AARC Clinical Practice Guideline: Effectiveness of Pharmacologic Airway Clearance Therapies in Hospitalized Patients

Abstract

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.

Is inhaled prophylactic heparin useful for prevention and Management of Pneumonia in ventilated ICU patients?

“…In the current trial, doses of heparin used were consistent with previous studies in burns, [1] asthma, [30] bronchiectasis [31] and cystic fibrosis. [6] The lack of effect of heparin in this study compared to previous studies may have been due to different patterns of airway inflammation seen in acutely ventilated patients or a low baseline VAP rate.…”

Year in Review 2014: Airway Clearance

“…1 Lacombe et al 9 discovered, however, that mechanical insufflation-exsufflation alone may not be enough to produce adequate airway clearance. As an independent airway clearance technique, mechanical insufflation-exsufflation generates a lower cough peak flow than it does when paired with manually assisted cough and also intermittent positive-pressure breathing paired with manually assisted cough.…”

“…12 The routine use of PEP for patients with COPD is not recommended but may be an option for those patients with COPD and symptomatic secretion retention. 1 Osadnik et al 13 conducted a randomized controlled trial to study the effect of PEP added to the usual care of hospitalized subjects with COPD exacerbations. They found that adding PEP to the hospitalized pulmonary regime did not improve symptoms, quality of life, or incidence of future exacerbations.…”

“…[1][2][3] In a well-powered study investigating the effectiveness of chest physical therapy in mechanically ventilated subjects diagnosed with sepsis, a statistically significant short-term improvement in oxygenation and ventilation was observed. 4 The researchers' conclusion that chest physical therapy may produce immediate effects of improved oxygenation (P Ͻ .02) and lactate levels (P Ͻ .001) is tempered by the lack of discussion as to whether the improvement is sustainable or temporary and by the number of uncontrolled variables and the immediate timeframe of the post-intervention measurements.…”

“…In truth, there is a significant lack of high-level evidence for airway clearance techniques. 1 Recent research has focused on a variety of airway clearance interventions, including chest physical therapy, high-frequency chestwall compression (HFCWC), intrapulmonary ventilation (IPV), mechanical insufflation-exsufflation, and positive expiratory pressure (PEP), in a variety of patient populations.…”