A Novel Pharyngeal Clearance Maneuver for Initial Tracheostomy Tube Cuff Deflation in High Cervical Tetraplegia

Abstract

Mechanical insufflation-exsufflation, or “cough assist,” is a commonly used method of clearing tracheal and pulmonary secretions in patients with respiratory insufficiency secondary to spinal cord injury. This report presents a novel technique termed the pharyngeal clearance maneuver, which uses a modified application of the mechanical insufflation-exsufflation device to mobilize “secretion burden” at the portion of the trachea above the tracheostomy cuff during cuff deflation. Utilization of this strategy may reduce the risk of aspiration, infection, and respiratory compromise for patients with high cervical spinal cord injury in the acute rehabilitation setting. It is of particular benefit for those whose cuffs are being deflated for the first time and who may have large secretion volumes above the cuff. It can be further used as needed before speaking trials and swallow therapies. We anticipate that the pharyngeal clearance maneuver may be used in other populations with impaired cough and need for invasive ventilator support because of ventilator pump failure (eg, spinal muscular atrophy, congenital myopathies, obesity hypoventilation, amyotrophic lateral sclerosis, muscular dystrophy, and acute inflammatory demyelinating polyneuropathy).

Current approaches to reporting pharyngo-laryngeal secretions

“…Some studies have suggested a reduction in secretion ratings following therapeutic oral trials [21] and respiratory muscle strength training [28]. Ehsanian et al [39] describe a 'cough assist' manoeuvre during tracheostomy tube cuff deflation for therapeutic gain. Certainly, efficacious treatment needs to be informed by improving knowledge of the underlying physiological mechanisms associated with poor secretion management, specifically by determining whether accumulation is due to impaired sensation, ineffective clearance due to motor impairment or a combination of deficits.…”

Effect of nutritional status on occurrence of pneumonia after traumatic cervical spinal cord injury

“…Previous studies have shown that the occurrence of pneumonia in SCI is associated with several factors, such as the severity of paralysis, severity of dysphagia 5 , male sex, presence of chest trauma, delayed intubation 2 , increased tracheal secretion 6 , enteral feeding, and mechanical ventilation 4 . In contrast, nutrition- and inflammation-related indicators have been used to predict surgical risks and postoperative complications 4 , 7 , 8 .…”