Lane Fox Respiratory Service, St Thomas' Hospital, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom; Lane Fox Clinical Respiratory Physiology Centre, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom; Centre for Human and Applied Physiological Sciences (CHAPS), King's College London, London, United Kingdom.
Critical Care, St Thomas' Hospital, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom; GKT School of Medical Education, King's College London, London, United Kingdom.
Chest. 2024 Apr;165(4):929-941. doi: 10.1016/j.chest.2023.10.015. Epub 2023 Oct 14.
Respiratory muscle weakness can impair cough function, leading to lower respiratory tract infections. These infections are an important contributor to morbidity and mortality in patients with neuromuscular disease. Mechanical insufflation-exsufflation (MIE) is used to augment cough function in these patients. Although MIE is widely used, there are few data to advise on the optimal technique. Since the introduction of MIE, the recommended pressures to be delivered have increased. There are concerns regarding the use of higher pressures and their potential to cause lung derecruitment and upper airway closure.
What is the impact of high-pressure MIE (HP-MIE) on lung recruitment, respiratory drive, upper airway flow, and patient comfort, compared with low-pressure MIE (LP-MIE), in patients with respiratory muscle weakness?
Clinically stable patients using domiciliary MIE with respiratory muscle weakness secondary to Duchenne muscle dystrophy, spinal cord injury, or long-term tracheostomy ventilation received LP-MIE (30/-30 cm HO) and HP-MIE (60/-60 cm HO) in a random sequence. Lung recruitment, neural respiratory drive, and cough peak expiratory flow were measured throughout, and patients reported comfort and breathlessness following each intervention.
A total of 29 patients (10 with Duchenne muscle dystrophy, eight with spinal cord injury, and 11 with long-term tracheostomy ventilation) were included in this study. HP-MIE augmented cough peak expiratory flow compared with LP-MIE (mean cough peak expiratory flow HP-MIE 228 ± 81 L/min vs LP-MIE 179 ± 67 L/min; P = .0001) without any significant change in lung recruitment, neural respiratory drive, or patient-reported breathlessness. However, in patients with more pronounced respiratory muscle weakness, HP-MIE resulted in an increased rate of upper airway closure and patient discomfort that may have an impact on clinical efficacy.
HP-MIE did not lead to lung derecruitment or breathlessness compared with LP-MIE. However, it was poorly tolerated in individuals with advanced respiratory muscle weakness. HP-MIE generates more upper airway closure than LP-MIE, which may be missed if cough peak expiratory flow is used as the sole titration target.
ClinicalTrials.gov; No.: NCT02753959; URL: www.
gov.
呼吸肌无力可损害咳嗽功能，导致下呼吸道感染。这些感染是神经肌肉疾病患者发病率和死亡率的重要原因。机械通气-呼气（MIE）用于增强这些患者的咳嗽功能。尽管 MIE 应用广泛，但关于最佳技术的建议数据很少。自从 MIE 引入以来，建议的输送压力有所增加。人们对使用更高的压力及其导致肺去复张和上气道关闭的潜在风险表示担忧。
与低压力 MIE（LP-MIE）相比，高压力 MIE（HP-MIE）对呼吸肌无力患者的肺复张、呼吸驱动、上气道流量和患者舒适度有何影响？
患有由杜氏肌营养不良症、脊髓损伤或长期气管造口通气引起的呼吸肌无力的临床稳定患者接受 LP-MIE（30/-30 cm HO）和 HP-MIE（60/-60 cm HO）的随机顺序治疗。在整个过程中测量肺复张、神经呼吸驱动和咳嗽峰流速，并在每次干预后报告舒适度和呼吸困难。
本研究共纳入 29 例患者（10 例杜氏肌营养不良症、8 例脊髓损伤、11 例长期气管造口通气）。与 LP-MIE 相比，HP-MIE 增加了咳嗽峰流速（平均咳嗽峰流速 HP-MIE 228±81 L/min 与 LP-MIE 179±67 L/min；P=0.0001），而肺复张、神经呼吸驱动或患者报告的呼吸困难无明显变化。然而，在呼吸肌无力更严重的患者中，HP-MIE 导致上气道关闭和患者不适的发生率增加，这可能会对临床疗效产生影响。
与 LP-MIE 相比，HP-MIE 不会导致肺去复张或呼吸困难。然而，它在呼吸肌严重衰弱的个体中耐受性较差。HP-MIE 产生的上气道关闭比 LP-MIE 多，如果仅使用咳嗽峰流速作为滴定目标，可能会错过。
ClinicalTrials.gov；编号：NCT02753959；网址：www.clinicaltrials.gov。
