title: Effects of mechanical insufflation-exsufflation in preventing respiratory failure after extubation: a randomized controlled trial.
abstract: BACKGROUND
  Weaning protocols that include noninvasive ventilation (NIV) decrease re-intubation rates and ICU length of stay. However, impaired airway clearance is associated with NIV failure. Mechanical insufflation-exsufflation (MI-E) has been proven to be very effective in patients receiving NIV. We aimed to assess the efficacy of MI-E as part of an extubation protocol.
  
  
  METHODS
  Patients with mechanical ventilation (MV) for more than 48 hours with specific inclusion criteria, who successfully tolerated a spontaneous breathing trial (SBT), were randomly allocated before extubation, either for (A) a conventional extubation protocol (control group), or (B) the MI-E extubation protocol (study group). During the postextubation period (48 hours), group A patients received standard medical treatment (SMT), including NIV in case of specific indications, whereas group B received the same postextubation approach plus three daily sessions of mechanical in-exsufflation (MI-E). Reintubation rates, ICU length of stay, and NIV failure rates were analyzed.
  
  
  RESULTS
  Seventy-five patients (26 women) with a mean age of 61.8 ± 17.3 years were randomized to a control group (n = 40; mean SAPS II, 47.8 ± 17.7) and to a study group (n = 35; mean SAPS II, 45.0 ± 15.0). MV time before enrollment was 9.4 ± 4.8 and 10.5 ± 4.1 days for the control and the study group, respectively. In the 48 hours after extubation, 20 control patients (50%) and 14 study patients (40%) used NIV. Study group patients had a significant lower reintubation rate than did controls; six patients (17%) versus 19 patients (48%), P < 0.05; respectively, and a significantly lower time under MV; 17.8 ± 6.4 versus 11.7 ± 3.5 days; P < 0.05; respectively. Considering only the subgroup of patients that used NIV, the reintubation rates related to NIV failure were significantly lower in the study group when compared with controls; two patients (6%) versus 13 (33%); P < 0.05, respectively. Mean ICU length of stay after extubation was significantly lower in the study group when compared with controls (3.1 ± 2.5 versus 9.8 ± 6.7 days; P < 0.05). No differences were found in the total ICU length of stay.
  
  
  CONCLUSIONS
  Inclusion of MI-E may reduce reintubation rates with consequent reduction in postextubation ICU length of stay. This technique seems to be efficient in improving the efficacy of NIV in this patient population.
authors.affiliation: Lung Function and Ventilation Unit, Pulmonology Department, University Hospital of São João, Faculty of Medicine, Av. Prof. Hernâni Monteiro, 4200-319 Porto, Portugal. goncalvesmr@gmail.com
authors.forename: Miguel R
authors.initials: MR
authors.lastname: Gonçalves
authors.forename: Teresa
authors.initials: T
authors.lastname: Honrado
authors.forename: João Carlos
authors.initials: JC
authors.lastname: Winck
authors.forename: José Artur
authors.initials: JA
authors.lastname: Paiva
mesh_terms: D060666:Airway Extubation / Q000379:methods*; D005260:Female; D006801:Humans; D007362:Intensive Care Units; D008297:Male; D008875:Middle Aged; D012121:Respiration, Artificial; D012131:Respiratory Insufficiency / Q000209:etiology / Q000517:prevention & control*; D018709:Statistics, Nonparametric; D013997:Time Factors; D016896:Treatment Outcome; D015300:Ventilator Weaning / Q000379:methods*