Excess Respiratory Secretions Research Articles

Incidence, causes, and predictors of unsuccessful decannulation following prolonged weaning.

Background:Liberation from prolonged tracheostomy ventilation involves ventilator weaning and removal of the tracheal cannula (referred to as decannulation). This study evaluated the incidence, causes, and predictors of unsuccessful decannulation following prolonged weaning.Methods:Observational retrospective cohort study of 532 prolonged mechanically ventilated, tracheotomized patients treated at a specialized weaning center between June 2013 and January 2021. We summarized the causes for unsuccessful decannulations and used a binary logistic regression analysis to derive and validate associated predictors.Results:Failure to decannulate occurred in 216 patients (41%). The main causes were severe intensive care unit (ICU)-acquired dysphagia (64%), long-term ventilator dependence following weaning failure (41%), excessive respiratory secretions (12%), unconsciousness (4%), and airway obstruction (3%). Predictors of unsuccessful decannulation from any cause were age [odds ratio (OR) = 1.04 year−1; 95% confidence interval (CI), 1.02–1.06; p < 0.01], body mass index [0.96 kg/m2 (0.93–1.00); p = 0.027], Acute Physiology and Chronic Health Evaluation II (APACHE-II) score [1.05 (1.00–1.10); p = 0.036], pre-existing non-invasive home ventilation [3.57 (1.51–8.45); p < 0.01], percutaneous tracheostomies [0.49 (0.30–0.80); p < 0.01], neuromuscular diseases [4.28 (1.21–15.1); p = 0.024], and total mechanical ventilation duration [1.02 day−1 (1.01–1.02); p < 0.01]. Regression models examined in subsets of patients with severe dysphagia and long-term ventilator dependence as the main reason for failure revealed little overlapping among predictors, which even showed opposite effects on the outcome. The application of non-invasive ventilation as a weaning technique contributed to successful decannulation in 96 of 221 (43%) long-term ventilator-dependent patients following weaning failure.Conclusion:Failure to decannulate after prolonged weaning occurred in 41%, mainly resulting from persistent ICU-acquired dysphagia and long-term ventilator dependence following weaning failure, each associated with its own set of predictors.

Idiopathic Parkinson's Disease at the End of Life: A Retrospective Evaluation of Symptom Prevalence, Pharmacological Symptom Management and Transdermal Rotigotine Dosing.

Distressing symptoms are prevalent in patients with idiopathic Parkinson's disease, yet little is known about symptom burden and subsequent pharmacological management at the end of life. Additionally, when oral administration of antiparkinsonian medications is no longer possible in dying patients, it is becoming common place to initiate transdermal rotigotine, despite a paucity of evidence to guide dosing. To assess: (1) symptom prevalence from the use of anticipatory medicines in patients with idiopathic Parkinson's disease, (2) the prescribing of antiparkinsonian medication at the end of life; and (3) the accuracy of conversion from oral antiparkinsonian medicines to transdermal rotigotine and any associations between rotigotine dosing and end-of-life symptoms. A retrospective case review was performed. One hundred consecutive patients with idiopathic Parkinson's disease who died during an inpatient admission at a UK teaching hospital were assessed. The most prevalent terminal symptoms were excess respiratory secretions (58%), pain (52%), agitation (51%) and fever (23%). The majority of patients were converted to transdermal rotigotine (90%). Patients converted to a higher than equivalent dose of rotigotine were more likely to be agitated (p<0.05), whilst those converted to a lower than equivalent dose were less likely to develop excess respiratory secretions (p<0.05). The prevalence of pain did not differ according to rotigotine dosing. This study highlights for the first time use of anticipatory medications at the end of life in patients with idiopathic Parkinson's disease and the prevalence of terminal symptoms. It also demonstrates the widespread use of rotigotine patches, and that lower than equivalent doses may be better tolerated.

Croup Is One of the Clinical Manifestations of Novel Coronavirus in Children

The manifestations of novel coronavirus are diverse and can manifest through respiratory, gastrointestinal, and even nervous symptoms. Respiratory involvement is usually an upper tract infection or pneumonia but can also present as other forms of pulmonary disorders. A 3-year-old boy presented with cough, hoarseness, and stridor. He was treated with dexamethasone and nebulized adrenaline and a clinical diagnosis of croup was established. After treatment, his symptoms improved for a short time, but suddenly cough exacerbated and was accompanied by respiratory failure and seizures. He was then intubated and mechanically ventilated. Because of the coronavirus epidemic, Reverse-Transcription Polymerase Chain Reaction (RT-PCR) assay was taken from the pharyngeal secretions and was positive. The child was isolated. Due to excessive respiratory secretions and worsening of the general condition, bronchoscopy was performed depicting an image compatible with bacterial tracheitis. He was treated with broad-spectrum antibiotics, antivirals, and supportive care. Finally, after 4 weeks of treatment, the child was discharged in good general condition. Croup is one of the respiratory symptoms of novel coronavirus and can be a risk factor for bacterial tracheitis. Therefore, the presence of clinical manifestations of croup indicates the need for coronavirus PCR testing.

N-acetylcysteine in clinical practice – properties, use and adverse effects

N-acetylcysteine is a simple chemical compound with antioxidant and mucolytic properties. Currently, it is the primary treatment for acetaminophen poisoning. Prior to the introduction of acetylcysteine, acetaminophen overdose was associated with high mortality due to acute liver failure. Owing to its antioxidant properties, acetylcysteine maintains appropriate levels of glutathione, thereby protecting the liver from damage by toxic metabolites of paracetamol. Acetylcysteine is also used for infections with excess respiratory secretions. The mechanism of action of cysteine derivatives involves cleavage of disulfide bonds between the macromolecules present in the mucus and, consequently, reduction of mucus viscosity. Clinical trials have shown that N-acetylcysteine also plays an important role in relieving cough by eliminating mucus from the airways. Owing to its antioxidant properties, it can also prevent contrast-induced nephropathy. It was shown that prophylactic doses of acetylcysteine administered the day before and at the day of contrast administration are effective in preventing contrastinduced nephropathy in patients with chronic kidney disease. The compound can also modulate pathophysiological processes involved in many mental and neurological disorders. There is also evidence supporting the efficacy of acetylcysteine in mental disorders such as autism, schizophrenia, Alzheimer’s disease, psychoactive substance dependence or bipolar disorder. However, in addition to its therapeutic activity, the drug may also induce adverse effects. Adverse effects of varying severity have been reported since the introduction of acetylcysteine into clinical use.

Could reflex cough induced through nebulized capsaicin achieve airway clearance in patients with acute retention of lung secretions?

Nasotracheal suctioning (NTS) is a procedure commonly performed by respiratory physiotherapists and nurses to remove excess respiratory secretions from the tracheobronchial tree in a self-ventilating, non-intubated and non-tracheotomized patient. NTS is an important treatment modality for patients with acute secretion retention who are at high risk of progressive respiratory deterioration and arrest. However, NTS is a blind invasive procedure with risk of serious adverse events, and the patient experience of NTS is often extremely negative.Capsaicin, a substance extracted from cayenne pepper, elicits reflex coughs when inhaled. It is hypothesized that capsaicin-induced reflex cough may offer an alternative treatment option to NTS. It is suggested that repeated reflex cough bouts, elicited through inhalation of nebulized capsaicin via a facemask, could achieve clearance of retained secretions from the tracheobronchial tree to the oropharynx, thereby avoiding the need for NTS.This hypothesis is supported by preliminary cough flow data from a stroke trial. Stroke patients underwent assessments of peak cough flow (PCF, a measure of cough effectiveness) of both maximal volitional cough and capsaicin-induced reflex cough. In a sub-group of 20 stroke patients with weak volitional cough (mean PCF 220 L/min, SD 80), PCF of capsaicin-induced reflex cough was on average 184 L/min (SD 130) higher than PCF of subjects’ maximal volitional cough effort. Cough flow traces indicate a pattern of cough augmentation during consecutive reflex cough bouts.It is suggested that the hypothesis may best be tested in a pragmatic applied clinical study, i.e. through the application of nebulized capsaicin in relevant clinical situations, as opposed to observational or experimental physiological studies.

Pharmacological Management of Symptoms in Children with Life-Limiting Conditions at the End of Life in the Asia Pacific.

The provision of pediatric palliative care in Asia Pacific varies between countries and availability of essential medications for symptoms at the end of life in this region is unclear. To determine medications available and used in the management of six symptoms at the end of life among pediatric palliative care practitioners in Asia Pacific. To identify alternative pharmacological strategies for these six symptoms if the oral route was no longer possible and injections are refused. An online survey of all Asia Pacific Hospice Palliative Care Network (APHN) members was carried out to identify medications used for six symptoms (pain, dyspnea, excessive respiratory secretions, nausea/vomiting, restlessness, seizures) in dying children. Two scenarios were of interest: (1) hours to days before death and (2) when injectables were declined or refused. There were 54 responses from 18 countries. Majority (63.0%) of respondents were hospital based. About half of all respondents were from specialist palliative care services and 55.6% were from high-income countries. All respondents had access to essential analgesics. Several perceived that there were no available drugs locally to treat the five other commonly encountered symptoms. There was a wide variation in preferred drugs for treating each symptom that went beyond differences in drug availability or formulations. Future studies are needed to explore barriers to medication access and possible knowledge gaps among service providers in the region, so that advocacy and education endeavors by the APHN may be optimized.

Noninvasive Ventilation for Acute Respiratory Failure due to Noncystic Fibrosis Bronchiectasis.

Purpose of the Study:Data regarding the use of noninvasive ventilation (NIV) for treatment of acute respiratory failure (ARF) among patients with noncystic fibrosis (CF) bronchiectasis are limited. We intend to describe our experience with NIV use in this setting.Methodology:This was a retrospective study which included 99 patients with bronchiectasis and ARF who required either NIV or invasive mechanical ventilation (IMV).Results:NIV was started as the primary modality of ventilatory support in 81 (66.3%) patients. Fifty-three (65.4%) patients were managed successfully with NIV. Twenty-eight (34.56%) patients failed NIV and required endotracheal intubation. Reasons for NIV failure were worsening or nonimprovement of ventilatory or oxygenation parameters (n = 15), hypotension (n = 6), worsening of sensorium (n = 3), and intolerance (n = 4). None of the patients failed NIV due to excessive respiratory secretions. The rate of correction of arterial blood gases was comparable between NIV and IMV groups. The total duration of stay (median [interquartile range] days) in hospital was comparable between patients treated with NIV and IMV (8 [7–10] vs. 11 [5–11]; P = 0.99), respectively. The mortality rate between NIV and IMV groups were statistically comparable (8.64% vs. 16.6%; P = 0.08). High APACHE score at admission was associated with NIV failure (odd's ratio [95% confidence interval]: 1.21 (1.07–1.38)].Conclusions:NIV is feasible for management of ARF with non-CF bronchiectasis. High APACHE may predict NIV failure among these patients.

O-6 A cluster randomised trial of clinically assisted hydration at the end of life

Background Clinically-assisted hydration (CAH) at the end-of-life is one of the most contentious issues in medicine, partly due to the fact that there is no good data to support/refute its use in this scenario. Methods The study was a cluster randomised trial (feasibility study) comparing CAH with oral care in patients with advanced cancer receiving end-of-life care under palliative care teams in 12 hospices/hospitals in the UK. The main outcomes related to the feasibility of conducting a definitive study, whilst the clinical outcomes included the prevalence of end-of-life care symptoms (particularly hyperactive delirium), adverse effects, and overall survival. Results 200 patients were recruited in 1 year, and all feasibility criteria were achieved. The prevalence of delirium was similar in the two groups, although the onset of delirium was delayed in the CAH group (112 hour versus 58 hour). Similar results were seen for excess respiratory secretions (”death rattle”). Median survival was greater in the CAH group (i.e. 5 days versus 3 days). Thirty-eight percent patients discontinued CAH due to perceived adverse effects (e.g. localised swelling, respiratory secretions). Conclusion Interventional trials are possible in patients at the end-of-life, but the methodology needs to be somewhat adapted. The results of the feasibility study suggest that CAH may have a positive influence of end-of-life problems, and possibly survival. However, a larger/definitive study is required to confirm these findings. CAH is associated with adverse effects in some patients, but these may be less than perceived by palliative care specialists.

Ophthalmic atropine for sublingual use: A novel treatment for excessive respiratory secretions

We describe a novel case of utilizing ophthalmic atropine suspension via sublingual route to control excessive secretions in a critically ill patient. In addition, a medication event related to a labeling and administration event is described where the patient received the drug via ophthalmic route. A 32-year-old Hispanic female presenting with NMDA-receptor antibody mediated encephalitis experienced a prolonged intensive care unit (ICU) stay secondary to hypercarbic respiratory failure complicated by excessive respiratory secretions. After one week on mechanical ventilation, the patient was set to undergo a percutaneous endoscopic gastrostomy (PEG) tube placement and tracheotomy. The patient’s respiratory status was compromised by copious secretion production, preventing the patient from being transitioned to the general care floor. For secretion control, pharmacological interventions such as scopolamine transdermal patches and glycopyrrolate oral tablets were trialed, however systemic exposure to these agents resulted in urinary retention requiring catherization with a mild and persistent tachycardia. Ophthalmic atropine was administered sublingually at a dose of 1 mg every six hours to provide local relief of the patient's secretion production. Secretion production improved within 72 hours and the patient’s urinary retention resolved at the time of scopolamine and glycopyrrolate discontinuation. Previously in the literature the use of sublingual atropine was only described for secretion control in patients receiving end of life care, drug induced sialorrhea and neuro-developmental disorders. As observed in this case report, sublingual atropine may be an effective treatment to control respiratory secretions in critically ill patients who are unable to tolerate other therapies.

Quality end of life care

Implemented on an all-Wales basis in 2000 the Welsh Integrated Care Pathway (ICP) for the last days of life has gone from strength to strength. Starting with 38 sites there...

Clinical course and spectrum of intensive care unit patients reactivating herpes simplex-1 virus: A retrospective analysis

Background:Herpes simplex-1 virus (HSV-1) reactivation in the respiratory tract is common in intensive care unit (ICU) patients. However, susceptible ICU populations are poorly defined. Clinical recognition of HSV infection of the respiratory tract is difficult and the impact of such reactivation is not understood.Materials and Methods:A retrospective analysis of HSV-1 positive patients encountered over a 5-year period at a multispecialty ICU was carried out. HSV-1 was identified in respiratory secretions using a qualitative polymerase chain reaction (PCR) technique. Patient charts were reviewed for clinical features that would typify HSV-1 respiratory involvement, and the morbidity and mortality risks found with HSV-1 respiratory involvement.Results:A review of 48 HSV-1 positive ICU patients showed that patients reactivating HSV in the respiratory tract fell into one of the three categories: (1) septic elderly patients with and without ARDS, (2) immunosuppressed patients, especially those receiving high-dose steroids, and (3) post-thoracotomy patients. Abnormalities suggestive of HSV-1 reactivation in the respiratory tract included, haemorrhagic or excessive respiratory secretions, concomitant orofacial herpes (42%), and bronchoscopic abnormalities (hemorrhagic ulcers and mucosal friability) (83%). Twenty eight percent of the HSV-1 infected patients experienced postextubation stridor. HSV-1 reactivation was associated with extended ventilator stays, significant mortality (42%), and ventilator-associated pneumonias (52%).Conclusions:Identification of susceptible populations and definition of clinical features of HSV-1 related respiratory disease can enable diagnosis of HSV-1 infection in ICU patients. Although detection by a PCR technique can rapidly diagnose HSV-1 reactivation, prospective studies are required to clarify HSV disease versus mere shedding, and understand the impact of HSV-1 reactivation in hospitalized patients.

‘Death rattle’ after withdrawal of mechanical ventilation: Practical and ethical considerations

The noise produced by oscillatory movements of secretions in oropharynx, hypopharynx and trachea during inspiration and expiration in unconscious terminal patients is often described as 'the death rattle'. The reported incidence of death rattle in terminally ill patients varied between six and 92%. It is most commonly reported in patients dying from pulmonary malignancies, primary brain tumours or brain metastases, and predicts death within 48 hours in 75% of the patients. Clinical studies demonstrate that hyoscine hydrobromide is effective at improving symptoms. After withdrawal of artificial ventilation on the intensive care unit, excessive respiratory secretions resulting in rattling breathing, during the last hours of life, is not uncommon. Physicians and nurses experience considerable difficulties and frustrations in treating the death rattle. The distressing experience and negative influence in the bereavement process indicates an ethical demand to treat this symptom from the perspective of others merely than that of the patient. This article provides practical and ethical considerations in the management of this near-death symptom. The fact that relatives were relieved in almost all cases, in which a positive effect was obtained, makes treatment in anticipation of death rattle an ethical demand. In practice, injectable scopolamine is the reference drug for symptomatic treatment of death rattle.

Extubation failure: an outcome to be avoided

Extubation failure is an outcome of increasing importance but nearly all studies have been conducted in academic settings. The article by Seymour and colleagues demonstrates that extubation failure is an outcome to be avoided in the community hospital setting as well. Patients failing extubation experience longer lengths of stay, experience higher intensive care unit mortality, and incur greater hospital costs. Investigators have identified tools for predicting extubated patients at highest risk for reintubation. The predictors focus on detecting upper airway obstruction, inadequate cough, excess respiratory secretions, and abnormal mental status. Systematic application of these predictors has the potential to improve outcome.

Extubation failure: magnitude of the problem, impact on outcomes, and prevention.

Extubation failure, defined as the need for reinstitution of ventilatory support within 24 to 72 hours of planned endotracheal tube removal, occurs in 2 to 25% of extubated patients. The pathophysiologic causes of extubation failure include an imbalance between respiratory muscle capacity and work of breathing, upper airway obstruction, excess respiratory secretions, inadequate cough, encephalopathy, and cardiac dysfunction. Compared with patients who tolerate extubation, those who require reintubation have a higher incidence of hospital mortality, increased length of ICU and hospital stay, prolonged duration of mechanical ventilation, higher hospital costs, and an increased need for tracheostomy. Given the lack of proven treatments for extubation failure, clinicians must be aware of the factors that predict extubation outcome to improve clinical decision making. Risk factors for extubation failure include being a medical, multidisciplinary, or pediatric patient; age greater than 70 years; a longer duration of mechanical ventilation; continuous intravenous sedation; and anemia. Tests designed to assess for upper airway obstruction, secretion volume, and the effectiveness of cough can help to improve prediction of extubation failure. Rapid reinstitution of ventilatory support in patients who fail extubation may improve outcome.

An integrated care pathway for the last two days of life: Wales-wide benchmarking in palliative care.

Functional benchmarking assesses performance and practice across a broad range of settings and carries the potential to effect change in practice. An integrated care pathway (ICP) can assist in the benchmarking process, defining desired outcomes for specific patient groups over a designated time frame. Any variations to the agreed course of care are documented using the 'variance sheet'. This article describes the Wales-wide implementation of an ICP for the last two days of life. The project has enabled an ongoing centralized collection and analysis of variance sheets, which reflect the care of the dying patient in four different care settings crossing the voluntary and statutory sectors. Initial analysis of the first 500 variance sheets to be generated by the ICP for the last two days of life indicates that the management of pain, agitation, excess respiratory secretions and mouth care may be problematic. The same problems were experienced across acute, hospice, specialist inpatient units and community care. Closing the audit cycle involves incorporating the information from the variance analysis into clinical practice.

Decision to extubate.

The need for reintubation within 24-72 h of planned extubation is a common event, occurring in 2-25% of extubated patients. Risk factors for extubation failure include being a medical, multidisciplinary or paediatric patient; age >70 years; a longer duration of mechanical ventilation; use of continuous intravenous sedation; and anaemia (haemoglobin <10 g/dl or haematocrit <30%) at the time of extubation. The pathophysiology of extubation failure can be distinct from that seen with weaning failure and includes upper airway obstruction, inadequate cough, excess respiratory secretions, encephalopathy, and cardiac dysfunction. Extubation failure prolongs the duration of mechanical ventilation, increases the length of ICU and hospital stay, increases the need for tracheostomy, and is associated with a higher hospital mortality. Great emphasis has been placed on accurately predicting extubation outcome because extubation delay is also associated with increased length of stay and mortality. Tests designed to assess for upper airway obstruction, secretion volume, and the effectiveness of cough seem most promising for improving the decision to extubate. Mortality increases with delays in reintubation for patients failing extubation. Timely identification of patients at elevated risk of extubation failure followed by rapid re-establishment of ventilatory support can improve outcome.