title: Cough augmentation techniques for extubation or weaning critically ill patients from mechanical ventilation.
abstract: There are various reasons why weaning and extubation failure occur, but ineffective cough and secretion retention can play a significant role. Cough augmentation techniques, such as lung volume recruitment or manually- and mechanically-assisted cough, are used to prevent and manage respiratory complications associated with chronic conditions, particularly neuromuscular disease, and may improve short- and long-term outcomes for people with acute respiratory failure. However, the role of cough augmentation to facilitate extubation and prevent post-extubation respiratory failure is unclear.
  
  
  
  Our primary objective was to determine extubation success using cough augmentation techniques compared to no cough augmentation for critically-ill adults and children with acute respiratory failure admitted to a high-intensity care setting capable of managing mechanically-ventilated people (such as an intensive care unit, specialized weaning centre, respiratory intermediate care unit, or high-dependency unit).Secondary objectives were to determine the effect of cough augmentation techniques on reintubation, weaning success, mechanical ventilation and weaning duration, length of stay (high-intensity care setting and hospital), pneumonia, tracheostomy placement and tracheostomy decannulation, and mortality (high-intensity care setting, hospital, and after hospital discharge). We evaluated harms associated with use of cough augmentation techniques when applied via an artificial airway (or non-invasive mask once extubated/decannulated), including haemodynamic compromise, arrhythmias, pneumothorax, haemoptysis, and mucus plugging requiring airway change and the type of person (such as those with neuromuscular disorders or weakness and spinal cord injury) for whom these techniques may be efficacious.
  
  
  
  We searched the Cochrane Central Register of Controlled Trials (CENTRAL; Issue 4, 2016), MEDLINE (OvidSP) (1946 to April 2016), Embase (OvidSP) (1980 to April 2016), CINAHL (EBSCOhost) (1982 to April 2016), and ISI Web of Science and Conference Proceedings. We searched the PROSPERO and Joanna Briggs Institute databases, websites of relevant professional societies, and conference abstracts from five professional society annual congresses (2011 to 2015). We did not impose language or other restrictions. We performed a citation search using PubMed and examined reference lists of relevant studies and reviews. We contacted corresponding authors for details of additional published or unpublished work. We searched for unpublished studies and ongoing trials on the International Clinical Trials Registry Platform (apps.who.int/trialsearch) (April 2016).
  
  
  
  We included randomized and quasi-randomized controlled trials that evaluated cough augmentation compared to a control group without this intervention. We included non-randomized studies for assessment of harms. We included studies of adults and of children aged four weeks or older, receiving invasive mechanical ventilation in a high-intensity care setting.
  
  
  
  Two review authors independently screened titles and abstracts identified by our search methods. Two review authors independently evaluated full-text versions, independently extracted data and assessed risks of bias.
  
  
  
  We screened 2686 citations and included two trials enrolling 95 participants and one cohort study enrolling 17 participants. We assessed one randomized controlled trial as being at unclear risk of bias, and the other at high risk of bias; we assessed the non-randomized study as being at high risk of bias. We were unable to pool data due to the small number of studies meeting our inclusion criteria and therefore present narrative results rather than meta-analyses. One trial of 75 participants reported that extubation success (defined as no need for reintubation within 48 hours) was higher in the mechanical insufflation-exsufflation (MI-E) group (82.9% versus 52.5%, P < 0.05) (risk ratio (RR) 1.58, 95% confidence interval (CI) 1.13 to 2.20, very low-quality evidence). No study reported weaning success or reintubation as distinct from extubation success. One trial reported a statistically significant reduction in mechanical ventilation duration favouring MI-E (mean difference -6.1 days, 95% CI -8.4 to -3.8, very low-quality evidence). One trial reported mortality, with no participant dying in either study group. Adverse events (reported by two trials) included one participant receiving the MI-E protocol experiencing haemodynamic compromise. Nine (22.5%) of the control group compared to two (6%) MI-E participants experienced secretion encumbrance with severe hypoxaemia requiring reintubation (RR 0.25, 95% CI 0.06 to 1.10). In the lung volume recruitment trial, one participant experienced an elevated blood pressure for more than 30 minutes. No participant experienced new-onset arrhythmias, heart rate increased by more than 25%, or a pneumothorax.For outcomes assessed using GRADE, we based our downgrading decisions on unclear risk of bias, inability to assess consistency or publication bias, and uncertainty about the estimate of effect due to the limited number of studies contributing outcome data.
  
  
  
  The overall quality of evidence on the efficacy of cough augmentation techniques for critically-ill people is very low. Cough augmentation techniques when used in mechanically-ventilated critically-ill people appear to result in few adverse events.
authors.affiliation: Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, 155 College St, Toronto, ON, Canada, M5T 1P8.|Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada.|Provincial Weaning Centre of Excellence, Toronto East General Hospital, Toronto, Canada.|Department of Critical Care Medicine and Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Canada.
authors.forename: Louise
authors.initials: L
authors.lastname: Rose
authors.affiliation: Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada.|Department of Critical Care Medicine and Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Canada.
authors.forename: Neill Kj
authors.initials: NK
authors.lastname: Adhikari
authors.affiliation: Critical Care, Department of Medicine, London Health Sciences Centre, 339 Windermere Road, London, ON, Canada, N6A 5A5.
authors.forename: David
authors.initials: D
authors.lastname: Leasa
authors.affiliation: Clinical Epidemiology Program, Ottawa Hospital Research Institute, 501 Smyth Road, Ottawa, ON, Canada, K1H 8L6.
authors.forename: Dean A
authors.initials: DA
authors.lastname: Fergusson
authors.affiliation: Respiratory Rehabilitation and Sleep Centre, Ottawa Hospital, 501 Smyth Rd, Ottawa, ON, Canada, K1H 8L6.
authors.forename: Douglas
authors.initials: D
authors.lastname: McKim
mesh_terms: D000328:Adult; D060666:Airway Extubation / Q000379:methods*; D015331:Cohort Studies; D003371:Cough / Q000503:physiopathology*; D016638:Critical Illness; D006801:Humans; D007223:Infant; D007327:Insufflation / Q000379:methods; D007362:Intensive Care Units; D007902:Length of Stay; D016032:Randomized Controlled Trials as Topic; D015300:Ventilator Weaning / Q000379:methods*