Professional Documents
Culture Documents
Andrea Vianello, MD
Antonio Corrado, MD
Giovanna Arcaro, MD
Federico Gallan, MD
Carlo Ori, MD
Michele Minuzzo, MD
Matteo Bevilacqua, MD
Pulmonary
RESEARCH ARTICLE
Affiliations:
From Unit di Terapia Semi-Intensiva
Respiratoria, Azienda Ospedaliera di
Padova, Padova, Italy (AV, GA, FG,
MM, MMB); Unit di Terapia
Intensiva Respiratoria, Ospedale
Careggi di Firenze, Firenze, Italy
(AC); and Sezione di Anestesia e
Rianimazione, Dipartimento di
Farmacologia, Universit di Padova,
Padova, Italy (CO).
Mechanical InsufflationExsufflation
Improves Outcomes for
Neuromuscular Disease Patients
with Respiratory Tract Infections
Correspondence:
All correspondence and requests for
reprints should be addressed to
Andrea Vianello, MD, U.O.
Fisiopatologia Respiratoria, Azienda
Ospedaliera di Padova, Via
Giustiniani, 3, 35128 Padova, Italy.
ABSTRACT
0894-9115/05/8402-0083/0
American Journal of Physical
Medicine & Rehabilitation
Copyright 2005 by Lippincott
Williams & Wilkins
DOI: 10.1097/01.PHM.0000151941.97266.96
Results: Treatment failure was significantly lower (P 0.05) in the mechanical insufflation exsufflation group than in the conventional chest physical treatments group (2/11 vs. 10/16 cases). The use of bronchoscopy-assisted
aspiration was similar in the two groups (5/11 vs. 6/16 cases). Mechanical
insufflation exsufflation did not produce serious side effects and was well
tolerated by all subjects.
Conclusions: Provision of mechanical insufflation exsufflation in combination
with standard chest physical treatments may improve the management of airway
mucous encumbrance in neuromyopathic patients; its use should be included in
the noninvasive approach to treatment of respiratory tract infections with impaired mucous clearance.
Key Words: Mechanical InsufflationExsufflation, Neuromuscular Disease, Respiratory
Tract Infection, Endotracheal Intubation
February 2005
Mechanical InsufflationExsufflation
83
84
Vianello et al.
METHODS
We compared the short-term outcomes of 11
NMD patients with URTI who were treated by MI-E
in addition to conventional CPTs (group A) with
the outcomes of a population of 16 historical control patients who had received CPTs alone (group
B). The two groups received similar pharmacologic
therapy (antibiotics and steroids as indicated) and
NPPV when needed. The patients gave their informed consent to the application of MI-E; those
younger than 18 yrs of age reached this decision in
accordance with their parents.
Patients
Eleven consecutive NMD patients admitted to
our intensive care unit between January 2001 and
March 2003 with dyspnea due to chest infections
were recruited. The diagnoses were based on standard clinical, enzymatic, electromyographic, DNA,
and biopsy data.
The diagnosis of URTI was based on the presence of one or more of the following symptoms or
signs: coryza, fever, throat irritation or sore throat,
hoarseness, and cough. The accumulation of airway mucous was defined as the coexistence of auscultatory rhonchi and oxyhemoglobin desaturation
(SaO2 95%).5,10 The diagnosis of pneumonia was
based on the concomitant presence of infiltrates on
chest radiographs.
The control group (group B) consisted of 16
historical controls consecutively admitted to our
department between 1996 and 1999; these patients
were affected with NMD and had received conventional medical therapy along with CPTs alone. Patients admitted in 2000 could not be considered
due to the lack of availability of clinical records.
None of the control patients was subsequently enrolled as a study patient.
Measurements
The Groups were compared for the variables
listed in Tables 1 and 2. The Gilardeau score was
used to assess bulbar innervated muscle function.14
The peak expiratory flow and forced vital capacity,
Am. J. Phys. Med. Rehabil.
TABLE 1 Anthropometric, clinical, pulmonary function, and blood gas data at study entry and clinical outcomes of
(mechanical insufflation exsufflation [MI-E]) group A and (control) group B
Patient
No.
Type of
NMD
1A
2A
3A
LGMD
DMD
ALS
4A
5A
6A
7A
8A
9A
DMD
SMA
DMD
SMA
ALS
FSHMD
10A
11A
1B
2B
DMD
SMA
LGMD
DMD
3B
4B
5B
6B
LGMD
DMD
DMD
DMD
7B
8B
9B
10B
11B
12B
13B
14B
15B
16B
DMD
ALS
CM
ALS
ALS
ALS
ALS
ALS
DMD
DMD
Group A
Group B
Reasons for
Admission
PaO2,a PaCO2,
mmHg mmHg
Age,
yrs
BMI
Home NPPV,
hrs/day
GS
PEF,
liters/sec
RD, Bronchitis
ARF, dysphagia
Lobar atelectasis
44
16
64
23.4
NA
21.4
0
9
8
1
3
0
1.41
0.65
1.88
65
64
60
37
64
60
7.40
7.30
7.38
Severe ARF
RD, fever
RD, Bronchitis
RD
Dehydratation, ARF
Pneumonia,
atelectasis
RD, malnutrition
ARF, pneumonia
RD, bronchitis
RD, bronchitis,
dehydration
20
41
21
30
64
37
21.4
21.3
17.1
16.5
13.3
18.4
14
0
0
12
0
15
3
0
0
1
4
3
1.32
2.03
2.74
0.99
0.3
2.09
64
57
67
63
54
62
65
63
43
53
45
60
31
16
54
23
13.5
21.4
NA
22.2
15
12
0
16
3
4
0
0
1.97
NA
NA
3.64
70
50
49
69
Dehydration, lethargy
Dehydratation, fever
Atelectasis, fever
54
23
25
14
NA
14.1
10.2
20.7
10
15
18
10
0
0
3
0
NA
4.48
1.35
0.73
Lobar atelectasis
RD, bronchitis
Bronchitis, fatigue
Bronchitis, fatigue
Atelectasis, sepsis
Atelectasis
RD, bronchitis
Bronchitis, lethargy
Atelectasis
Atelectasis, dysphagia
24
67
11
58
63
34
68
72
23
23
23.3
26.1
19.5
22.8
NA
NA
NA
NA
NA
20.3
15
0
0
0
10
0
0
0
8
10
0
4
0
3
0
2
3
3
0
4
1.51
2.53
2.07
1.51
1.7
NA
NA
NA
NA
1.71
pH
Complications and
Clinical Outcome
BAA
Yes
No
Yes
7.26
7.35
7.44
7.38
7.46
7.26
Success
GER, ETI, trach, discharged
Ineffective MI-E, ETI,
ventricular arrhythmia,
died
Success
Success
Success
Gastric distension, success
Success
Success
29
55
33
48
7.34
7.42
7.49
7.35
Success
Epistaxis, success
CM, discharged
CM, discharged
No
No
No
Yes
68
62
56
64
64
69
57
48
7.34
7.31
7.45
7.34
No
No
Yes
Yes
62
62
75
69
64
51
65
53
56
63
37
40
54
56
38
21
41
74
34
58
7.42
7.51
7.40
7.37
7.42
7.40
7.44
7.23
7.48
7.40
Success
Success
ETI, trach, discharged
CM, superimposed
pneumonia, died
CM, discharged
Success
Success
Success
ETI, trach, discharged
ETI, trach, discharged
CM, discharged
ETI, trach, discharged
Success
ETI, trach
Yes
Yes
No
Yes
No
No
Yes
No
No
No
No
No
No
No
Yes
Yes
NMD, neuromuscular disease; BMI, body mass index; GS, Gilardeau score; PEF, peak expiratory flow; BAA, bronchoscopy-assisted aspiration;
LGMD, limb-girdle muscular dystrophy; RD, respiratory distress; DMD, Duchenne muscular dystrophy; ARF, acute respiratory failure; GER,
gastroesophageal reflux; ETI, endotracheal intubation; trach, tracheostomy; ALS, amyotrophic lateral sclerosis; SMA, spinal muscular atrophy;
FSHMD, facio-scapulo-humeral muscular dystrophy; CM, congenital myopathy.
a
Measured in room air.
Treatment
MI-E was administered as follows.
Each treatment consisted of about five positiveto-negative pressure cycles, followed by a period
of normal breathing or ventilator use for 20 30
secs to avoid hyperventilation; five or more treatments were given in one session.10 Patients were
connected to MI-E by means of a light-weight,
elastic oronasal mask.
The insufflation and exsufflation pressures and
timing were independently adjusted according to
efficacy and patient tolerance. For a patient us-
February 2005
85
Number of subjects
Age, yrs
Body mass index
Sex (males, females)
Patients administered home NPPV, n
No. of hospitalizations in 1 year
FVC, liters
PEF, liters/sec
Gilardeau score
Patients with fever, n (temperature 38C)
Patients with leukocytosis, n (WBC 12,000 109/liter)
PaO2, mm Hg
PaCO2, mm Hg
pH
Group A
Group B
P Value
11
34.91 17.28
18.76 3.57
7, 4
7
0.64 0.81
0.38 0.08
1.54 0.74
2.09 1.70
1
7
61.5 5.84
52.18 12.06
7.36 0.07
16
39.75 21.56
20.32 5.08
12, 4
9
0.58 0.67
0.97 0.88
2.12 1.14
1.38 1.67
3
5
66.25 10.48
48.25 14.46
7.40 0.07
0.541
0.446
0.541
0.990
0.865
0.305
0.191
0.659
0.624
0.130
0.182
0.466
0.229
NPPV, noninvasive positive-pressure ventilation; FVC, forced vital capacity; PEF, peak expiratory flow; WBC, white blood cell
count.
86
Vianello et al.
RESULTS
Table 1 lists anthropometric and other data.
Two subjects in group A and 6 in group B were
rapidly progressing patients with amyotrophic lateral sclerosis. All had mild to moderate bulbar
dysfunction with the exceptions of cases 8A, 8B,
and 12B, who had severely diminished glottic function. All of the subjects (except for case 3 in group
A) were wheelchair-bound.
The mean number of MI-E sessions per day
was 2.7 0.9, including treatments administered
by nonprofessional caregivers. The mean insufflaAm. J. Phys. Med. Rehabil.
DISCUSSION
In the early 1950s devices were introduced to
deliver MI-E via facemasks or mouthpieces to facilitate the expulsion of airway mucous. Although
there were reports suggesting their effectiveness,17
they never gained widespread popularity due to the
increasing application of tracheostomy and invasive suctioning. Noninvasive methods are now being more widely used and are more desirable to
patients than is tracheostomy.
Although the use of historical controls and a
relatively small number of patients is a limitation,
this study, nevertheless, suggests the effectiveness
of MI-E in promoting an effective cough. It is
important to note that, aside from administration
Group A
Group B
P Value
8
11
9.4 6.9
20.5 20
2
5
14
13
13.5 11.9
19.8 17
10
6
0.370
0.248
0.299
0.927
0.047
0.710
NPPV, noninvasive positive-pressure ventilation; MV, mechanical ventilation; BAA, bronchoscopy-assisted aspiration.
February 2005
Mechanical InsufflationExsufflation
87
ease developed gastric distension and gastroesophageal reflux. Because the re-entry of digested food
and gastric acids into the pharynx can result in
aspiration, especially in subjects with airway clearance dysfunction, caution should be observed when
using MI-E in patients with a history of gastroesophageal reflux disease, particularly if abdominal
distension develops.
Finally, it should be emphasized that in most
cases, the administration of MI-E was effective and
safely carried out by trained nonprofessional caregivers. We believe that this supports extending the
use of MI-E into home management where it can
be used in combination with NPPV to reduce the
need for hospitalization, thus maintaining a higher
quality of life for the NMD patient. In conclusion,
the findings of our study provide support for considering the administration of MI-E in combination
with conventional CPTs in the management of
mucous retention during URTI in patients with
NMDs.
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