What’s new in management and clearing of airway secretions in ICU patients? It is time to focus on cough augmentation

  • Nicolas Terzi
  • Claude GuerinEmail author
  • Miguel R. Gonçalves
What's New in Intensive Care


An effective clearing of the airways requires a balance between production and removal of respiratory secretions through the muco-ciliary escalator. In ICU patients, both sides of the balance can be impaired. The amount of respiratory secretions can be increased from infection, aspiration, or swallowing disorders. The removal of respiratory secretions can be reduced by upper airway dysfunction and/or respiratory muscle weakness. Many pre-existing or ICU-acquired situations, like chronic neuromuscular disease (NMD), ICU-acquired neuromuscular weakness, sepsis, delirium or conscious level decline due to brain damage may compromise optimal glottis functioning or respiratory muscle strength [1] and, hence, promote unbalance between production and removal of respiratory secretions. Important pathophysiological consequences of this unbalance include increased airway resistance and work of breathing, hypoxemia, atelectasis, and superinfection. Any caregiver in the ICU, whether...


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Conflicts of interest

The authors declare no conflict of interest.


  1. 1.
    Demoule A, Jung B, Prodanovic H, Molinari N, Chanques G et al (2013) Diaphragm dysfunction on admission to the intensive care unit. Prevalence, risk factors, and prognostic impact—a prospective study. Am J Respir Crit Care Med 188:213–219CrossRefPubMedGoogle Scholar
  2. 2.
    Thille AW, Richard JC, Brochard L (2013) The decision to extubate in the intensive care unit. Am J Respir Crit Care Med 187:1294–1302CrossRefPubMedGoogle Scholar
  3. 3.
    Beduneau G, Pham T, Schortgen F, Piquilloud L, Zogheib E et al (2017) Epidemiology of weaning outcome according to a new definition. The WIND study. Am J Respir Crit Care Med 195:772–783CrossRefPubMedGoogle Scholar
  4. 4.
    Jaber S, Quintard H, Cinotti R, Asehnoune K, Arnal JM et al (2018) Risk factors and outcomes for airway failure versus non-airway failure in the intensive care unit: a multicenter observational study of 1514 extubation procedures. Crit Care 22:236CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Thille AW, Cortes-Puch I, Esteban A (2013) Weaning from the ventilator and extubation in ICU. Curr Opin Crit Care 19:57–64CrossRefPubMedGoogle Scholar
  6. 6.
    Beuret P, Roux C, Auclair A, Nourdine K, Kaaki M et al (2009) Interest of an objective evaluation of cough during weaning from mechanical ventilation. Intensive Care Med 35:1090–1093CrossRefPubMedGoogle Scholar
  7. 7.
    Smina M, Salam A, Khamiees M, Gada P, Amoateng-Adjepong Y et al (2003) Cough peak flows and extubation outcomes. Chest 124:262–268CrossRefPubMedGoogle Scholar
  8. 8.
    Salam A, Tilluckdharry L, Amoateng-Adjepong Y, Manthous CA (2004) Neurologic status, cough, secretions and extubation outcomes. Intensive Care Med 30:1334–1339CrossRefPubMedGoogle Scholar
  9. 9.
    Duan J, Liu J, Xiao M, Yang X, Wu J et al (2014) Voluntary is better than involuntary cough peak flow for predicting re-intubation after scheduled extubation in cooperative subjects. Respir Care 59:1643–1651CrossRefPubMedGoogle Scholar
  10. 10.
    Terzi N, Lofaso F, Masson R, Beuret P, Normand H et al (2018) Physiological predictors of respiratory and cough assistance needs after extubation. Ann Intensive Care 8:18CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Gobert F, Yonis H, Tapponnier R, Fernandez R, Labaune MA et al (2017) Predicting extubation outcome by cough peak flow measured using a built-in ventilator flow meter. Respir Care 62:1505–1519CrossRefPubMedGoogle Scholar
  12. 12.
    Templeton M, Palazzo MG (2007) Chest physiotherapy prolongs duration of ventilation in the critically ill ventilated for more than 48 hours. Intensive Care Med 33:1938–1945CrossRefPubMedGoogle Scholar
  13. 13.
    Ntoumenopoulos G (2007) Comment on “Chest physiotherapy prolongs duration of ventilation in the critically ill ventilated for more than 48 hours” by Drs. Templeton and Palazzo. Intensive Care Med 33:2027 (author reply 2028–2029) CrossRefPubMedGoogle Scholar
  14. 14.
    Castro AA, Calil SR, Freitas SA, Oliveira AB, Porto EF (2013) Chest physiotherapy effectiveness to reduce hospitalization and mechanical ventilation length of stay, pulmonary infection rate and mortality in ICU patients. Respir Med 107:68–74CrossRefPubMedGoogle Scholar
  15. 15.
    Chatwin M, Toussaint M, Goncalves MR, Sheers N, Mellies U et al (2018) Airway clearance techniques in neuromuscular disorders: a state of the art review. Respir Med 136:98–110CrossRefPubMedGoogle Scholar
  16. 16.
    Rose L, Adhikari NK, Leasa D, Fergusson DA, McKim D (2017) Cough augmentation techniques for extubation or weaning critically ill patients from mechanical ventilation. Cochrane Database Syst Rev 1:CD011833PubMedGoogle Scholar
  17. 17.
    Goncalves MR, Honrado T, Winck JC, Paiva JA (2012) Effects of mechanical insufflation-exsufflation in preventing respiratory failure after extubation: a randomized controlled trial. Crit Care 16:R48CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Bach JR, Goncalves MR, Hamdani I, Winck JC (2010) Extubation of patients with neuromuscular weakness: a new management paradigm. Chest 137:1033–1039CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Service de Médecine Intensive-RéanimationCentre Hospitalier Universitaire GrenobleGrenobleFrance
  2. 2.Université de GrenobleGrenobleFrance
  3. 3.INSERM, U1042, University of Grenoble-AlpesGrenobleFrance
  4. 4.Service de Médecine intensive-RéanimationHospices civils de LyonLyonFrance
  5. 5.Université de LyonLyonFrance
  6. 6.INSERM 955CréteilFrance
  7. 7.Noninvasive Ventilatory Support Unit, Pulmonology DepartmentSão João University HospitalPortoPortugal
  8. 8.Intensive Care Medicine DepartmentSão João University HospitalPortoPortugal
  9. 9.Faculty of MedicineUniversity of PortoPortoPortugal

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