title: Efficacy of mechanical insufflation-exsufflation in extubating unweanable subjects with restrictive pulmonary disorders.
abstract: BACKGROUND
  Subjects who do not pass ventilator weaning parameters but whose ambient air oxyhemoglobin saturation can be normalized by mechanical insufflation-exsufflation (MIE) can be extubated to continuous noninvasive ventilatory support (CNVS) with MIE used to maintain extubation. Our aim was to study MIE-associated changes in breathing tolerance, pulse oximetry, and vital capacity (VC) for consecutive unweanable subjects.
  
  
  METHODS
  A retrospective chart review was performed for consecutively referred intubated subjects with single-organ (respiratory muscle) failure. At presentation, CO2 was normalized by adjusting ventilator settings and VC was measured (point 1). Then, MIE was used via the tube up to every h until oximetry remained ≥ 95% on ambient air and VC was remeasured (point 2) immediately before extubation. Subjects who could not meet ventilator weaning criteria and had no ventilator-free breathing ability upon extubation to CNVS were enrolled. Post-extubation, the MIE was used to maintain oximetry ≥ 95% in room air. VC and breathing tolerance were remeasured within 3 weeks (point 3).
  
  
  RESULTS
  Ninety-seven of 98 subjects were successfully extubated despite 45 having been CNVS-dependent for 4 months to 18 y before being intubated. Sixty-nine of the 98 were intubated for 24.9 ± 22 (range 1-158) d and failed 0-6 (mean 1.7) extubation attempts before being transferred and successfully extubated in 2.24 ± 1.78 (range < 1-8) d to CNVS. VC increased by 270% (P < .001) from points 1 to 3. Weaning from CNVS to part-time NVS was achieved by all 52 subjects who had not been CNVS-dependent before intubation. One subject underwent tracheotomy.
  
  
  CONCLUSIONS
  Many unweanable subjects can be extubated to CNVS and MIE. The latter can normalize O2 saturation, increase VC, and facilitate extubation.
authors.affiliation: Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, University Hospital, Newark, New Jersey bachjr@njms.rutgers.edu.
authors.forename: John R
authors.initials: JR
authors.lastname: Bach
authors.affiliation: Department of Pediatrics, Rutgers New Jersey Medical School, University Hospital, Newark, New Jersey.
authors.forename: Diane M
authors.initials: DM
authors.lastname: Sinquee
authors.affiliation: Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, University Hospital, Newark, New Jersey.
authors.forename: Louis R
authors.initials: LR
authors.lastname: Saporito
authors.affiliation: Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Kessler Foundation, West Orange, New Jersey.
authors.forename: Amanda L
authors.initials: AL
authors.lastname: Botticello
mesh_terms: D000293:Adolescent; D000328:Adult; D060666:Airway Extubation; D002648:Child; D002675:Child, Preschool; D006801:Humans; D007327:Insufflation; D008173:Lung Diseases, Obstructive / Q000150:complications*; D063087:Noninvasive Ventilation / Q000379:methods*; D010092:Oximetry; D012131:Respiratory Insufficiency / Q000209:etiology / Q000628:therapy*; D012132:Respiratory Muscles; D012138:Respiratory Therapy / Q000379:methods*; D012189:Retrospective Studies; D015300:Ventilator Weaning; D014797:Vital Capacity; D055815:Young Adult
keywords: Duchenne muscular dystrophy; mechanical insufflation-exsufflation; neuromuscular disease; noninvasive ventilation; respiratory; spinal cord injury