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BACKGROUND: Mechanical insufflation-exsufflation (MI-E) applied through the endotracheal tube (ETT) can effectively eliminate airway secretions in intubated patients. However, the effect of the interface (ETT vs face mask) on expiratory air flow generated by MI-E has not been investigated. This study aimed to investigate the effect of the ETT on peak expiratory flow (PEF) along with other associated factors that could influence PEF generated by MI-E. METHODS: Intubated participants received 2 sessions of MI-E via ETT therapy per d for 2 consecutive days. One MI-E session consisted of 5 sets of either constant (+40/−40 cm H2O) or incremental (+30/−30 to +50/−50 cm H2O) pressure applications. Following extubation, MI-E sessions were repeated using face mask. Expiratory air flow during MI-E therapy was continuously measured, and every PEF during each application was analyzed using linear mixed-effect and generalized linear mixed models. RESULTS: A total of 12 participants (9 [75.0%] men; mean [SD] age, 74.0 [10.2] y) completed all MI-E sessions with both ETT and face mask interfaces. The PEF generated during MI-E treatment was influenced by the interface (ETT vs face mask), pressure gradient, and number of session repetitions. Adjusted mean PEF values for MI-E via ETT and face mask at +40/−40 cm H2O were −2.521 and −3.114 L/s, respectively, and −2.956 and −3.364 L/s at +50/−50 cm H2O, respectively. At a pressure gradient of +40/−40 cm H2O, only 172 of 528 MI-E trials via ETT (32.6%) achieved a PEF faster than −2.7 L/s, whereas 304 of 343 MI-E trials via face mask (88.6%) exceeded PEF CONCLUSIONS: MI-E via ETT generated slower PEF than via face mask, suggesting that a higher-pressure protocol should be prescribed for intubated patients. An insufflation-exsufflation pressure up to +50/−50 cm H2O could be considered to produce a PEF faster than 2.7 L/s, and the applications were safe and feasible for subjects on invasive mechanical ventilation.

BACKGROUND: Mechanical insufflation-exsufflation (MI-E) is a noninvasive technique performed to simulate cough and remove sputum from proximal airways. To date, the effects of MI-E on critically ill patients on invasive mechanical ventilation are not fully elucidated. In this randomized crossover trial, we evaluated the efficacy and safety of MI-E combined to expiratory rib cage compressions (ERCC). METHODS: Twenty-six consecutive subjects who were sedated, intubated, and on mechanical ventilation > 48 h were randomized to perform 2 sessions of ERCC with or without additional MI-E before tracheal suctioning in a 24-h period. The primary outcome was sputum volume following each procedure. Secondary end points included effects on respiratory mechanics, hemodynamics, and safety. RESULTS: In comparison to ERCC alone, median (interquartile range) sputum volume cleared was significantly higher during ERCC+MI-E (0.42 [0–1.39] mL vs 2.29 [1–4.67] mL, P < .001). The mean ± SD respiratory compliance improved in both groups immediately after the treatment, with the greater improvement in the ERCC+MI-E group (54.7 ± 24.1 mL/cm H(2)O vs 73.7 ± 35.8 mL/cm H(2)O, P < .001). Differences between the groups were not significant (P = .057). Heart rate increased significantly in both groups immediately after each intervention (P < .05). Additionally, a significant increase in oxygenation was observed from baseline to 1 h post-intervention in the ERCC+MI-E group (P < .05). Finally, several transitory hemodynamic variations occurred during both interventions, but these were nonsignificant and were considered clinically irrelevant. CONCLUSIONS: In mechanically ventilated subjects, MI-E combined with ERCC increased the sputum volume cleared without causing clinically important hemodynamic changes or adverse events. (ClinicalTrials.gov registration: NCT03316079.)

Many neuromuscular disease patient populations suffer from a weak, inadequate cough, which may lead to respiratory tract infections, respiratory failure, and increased mortality. Hospitalized neuro...

Aim Ventilator-associated pneumonia (VAP) is the most common intensive care unit (ICU)-acquired infection. The current study aimed to assess the efficacy of mechanical insufflation-exsufflation (MI-E) in preventing VAP in critically ill patients. Materials and methods This retrospective cohort study was conducted at the ICU of Chiba University Hospital between January 2014 and September 2017. The inclusion criteria were patients who required invasive mechanical ventilation ≥48 hours and those who underwent rehabilitation, including chest physical therapy (CPT). In 2015, the study institution started the use of MI-E in patients with impaired cough reflex. From January to December 2014, patients undergoing CPT were classified under the historical control group, and those who received treatment using MI-E from January 2015 to September 2017 were included in the intervention group. The patients received treatment using MI-E via the endotracheal or tracheostomy tube, with insufflation-exsufflation pressure of 15-40 cm H2O. The treatment frequency was one to three sessions daily, and a physical therapist who is experienced in using MI-E facilitated the treatment. Results From January 2015 to September 2017, 11 patients received treatment using MI-E. Of the 169 patients screened in 2014, 19 underwent CPT. The incidence of VAP was significantly different between the CPT and MI-E groups (84.2% [16/19] vs 26.4% [3/11], p = 0.011). After adjusting for covariates, a multivariate logistic regression analysis was performed, and results showed that the covariates were not associated with the incidence of VAP. Conclusion This retrospective cohort study suggests that the use of MI-E in critically ill patients is independently associated with a reduced incidence of VAP. Clinical significance Assessing the efficacy of MI-E to prevent VAP. How to cite this article Kuroiwa R, Tateishi Y, Oshima T, Inagaki T, Furukawa S, Takemura R, et al. Mechanical Insufflation-exsufflation for the Prevention of Ventilator-associated Pneumonia in Intensive Care Units: A Retrospective Cohort Study. Indian J Crit Care Med 2021;25(1):62-66.

BACKGROUND: Mechanical insufflation-exsufflation (MI-E) applied via tracheostomy tubes in patients with amyotrophic lateral sclerosis (ALS) who are on home mechanical ventilation via tracheostomy is an effective procedure for respiratory secretion management. Nonetheless, tenacious secretions may remain and increase the risk of respiratory infections. The aim of this study was to determine whether adding oscillations to MI-E could reduce the rate of respiratory infections and the need for bronchoscopy to remove secretions in patients with ALS on home mechanical ventilation via tracheostomy. METHODS: This was a 2-y, prospective, crossover study. Subjects were treated with conventional MI-E and MI-E with oscillations for 2 alternate 6-month periods. Data were collected on episodes of respiratory infections, hospital admission, and number of bronchoscopy procedures. RESULTS: In the 19 ALS subjects enrolled, the median (interquartile range [IQR]) number of acute respiratory infections per subject was 1.0 (0.5–2.0) in the MI-E period and 0.0 (0.0–2.0) in the MI-E plus oscillations period (P = .92). The median (IQR) number of hospital stays was 0.0 (0.0–1.0) in the MI-E period and 0.0 (0.0–1.0) in the MI-E plus oscillations period (P = .80). The median (IQR) number of bronchoscopies per subject was 0.0 (0.0–1.0) in MI-E period and 0.0 (0.0–0.5) in the MI-E plus oscillations period (P = .26). MI-E plus oscillations treatment had no impact on the risk of respiratory infections (odds ratio 3.71, 95% CI 0.81–16.84, P = .09) or the need for bronchoscopy (odds ratio 2.70, 95% CI 0.44–16.68, P = .29). CONCLUSIONS: Adding oscillations to MI-E therapy in subjects with ALS on home mechanical ventilation via tracheostomy did not decrease the risk of respiratory infections, hospital admission, or need for bronchoscopy.

Mechanical insufflation-exsufflation (MI-E) was introduced in the early 1950s by Barach, Beck, Bickerman, and colleagues[1][1]–[7][2] as a method for improving cough in patients with neuromuscular weakness, respiratory disease, and retained pulmonary secretions. Their work reported enhanced

Introduction Electrostatic precipitation Pressurized IntraPeritoneal Aerosol Chemotherapy (ePIPAC) has shown superior penetration depth and tissue uptake compared to standard PIPAC. We investigated the feasibility and objective tumor response to ePIPAC with 1 min of precipitation in patients with peritoneal metastasis (PM). Materials and methods Patients with PM from various abdominal cancers were included in an amendment to the ongoing prospective PIPAC-OPC2 trial. Colorectal and appendiceal PM were treated with oxaliplatin, patients with PM from other primaries were treated with a combination of cisplatin and doxorubicin. Three ePIPAC procedures were planned in each patient including repeated peritoneal biopsies for response evaluation. After emission to the peritoneal cavity, the aerosolized chemotherapeutics were precipitated for 1 min followed by immediate exsufflation and abdominal closure. Histological regression from the first to the third ePIPAC was evaluated according to the Peritoneal Regression Grading Score (PRGS) and compared to data from the PIPAC-OPC1 trial. Complications and toxicities were recorded according to Dindo-Clavien and CTCAE. Results Sixty-five ePIPAC procedures were performed in 33 patients (median 2, range 1–6). Ten patients were eligible for response evaluation based on biopsies from the first and third ePIPAC procedure. Four patients had disease progression, four patients had regressive disease, and two patients had stable disease according to PRGS. No life threatening adverse reactions and no mortality was observed following ePIPAC. Conclusion One minute ePIPAC was feasible and safe, but the histological tumor response was insufficient compared to standard PIPAC directed therapy with 30 min passive diffusion time.

BACKGROUND: Despite expert recommendations for use, limited evidence identifies effectiveness of mechanical insufflation-exsufflation (MI-E) in addressing respiratory morbidity and resultant health care utilization and costs for individuals with neuromuscular disorders. We examined the impact of provision of publicly funded MI-E devices on health care utilization, health care costs, and survival trajectory. METHODS: This is a retrospective pre/post cohort study linking data on prospectively recruited participants using MI-E to health administrative databases to quantify outcomes. RESULTS: We linked data from 106 participants (8 age < 15 y) and determined annualized health care use pre/post device. We found no difference in emergency department (ED) visit or hospital admission rates. Following MI-E approval, participants required fewer hospital days (median [interquartile range] [IQR]) 0 [0–9] vs 0 [0–4], P = .03). Rates of physician specialist visits also decreased (median IQR 7 [4–11] vs 4 [2–7], P < .001). Conversely, rates of home care nursing and homemaking/personal support visits increased. Following MI-E, total costs were lower for 59.4%, not different for 13.2%, and higher for 27.4%. Physician billing costs decreased whereas home care costs increased. Regression modeling identified pre-MI-E costs were the most important predictor of costs after approval. At 12 months, 23 (21.7%) participants had died. Risk of death was higher for those using more medical devices (hazard ratio 1.12, [95% CI 1.02–1.22]) in the home. CONCLUSIONS: Provision of publicly funded MI-E devices did not influence rates of ED visits or hospital admission but did shift health care utilization and costs from the acute care to community sector. Although increased community costs negated cost savings from physician billings, evidence suggests costs savings from reduced hospital days and fewer specialist visits. Risk of death was highest in individuals requiring multiple medical technologies.

Background and objectives To investigate the effect of the steep Trendelenburg position (35° to 45°) and carbon dioxide (CO2) insufflation on optic nerve sheath diameter (ONSD), intraocular pressure (IOP), and hemodynamic parameters in patients undergoing robot-assisted laparoscopic prostatectomy (RALP), and to evaluate possible correlations between these parameters. Methods A total of 34 patients were included in this study. ONSD was measured using ultrasonography and IOP was measured using a tonometer at four time points: T1 (5 minutes after intubation in the supine position); T2 (30 minutes after CO2 insufflation); T3 (120 minutes in steep Trendelenburg position); and T4 (in the supine position, after abdominal exsufflation). Systolic and diastolic arterial pressure, heart rate, and end-tidal CO2 (etCO2) were also evaluated. Results The mean IOP was 12.4 mmHg at T1, 20 mmHg at T2, 21.8 mmHg at T3, and 15.6 mmHg at T4. The mean ONSD was 4.87 mm at T1, 5.21 mm at T2, 5.30 mm at T3, and 5.08 at T4. There was a statistically significant increase and decrease in IOP and ONSD between measurements at T1 and T4, respectively. However, no significant correlation was found between IOP and ONSD. A significant positive correlation was found only between ONSD and diastolic arterial pressure. Mean arterial pressure, heart rate, and etCO2 were not correlated with IOP or ONSD. Conclusions A significant increase in IOP and ONSD were evident during RALP; however, there was no significant correlation between the two parameters.

Upper airways (UA) include the nasal cavities, pharynx, and larynx, and its main function is to warm and filter the inspired air. UA dysfunction is in the pathogenesis of various disorders, such as obstructive sleep apnea syndrome (OSAS) and vocal cord dysfunction. In addition, in some neurodegenerative diseases (e.g. Amyotrophic Lateral Sclerosis – ALS), UA dysfunction may also compromise the effective use of ventilatory support (VS). In this context, the endoscopic evaluation of UA may be useful in understanding the OSAS mechanisms, in determining the causes for treatment-induced airway obstruction and even in helping to titrate noninvasive ventilation (NIV) in ALS patients with bulbar or pseudo-bulbar (spastic) dysfunction. Specifically, in OSAS patients, when residual obstructive events persist, although an optimal ventilatory mode has been apparently achieved, along with interface and equipment, the endoscopic evaluation of UA seems to be a valuable tool in understanding its mechanisms, even assisting adjustments to NIV parameters. In addition, it has also been described as being useful in laryngeal response to mechanical in-exsufflation (MI-E) and Exercise-Induced Laryngeal Obstruction (EILO). However, no protocol has yet been published or validated for this. For this reason, a literature review was conducted on UA function and its response to positive pressure and MI-E. Special emphasis has also been given to the current indication for video endoscopy in chronically ventilated patients. Martins N. would like to thank the Portuguese Foundation for Science and Technology (FCT – Portugal) for the Strategic project ref. UID/BIM/04293/2013 and “ NORTE2020—Programa Operacional Regional do Norte ” ( NORTE-01-0145-FEDER-000012 ).

The effect of intraoperative recruitment maneuver on ischemia-modified albumin (IMA) and oxidative stress in performed laparoscopic cholecystectomy with intra-abdominal 12 mmHg pressure was investigated. Fifty patients undergoing laparoscopic cholecystectomy were included in the study by separating the two groups. Basal ventilator settings in both groups were set as tidal volume: 6-8 ml / kg, respiratory rate: 12 breaths / min, I: E = 1: 2, flow: 4 l / min. In group R, after intubation, 5 cm H2O PEEP was adjusted in addition to basal ventilator settings. Five minutes after CO2 insufflation and exsufflation, PEEP was step by step raised to 10-15-20 cm H2O, and patients were ventilated for 10 breaths. Venous blood samples were taken from the patients for three times in perioperative periods to measure IMA and oxidative stress.There was no difference between the groups in terms of demographic data, surgery and insufflation times. Significant differences in IMA,TOS,TAS and OSI levels within the group were observed but no difference was between groups. The recruitment maneuver that we used in laparoscopic cholecystectomies was found to have no effect reducing tissue ischemia and oxidative stress response in the intraoperative period. [Med-Science 2019; 8(2.000): 325-9]

The effects of preoperative oral administration of glucose solution combined with postoperative probiotics on inflammation and intestinal barrier function in patients after colorectal cancer surgery were observed. Sixty patients treated and scheduled to undergo radical resection of colorectal cancer in The Second Affiliated Hospital of Kunming Medical University from March 2017 to December 2017 were selected and randomly divided into the glucose solution group (n=30) and combined probiotics group (n=30). Patients in both groups took orally 12.5% glucose solution before surgery, and those in the combined probiotics group received bifidus-triple viable preparation every day for 7 consecutive days. Changes in endotoxin, insulin-like growth factor-I (IGF-I) concentration, white blood cell count (WBC), C-reactive protein (CRP), D-lactic acid and urinary lactulose/mannitol (L/M) were detected before surgery and at 1, 3 and 7 days after surgery. The general condition was observed and changes in intestinal florae were compared between the two groups. The body temperature was measured every 4 h with an electronic thermometer, and the duration of fever was recorded (from the first day after operation to the time with normal body temperature after operation, axillary temperature

International audience; BACKGROUND: Collapsibility of upper airways may impair the efficacy of mechanical insufflation-exsufflation (MI-E) devices. The aim of this study was to determine the effect of a collapsible tube on peak expiratory flow (PEF) when using an MI-E device.METHODS: An MI-E device was attached to a lung simulator. Resistance was set at 5 and 20 cm H2O/L/s (R5, R20) for compliance settings of 20, 40, and 60 mL/cm H2O (C20, C40, C60). A series of 5 cycles were delivered at 3 pressures in the following order: +30/−30, +40/−40, and +50/−50 cm H2O for each compliance/resistance combination with and without the collapsible tube. Each respiratory mechanics profile was tested in random order. Pressure and flow were measured upstream of the MI-E device, and the primary outcome measure was PEF. The relationships of PEF to maximum expiratory pressure were compared with and without the collapsible tube using a linear regression model.RESULTS: For the C20-R5 condition, the effect of the collapsible tube on the intercept (−0.35 cm H2O) was not significant, but this was offset by a significant (and the largest) increase in slope (+0.12 L/s/cm H2O). For the C60-R20 condition, the effect of the collapsible tube on the slope (−0.003 L/s/cm H2O) was not significant, but this was offset by a significant (and the largest) increase of the intercept (+3.16 cm H2O) at 30 cm H2O expiratory pressure. For the other conditions, the collapsible tube significantly increased PEF at 30 cm H2O expiratory pressure, and the gap further increased above this pressure as the slope increased with the collapsible tube.CONCLUSIONS: The collapsible tube resulted in a higher PEF for all respiratory mechanics profiles tested.

Amyotrophic lateral sclerosis is a progressive neuromuscular disease characterized by both lower motor neuron and upper motor neuron dysfunction. Although clinical presentations can vary, there is no cure for ALS, and the disease is universally terminal, with most patients dying of respiratory complications. Patients die, on average, within 3 to 5 years of diagnosis, unless they choose to undergo tracheostomy, in which case, they may live, on average, 2 additional years. Up to 95% of patients with ALS in the United States choose not to undergo tracheostomy; management of respiratory failure is therefore aimed at both prolonging survival as well as improving quality of life. Standard of care for patients with ALS includes treatment from multidisciplinary teams, but many patients do not have consistent access to a pulmonary physician who regularly sees patients with this disease. The goal of this review was to serve as an overview of respiratory considerations in the management of ALS. This article discusses noninvasive ventilation in the management of respiratory muscle weakness, mechanical insufflation/exsufflation devices for airway clearance, and treatment of aspiration, including timing of placement of a percutaneous endoscopic gastrostomy tube, as well as secretion management. In addition, it is important for physicians to consider end-of-life issues such as advanced directives, hospice referral, and ventilator withdrawal.

Background Amyotrophic lateral sclerosis (ALS) is an incurable neurodegenerative disease affecting upper and lower motor neurons and resulting in progressive skeletal muscle weakness. Weak cough and difficulty in clearing secretions are often the cause of pulmonary infections and acute respiratory failure. Cough assistance is commonly used to provide support in coughing for patients with ALS. Methods This was a preliminary parallel randomized study comparing two cough-assist devices: one utilizing mechanical insufflation/exsufflation (MI/E) and expiratory flow accelerator (EFA) technology, the other utilizing only MI/E technology. The aim was to compare the effectiveness, safety and acceptability of the two devices. Thirty patients with ALS and similar severity and functional scale were enrolled. The primary outcome was the change in respiratory function, respiratory muscle function, gas exchange, and peak cough expiratory flow as an indicator of cough efficacy. Secondary outcomes were the number of exacerbations at 1, 6 and 12 months of treatment, and the patient-perceived comfort/distress related to the interventions together with the perceived efficacy of cough. Results 30 subjects were recruited and randomized into the two groups (1:1 ratio). Primary outcomes: Respiratory function parameters decreased over time in both groups, but significantly less in the Kalos group, as did the respiratory muscle strength parameters and peak cough flows. Gas exchanges decreased over time in both groups with no clinically relevant differences between groups. Secondary outcomes there were no significant differences between groups regarding the number of exacerbations over time. No adverse events were reported. All participants, in both groups, reported a similar increase in perceived cough efficacy and there was no significant difference in comfort and distress between the two treatments. Conclusions The cough-assist device with EFA technology performed better than a traditional MI/E device in ALS patients regarding respiratory function and cough efficacy, although number of exacerbations and acceptability of the two devices was similar. Following these promising preliminary results, further investigation is required in a larger cohort to confirm the superiority of EFA technology associated with a MI/E device.

BACKGROUND: Mechanical insufflation-exsufflation (MI-E) applied via tracheostomy tubes in patients with amyotrophic lateral sclerosis (ALS) who are on home mechanical ventilation via tracheostomy is an effective procedure for respiratory secretion management. Nonetheless, tenacious secretions may remain and increase the risk of respiratory infections. The aim of this study was to determine whether adding oscillations to MI-E could reduce the rate of respiratory infections and the need for bronchoscopy to remove secretions in patients with ALS on home mechanical ventilation via tracheostomy. METHODS: This was a 2-y, prospective, crossover study. Subjects were treated with conventional MI-E and MI-E with oscillations for 2 alternate 6-month periods. Data were collected on episodes of respiratory infections, hospital admission, and number of bronchoscopy procedures. RESULTS: In the 19 ALS subjects enrolled, the median (interquartile range [IQR]) number of acute respiratory infections per subject was 1.0 (0.5–2.0) in the MI-E period and 0.0 (0.0–2.0) in the MI-E plus oscillations period (P = .92). The median (IQR) number of hospital stays was 0.0 (0.0–1.0) in the MI-E period and 0.0 (0.0–1.0) in the MI-E plus oscillations period (P = .80). The median (IQR) number of bronchoscopies per subject was 0.0 (0.0–1.0) in MI-E period and 0.0 (0.0–0.5) in the MI-E plus oscillations period (P = .26). MI-E plus oscillations treatment had no impact on the risk of respiratory infections (odds ratio 3.71, 95% CI 0.81–16.84, P = .09) or the need for bronchoscopy (odds ratio 2.70, 95% CI 0.44–16.68, P = .29). CONCLUSIONS: Adding oscillations to MI-E therapy in subjects with ALS on home mechanical ventilation via tracheostomy did not decrease the risk of respiratory infections, hospital admission, or need for bronchoscopy.

Aim To determine the prevalence of long-term mechanical insufflation-exsufflation (MI-E) and concomitant mechanical ventilation in children with neurological conditions, with reported reasons behind the initiation of treatment. Method This was a population-based, cross-sectional study using Norwegian national registries and a questionnaire. Results In total, 114 of 19 264 children with a neurological condition had an MI-E device. Seventy-three of 103 eligible children (31 females, 42 males), median (min-max) age of 10 years 1 month (1y 5mo-17y 10mo), reported their MI-E treatment initiation. Overall, 76% reported airway clearance as the main reason to start long-term MI-E. A prophylactic use was mainly reported by children with neuromuscular disorders (NMDs). Prevalence and age at initiation differed by diagnosis. In spinal muscular atrophy and muscular dystrophies, MI-E use was reported in 34% and 7% of children, of whom 83% and 57% respectively received ventilator support. One-third of the MI-E users were children with central nervous system (CNS) conditions, such as cerebral palsy and degenerative disorders, and ventilator support was provided in 31%. The overall use of concomitant ventilatory support among the long-term MI-E users was 56%. Interpretation The prevalence of MI-E in a neuropaediatric population was 6 per 1000, with two-thirds having NMDs and one-third having conditions of the CNS. The decision to initiate MI-E in children with neurological conditions relies on clinical judgment. What this paper adds The prevalence and age at initiation of mechanical insufflation/exsufflation (MI-E) differed between diagnoses. MI-E was most commonly used in spinal muscular atrophy, where it generally coincided with ventilatory support. One-third of MI-E devices were given to children with central nervous system conditions, and one-third also received ventilatory support.

The effect of mechanical insufflation-exsufflation (MIE) for airway clearance in patients with spinal muscular atrophy type I (SMA-I) on the distribution of ventilation in the lung is unknown, as is the duration of its beneficial effects. A pilot study to investigate the feasibility of using three dimensional (3-D) electrical impedance tomography (EIT) images to estimate lung volumes pre- and post-MIE for assessing the effectiveness of mechanical insufflation-exsufflation (MIE) was conducted in 6 pediatric patients with SMA-I in the neuromuscular clinic at Children's Hospital Colorado. EIT data were collected before, during, and after the MIE procedure on two rows of 16 electrodes placed around the chest. Lung volumes were computed from the images and compared before, during, and after the MIE procedure to assess the ability of EIT to estimate changes in lung volume during insufflation and exsufflation. Images of pulsatile pulmonary perfusion were computed in subjects able to perform breath-holding. In four of the six subjects, lung volumes during tidal breathing increased after MIE (average change from pre to post MIE was 58.8±55.1 mL). The time-dependent plots of lung volume computed from the EIT data clearly show when the MIE device insufflates and exsufflates air and the rest periods between mechanical coughs. Images of pulmonary pulsatile perfusion were computed from data collected during breathing pauses. The results suggest that EIT holds promise for estimating lung volumes and ventilation/perfusion mismatch, both of which are useful for assessing the effectiveness of MIE in clearing mucus plugs.

Background: Ineffective cough is a common cause of extubation failure. Mechanical insufflation/exsufflation(MI-E) is an airway clearance device improving cough efficacy. However, data of using MI-E in weaning patients were limited. Methods: We conducted a RCT to determine the efficacy of MI-E to reduce reintubation during a postextubation period. Patients assisted with MV for > 48 hours who passed SBT but impaired cough strength were enrolled. The patients were randomized to control group or MI-E group. The airway clearance procedure with MI-E was applied in MI-E group during the 48-hour postextubation period. Both groups received the same standard care. The primary outcome was the reintubation rate in 48 hours after extubation and the secondary outcomes were oxygenation improvement, cough peak flow(CPF) changes, NIV uses and adverse events during the 48-hour period. Results: Totally, 43 patients were enrolled; 22 in MI-E group and 21 in control group. There was 1 patient in MI-E group reintubated due to volume overload. The MI-E group tended to have better oxygen improvement between 24 and 48 hours after extubation with PF ratio difference of 20(68.4) mmHg in MI-E group VS 0.74(53.87) mmHg in control group, p= 0.312). No deoxygenation, NIV rescue, NIV failure or adverse events appeared in both groups. CPF tended to increase in MI-E group (the difference of CPF 6.82(14.27) LPM in MI-E group and -0.48(42.36) LPM in control group, p= 0.449). Conclusions: The cough assist procedure during the postextubation period did not prevent reintubation but might improve oxygenation and cough strength during the 48-hour postextubation period without increased adverse events.

Introduction: In patients with Amyotrophic Lateral Sclerosis (ALS), Mechanical Insufflation-Exsufflation (MI-E) pressures may evoke adverse laryngeal responses that lead to treatment failure. Aims: Explore possible relationships between visualized laryngeal response patterns and airflow geometry (pressure and flow characteristics) during MI-E in healthy controls and patients with ALS. Methods: Descriptive observational study. We analysed 61 examinations of 10 healthy controls and 51 ALS subtypes (25 spinal, 16 pseudobulbar and 10 progressive bulbar) using MI-E with a protocol utilizing pressure range of ±20 to ±50 cmH2O with subjects instructed to both exhale and cough. Transnasal fiberoptic laryngoscopy was performed concurrent with flow and pressure recordings. Airflow geometry patterns were compared to visualized laryngeal events and to participant category. Results: Efforts to cough or exhale during exsufflation affected the airflow geometry. Laryngeal adduction clearly interfered with airflow geometry, but we were unable to link visualized laryngeal response characteristics to unique airflow geometry patterns. We identified four MI-E airflow geometry patterns that were associated with being healthy and the ALS subtypes. Conclusions: Recording airflow geometry during MI-E provides information that can be used to design tailored flow and pressure settings, possibly facilitating prolonged successful use of MI-E treatment in ALS.

Background: A cervical spinal cord injury (CSCI) is a life-changing event resulting in neurological weakness. Acutely, respiratory complications (RC) are the leading cause of mortality. Mechanical insufflation-exsufflation (MI-E) is used to augment cough and promote airway clearance in the prevention and treatment of RC in this population. The incidence of RC in patients with CSCI who receive MI-E is not widely reported. Aims: To report on the incidence of RC, and to evaluate the clinical application of MI-E in patients with acute traumatic CSCI. Methods: This was a retrospective case note review of patients with acute traumatic CSCI admitted to a UK major trauma centre between January 2017 and September 2018. Incidence of RC on admission and fourteen days post-discontinuation of MI-E were recorded, as well as detail relating to MI-E clinical application, where used. Results: 33 patients were included. Overall incidence of RC was 21.1%. There was no difference in rates of RC between those who received prophylactic MI-E and those who did not (p=0.23). There was a significant difference in the clinical application of therapeutic MI-E compared to prophylactic MI-E, with those receiving therapeutic treatment more frequently (p=0.01) and with higher exsufflation pressures (p=0.003). Conclusion: The findings of this review suggest that MI-E provides no additional benefit in prophylactic management of RC following acute traumatic CSCI. However, this result may be confounded by a small sample size. Further incidence reporting of larger samples including those with thoracic injuries is warranted.

IntroductionThe optimal dosage of dexmedetomidine (DEX) as an adjuvant combined with ropivacaine for postoperative analgesia in laparoscopic myomectomy is still controversial. The main aim of this prospective clinical trial was to evaluate the analgesic effect and relevant adverse effects of different doses of dexmedetomidine applied locally for ropivacaine-induced bilateral transmuscular quadratus lumborum block (TQLB).MethodsTQLB was conducted using different doses of dexmedetomidine per side (R group: control group; DEX1 group: 0.1μg/kg; DEX2 group: 0.3μg/kg; DEX3 group: 0.5μg/kg). Numeric rating scales (NRS) of pain score, heart rate (HR) and blood pressure (BP) were assessed at different time points after performing TQLB. Dosage of additional analgesics via patient-controlled analgesia pump, recovery time for anal exsufflation, hospital stay and clinical events such as nausea, vomiting and pruritus were also compared among groups.ResultsA total of 200 patients underwent laparoscopic myomectomy were enrolled in this study and divided into 4 groups (R, DEX1, DEX2 and DEX3 group) randomly, 50 for each group. Compared with R group, NRS pain score was significantly lower in DEX2 group and DEX3group (pConclusion0.3μg/kg per side of dexmedetomidine as an adjuvant for TQLB was recommended to effectively relieve postoperative pain after laparoscopic myomectomy.Trial registrationChinese Clinical Trial Registry with registration number ChiCTR1900028509. Date of registration: 24 November 2019. http://www.chictr.org.cn/edit.aspx?pid=42635=htm=4

Background: Mechanical insufflation-exsufflation (MI-E) is a non-invasive technique performed through the CoughAssist In-Exsufflator to simulate cough and remove mucus from proximal airways. To date, the effects of MI-E on critically ill patients on invasive mechanical ventilation (MV) are not fully elucidated. The purpose of this study was to compare the efficacy and safety of MI-E combined or not to manual chest physiotherapy (CPT) in these patients.Methods: This cross-over clinical study enrolled consecutive patients who were sedated, intubated and on MV > 48h with expected maintenance of these criteria > 24h. Over a 24-hour period, patients randomly performed two sessions of manual CPT with or without additional MI-E before tracheal suctioning. Following each procedure, volume of retrieved mucus (ml) was assessed to evaluate efficacy. We evaluated respiratory flows, pulmonary mechanics and hemodynamics before, during, and after treatment. In addition, safety of MI-E was also appraised.Results: 26 patients were included. In comparison to CPT, mucus volume retrieved was significantly higher during CPT+MI-E (0.42 [0; 1.39] ml vs 2.29 [1; 4.67] ml; p < 0.001). The respiratory system compliance immediately improved from pre and post Crs values in CPT+MI-E group (55.7 ml/cmH2O [38.3; 67.4] vs. 68.6ml/cmH2O [47.8;94.9]; p was observed in the CPT+MI-E group when comparing the baseline values with the values one-hour post-intervention (pConclusion: In mechanically ventilated patients, MI-E increases the amount of secretions that can be retrieved post-CPT, without causing clinically significant adverse events.Clinical Trials Registration Number: NCT03316079 (24/11/2015; retrospectively registered)

Background Postoperative positive pressure lung expansion is associated with decreased pulmonary complications and improved clinical outcomes. The aim of the present study was to compare the differences in post-operative pulmonary complications and clinical outcomes between two groups of study subjects who underwent cardiac surgery; one included subjects who received mechanical insufflation-exsufflation (MI-E) and the other included subjects who received intermittent positive pressure breathing (IPPB) therapy. Methods This retrospective study included 51 subjects, who underwent cardiac surgery in an intensive care unit of a tertiary hospital during the time period from June 2017 to February 2018. After liberation from mechanical ventilation, the subjects received lung expansion therapy by means of two types of positive pressure devices, MI-E (n = 21) or IPPB (n = 30). The pulmonary complications, lung function, and clinical outcomes were compared between the two groups. Results Subjects in both groups displayed similar baseline characteristics and underwent similar types of surgical procedures. Compared to subjects who received non-oscillatory therapy, those who received MI-E therapy had higher post-operative force vital capacity (58.4 ± 4.74% vs. 46.0 ± 3.70%, p = 0.042), forced expiratory volume in one second (62.4 ± 5.23% vs. 46.8 ± 3.83%, p = 0.017), and peak flow rate (67.1 ± 5.53 L vs. 55.7 ± 4.44 L p = 0.111). However, the incidence of chest pain was higher in the MI-E group (n = 13, 61.9%) than in the IPPB group (n = 4, 16.7%; odds ratio, 0.123, 95% confidence interval, 0.03–0.45; p = 0.002). The length of hospital and ICU stay, development of atelectasis, pneumonia, and pleural effusion were similar in both the groups. Conclusion Both IPPB and MI-E therapies have similar effects on preventing post-operative complications in cardiac surgery patients. However, compared to IPPB therapy, MI-E therapy was associated with better-preserved pulmonary function and higher incidence of chest pain.

Mechanical insufflation-exsufflation (MI-E) devices have been around since the polio epidemic. They have been used in the treatment of other neuromuscular disorders, and they are usually the first option for secretion clearance in patients with amyotrophic lateral sclerosis (ALS) regardless of

The Covid-19 pandemic has markedly changed our practices. This article analyses the risks of contamination among healthcare professionals (HCPs) during laparoscopic surgery on patients with Covid-19. Harmful effects of aerosols from a pneumoperitoneum, with the virus present, have not yet been quantified. Measures for the protection of HCPs are an extrapolation of those taken during other epidemics. They must still be mandatory to minimise the risk of viral contamination. Protection measures include personal protection equipment for HCPs, adaptation of surgical technique (method for obtaining pneumoperitoneum, filters, preferred intracorporeal anastomosis, precautions during the exsufflation of the pneumoperitoneum), and organisation of the operating room.

To determine the risk factors, morbidity, and quality of life associated with same-day surgery in gynecologic oncology. In this prospective study, patients with a good performance status and an indication for a simple procedure [diagnostic laparoscopy (peritoneal carcinomatosis index, biopsy, and Port-A-Cath), adnexectomy or fimbriectomy] and a complex procedure [total hysterectomy, omentectomy with peritoneal staging, pelvic lymphadenectomy (or sentinel lymph node (SLN)), and/or paraaortic lymphadenectomy by minimally invasive surgery] were included. Univariate logistic regression analysis, multivariate analysis, and the Wilcoxon signed-rank test were used in the statistical analyses. There were 171 consecutive surgeries (55 complex and 116 simple procedures). The rate of readmissions on the same day and at 30 days postoperatively was, respectively, 8% versus 3% with simple procedures and 16% versus 11% with complex procedures. We modified our procedure to decrease complications by prescribing prophylactic low molecular weight heparin (LMWH) the next day at 8 am at home instead of the evening before discharge (fewer vaginal hematomas after hysterectomy: 2 hematomas/5 hysterectomies with LMWH on the same day versus 0/22 with LMWH on the next day, P = 0.03). The following factors were significantly associated with readmission: complex procedure (odds ratio [OR] 4.25, 95% confidence interval [CI] 1.66–10.85, P = 0.003), absence of an exsufflation drain (OR 2.96, 95% CI 1.19–7.31, P = 0.019), and end of surgery after 2 pm (OR 5.82, 95% CI 2.13–15.94, P = 0.001). We modified our protocol to decrease complications (vaginal hematomas after hysterectomy) by prescribing prophylactic LMWH the next day at 8 am at home instead of the evening before discharge.

Introduction: Few data described practicalities of using mechanical insufflation-exsufflation (MI-E) for invasively ventilated ICU patients and evidence for benefit of their use is lacking. Aim and objective: To identify barriers and facilitators to use MI-E devices in invasively ventilated ICU patients, and to explore reasons for their use in various patient indications. Methods: Four focus group discussions; 3 national (Netherlands) and 1 with international representation, each with a purposeful interprofessional sample of a maximum 10 participants with experience in using MI-E in invasively ventilated ICU patients. We developed a semi-structured interview guide informed by the Theoretical Domain Framework. An observer was present in each session. Sessions were audio recorded and transcribed verbatim. Data were analysed using content analysis. Results: Barriers for MI-E use were lack of evidence and lack of expertise in MI-E, as well as lack of device availability within the ICU. Facilitators were experience with MI-E and perceived clinical improvement in patients with MI-E use. Common reasons to start using MI-E were difficult weaning, recurrent atelectasis and pneumonia. Main contraindications were, bullous emphysema, ARDS, high PEEP, hemodynamic instability, recent pneumothorax. There was substantial variability on used technical settings of MI-E in invasively ventilated patients. Conclusions: Key barriers and facilitators to MI-E were lack of evidence, available expertise and perceived clinical improvement. Variability on technical settings likely reflect lack of evidence. Future studies should focus on settings, safety and feasibility of MI-E in invasively ventilated patients before studies on effect can be conducted.

Background: Increasing numbers of patients with NMD are being referred for long term NIV as outpatients. Whilst incidence of hospitalisation due to CI is well documented, little is known about incidence in the early stages of intervention in this population, who remain in their home environment supported by oral antibiotics and their caregivers. Objective: To inform current practice and allow informed consent with regard to the risk of CI following set up of NIV or MI-E Methods: Retrospective data were collected on 92 patients referred for NIV or MI-E between 01/11/16 and 01/11/17 with a diagnosis of NMD. 41 patients were excluded due to not commencing treatment or already being dependent on NIV. The records of the remaining 51 patients were reviewed for documented incidence of CI, defined as the requirement for antibiotics to treat a respiratory deterioration, in the first 14 days after commencement of NIV or MI-E. Results: 52% (27) of patients commenced on NIV or MI-E had a documented CI requiring antibiotics within the first 14 days of treatment. Those starting MI-E only, were at greater risk than those on NIV only, with CI incidence of 72% for MI-E and 48% for NIV. Conclusion: NIV and MI-E are both well-established treatments in the NMD population however they may be associated with an increased risk of CI and need for antibiotics following commencement. Further study into the physiological reasons for this increased incidence is required. We recommend patients with NMD commencing NIV or MI-E therapy be counselled about the possible risks of CI following commencement of treatment.

Introduction: The mechanical insufflation/exsufflation device (MI-E) is an instrumental cough augmentation technique prescribed to patients with inefficient cough and recurrent infections. Its impact on respiratory complications, quality of life and survival remains unclear, and is possibly affected by the frequency of its use. Aim: To identify factors that influence the use of MI-E in the home setting. Methods: 26 patients with neuromuscular disease and an active prescription of an MI-E were studied. Clinical and demographic data were recorded as well as information concerning the use of the device. MI-E data was downloaded using dedicated software. Results:Table 1 illustrates patients’ characteristics. Fifteen patients (58%) reported regular use of the device, thirteen (50%) reported improvement of their respiratory symptoms, and nineteen (73%) were satisfied with the treatment. We found no associations between regular MI-E use and age, NIV use, bulbar involvement or a rapidly progressive neuromuscular disease. Institutionalised patients tend to use MI-E more regularly (78% vs 50%, p=0.229). Conclusion: MI-E improved reported respiratory symptoms in half of the patients. Our preliminary data suggest that regular use of the device is not associated with clinical parameters but is influenced by living facilities. This will have to be confirmed by further analysis.

Mechanical insufflation-exsufflation (MI-E) devices are frequently used in patients with respiratory muscle weakness to increase their cough peak flow and assist them in improving cough effectiveness and clearing mucus from the airways. An 89-year-old male was admitted to our university hospital due to fever and loss of appetite. He was diagnosed with lung abscess and pulmonary nontuberculous mycobacterial disease. He was unable to independently expectorate phlegm due to frailty. Subsequently, MI-E was introduced. On day 3 after its introduction, chest X-ray examination revealed bilateral pneumothorax, and use of the MI-E device was discontinued. After conservatively observing the clinical course, pneumothorax was improved on day 12 after it occurred. Although scientific evidence regarding MI-E is currently limited, healthcare professionals often do not have an alternative in clinical practice. However, treating physicians should consider the risk of MI-E-related pneumothorax, despite its low occurrence rate. Keywords: Mechanical insufflation-exsufflation, Pneumothorax

Background Duchenne Muscular Dystrophy (DMD) is a fatal X-linked recessive neuromuscular disease, characterized by progressive loss of muscle strength. Respiratory failure is the main cause of morbidity and mortality in DMD patients. Respiratory devices have been reported to increase the effectiveness of cough and pulmonary function, thus prolong the survival rate. However, there is scarcity of studies about DMD patients’ respiratory profiles and usage of respiratory devices in Indonesia. Methods We recruited 8 Indonesian DMD patients in Dr. Sardjito Hospital and UGM Academic Hospital, Yogyakarta. Baseline pulmonary function was measured using spirometry. Peak Cough Flow was measured at baseline, with chest compression, after air stacking with manual ventilation bag, and with the combined techniques. Data recorded was presented as mean ± SD and analysed using ANOVA. Results Here we show the respiratory profiles from 8 non-ambulatory DMD patients (mean age: 13.25 ± 3.96 years old) confirmed by genetic testing. None of them had access to respiratory devices. Spirometry measurements showed 7 of 8 patients had severe restrictive pulmonary function with mean FEV1/FVC 22.40 ± 10.30% of predictive values (normal ratio > 70%). In addition, all patients showed poor cough performances measured by peak cough flowmeter (160 ± 44.58 L/min (normal value > 270 L/min)) that were improved by air stacking using a manual ventilation bag (167.4 ± 46.72 L/min). Three patients who had nocturnal hypoventilation did not have daytime hypercapnia. Manual ventilation bag or mechanical in−/ex-sufflation was indicated in 75% of patients while nocturnal assisted ventilation was indicated in 50% of patients. Neither daytime assisted ventilation nor tracheostomy was indicated in these patients. Conclusion Use of manual exsufflation in combination with the manual ventilation bag for air stacking to improve cough performance is recommended as the first step of respiratory management in DMD patients. Provision of manual ventilation bag serve as an affordable and effective device for respiratory support in the early stage of respiratory involvement in those non-ambulatory patients with DMD.

BACKGROUND: Few studies have evaluated the effects of mechanical insufflation-exsufflation (MI-E) in subjects on mechanical ventilation. Therefore, this study aimed to evaluate the effectiveness of MI-E on airway mucus clearance among mechanically ventilated ICU subjects. METHODS: A randomized, parallel-group, open-label trial was conducted between June and November 2017 in a single, mixed ICU. Adult ICU subjects receiving mechanical ventilation for > 24 h with stable ventilatory and hemodynamic status were randomized to receive either standard respiratory physiotherapy alone (control group) or respiratory physiotherapy by using an MI-E device (intervention group). The primary outcome was the weight of aspirated airway mucus after study interventions. Secondary outcomes included variation in static lung compliance (ΔCL), airway resistance (ΔRaw), work of breathing (ΔWOB) in relation to the pre-intervention period, and hemodynamic and ventilator complications during the procedures. RESULTS: There were 90 subjects in each group. The mean ± SD weight of the aspirated airway mucus was higher in the intervention group than in the control group (2.42 ± 2.32 g vs 1.35 ± 1.56 g, P CONCLUSIONS: Among the general ICU subjects receiving mechanical ventilation, use of an MI-E device during respiratory physiotherapy resulted in a larger amount of airway mucus clearance than respiratory physiotherapy alone. (ClinicalTrials.gov registration NCT03178565.)

BACKGROUND: Standard mechanical insufflation-exsufflation (MI-E) therapy is applied with fast insufflation-exsufflation pressures to achieve high peak expiratory flows (PEF) and assist airway clearance. No attention is given to the resultant high peak inspiratory flows (PIF), although it may impair secretion removal. It has been proposed that an expiratory flow bias (ie, PEF higher than PIF) might be the key determinant for mucus clearance instead of the PEF alone. We examined the effects of 2 MI-E maneuvers, standard versus optimized, with fast and slow insufflation, respectively, along with different MI-E pressure settings on secretion displacement in 3 lung-impedance scenarios that simulated a patient on mechanical ventilation. METHODS: The MI-E device was connected to a lung model that simulated a patient on mechanical ventilation. Known quantities of mucus simulant were injected into the system and exposed to various MI-E ventilation conditions. Mucus movement was examined with image-analysis software. RESULTS: The optimized MI-E maneuver resulted in a much lower PIF (37.5 L/min [interquartile range, 24.9–47.9 L/min] vs 101.8 L/min [interquartile range, 89.1–115.7 L/min], P CONCLUSIONS: The optimized MI-E maneuver, applied with slow insufflation, resulted in a higher expiratory flow bias, which made the therapy more effective at moving mucus outward, compared with the standard MI-E maneuver, typically applied with fast insufflation.

BACKGROUND: Duchenne muscular dystrophy (DMD) is characterized by progressive degeneration, wasting, and weakness of skeletal musculature, including respiratory muscles. Cough is also compromised with disease progression. Among cough-augmentation techniques, mechanical insufflation-exsufflation (MI-E) has demonstrated several clinical benefits in patients with chronic airway secretion obstruction and muscular weakness. In clinical practice, the use of MI-E in DMD patients is also suggested when they are stable with no airway infections. However, there is a paucity of studies that consider the effect of MI-E specifically on stable DMD patients who have adapted to the use of MI-E. METHODS: Twenty subjects with DMD with no active upper airway or lung infections, who used MI-E device regularly at home, were enrolled. They received a single MI-E treatment consisting of 5 cycles of 5 insufflations-exsufflations with their customary settings. Volume variations during quiet breathing, vital capacity, and cough before and after treatment were measured with optoelectronic plethysmography (OEP). RESULTS: A decrease in breathing frequency (P = .001) and the rapid shallow breathing index emerged (P = .007), while cough peak flow (Spirometer P = .86, OEP P = .58), vital capacity (Spirometer P = .78, OEP total chest wall P = .57), and end-expiratory volumes (Total chest wall P = .97, Ribcage P = .14, Abdomen P = .10) were not affected by the treatment. An increment of the chest wall volume variation during the expiratory cough phase was identified (P = .001), particularly due to an increase in abdominal expansion (P = .005). CONCLUSIONS: A single treatment of MI-E in subjects with stable DMD already adapted to the device can provide beneficial changes in breathing pattern through a significant decrease in breathing frequency and rapid shallow breathing. These findings suggest an improvement in short-term dyspnea, although there were no changes in lung-volume recruitment or unassisted cough peak flow.

Background Pulmonary recruitment maneuver (PRM) at the end of laparoscopic gynecologic surgery has been shown to reduce postoperative pain. This prospective, randomized, controlled clinical trial aimed to investigate postoperative pain (primary endpoint) and nausea when performing a ventilator-piloted PRM at the end of laparoscopic bariatric surgery. Settings A secondary-level public hospital in Sweden. Methods After giving written consent, patients undergoing elective laparoscopic bariatric surgery were randomized to receive routine exsufflation (control group) or a ventilator-piloted PRM to remove residual carbon dioxide from the abdomen at the end of surgery. Pain and nausea intensities were recorded at 4, 12, 24, 36, and 48 hours after surgery using a questionnaire with numeric rating scales. Postoperative consumption of analgesics and antiemetics was also evaluated. Results There were 150 randomly assigned patients recruited, 79 to PRM intervention and 71 controls. Pain intensity was significantly lower in the PRM group than in the control group 24 hours postoperatively (numeric rating scale 2 [1–3] versus 3 [2–5]; P = .002). Pain during the first 24 hours did not increase in the PRM group as it did in the control group ( P = .045). Opioid requirements were significantly lower in the PRM group than in the control group (5.0 mg [2–10] versus 9.0 mg [5–15]; P = .025). The PRM did not affect incidence or intensity of nausea and vomiting. Conclusions A ventilator-piloted PRM reduced postoperative pain intensity and opioid requirement after laparoscopic bariatric surgery. The heterogeneity of the study population and the large number of hospital staff involved indicate good generalizability of the results.

We thank Drs Toussaint, Goncalves, and Chatwin for their interest in our paper.[1][1] However, we do not think that our results may in any way create confusion or change the main focus and outcomes of mechanical insufflation-exsufflation (MI-E) treatment. On the contrary, as underlined by Joshua

Mechanical insufflation exsufflation creates cough flows to clear central airways secretions for patients with ineffective cough flows. At times, patients with even potentially effective spontaneous cough flows can have pain that prevents effective coughing. We describe a patient with Arnold-Chiari syndrome, syringomyelia, and hydrocephalus who had nine episodes of pneumonia through the age of 9 yrs, and cough associated headaches, who upon using mechanical insufflation exsufflation had no subsequent pneumonias for at least the next 17 yrs and no headaches when using it for coughing.

Background: Postpartum subinvolution of the uterus is a more common condition after cesarean section. Auricular acupressure (AA) is widely used for the treatment of postpartum diseases. However, few studies have explored the effects of AA as a treatment of uterine involution following cesarean section to date. This study aimed to assess the efficacy and safety of AA for uterine involution after cesarean section. Methods: A total of 109 women who underwent cesarean section participated in this study. They were randomly allocated to either real AA or sham AA in a 1:1 ratio by a computer program. For 3 days, the real AA and sham AA groups received treatment 3 times daily. A series of assessments at 42 days after cesarean section, namely on the uterine size, the incidence of hydrometra, the first anal exsufflation time, bleeding volume at 6 hours, bleeding volume at 6–24 hours along with other general assessments were carried out. Results: A total of 89 women completed the study. The uterine size at 42 days after a cesarean section was 6.3 cm smaller in the real AA group than in the sham AA group (P

Background Postoperative pain impairs enhanced recovery in patients after various surgeries. Local use of ropivacaine has become an effective strategy for postoperative pain management. The aim of this study was to assess the effectiveness and safety of wound infiltration with ropivacaine for postoperative analgesia as a fast-track approach in patients undergoing thoracotomy surgery. Materials and methods Forty adult patients with esophageal cancer scheduled for selective thoracotomy surgery were enrolled in this double-blind, randomized, controlled study. Patients were randomized (1:1) to receive ropivacaine or placebo wound infiltration before incision closure. Numerical rating score (NRS), postoperative analgesics consumption, length of hospital stay, time to anal exsufflation, defecation, ambulation, and patient satisfaction scores were recorded. Side effects including allergic reaction, nausea, vomiting, wound infection, and pneumonia were also assessed. Results NRS was significantly decreased in the ropivacaine group with less consumption of postsurgery analgesics. The ropivacaine group also showed shorter postoperative hospital stays, earlier anal exsufflation and ambulation, and higher patient satisfaction scores. However, there were no significant differences between the two groups regarding time of defecation. No allergic reactions occurred in either group. The incidences of nausea, vomiting, wound infection, and pneumonia were similar. Conclusions The present study showed that ropivacaine wound infiltration could be a safe and effective fast-track approach for patients undergoing thoracotomy surgery.

The objective of this study was to determine whether copious irrigation of peritoneal cavity during laparoscopic appendectomy for complicated appendicitis effectively reduces the incidence of postoperative complications and improves the postoperative recovery in adults compared with suction alone.In this prospective randomized trial, adult patients with complicated appendicitis were randomized to "irrigation and suction"(IS) group or "suction only"(SO) group. All surgery was performed with a standardized 3-port laparoscopic approach. The IS group received peritoneal irrigation with a minimum of 2000 mL sterile normal saline. The study primary outcomes included wound infection and postoperative intra-abdominal abscess. The study secondary outcomes included duration of operation, first anal exsufflation time, duration of hospital stay and hospital charges. Chi-squared and t-tests were used to analyze the study data.Between January 2015 and June 2016, a total of 260 patients with complicated appendicitis were enrolled in the study. The peritoneal irrigation resulted in a longer operation time (51.6 ± 16.1 vs. 41.5 ± 15.2 min, p0.001). There was no significant difference in the rate of wound infection between the two groups. However, the patients who received irrigation had a lower postoperative intra-abdominal abscess rate (3.1% vs. 9.2%, p = 0.039), earlier anal exsufflation (25.2 ± 16.5 vs. 30.7 ± 18.1 hr, p = 0.011), shorter hospital stay (10.2 ± 2.5 vs. 12.5 ± 2.8 days, p0.001) and lower hospital charges (¥14,592 ± 2,251 vs. 16,674 ± 2,163, p0.001) compared to those received suction alone.The study findings revealed that copious irrigation of peritoneal cavity during laparoscopic appendectomy could decrease the incidence of postoperative intra-abdominal abscess in adult patients with complicated appendicitis. These patients also had faster postoperative recovery and lower hospital charges.