Neuromuscular Compromise and Respiratory Failure — Airway and Secretion Clearance — Clinical Pathway: Inpatient and PICU

Neuromuscular Compromise and Respiratory Failure Clinical Pathway — Inpatient and PICU

Airway and Secretion Clearance

For all patients, evaluate chest X-ray PRN with clinical change.

Sequence Recommendations
Initial Management

Consult Pulmonology, if not already on service

(Patients on pulmonary floor must be off NIV at least 2 hrs BID for initial management)
  • Interface selection:
    • Nasal interface AND headgear
  • Airway clearance: CPT and MI-E (CoughAssist) Q2* and PRN
24 - 48 Hours (1-2 days) of Q2 hour therapy and no improvement based on assessment
  • If atelectasis and mucus plugging present, continue Q2 CPT and MI-E (CoughAssist)
  • Add second-line airway clearance (IPV or HFCWO/Vest®) Q4 or Q6 to CPT/MI-E (CoughAssist)
    For rest, consider Q4 MI-E (CoughAssist) therapy overnight
72 Hours (3 days) of Q2 hour therapy and no improvement based on assessment
  • Increase frequency of IPV or HFCWO (Vest®) to Q4 and continue therapy
    For rest, consider Q4 MI-E (CoughAssist) therapy overnight
120 Hours (5 days) of Q2 hour therapy and no improvement based on assessment
  • Consider adding:
    • Hypertonic saline for acute mucus plugs, not as a long-term therapy
    • Non-invasive/Invasive VDR
    • Therapeutic bronchoscopy if clearly identifiable lobar density
      • Note: In a non-intubated patient the bronchoscopy may result in the patient being intubated for a period of time after the procedure
  • For rest, consider Q4 MI-E (CoughAssist) therapy overnight

Continued lack of improvement: If the patient continues after 5 days of Q2 hour therapy with no improvement, a discussion about goals of care should occur with the family.

Improvement demonstrated during sequences above: Begin NIV Weaning Strategies.