Neuromuscular Compromise and Respiratory Failure — General Airway Management — Clinical Pathway: Inpatient and PICU

Neuromuscular Compromise and Respiratory Failure Clinical Pathway — Inpatient and PICU

General Airway Management: Mechanical Strategies and First- and Second-line Airway Clearance

Mechanical Strategies

Airway management in patients with neuromuscular disorders centers on secretion clearance using a combination of:

  • Secretion mobilization
    +
    Cough/secretion removal

Home therapies should be continued per patient/family preference. The therapies below can be tiring — for rest, consider Q4 MI-E (CoughAssist) therapy overnight. The table below outlines first- and second-line approaches to airway clearance.

See Oxygenation Goals

First-line Airway Clearance

Manual Chest Physiotherapy (CPT) (percussion and postural drainage) + MI-E (CoughAssist) + Suction
All to be completed at same frequency

Second-line Airway Clearance

Add either of the below if the patient is already at a Q2 CPT + MI-E + suction regimen frequency:

  • Intrapulmonary Percussive Ventilation (IPV) to CPT + MI-E + suction regimen
  • High Frequency Chest Wall Oscillation/Compression (HFCWO/HFCWC, Vest) to CPT + MI-E + suction regimen

First-line Airway Clearance

Mode Description Use Considerations
Manual CPT – Percussion and Postural Drainage
  • CPT: side to side with HOB down
  • Postural drainage: supine with head of bed down for 15 minutes or as tolerated
  • Mobilize secretions
  • Useful adjunct to MI-E
  • Can help with focused clearance in one lung region
  • Limit in GERD patients
  • May not be feasible for those with chest wall deformities (e.g., kyphoscoliosis)
  • Be cautious in patients prone to rib fractures (see Safe Patient Handling)
MI-E (Cough Assist)
  • The basis of all airway clearance for patients with neuromuscular disorders
  • Helps to bring mucus to central airway and higher

Should be used in all patients unless a clear contraindication

  • Set at highest tolerated pressure that delivers adequate chest expansion
  • Titrate based on chest wall expansion/comfort
  • Can administer via tracheostomy tube/ETT
  • Order as scheduled and PRN — MI-E (CoughAssist) Settings
  • Cough Assist

Hypoxemia can be due to V/Q mismatch resulting from secretions/mucus plugging.

With worsened hypoxemia:

  • Provide temporary supplemental oxygen
  • Continue cycles until back to baseline FiO2 or better.

Use of higher Pi/Pe than baseline settings is often required during illness to achieve adequate airway clearance
Oro-nasal Suction
  • Clears central airways after manual CPT and MI-E

Oropharynx and/or nasopharynx

Also via ETT tube/trach

Second-line Airway Clearance

Mode Description Use Considerations
Intrapulmonary Percussive Ventilation (IPV)
  • Positive pressure, vibration, nebulization
  • Helps mobilize secretions and move them centrally
  • Augments impact of MI-E (CoughAssist) (which must be available in room during use of IPV)
  • IPV
  • Does not replace MI-E
  • Administer via NIV in the non-intubated patient
High-frequency Chest Wall Oscillation/Compression (HFCWO/HFCWC, Vest)
  • Not effective in expectoration
  • Should not be used as a single airway clearance device
  • Use in conjunction with MI-E (CoughAssist) (which must be available in room during use of HFCWO, Vest)
  • Vest Airway Clearance System
  • Not recommended for use in intubated patients due to risk for tube dislodgement
  • Discontinue if patient does not tolerate pressure against chest wall

Note: there has been no direct comparison of IPV to HFCWO/Vest therapy in patients with neuromuscular disorders. Use is per provider and patient/family preference.

See information on: Pharmacologic Airway Clearance