pneumonia.

37 Addition of IPV to the usual CPT in tracheostomized patients improves gas exchange and expiratory muscle performance and reduces the incidence of pneumonia.

38 High-Frequency Oscillation of the Airway and Chest Wall Intermittent Percussive Ventilation The Percussionator (1.7-5Hz) Breas IMP2 (1-6Hz) High-Frequency External Chest Wall Compression The Vest (2-25Hz, 5-20cmH20) The Hayek Oscillator (1-17Hz, cmH20)

39 Hansen LG et al, Biomed Instrum Technol 1990: 289

42 HFCWO (10-15min twice daily) for 3 months in 22 ALS patients (vs 24 controls) with a mean FVC % improved breathlessness and increased cough at night Lange DJ et al Neurology 2006: 991

43 After extubation, patients on HFCWO had greater number of sputum suctions and higher CRx improvement

45 The mechanism of mucus clearance during MI-E

46 In-exsufflator models COMFORT COUGH (KOREA) COFFLATOR (USA 1953) PEGASO (ITALY) COUGH ASSIST 2001 E IN-EXSUFFLATOR USA 1993 NIPPY CLEARWAY (UK)

L/s); Increasing insufflation time from 2 to 3 sec

48 Settings during MI-E Pressures < 30 to 30 cmh20 do not achieve minimally 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

49 Settings during MI-E Each application: 6 cycles of +-40cmH20, 3sec insufflation, 4 sec exsufflation, 2 sec pause Insp Time Exp Time Pause Pressure Winck JC, Chest 2004

50 Efficacy ofmi-e in Neuromuscular Patients Study Year Subjects Improvement of PCF Bach (non ALS) 313% Sivasothy (7 ALS) 39% Chatwin % Mustfa ALS 26-28% Sancho ALS (15 bulbar) -19% Winck (13 ALS) 17-22%

51 Use ofmi-e in Neuromuscular Patients Chatwin M, ERJ 2003

52 MI-E (Mean:+40-24cmH20) increased significantly PCF in nonbulbar (n=26) as well as bulbar patients (n=21)

53 Physiologic Effects of MI-E SpO2 DOENÇA= ALS ALS Group * PCF Winck, Chest SPO2BAS 100 PCEFB 88 N = 13 Baseline MI-E40 13 SPO2POS 0 N = Baseline MI-E40 PCEFPOS P < P < *PIFMF significantly increased with pressures at 40 to -40 cmh20

54 MI-E (Mean:+40-24cmH20) increased significantly PCF in nonbulbar (n=26) as well as bulbar patients (n=21)

56 Use ofmi-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-cause of UA collapse? Sancho, Chest 2004

58 How to use MI-E in Bulbar ALS Andersen T, Thorax 2016

59 New features CoughAssist E70

60 Monitoring Peak cough flow and tidal volume During therapy: updated at each cycle during therapy latest measurement displayed at rest 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)

61 Oscillation feature E70 Oscillations assist in releasing mucus from the bronchial walls, increasing mobilization improving bronchial drainage Pressure (cmh 2 O) Mechanism of action Inhale pressure set amplitude Time (s) Exhale Pressure set 1 frequency

62 Respir Care 2016;61(8):

63 CPF generated by mechanical in-exsufflation, independent of the severity of bulbar dysfunction, does not change despite the addition of high-frequency oscillations. Respir Care 2016;61(8):

64 Improve synchronisation: Cough-Trak It will only trigger upon inhale, initiating an inspiration for the set inhale time, automatically switch to exhale for the set exhale time, and then wait for the next patient initiated inhale E70 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

65 Longterm effects of MI-E in survival Improves outcomes in Duchenne Muscular Distrophy Gomez-Merino, Am J Phys Med Rehabil 2002

66 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

67 TIV users required MI-E twice as many days per month as NIV users. On-demand MI-E compared with standard continuous saves 108,758.

68 Home Cough augmentation techniques: Carer strain Index

70 Effects of mechanical insufflation-exsufflation in preventing respiratory failure after extubation. A randomized controlled trial. M Gonçalves et al. Crit Care 2012

71 Daily Post extubation MI-E application (pressures- IN: 40cmH2O; Ex: -40cmH2O) through a oronasal mask in a patient with NIV indication

73 Use of MI-E in patients with artificial airway Sancho J, Am J Phys Med Rehabil 2003

74 MI-E in tracheostomized patients Preference for suctioning or MI-E in SCI Garstang S, J Spinal Cord Med 2000

75 MI-E in tracheostomized patients In patients with endotracheal tube or tracheostomy inflation pressure may be higher than cmh20 to overcome the resistance of the tube or cannula. Higher expiratory pressures are needed with narrower tubes (with 6 tracheostomy tube, pressure of 60cmh20 may be needed). Cuffs should be inflated to prevent leaks Guerin C et al Repir Care 2011 Aug;56(8):

76 WHAT ABOUT COMBINING TECHNIQUES?

77 What about combining techniques? Pre-tx Post-tx

78 Stable C6 tetraplegia ASIA A

79 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 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

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