Effects of Mechanical Insufflation-Exsufflation With Different Pressure Settings on Respiratory Mucus Displacement During Invasive Ventilation
Joan-Daniel Martí, Roberto Martínez-Alejos, Xabier Pilar-Diaz, Hua Yang, Francesco Pagliara, Denise Battaglini, Andrea Meli, Milan Yang, Joaquim Bobí, Monsterrat Rigol, Oystein Tronstad, Márcia Souza Volpe, Marcelo B. P. Amato, Gianluigi Li Bassi, Antoní Torres
Abstract
BACKGROUND: Mechanical insufflation-exsufflation (MI-E) has been proposed as a potential strategy to generate high expiratory flows and simulate cough in the critically ill. However, efficacy and safety of MI-E during invasive mechanical ventilation are still to be fully elucidated. This study in intubated and mechanically ventilated pigs aimed to evaluate the effects of 8 combinations of insufflation-exsufflation pressures during MI-E on mucus displacement, respiratory flows, as well as respiratory mechanics and hemodynamics. METHODS: Six healthy Landrace-Large White female pigs were orotracheally intubated, anesthetized, and invasively ventilated for up to 72 h. Eight combinations of insufflation-exsufflation pressures (+40/−40, +40/−50, +40/−60, +40/−70, +50/−40, +50/−50, +50/−60, +50/−70 cm H 2 O) were applied in a randomized order. The MI-E device was set to automatic mode, medium inspiratory flow, and an inspiratory-expiratory time 3 and 2 s, respectively, with a 1-s pause between cycles. We performed 4 series of 5 insufflation-exsufflation cycles for each combination of pressures. Velocity and direction of movement of a mucus simulant containing radio-opaque markers were assessed through sequential lateral fluoroscopic images of the trachea. We also evaluated respiratory flows, respiratory mechanics, and hemodynamics before, during, and after each combination of pressures. RESULTS: In 3 of the animals, experiments were conducted twice; and for the remaining 3, they were conducted once. In comparison to baseline mucus movement (2.85 ± 2.06 mm/min), all insufflation-exsufflation pressure combinations significantly increased mucus velocity ( P = .01). Particularly, +40/−70 cm H 2 O was the most effective combination, increasing mucus movement velocity by up to 4.8-fold ( P < .001). Insufflation pressure of +50 cm H 2 O resulted in higher peak inspiratory flows ( P = .004) and inspiratory transpulmonary pressure ( P < .001) than +40 cm H 2 O. CONCLUSIONS: MI-E appeared to be an efficient strategy to improve mucus displacement during invasive ventilation, particularly when set at +40/−70 cm H 2 O. No safety concerns were identified although a transient significant increase of transpulmonary pressure was observed.