Airway clearance therapy (ACT) is used in a variety of settings for a variety of ailments. These guidelines were developed from a systematic review with the purpose of determining whether the use of nonpharmacologic ACT improves oxygenation, reduces length of time on the ventilator, reduces stay in the ICU, resolves atelectasis/consolidation, and/or improves respiratory mechanics, versus usual care in 3 populations. For hospitalized, adult and pediatric patients without cystic fibrosis, 1) chest physiotherapy (CPT) is not recommended for the routine treatment of uncomplicated pneumonia; 2) ACT is not recommended for routine use in patients with COPD; 3) ACT may be considered in patients with COPD with symptomatic secretion retention, guided by patient preference, toleration, and effectiveness of therapy; 4) ACT is not recommended if the patient is able to mobilize secretions with cough, but instruction in effective cough technique may be useful. For adult and pediatric patients with neuromuscular disease, respiratory muscle weakness, or impaired cough, 1) cough assist techniques should be used in patients with neuromuscular disease, particularly when peak cough flow is < 270 L/min; CPT, positive expiratory pressure, intrapulmonary percussive ventilation, and high-frequency chest wall compression cannot be recommended, due to insufficient evidence. For postoperative adult and pediatric patients, 1) incentive spirometry is not recommended for routine, prophylactic use in postoperative patients, 2) early mobility and ambulation is recommended to reduce postoperative complications and promote airway clearance, 3) ACT is not recommended for routine postoperative care. The lack of available high-level evidence related to ACT should prompt the design and completion of properly designed studies to determine the appropriate role for these therapies.

Aerosolized medications are used as airway clearance therapy to treat a variety of airway diseases. These guidelines were developed from a systematic review with the purpose of determining whether the use of these medications to promote airway clearance improves oxygenation and respiratory mechanics, reduces ventilator time and ICU stay, and/or resolves atelectasis/consolidation compared with usual care. Recombinant human dornase alfa should not be used in hospitalized adult and pediatric patients without cystic fibrosis. The routine use of bronchodilators to aid in secretion clearance is not recommended. The routine use of aerosolized N-acetylcysteine to improve airway clearance is not recommended. Aerosolized agents to change mucus biophysical properties or promote airway clearance are not recommended for adult or pediatric patients with neuromuscular disease, respiratory muscle weakness, or impaired cough. Mucolytics are not recommended to treat atelectasis in postoperative adult or pediatric patients, and the routine administration of bronchodilators to postoperative patients is not recommended. There is no high-level evidence related to the use of bronchodilators, mucolytics, mucokinetics, and novel therapy to promote airway clearance in these populations.

The ability to apply continuous distending pressure through consistent application of NRS with the RAM cannula attached to a ventilator may improve clinical outcomes, including the duration of respiratory support and pressure-ulcer rates. The influence of this system on the development of bronchopulmonary dysplasia and the significantly increased retinopathy of prematurity requires further study.

Dry powder inhalers (DPIs) are breath actuated, and patients using DPIs need to generate an optimal inspiratory flow during the inhalation maneuver for effective drug delivery to the lungs. However, practical and standardized recommendations for measuring peak inspiratory flow (PIF)-a potential indicator for effective DPI use in chronic obstructive pulmonary disease (COPD)-are lacking. To evaluate recommended PIF assessment approaches, we reviewed the Instructions for Use of the In-Check™ DIAL and the prescribing information for eight DPIs approved for use in the treatment of COPD in the United States. To evaluate applied PIF assessment approaches, we conducted a PubMed search from inception to August 31, 2021, for reports of clinical and real-life studies where PIF was measured using the In-Check™ DIAL or through a DPI in patients with COPD. Evaluation of collective sources, including 47 applicable studies, showed that instructions related to the positioning of the patient with their DPI, instructions for exhalation before the inhalation maneuver, the inhalation maneuver itself, and post-inhalation breath-hold times varied, and in many instances, appeared vague and/or incomplete. We observed considerable variation in how PIF was measured in clinical and real-life studies, underscoring the need for a standardized method of PIF measurement. Standardization of technique will facilitate comparisons among studies. Based on these findings and our clinical and research experience, we propose specific recommendations for PIF measurement to standardize the process and better ensure accurate and reliable PIF values in clinical trials and in daily clinical practice.

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To generate a preliminary version of a novel risk score to predict the need for invasive mechanical ventilation (MV) in patients with COVID-19. METHODS: Retrospective analysis of patients >18 years-of-age with laboratory-confirmed COVID-19 admitted between March 15-April 15, 2020 to a tertiary-care center. Demographic, laboratory, clinical, and outcome information were recorded, using a standard data-collection format. RESULTS: The cohort included 265 subjects (mean age 59.3 AE16.4 years, 55.1% male) and 54 (20.4%) required invasive MV. Significant between-group univariate results, based on the need for invasive MV, were used in multiple-regression analysis. Admission heart rate (HR) (OR 1.032 [CI 1.013-1.015]; p<0.001), SpO2/FIO2 (S/F) ratio (OR .619 [CI .463-.829]; p=0.001), and any positive initial troponin (TnI) (OR 4.18 [CI 1.93-9.036]; p<0.001] independently predicted the need for invasive MV. The best cutoff points for the variables HR and S/F ratio were also determined: HR >101.5 BPM (AUC 0.686, 68.5% sensitivity & 66.4% specificity) and S/F ratio <4.4 (AUC 0.714, 72.2% sensitivity & 61.6% specificity). The overall model showed good calibration (Hosmer-Lemeshow = 6.3; p=0.39) and predictive ability (AUC = .80). Patients with a single, positive variable had an invasive MV risk = 15.4%, but this increased to 29% with 2 variables and 60.5% (p<0.001) with the presence of all 3. CONCLUSIONS: This pilot study provides insight into early factors related to patient acuity and the use of medical resources. Thresholds for 3 common clinical variables-HR, S/F ratio and TnIpredicted the need for invasive MV with good accuracy and provide an easily-applied scoring system to determine risk. CLINICAL IMPLICATIONS: We developed a simple, novel risk score to quantify the need for invasive MV in COVID-19 patients, with preliminary testing showing the 3 components had good predictive ability.

To examine COVID-19 patients requiring invasive mechanical ventilation (MV) and/or Extracorporeal Membrane Oxygenation (ECMO) to better understand patient selection for ECMO, clinical management, and short-term outcomes. METHODS: Retrospective study of patients >18-years-old admitted to the hospital with COVID-19 requiring MV. Lungprotective ventilation was used in all patients with initial set PEEP of 8-10 cm H20 for plateau pressure <30 cm H20. ECMO was considered per pre-specified institutional criteria for refractory hypoxemia despite maximum-medical therapy, in qualifying patients. Exclusion criteria for ECMO included age >65 years, multi-system organ failure, and MV >10 d. Data captured included baseline patient characteristics, co-morbidities, pre-ECMO respiratory support, ECMO settings, laboratory results, and COVID-19 therapeutic interventions.

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