Técnicas de estimulación de la tos para la extubación o retirada de los pacientes graves de la asistencia respiratoria mecánica
Información
- DOI:
- https://doi.org/10.1002/14651858.CD011833.pub2Copiar DOI
- Base de datos:
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- Cochrane Database of Systematic Reviews
- Versión publicada:
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- 11 enero 2017see what's new
- Tipo:
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- Intervention
- Etapa:
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- Review
- Grupo Editorial Cochrane:
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Grupo Cochrane de Atención crítica y de emergencia
- Copyright:
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- Copyright © 2019 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Cifras del artículo
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Autores
Contributions of authors
Louise Rose (LR), Neill KJ Adhikari (NA), David Leasa (DL), Dean A Fergusson (DF), Douglas McKim (DM)
Conceiving the review: LR, DM
Co‐ordinating the review: LR
Undertaking manual searches: LR
Screening search results: LR, DM
Organizing retrieval of papers: LR
Screening retrieved papers against inclusion criteria: LR, DM
Appraising quality of papers: NA, DL
Abstracting data from papers: NA, DL
Writing to authors of papers for additional information: LR
Providing additional data about papers: LR
Obtaining and screening data on unpublished studies: LR
Data management for the review: LR
Entering data into Review Manager 5 (RevMan 2014): LR
Review Manager 5 statistical data: LR, DF
Other statistical analysis not using Review Manager 5: DF
Interpretation of data: All authors
Statistical inferences: All authors
Writing the review: All authors
Securing funding for the review: LR
Performing previous work that was the foundation of the present study: Not applicable
Guarantor for the review (one author) LR
Person responsible for reading and checking review before submission: LR
Sources of support
Internal sources
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No sources of support supplied
External sources
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Canadian Institutes of Health Research, Canada.
CIHR provided funding support
Declarations of interest
Louise Rose: none to declare
Neill KJ Adhikari: none to declare
David Leasa: none to declare
Dean A Fergusson: none to declare
Douglas McKim: none to declare
Acknowledgements
We would like to thank Rodrigo Cavallazzi (content editor), Cathal Walsh (statistical editor), Antonio M Esquinas, John R Bach, Yuka Ishikawa (peer reviewers), Janet Wale (consumer editor) for their help and editorial advice during the preparation of the systematic review.
We would also like to acknowledge our Information Specialist Becky Skidmore for her invaluable assistance generating our search strategies, as well as Rodrigo Cavallazzi (content editor), Harald Herkner (statistical editor), Thomas Bongers, Yuka Ishikawa, and John Bach (peer reviewers) for their help and editorial advice during the preparation of the protocol (Rose 2015), for the systematic review.
Version history
| Published | Title | Stage | Authors | Version |
| 2017 Jan 11 | Cough augmentation techniques for extubation or weaning critically ill patients from mechanical ventilation | Review | Louise Rose, Neill KJ Adhikari, David Leasa, Dean A Fergusson, Douglas McKim | |
| 2015 Aug 10 | Cough augmentation techniques for extubation and weaning critically ill patients from mechanical ventilation | Protocol | Louise Rose, Neill KJ Adhikari, David Leasa, Dean A Fergusson, Douglas McKim | |
Differences between protocol and review
We added randomized cross‐over studies as an exclusion criterion, as this design does not allow determination of the efficacy of the intervention on clinical outcomes such as weaning success.
We clarified that included non‐randomized studies were those with a non‐exposed control group.
We added duration of weaning, length of stay, tracheostomy, and tracheostomy decannulation to the outcomes listed in the Outcomes section to align with our a priori set objectives.
As we had anticipated that no eligible trials would be blinded to the use of cough augmentation techniques, we added in the review that non‐blinding of personnel and participants would not necessarily be rated as high risk of bias when considering objective outcomes.
We revised the review to state that high risk of bias was defined as one or more domains (as opposed to two) scored as high risk, as this reflects the guidance in the Cochrane Handbook for Systematic Reviews of Interventions . We also clarified that unclear risk of bias also means that no domains are scored as high risk of bias.
Due to the small number of studies meeting our inclusion criteria, we could not synthesize data and conduct a meta‐analysis; assess statistical heterogeneity; perform subgroup and sensitivity analyses; and construct funnel plots to assess reporting bias, as planned in our protocol (Rose 2015).
Keywords
MeSH
Medical Subject Headings (MeSH) Keywords
Medical Subject Headings Check Words
Adult; Humans; Infant;
PICO
Study flow diagram.
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
| Cough augmentation techniques compared with no cough augmentation techniques for critically‐ill, mechanically‐ventilated adults and children | ||||||
| Patient or population: critically‐ill mechanically‐ventilated adults and children requiring extubation from mechanical ventilation Settings: High acuity setting including ICUs, weaning centres, respiratory intermediate care units, and high‐dependency units in Europe and North America Intervention: Cough augmentation techniques including lung volume recruitment, manually‐assisted cough and mechanical insufflation‐exsufflation Comparison: No cough augmentation | ||||||
| Outcomes | Illustrative comparative risks* (95% CI) | Relative effect | No of Participants | Quality of the evidence | Comments | |
| Assumed risk | Corresponding risk | |||||
| No cough augmentation | Cough augmentation | |||||
| Extubation successa | 87% | 83% | RR 1.58 (1.13 to 2.20) | 75 participants | ⊕⊝⊝⊝ | |
| Duration of mechanical ventilationb | 4 days | 11.7 days | Mean difference ‐6.1 days (‐8.4 to ‐3.8) | 75 participants | ⊕⊝⊝⊝ | |
| ICU mortalitya | 28% | 0% | Not calculable, as no event rates in the 1 trial reporting data on this outcome | 75 participants | ⊕⊝⊝⊝ | |
| Adverse events 1. Hypotensionc 2. Hypertensiond 3. Secretion encumbrance resulting in severe hypoxaemia requiring reintubationc | 12% 6.5% 9% | 3% 10% 6% | RR 3.4 (0.1 to 81.3) RR 3.0 (0.1 to 65.9) RR 0.25 (0.1 to 1.1) | 75 participants 20 participants 1 trial 75 participants | ⊕⊝⊝⊝ | |
| *The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). aAssumed risk is derived from a large international cohort study of mechanical ventilation and weaning by Esteban 2013 and refers to the rate of reintubation reported in this study. bAssumed risk is derived from a large international cohort study of mechanical ventilation and weaning by Esteban 2008. cAssumed risk is derived from adverse events (hypotension and hypoxaemia) reported in a systematic review of recruitment manoeuvres in people with acute lung injury (Fan 2008). dAssumed risk is derived from rates of hypertension noted during 6691 episodes of endotracheal suctioning (Evans 2014). | ||||||
| GRADE Working Group grades of evidence | ||||||
| 1We based our downgrading decisions from high to very low on unclear risk of bias, inability to assess consistency or publication bias, and uncertainty about the estimate of effect due to the limited number of studies contributing outcome data. 2We based our downgrading decisions from high to very low on unclear risk of bias, inability to assess consistency or publication bias, imprecision due to wide confidence intervals, and uncertainty about the estimate of effect due to the limited number of studies contributing outcome data. We have not included reintubation or weaning success in the 'Summary of findings' table as no studies reported these outcomes. | ||||||
| Cough augmentation | No cough augmentation | |||||
| Study | N | mean (SD) | N | mean (SD) | mean difference | 95% CIs |
| Duration of mechanical ventilation (days) | ||||||
| 35 | 11.7 (3.5) | 40 | 17.8 (6.4) | ‐6.1 | ‐8.4 to ‐3.8 | |
| ICU length of stay (days)1 | ||||||
| 35 | 16.9 (11.1) | 40 | 19.3 (8.1) | ‐2.4 | ‐6.9 to 2.01 | |
| 10 | 47.6 (7.3) | 7 | 51.1 (7.8) | ‐3.5 | ‐10.8 to 3.8 | |
| 1The ICU length of stay for cases reported in Niranjan 1998 includes the four cases that were not intubated at the start of the study. | ||||||
| Cough augmentation | No cough augmentation | |||||
| Study | Events | Total | Events | Total | RR | 95% CIs |
| Haemodynamic compromise | ||||||
| 1 | 35 | 0 | 40 | 3.4 | 0.1 to 81.3 | |
| 1 | 10 | 0 | 10 | 3.0 | 0.1 to 65.9 | |
| Secretion encumbrance resulting in severe hypoxaemia requiring reintubation | ||||||
| 2 | 35 | 9 | 40 | 0.25 | 0.1 to 1.1 | |
