Secretion management

Pulmonaty Medicine Department, Intensive Care and Emergency Department, University Hospital S. Joao, Porto, Portugal 

In healthy individuals, mucociliary clearance and cough mechanisms are normally effective and efficient for defense on secretion encumbrance, but may become ineffective if these systems malfunction and in the presence of excessive bronchial secretions. Mucus secretion and clearance are extremely important for airway integrity and pulmonary defense. It has been estimated that mucus secretion volume is between 10 and 100 mL/day in healthy subjects (1). 

The effective elimination of airway mucus and other debris is one of the most important factor that permits successful use of chronic and acute ventilation support (noninvasive and invasive) for patients with either ventilatory or oxygenation impairment. In ventilatory dependent patients, the goals of intervention are to maintain lung compliance and normal alveolar ventilation at all times and to maximize cough flows for adequate bronchopulmonary secretion clearance (6). 

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Registered nurses, licensed practical nurse, assistants with experience in PMV, CTOss-trained in airway and secretion management provide patient and family education. Nursing care by jnotocols, e.g., tracheostomy care, indwelling lines, feeding tubes, bowel routines, bladder catheters, skin care, and communication with other team members Respiratory therapist... 

The issue of secretion management is addressed elsewhere in this text. However, mechanically assisted cough is an essential complement of NIV and a key to successful fulltime NIV (97). 

The term weaning encompasses two different stages with specific requirements (i) discontinuation of invasive ventilation and (//) removal of the artificial airway (Fig. 1). The first step is to assess the potential to discontinue invasive ventilation either to autonomous breathing or to NTV support. If the patient fulfills the necessary criteria, a formal spontaneous breathing test (SET) is performed. If successful, the patient can then be disconnected from the ventilator, or in case of a failed SET transitioned to NIV. The next step includes removal of the artificial airway, provided secretion management or upper airway obstruction is not an issue. 

Diaphragmatic pacing is a viable alternative to PPV for a small number of carefully selected patients, with SCI or central hypoventilation. Regular assessments by an experienced clinical team, backup ventilation, GPB, effective secretion management, and appropriate education will enable these complex patients to enjoy increased independence and an improved quality of life. 

VI. Mechanical Respiratory Muscle Aids for Secretion Management... 

Garstang SV, Kirshblum SC, Wood KE. Patient preference for in-exsufflation for secretion management with spinal cord injury. J Spinal Cord Med 2000 23(2) 80-85. 

Servera E, Sancho J, Zafra MJ, et al. Secretion management must be considered when reporting success or failure of noninvasive ventilation. Chest 2003 123 1773. 

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