Cough Augmentation Techniques in the Critically Ill: A Canadian National Survey.
BACKGROUND
Critically ill mechanically ventilated patients experience impaired airway clearance due to ineffective cough and impaired secretion mobilization. Cough augmentation techniques, including mechanical insufflation-exsufflation (MI-E), manually assisted cough, and lung volume recruitment, improve cough efficiency. Our objective was to describe use, indications, contraindications, interfaces, settings, complications, and barriers to use across Canada.


METHODS
An e-mail survey was sent to nominated local survey champions in eligible Canadian units (ICUs, weaning centers, and intermediate care units) with 4 telephone/e-mail reminders.


RESULTS
The survey response rate was 157 of 238 (66%); 78 of 157 units (50%) used cough augmentation, with 50 (64%) using MI-E, 53 (68%) using manually assisted cough, and 62 (79%) using lung volume recruitment. Secretion clearance was the most common indication (MI-E, 92%; manually assisted cough, 88%; lung volume recruitment, 76%), although the most common units (44%) used it <50% of the time. Use during weaning from invasive (MI-E, 21%; manually assisted cough, 39%; lung volume recruitment, 3%) and noninvasive ventilation (MI-E, 21%; manually assisted cough, 33%; lung volume recruitment, 21%) was infrequent. The most common diagnoses were neuromuscular disease (97%) and spinal cord injury (83%). Pneumothorax was the most frequently identified absolute contraindication for MI-E (93%) and lung volume recruitment (83%); rib fracture was most frequently identified for manually assisted cough (69%). MI-E mean inspiratory pressure was 31 cm H2O, and expiratory pressure was -32 cm H2O. Mucus plugging requiring tracheostomy inner change was the most frequent complication for MI-E (23%), chest pain for manually assisted cough (36%), and hypotension for lung volume recruitment (17%). The most commonly cited barriers were lack of expertise (70%), knowledge (65%), and resources (52%).


CONCLUSIONS
We found moderate adoption of cough augmentation techniques, particularly for secretion management. Lack of expertise and knowledge are potentially modifiable barriers addressed with educational interventions.
Sunnybrook Health Sciences Centre; the Lawrence S Bloomberg Faculty of Nursing, University of Toronto; the Provincial Centre of Weaning Excellence/Prolonged Ventilation Weaning Centre, Toronto East General Hospital; Mount Sinai Hospital; the Li Ka Shing Knowledge Institute, St. Michael's Hospital; and the West Park Healthcare Centre, Toronto, Ontario, Canada. louise.rose@utoronto.ca.
Louise
L
Rose
Sunnybrook Health Sciences Centre, Interdivisional Department of Critical Care, University of Toronto, Toronto, Ontario, Canada.
Neill K
NK
Adhikari
Faculty of Medicine, University of Sydney, Sydney, New South Wales, Australia.
Joseph
J
Poon
Critical Care Western and London Health Sciences Centre and Western University, London, Ontario, Canada.
David
D
Leasa
Ottawa Hospital Respiratory Rehabilitation Center, the Ottawa Hospital Sleep Centre, and the University of Ottawa, Ottawa, Ontario, Canada.
Douglas A
DA
McKim
D002170:Canada; D003371:Cough; D016638:Critical Illness / Q000628:therapy*; D006801:Humans; D007327:Insufflation / Q000379:methods*; D007362:Intensive Care Units; D008168:Lung / Q000503:physiopathology; D063087:Noninvasive Ventilation / Q000379:methods; D012123:Pulmonary Ventilation; D012121:Respiration, Artificial / Q000379:methods*; D012131:Respiratory Insufficiency / Q000209:etiology / Q000628:therapy*; D011795:Surveys and Questionnaires
acute respiratory failure; cough augmentation; intensive care; mechanical insufflation-exsufflation; mechanical ventilation