|
||||
|
|
Chinese Journal of Critical Care & Intensive Care Medicine(Electronic Edition) >
2020 , Vol. 06 >Issue 03: 272 - 282
DOI: https://doi.org/10.3877/cma.j.issn.2096-1537.2020.03.007
Expert consensus of airway clearance in critically ill patients
Airway clearance therapy is used to treat many diseases. This expert consensus is based on the impaired mechanism of airway clearance in critically ill patients, combined with the principles of pharmacologic and nonpharmacologic therapy, to select the appropriate treatment plan according to the following recommendations: (1) Hypertonic saline and isotonic saline atomization therapy can be used to induce the formation of sputum to facilitate specimen collection; (2) for patients with invasive mechanical ventilation, it is recommended that acetylcysteine be inhaled as needed according to the viscosity of airway secretion; (3) due to the lack of evidence on the safety and effectiveness of airway clearance drug inhalation, it is recommended not to use intravenous medication for aerosol inhalation; (4) before airway clearance, the causes of respiratory function and sputum excretion disorders should be evaluated to develop individualized airway clearance regimen; (5) PEP/OPEP can be used in the treatment of chronic obstructive pulmonary disease, cystic fibrosis, and bronchiectasis, which is more effective than conventional physical therapy, The therapeutic effect depends on the selected device, the set resistance and the compliance of patients; (6) the combined application of airway clearance technology is better than a single modality. For patients with artificial airways, tracheoscopy combined with vibratory sputum treatment significantly increases the clearance of airway secretions; (7) mechanical cough assistive technology can be used for patients with expiratory muscles weakness, but should be used with caution in patients with obstructive airway disease.
Key words： Airway clearance; Intensive care; Expert consensus
Respiratory Therapy Group of Chinese Society of Critical Care Medicine . Expert consensus of airway clearance in critically ill patients[J]. Chinese Journal of Critical Care & Intensive Care Medicine(Electronic Edition), 2020 , 06(03) : 272 -282 . DOI: 10.3877/cma.j.issn.2096-1537.2020.03.007
| 1 | Fahy JV, Dickey BF. Airway mucus function and dysfunction [J]. N Engl J Med, 2010, 363(23): 2233-2247. |
| 2 | Randell SH, Boucher RC. University of North Carolina Virtual Lung Group. Effective mucusclearance is essential for respiratory health [J]. Am J Respir Cell Mol Biol, 2006, 35(1): 20-28. |
| 3 | Rubin BK. Physiology of airway mucus clearance [J]. Respir Care, 2002, 47: 761. |
| 4 | Chilvers MA, O′Callaghan C. Local mucociliary defence mechanisms [J]. Paediatr Respir Rev, 2000, 1(1): 27-34. |
| 5 | Robert M, James K, Albert J. Egan′s Fundamentals of Respiratory Care [M]. 11 Edition. Geneeskunde algemeen：2012. |
| 6 | Chang AB. The physiology of cough [J]. Paediatr Respir Rev, 2006, 7(1): 2-8. |
| 7 | McCool FD. Global physiology and pathophysiology of cough: ACCP evidence-based clinical practice guidelines [J]. Chest, 2006, 129(1 Suppl): 48S-53S. |
| 8 | Innes AL, Woodruff PG, Ferrando RE, et al. Epithelial mucin stores are increased in the large airways of smokers with airflow obstruction [J]. Chest, 2006, 130(4): 1102-1108. |
| 9 | Fahy JV, Dickey BF. Airway mucus function and dysfunction [J]. N Engl J Med, 2010, 363(23): 2233-2247. |
| 10 | Ma J, Rubin BK, Voynow JA. Mucins, Mucus, and Goblet Cells [J]. Chest, 2018, 154(1): 169-176. |
| 11 | Liu CL, Shi GP. Calcium-activated chloride channel regulator 1 (CLCA1): More than a regulator of chloride transport and mucus production [J]. World Allergy Organ J, 2019, 12(11): 100077. |
| 12 | Rubin BK. Secretion properties, clearance, and therapy in airway disease [J]. Transl Respir Med, 2014, 2: 6. |
| 13 | Fahy JV, Dickey BF. Airway mucus function and dysfunction [J]. N Engl J Med, 2010, 363(23): 2233-2247. |
| 14 | 黄绍光, 康健, 林江涛, 等. 慢性气道炎症性疾病气道黏液高分泌管理中国专家共识 [J].中华结核和呼吸杂志, 2015, 38(10): 723-729. |
| 15 | Park GY, Park JW, Jeong DH, et al. Prolonged airway and systemic inflammatory reactions after smoke inhalation [J]. Chest, 2003, 123(2): 475-480. |
| 16 | Zorc JJ, Hall CB. Bronchiolitis: recent evidence on diagnosis and management [J]. Pediatrics, 2010, 125(2): 342-349. |
| 17 | Maselli R, Paciocco G. Asthma: pathophysiology of the bronchial obstruction [J]. Allergy, 2000, 55 (Suppl 61): 49-51. |
| 18 | Milne S, King GG. Advanced imaging in COPD: insights into pulmonary pathophysiology [J]. J Thorac Dis, 2014, 6(11): 1570-1585. |
| 19 | Schechter MS. Airway clearance applications in infants and children [J]. Respir Care, 2007, 52(10): 1382-1391. |
| 20 | Jolley SE, Bunnell AE, Hough CL. ICU-Acquired Weakness [J]. Chest, 2016, 150(5): 1129-1140. |
| 21 | Yang T, Li Z, Jiang L, et al. Corticosteroid use and intensive care unit-acquired weakness: a systematic review and meta-analysis [J]. Crit Care, 2018, 22(1): 187. |
| 22 | Batt J, Herridge M, Dos Santos C. Mechanism of ICU-acquired weakness: skeletal muscle loss in critical illness [J]. Intensive Care Med, 2017, 43(12): 1844-1846. |
| 23 | Benditt JO, Boitano LJ. Pulmonary issues in patients with chronic neuromuscular disease [J]. Am J Respir Crit Care Med, 2013, 187(10): 1046-1055. |
| 24 | van Wagenberg L, Witteveen E, Wieske L, et al Causes of Mortality in ICU-Acquired Weakness [J]. J Intensive Care Med, 2020, 35(3): 293-296. |
| 25 | Oliveira MA, Vidotto MC, Nascimento OA, et al. Evaluation of lung volumes, vital capacity and respiratory muscle strength after cervical, thoracic and lumbar spinal surgery [J]. Sao Paulo Med J, 2015, 133(5): 388-393. |
| 26 | Ayoub J, Cohendy R, Prioux J, et al. Diaphragm movement before and after cholecystectomy: a sonographic study [J]. Anesth Analg, 2001, 92(3): 755-761. |
| 27 | Kim SH, Na S, Choi JS, et al. An evaluation of diaphragmatic movement by M-mode sonography as a predictor of pulmonary dysfunction after upper abdominal surgery [J]. Anesth Analg, 2010, 110(5): 1349-1354. |
| 28 | Crema E, Benelli AG, Silva AV, et al. Assessment of pulmonary function in patients before and after laparoscopic and open esophagogastric surgery [J]. Surg Endosc, 2005, 19(1): 133-136. |
| 29 | Dureuil B, Cantineau JP, Desmonts JM. Effects of upper or lower abdominal surgery on diaphragmatic function [J]. Br J Anaesth, 1987, 59(10): 1230-1235. |
| 30 | Gazzotti MR, Vidotto MC, Sogame LC, et al. Vital capacity reduction in postoperative of elective craniotomy [J]. Rev Neurol, 2008, 47(3): 124-128. |
| 31 | Sogame LC, Faresin SM, Vidotto MC, et al. Postoperative study of vital capacity and ventilation measurements following elective craniotomy [J]. Sao Paulo Med J, 2008, 126(1): 11-16. |
| 32 | Di Pietro TL, Sogame LM, Vidotto MC, et al. Study of respiratory muscle strength, vital capacity, and ventilometry in the postoperative period of spinal surgery by posterior access [J]. Spine (Phila Pa 1976), 2006, 31(12): E367-E372. |
| 33 | Kallet RH. Adjunct therapies during mechanical ventilation: airway clearance techniques, therapeutic aerosols, and gases [J]. Respir Care, 2013, 58(6): 1053-1073. |
| 34 | Pneumatikos IA, Dragoumanis CK, Bouros DE. Ventilator-associated pneumonia or endotracheal tube-associated pneumonia? An approach to the pathogenesis and preventive strategies emphasizing the importance of endotracheal tube [J]. Anesthesiology, 2009, 110(3): 673-680. |
| 35 | Truong AD, Fan E, Brower RG, et al. Bench-to-bedside review: mobilizing patients in the intensive care unit--from pathophysiology to clinical trials [J]. Crit Care, 2009, 13(4): 216. |
| 36 | Strickland SL, Rubin BK, Drescher GS, et al. AARC clinical practice guideline: effectiveness of nonpharmacologic airway clearance therapies in hospitalized patients [J]. Respir Care, 2013, 58(12): 2187-2193. |
| 37 | Ntoumenopoulos G, Presneill JJ, McElholum M, et al. Chest physiotherapy for the prevention of ventilator-associated pneumonia [J]. Intensive Care Med, 2002, 28(7): 850-856. |
| 38 | Pattanshetty RB, Gaude GS. Effect of multimodality chest physiotherapy in prevention of ventilator-associated pneumonia: A randomized clinical trial [J]. Indian J Crit Care Med, 2010, 14(2): 70-76. |
| 39 | Guessous I, Cornuz J, Stoianov R, et al. Efficacy of clinical guideline implementation to improve the appropriateness of chest physiotherapy prescription among inpatients with community-acquired pneumonia [J]. Respir Med, 2008, 102: 1257-1263. |
| 40 | Spapen HD, De Regt J, Honoré PM. Chest physiotherapy in mechanically ventilated patients without pneumonia-a narrative review [J]. J Thorac Dis, 2017, 9(1): E44-E49. |
| 41 | 曾慧, 张珍, 龚媛, 等. 胸肺物理治疗用于机械通气患者的疗效:一项前瞻性随机对照研究 [J]. 中华危重病急救医学, 2017, 29(5): 403-406, 412. |
| 42 | Yang M, Yuping Y, Yin X, et al. Chest physiotherapy for pneumonia in adults [J]. Cochrane Database Syst Rev, 2010(2): CD006338. |
| 43 | s.n. Efficacy of chest physiotherapy and intermittent positive-pressure breathing in the resolution of pneumonia [J]. N Engl J Med, 1979, 300(5): 260-261. |
| 44 | s.n. AARC (American Association for Respiratory Care) clinical practice guideline. Postural drainage therapy [J]. Respir Care, 1991, 36(12): 1418-1426. |
| 45 | Cook TM, El-Boghdadly K, McGuire B, et al. Consensus guidelines for managing the airway in patients with COVID-19: Guidelines from the Difficult Airway Society, the Association of Anaesthetists the Intensive Care Society, the Faculty of Intensive Care Medicine and the Royal College of Anaesthetists [J]. Anaesthesia, 2020, 75(6): 785-799. |
| 46 | Todisco T, Polidori R, Rossi F, et al. Effect of N-acetylcysteine in subjects with slow pulmonary mucociliary clearance [J]. Eur J Respir Dis Suppl, 1985, 139: 136-141. |
| 47 | Masoompour SM, Anushiravani A, Tafaroj Norouz A. Evaluation of the Effect of Nebulized N-Acetylcysteine on Respiratory Secretions in Mechanically Ventilated Patients: Randomized Clinical Trial [J]. Iran J Med Sci, 2015, 40(4): 309-315. |
| 48 | van Meenen DMP, van der Hoeven SM, Binnekade JM, et al. Effect of On-Demand vs Routine Nebulization of Acetylcysteine With Salbutamol on Ventilator-Free Days in Intensive Care Unit Patients Receiving Invasive Ventilation: A Randomized Clinical Trial [J]. JAMA, 2018, 319(10): 993-1001. |
| 49 | Aylward M, Maddock J, Dewland P. Clinical evaluation of acetylcysteine in the treatment of patients with chronic obstructive bronchitis: a balanced double-blind trial with placebo control [J]. Eur J Respir Dis Suppl, 1980, 111: 81-89. |
| 50 | Youness HA, Mathews K, Elya MK, et al. Dornase alpha compared to hypertonic saline for lung atelectasis in critically ill patients [J]. J Aerosol Med Pulm Drug Deliv, 2012, 25(6): 342-348. |
| 51 | Rubin BK. Mucolytics, expectorants, and mucokinetic medications [J]. Respir Care, 2007, 52(7): 859-865. |
| 52 | Donaldson SH, Bennett WD, Zeman KL, et al. Mucus clearance and lung function in cystic fibrosis with hypertonic saline [J]. N Engl J Med, 2006, 354(3): 241-250. |
| 53 | Brightling CE. Clinical applications of induced sputum [J]. Chest, 2006, 129(5): 1344-1348. |
| 54 | Jager EG. Double-blind, placebo-controlled clinical evaluation of guaimesal in outpatients [J]. Clin Ther, 1989, 11(3): 341-362. |
| 55 | Rubin BK, Ramirez O, Ohar JA. Iodinated glycerol has no effect on pulmonary function, symptom score, or sputum properties in patients with stable chronic bronchitis [J]. Chest, 1996, 109(2): 348-352. |
| 56 | Hoffer-Schaefer A, Rozycki HJ, Yopp MA, et al. Guaifenesin has no effect on sputum volume or sputum properties in adolescents and adults with acute respiratory tract infections [J]. Respir Care, 2014, 59(5): 631-636. |
| 57 | 中华医学会呼吸病学分会雾化吸入疗法在呼吸疾病中的应用专家共识》制定专家组. 雾化吸入疗法在呼吸机疾病中的应用专家共识 [J]. 中华医学杂志, 2016, 96(34): 2696-2708. |
| 58 | Rogers DF. Mucoactive agents for airway mucus hypersecretory diseases [J]. Respir Care, 2007, 52(9): 1176-1197. |
| 59 | Rubin BK. Secretion properties, clearance, and therapy in airway disease [J]. Transl Respir Med, 2014, 2: 6. |
| 60 | Hashemian SM, Mortaz E, Jamaati H, et al. Budesonide facilitates weaning from mechanical ventilation in difficult-to-wean very severe COPD patients: Association with inflammatory mediators and cells [J]. J Crit Care, 2018, 44: 161-167. |
| 61 | Chen YQ, Li JP, Xiao J. Prophylactic effectiveness of budesonide inhalation in reducing postoperative throat complaints [J]. Eur Arch Otorhinolaryngol, 2014, 271(6): 1667-1672. |
| 62 | Kashefi P, Abbasi A, Abbasi M, et al. Comparison of the efficacy of nebulized budesonide and intravenous dexamethasone administration before extubation in prevention of post-extubation complications among patients admitted in intensive care unit [J]. Adv Biomed Res, 2015, 4: 11. |
| 63 | Vogelmeier CF, Criner GJ, Martinez FJ, et al. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease 2017 Report. GOLD Executive Summary [J]. Am J Respir Crit Care Med, 2017, 195(5): 557-582. |
| 64 | Bateman ED, Rennard S, Barnes PJ, et al. Alternative mechanisms for tiotropium [J]. Pulm Pharmacol Ther, 2009, 22(6): 533-542. |
| 65 | Tamaoki J, Chiyotani A, Tagaya E, et al. Effect of long term treatment with oxitropium bromide on airway secretion in chronic bronchitis and diffuse panbronchiolitis [J]. Thorax, 1994, 49(6): 545-548. |
| 66 | Volsko TA. Airway clearance therapy: finding the evidence [J]. Respir Care, 2013, 58(10): 1669-1678. |
| 67 | Strickland SL, Rubin BK, Drescher GS, et al. AARC clinical practice guideline: effectiveness of nonpharmacologic airway clearance therapies in hospitalized patients [J]. Respir Care, 2013, 58(12): 2187-2193. |
| 68 | Chatwin M, Toussaint M, Gon?alves MR, et al. Airway clearance techniques in neuromuscular disorders: A state of the art review [J]. Respir Med, 2018, 136: 98-110. |
| 69 | Westerdahl E, Osadnik C, Emtner M. Airway clearance techniques for patients with acute exacerbations of chronic obstructive pulmonary disease: Physical therapy practice in Sweden [J]. Chron Respir Dis, 2019, 16: 1479973119855868. |
| 70 | Snijders D, Fernandez Dominguez B, Calgaro S, et al. Mucociliary clearance techniques for treating non-cystic fibrosis bronchiectasis: Is there evidence? [J]. Int J Immunopathol Pharmacol, 2015, 28(2): 150-159. |
| 71 | Wilson LM, Morrison L, Robinson KA. Airway clearance techniques for cystic fibrosis: an overview of Cochrane systematic reviews [J]. Cochrane Database Syst Rev, 2019, 1(1): CD011231. |
| 72 | Ren S, Li W, Wang L, et al. Numerical Analysis of Airway Mucus Clearance Effectiveness Using Assisted Coughing Techniques [J]. Sci Rep, 2020, 10(1): 2030. |
| 73 | Mckoy NA, Wilson LM, Saldanha IJ, et al. Active cycle of breathing technique for cystic fibrosis [J]. Cochrane Database Syst Rev, 2016, 7: CD007862. |
| 74 | McCormack P, Burnham P, Southern KW. A systematic Cochrane Review of autogenic drainage (AD) for airway clearance in cystic fibrosis [J]. Paediatr Respir Rev, 2019, 29: 23-24. |
| 75 | McIlwaine M, Button B, Nevitt SJ. Positive expiratory pressure physiotherapy for airway clearance in people with cystic fibrosis [J]. Cochrane Database Syst Rev, 2019, 2019(11): CD003147. |
| 76 | Poncin W, Reychler G, Liistro M, et al. Comparison of 6 Oscillatory Positive Expiratory Pressure Devices During Active Expiratory Flow [J]. Respir Care, 2020, 65(4): 492-499. |
| 77 | de Souza Simoni LH, Dos Santos DO, de Souza HCD, et al. Acute Effects of Oscillatory PEP and Thoracic Compression on Secretion Removal and Impedance of the Respiratory System in Non-Cystic Fibrosis Bronchiectasis [J]. Respir Care, 2019, 64(7): 818-827. |
| 78 | Reychler G, Debier E, Contal O, et al. Intrapulmonary Percussive Ventilation as an Airway Clearance Technique in Subjects With Chronic Obstructive Airway Diseases [J]. Respir Care, 2018, 63(5): 620-631. |
| 79 | Nicolini A, Grecchi B, Ferrari-Bravo M, et al. Safety and effectiveness of the high-frequency chest wall oscillation vs intrapulmonary percussive ventilation in patients with severe COPD [J]. Int J Chron Obstruct Pulmon Dis, 2018, 13: 617-625. |
| 80 | 马玥. 振动排痰联合纤维支气管镜肺灌洗治疗重症肺炎机械通气患者的临床疗效 [J]. 中国医疗器械信息, 2020, 26(03): 107-109. |
| 81 | 李亚明, 张进召, 潘双. 纤维支气管镜肺泡灌洗诊疗术联合振动排痰对呼吸机相关性肺炎患者的影响 [J]. 实用心脑肺血管病杂志, 2020, 28(1): 97-101. |
| 82 | 吴袁琴, 陈凌波, 彭晶. 不同体位通气联合震动排痰在急性呼吸窘迫综合征患者中的应用及效果评价 [J]. 中国医药指南, 2019, 17(32): 112-113. |
| 83 | 孙烯辉, 杨丽, 黄德斌, 等. 机械通气患者胸部物理治疗效果的Meta分析 [J]. 护理学报, 2019, 26(17): 31-36. |
| 84 | Zorc JJ, Hall CB. Bronchiolitis: recent evidence on diagnosis and management [J]. Pediatrics, 2010, 125(2): 342-349. |
| 85 | Milne S, King GG. Advanced imaging in COPD: insights into pulmonary pathophysiology [J]. J Thorac Dis, 2014, 6(11): 1570-1585. |
| 86 | Masoompour SM, Anushiravani A, Tafaroj Norouz A. Evaluation of the Effect of Nebulized N-Acetylcysteine on Respiratory Secretions in Mechanically Ventilated Patients: Randomized Clinical Trial [J]. Iran J Med Sci, 2015, 40(4): 309-315. |
| 87 | Cho PSP, Birring SS, Fletcher HV, et al. Methods of Cough Assessment [J]. J Allergy Clin Immunol Pract, 2019, 7(6): 1715-1723. |
| 88 | Jiang C, Esquinas A, Mina B. Evaluation of cough peak expiratory flow as a predictor of successful mechanical ventilation discontinuation: a narrative review of the literature [J]. J Intensive Care, 2017, 5: 33. |
| 89 | Sohn D, Park GY, Koo H, et al. Determining Peak Cough Flow Cutoff Values to Predict Aspiration Pneumonia Among Patients With Dysphagia Using the Citric Acid Reflexive Cough Test [J]. Arch Phys Med Rehabil, 2018, 99(12): 2532-2539.e1. |
| 90 | Kang SW, Shin JC, Park CI, et al. Relationship between inspiratory muscle strength and cough capacity in cervical spinal cord injured patients [J]. Spinal Cord, 2006, 44(4): 242-248. |
| 91 | Kaneko H, Suzuki A, Horie J. Relationship of Cough Strength to Respiratory Function, Physical Performance, and Physical Activity in Older Adults [J]. Respir Care, 2019, 64(7): 828-834. |
| 92 | Khamiees M, Raju P, DeGirolamo A, et al. Predictors of extubation outcome in patients who have successfully completed a spontaneous breathing trial [J]. Chest, 2001, 120(4): 1262-1270. |
| 93 | Duan J, Zhou L, Xiao M, et al. Semiquantitative cough strength score for predicting reintubation after planned extubation [J]. Am J Crit Care, 2015, 24(6): e86-e90. |
| 94 | Desai MH, Mlcak R, Richardson J, et al. Reduction in mortality in pediatric patients with inhalation injury with aerosolized heparin/N-acetylcystine [J]. J Burn Care Rehabil, 1998, 19(3): 210-212. |
| 95 | Strickland SL, Rubin BK, Haas CF, et al. AARC Clinical Practice Guideline: Effectiveness of Pharmacologic Airway Clearance Therapies in Hospitalized Patients [J]. Respir Care, 2015, 60(7): 1071-1077. |
| 96 | Taube C, Holz O, Mücke M, et al. Airway response to inhaled hypertonic saline in patients with moderate to severe chronic obstructive pulmonary disease [J]. Am J Respir Crit Care Med, 2001, 164(10 Pt 1): 1810-1815. |
/
| 〈 |
|
〉 |
|
京ICP 备07035254号-19 Copyright © Chinese Journal of Critical Care & Intensive Care Medicine(Electronic Edition), All Rights Reserved. Tel: 010-51322627 E-mail: ccm@cma.org.cn Powered by Beijing Magtech Co. Ltd |