The use of Mechanical Insufflation Exsufflation to prevent extubation failure in adult intensive care

Swingwood, Emma

Abstract

Introduction
A failed attempt to remove artificial ventilatory support in intensive care is associated with increased length of stay, impaired quality of life and higher mortality. One cause of this failure, secretion retention, results from poor cough effectiveness. A Mechanical Insufflation-Exsufflation device simulates cough, to aid secretion clearance which may help with the removal of artificial ventilation.
Aims
The aims of this research were to:
• Summarise the evidence-base regarding Mechanical Insufflation-Exsufflation in intensive care;
• Explore barriers and enablers for Mechanical Insufflation-Exsufflation use as perceived by clinicians working in intensive care; and
• Determine the feasibility of conducting a randomised controlled trial exploring Mechanical Insufflation-Exsufflation to promote successful removal of artificial ventilation.

Methods
A scoping review of primary research studies investigating the use of Mechanical Insufflation-Exsufflation with critically ill invasively ventilated adults was undertaken. Semi-structured online interviews were carried out with clinicians with experience of working in intensive care. Transcripts were analysed using content analysis, assigning quotes to Theoretical Domains Framework.
A single centre feasibility randomised controlled trial compared standard physiotherapy to Mechanical Insufflation-Exsufflation plus standard care. Trial analyses was descriptive based on feasibility outcomes. Electrical Impedance Tomography explored lung recruitment/de-recruitment during Mechanical Insufflation-Exsufflation. Semi-structured online interviews with patient participant and clinicians explored acceptability.
Results
The scoping review (28 studies) demonstrated variation in the methods used to deliver Mechanical Insufflation-Exsufflation as well as the outcomes measured, limiting the ability to make recommendations. A lack of qualitative data was also apparent.
Clinician interviews (n=29) indicated that knowledge and skills can facilitate initiation of Mechanical Insufflation-Exsufflation. Device use varies across specific professional groups. Culture and hierarchy are barriers to device implementation, and skill and knowledge development.
In general, feasibility and acceptability of a definitive trial was demonstrated but clinician interviews highlighted challenges regarding intervention timing and outcomes used. Patients described benefit from Mechanical Insufflation-Exsufflation despite experiencing discomfort.

Conclusion
This research demonstrated complex interplay between sources of knowledge and factors influencing Mechanical Insufflation-Exsufflation initiation. The design of a future definitive trial needs to take account of existing device use, methods of device application and outcome measurement.

• Thesis Type: Thesis
• Deposit Date: May 6, 2024
• Publicly Available Date: Sep 25, 2024
• Public URL: https://uwe-repository.worktribe.com/output/11977576
• Award Date: Sep 25, 2024