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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Set-up of an electronic peak flow meter &#40;PiKo I&#41; for measuring cough PEF through the tracheal cannula&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Insufficient cough strength plays a major role in failed extubation&#47;decannulation in patients with high level spinal cord injury&#44; primary neuromuscular disorders or ICU-acquired weakness&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">1&#44;2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Evidence-based assessments in the ventilator discontinuation process<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">3</span></a> suggest evaluation of cough strength in patients passing a spontaneous breathing trial&#44; however this procedure has not yet moved into clinical practice&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Extubation failure rate ranges from 10&#37; to 20&#37; of extubations and translates into higher mortality compared with successful extubation&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">4</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Decannulation failure ranges from 2&#37;&#44;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">5</span></a> in acute brain injury patients in rehabilitation facilities&#44; to 32&#46;4&#37;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">6</span></a> in patients with neuromuscular ventilator insufficiency &#40;predominantly spinal cord injuries&#41; admitted to a ventilator unit&#46; More recently in a prospective study&#44; Choate et al&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">7</span></a> report decannulation failure rate of 4&#46;8&#37;&#46; Comparison between these studies is difficult because of differences in definitions of decannulation failure&#44; lack of consistency in weaning and decannulation protocols&#44; and differing patient characteristics&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Patients who are decannulated have better survival rates&#46; O&#8217;Connor et al&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">8</span></a> examined the process of decannulation in patients transferred to a long-term acute care hospital&#46; Decannulation was successful in 35&#37; of patients at a median of 45 days following tracheostomy&#46; Patients who failed decannulation had a tracheostomy tube placed earlier and had a shorter stay in the referring acute care hospital&#46; At 3&#46;5 years&#44; 35&#37; of all patients and 62&#37; of decannulated patients were alive&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Where decannulation fails the majority require simple recannulation but others &#40;37&#46;5&#37;&#41; may require translaryngeal intubation&#44;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">7</span></a> and readmission to the ICU&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Cough capacity can be easily evaluated by measuring flows during coughing&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">1&#44;6</span></a> If cough flows are measured through the mouth &#40;with an active glottis&#41; we can call it a true cough peak flow &#40;CPF&#41;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">6</span></a> whereas if measured through a tracheostomy or an endotracheal tube it is more a peak expiratory flow &#40;PEF&#41;&#44; because of bypassing the glottis&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">1</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Cough PEF values during extubation &#40;see also <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;</span><p id="par0040" class="elsevierStylePara elsevierViewall">In a study by Smina et al&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">1</span></a> cough PEF was the strongest predictor of extubation outcome for patients without neuromucular disorders&#46; The mean PEFs were significantly lower in unsuccessful extubations compared with successful extubations &#40;64&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6&#46;8<span class="elsevierStyleHsp" style=""></span>L&#47;min vs 81&#46;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;7<span class="elsevierStyleHsp" style=""></span>L&#47;min&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;03&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">In the Pascal Beuret et al&#46; study&#44;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">9</span></a> which included ICU patients who had successfully passed the spontaneous breathing trial&#44; the optimal cough PEF value to predict extubation failure was &#62;35<span class="elsevierStyleHsp" style=""></span>L&#47;min&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">In patients unable to cooperate voluntarily cough PEF cannot be evaluated&#46; Involuntary cough may be assessed either by instilling normal saline<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">2</span></a> or by advancing a suctioning catheter through the patient&#39;s tracheostomy tube to induce a cough&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">10</span></a> Although not compared directly two different studies using voluntary<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">11</span></a> and involuntary cough PEF<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">2</span></a> have come out with approximately the same cut-off point &#40;60 versus 58&#46;5<span class="elsevierStyleHsp" style=""></span>L&#47;min respectively&#41;</p><p id="par0055" class="elsevierStylePara elsevierViewall">In the Salam et al&#46; study<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">11</span></a> Cough PEFs were measured in all but five patients who were unable to understand instructions or could not attempt a cough&#46; For the remaining 83 patients who attempted to cough&#44; the Cough PEFs ranged from 10 to 200<span class="elsevierStyleHsp" style=""></span>L&#47;min&#59; 41&#37; of the measurements were 60<span class="elsevierStyleHsp" style=""></span>L&#47;min or less&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The study of Smailes<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">12</span></a> demonstrated that patients with a cough PEF of &#8804;60<span class="elsevierStyleHsp" style=""></span>L&#47;min are nine times as likely to fail extubation as those with a CPF<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>60<span class="elsevierStyleHsp" style=""></span>L&#47;min&#46; Smina et al&#46; and Salam et al&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">1&#44;11</span></a> also identified a cough PEF threshold of 60<span class="elsevierStyleHsp" style=""></span>L&#47;min&#46; The study by Beuret et al&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">9</span></a> identified a much lower Cough PEF threshold&#44; which might be due to different patient populations or characteristics of the device used to measure cough&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">In effect the Cough PEF measured in intubated patients may be considered a &#8220;huff&#8221; or&#44; perhaps&#44; a peak expiratory flow maneuver and not a true peak cough flow&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Cough peak flow &#40;CPF&#41; and cough PEF values during decannulation &#40;see also <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;</span><p id="par0070" class="elsevierStylePara elsevierViewall">Bach and Saporito were the first to use CPF to predict decannulation failure&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">6</span></a> They proposed providing maximal insufflations together with an abdominal thrust timed to glottic opening &#40;manually assisted coughing&#41;&#46; In this way assisted CPF of at least 160<span class="elsevierStyleHsp" style=""></span>L&#47;min &#40;immediately after extubation or decannulation&#41; predicted successful extubation or decannulation&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">More recently the same authors<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">13</span></a> challenged the cut-off stating that with great experience in noninvasive management it was possible to extubate and decannulate patients even with CPF<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>160<span class="elsevierStyleHsp" style=""></span>L&#47;min&#59; however&#44; they warned that the less the upper airway patency as suggested by low CPF or mechanical in-exsufflation &#40;MIE&#41; flows&#44; the less effective is MIE in keeping the airways clear after extubation or decannulation and the greater the risk of failing noninvasive management&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">McKim et al&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">14</span></a> measured CPF through the mouth in tracheostomized patients with the cuffs deflated&#44; and cannulas capped&#46; In this study&#44; spontaneous CPF through the mouth in tracheostomized neuromuscular patients was about 35<span class="elsevierStyleHsp" style=""></span>L&#47;min lower than post-decannulation spontaneous CPF&#46; Those authors proposed that with the gain achieved post-decannulation&#44; a spontaneous CPF value of 130<span class="elsevierStyleHsp" style=""></span>L&#47;min may still anticipate a successful decannulation&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Hernandez et al&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">15</span></a> in 151 medical-surgical ICU patients measured cough PEF through the tracheostomy tube and showed that values were higher with the cuff deflated&#46; Moreover they demonstrated that low PEF &#40;percentile 33&#41; was negatively associated with decannulation&#46; Mean PEF in the 87 patients with prolonged weaning was 118<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>77<span class="elsevierStyleHsp" style=""></span>L&#47;min&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Cough flow values&#58; through the tube or through the mouth&#63;</span><p id="par0090" class="elsevierStylePara elsevierViewall">Peak flows through an endotracheal tube are bound to be lower than those in decannulated patients because intubated patients cannot close their glottis&#44; thereby limiting the pressure generated when attempting to cough&#46; Thus&#44; the reason for the lower threshold values described in the studies measuring CPF in intubated patients is a result of the different procedures as these patients perform a &#8220;glotic-free cough PEF&#46;&#8221;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Set-up to measure cough PEF in patients with an endotracheal tube</span><p id="par0095" class="elsevierStylePara elsevierViewall">The peak flow meter&#47;pneumotachograph should be connected to the proximal tip of the tracheal tube via a bacterial&#47;viral filter&#46; The patient&#44; who should be positioned in the semi-recumbent position&#44; should then be instructed to inspire deeply through a three-way connector positioned between the proximal tip of the tracheal tube and the peak flow meter&#46; The external port of the connector should then be occluded&#44; and the patient instructed to cough as strongly as possible through the tracheal tube&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Alternatively&#44; involuntary Cough PEF can be induced by removing the T-piece and dripping 2<span class="elsevierStyleHsp" style=""></span>mL of normal saline into the endotracheal tube at the end-inspiratory point&#44; with the patient in a head-up position at 45&#176; from the horizontal&#46; The end-inspiratory point is chosen to ensure that a full inspiration has occurred&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">The T-piece and flow sensor should be reconnected to the endotracheal tube as soon as possible&#46; The patients should be continuously observed until their breathing becomes smooth and regular&#46; The maximum expiratory flow value detected should be recorded as the involuntary cough PEF&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">2</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Set-up to measure cough flows in patients with a tracheostomy tube</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Measurement through the cannula &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;</span><p id="par0110" class="elsevierStylePara elsevierViewall">In uncooperative patients &#40;e&#46;g&#46; neurosurgical patients&#41;&#44; the patient should be in the supine position with the head of the bed elevated at 30&#176;&#46; Patients with a cuffed tracheotomy tube should have the cuff deflated before measurements are made&#46; Suctioning above the cuff should be done before the cuff is deflated&#46; Oxygen saturation and signs of respiratory distress should be monitored during the measurement process&#46; The cough PEF measurement procedure should be stopped immediately if any of the following occur&#58; respiratory rate greater than 35&#47;min&#59; oxygen saturation&#44; as measured by pulse oximetry&#44; less than 90&#37;&#59; heart rate above 140&#47;min or an increase of more than 20&#37; above resting levels&#46; With sterile conditions&#44; a standardized proportion &#40;12<span class="elsevierStyleHsp" style=""></span>cm&#41; of a 10F suction catheter should be introduced through the suction port of the swivel elbow connector&#46; The swivel connector with the suction catheter partially inserted is then attached to the patient&#39;s tracheotomy tube&#44; which is in turn connected to a viral&#47;bacterial respiratory filter allowing a pneumotachograph-calibrated electronic peak flow meter &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Measurement through the mouth &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;</span><p id="par0115" class="elsevierStylePara elsevierViewall">For cooperative patients the CPF measurements can be done with cuffs deflated&#44; tracheostomy cannulas capped and measured through the mouth<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">14</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0120" class="elsevierStylePara elsevierViewall">Patients should be asked to cough via an oronasal interface into a peak flow meter with the tracheostomy tube covered and cuff deflated&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">13</span></a> If a spontaneous CPF of 160<span class="elsevierStyleHsp" style=""></span>L&#47;min is not achieved then an assisted CPF should be determined by removing the tube&#44; covering the ostomy while ventilating the lungs by mouth piece non-invasive ventilation as needed&#44; and getting the patient to air stack consecutive ventilator-delivered volumes via a mouth piece to a deep lung volume and then coughing into a peak flow meter as an abdominal thrust is applied &#40;called manually assisted CPF&#44; that is the value following lung volume recruitment and manual abdominal trust&#41;&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Alternatively&#44; to measure CPF after lung volume recruitment&#44; breaths can be stacked to approximate the maximum insufflation capacity&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">14</span></a> To achieve a maximum insufflation capacity&#44; the patient is instructed to inhale fully&#44; hold his&#47;her breath&#44; and then place the lips tightly around a mouthpiece through which consecutive volumes of air are delivered using a manual resuscitation bag and held by a closed glottis&#46; The patient is then asked to cough and the flows are measured &#40;called lung volume recruitment CPF&#41;&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Measurements of cough flows&#58; with mechanical peak flow meter&#44; electronic peak flow meter or pneumotachograph&#63; &#40;see also <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;</span><p id="par0130" class="elsevierStylePara elsevierViewall">There is a great variability of devices used in the studies&#58; from a classical mini-Wright Peak flow meter&#44;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">12&#44;14&#44;15</span></a> an Aztech Peak flow meter&#44;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">1&#44;11</span></a> an Access Peak flow meter&#44;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">6&#44;13</span></a> to an electronic peak flow meter<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">9&#44;10</span></a> or a respiratory mechanics monitor&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">2</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">Sancho et al&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">16</span></a> compared CPF measurements with a mechanical peak flow meter &#40;asmaPLAN&#44; Vitalograph&#44; Ennis&#44; Ireland&#41; and pneumotachograph in healthy volunteers and spontaneously breathing neuromuscular disorders patients&#46; In their study PCF measurements made with the peak flow meter were reproducible and reasonably accurate when flows were &#62;270<span class="elsevierStyleHsp" style=""></span>L&#47;min&#46; However&#44; the authors have warned that caution is needed in clinical practice at lower PCF because of the tendency of this portable device to overestimate the lower flows&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">16</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">Electronic PEF meters &#40;like the PiKo-1&#41; can measure PEF in the range of 15 to 999<span class="elsevierStyleHsp" style=""></span>L&#47;min with a 1<span class="elsevierStyleHsp" style=""></span>L&#47;min resolution&#44; an accuracy of 6&#46;5&#37;&#44; and a better agreement with pneumotachograph compared to mechanical PEF meters&#46; Due to its low cost and storage capacity it could be a good alternative to the more expensive pneomotachograph&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">17</span></a></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Analysis of cough flow&#8211;volume curves</span><p id="par0145" class="elsevierStylePara elsevierViewall">Presence of transients of peak flow during cough flow-volume maneuvers may suggest also cough efficiency&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">18</span></a> In fact in a prospective study including 53 spontaneously breathing patients with Amyotrophic lateral sclerosis&#44; the absence of cough spikes in the flow-volume loops was related to an increased mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">19</span></a> So analysis of cough flow&#8211;volume curves with the use of a pneumotachograph may add to the analysis of the absolute CPF values&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Conclusions</span><p id="par0150" class="elsevierStylePara elsevierViewall">Cough flows should become the preferred method of assessing cough strength in patients for whom extubation or decannulation is being planned&#46; Only when the measurement is obtained with an active glottis should we call it cough peak flow&#44; otherwise it should be termed cough PEF&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Although cut-off values for high-risk patients have been defined&#44; different methodologies &#40;set-up and measuring devices&#41; and patient populations involved in the studies suggest some caution in interpreting absolute values&#46; However as a rule of thumb a value of cough peak flow &#62;160<span class="elsevierStyleHsp" style=""></span>L&#47;min measured at the mouth or a value of endotracheal cough PEF &#62;60<span class="elsevierStyleHsp" style=""></span>L&#47;min measured suggests that they are good candidates for decannulation or extubation&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Due to lower cough flow values in this setting&#44; use of more accurate devices like electronic PEF meters should be recommended&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Conflict of interest</span><p id="par0165" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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          "identificador" => "xres451697"
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              "identificador" => "abst0005"
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        1 => array:2 [
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          "titulo" => "Introduction"
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        3 => array:2 [
          "identificador" => "sec0010"
          "titulo" => "Cough PEF values during extubation &#40;see also Table 1&#41;"
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        4 => array:2 [
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          "titulo" => "Cough peak flow &#40;CPF&#41; and cough PEF values during decannulation &#40;see also Table 1&#41;"
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        5 => array:2 [
          "identificador" => "sec0020"
          "titulo" => "Cough flow values&#58; through the tube or through the mouth&#63;"
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        6 => array:2 [
          "identificador" => "sec0025"
          "titulo" => "Set-up to measure cough PEF in patients with an endotracheal tube"
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          "titulo" => "Set-up to measure cough flows in patients with a tracheostomy tube"
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              "identificador" => "sec0035"
              "titulo" => "Measurement through the cannula &#40;Fig&#46; 1&#41;"
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              "identificador" => "sec0040"
              "titulo" => "Measurement through the mouth &#40;Fig&#46; 2&#41;"
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        8 => array:2 [
          "identificador" => "sec0045"
          "titulo" => "Measurements of cough flows&#58; with mechanical peak flow meter&#44; electronic peak flow meter or pneumotachograph&#63; &#40;see also Table 1&#41;"
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        9 => array:2 [
          "identificador" => "sec0050"
          "titulo" => "Analysis of cough flow&#8211;volume curves"
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        10 => array:2 [
          "identificador" => "sec0055"
          "titulo" => "Conclusions"
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        11 => array:2 [
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          "titulo" => "References"
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    "fechaRecibido" => "2014-12-14"
    "fechaAceptado" => "2014-12-16"
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          "clase" => "keyword"
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            0 => "Cough strength"
            1 => "Extubation"
            2 => "Decannulation"
            3 => "Neuromuscular"
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    "resumen" => array:1 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Insufficient cough strength has a major role in extubation and decannulation outcomes&#46;</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Cough capacity can be easily evaluated by measuring flows during coughing&#46; Values vary depending on whether cough flows are measured through the mouth or through a tracheostomy or endotracheal tube&#46; It is important to standardize these measurements and start using them routinely in the extubation and decannulation processes&#46; Values of cough peak flow &#62;160<span class="elsevierStyleHsp" style=""></span>L&#47;min measured at the mouth or a value of cough PEF &#62;60<span class="elsevierStyleHsp" style=""></span>L&#47;min measured at the endotracheal tube suggest successful decannulation or extubation&#46;</p></span>"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Set-up of an electronic peak flow meter &#40;PiKo I&#41; for measuring cough PEF through the tracheal cannula&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Article&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Number of patients&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Diagnosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Measurement via mouth&#47;trach&#47;ET&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Device&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Outcome&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">95&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Critically ill&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ET&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Aztech&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Extubation failure&#44; mortality&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">150&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Critically ill&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ET&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Respiratory mechanics monitor&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Extubation failure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">49&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Neuromuscular&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Mouth&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">HealthScan&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Decannulation failure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">130&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Critically ill&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ET&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Piko-1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Extubation failure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">32&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Neurosurgical&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Trach&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Piko-1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Decannulation failure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">88&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Critically ill&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ET&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Aztech&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Extubation failure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">125&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Burn&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ET&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Mini-Wright&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Extubation failure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">61&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Neuromuscular&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Mouth&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Access&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Post-decannulation&#44; vital capacity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">26&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Neuromuscular&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Mouth&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Mini-Wright&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pre- vs post-decannulation value&#44; decannulation failure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">151&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Prolonged Weaning or Neurological&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Trach&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Mini-Wright&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Time to decannulation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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Special article
The value of cough peak flow measurements in the assessment of extubation or decannulation readiness
J.C. Wincka,b,
Corresponding author
jcwinck@mail.telepac.pt

Corresponding author.
, C. LeBlancc, J.L. Sotod, F. Planod
a Department of Pulmonology, Faculdade de Medicina, Universidade do Porto, Portugal
b Linde Healthcare, Pullach, Germany
c Ottawa Hospital Rehabilitation Centre, Canada
d REMEO® Centre el Pilar, Linde Group, Argentina
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Set-up of an electronic peak flow meter &#40;PiKo I&#41; for measuring cough PEF through the tracheal cannula&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Insufficient cough strength plays a major role in failed extubation&#47;decannulation in patients with high level spinal cord injury&#44; primary neuromuscular disorders or ICU-acquired weakness&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">1&#44;2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Evidence-based assessments in the ventilator discontinuation process<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">3</span></a> suggest evaluation of cough strength in patients passing a spontaneous breathing trial&#44; however this procedure has not yet moved into clinical practice&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Extubation failure rate ranges from 10&#37; to 20&#37; of extubations and translates into higher mortality compared with successful extubation&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">4</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Decannulation failure ranges from 2&#37;&#44;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">5</span></a> in acute brain injury patients in rehabilitation facilities&#44; to 32&#46;4&#37;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">6</span></a> in patients with neuromuscular ventilator insufficiency &#40;predominantly spinal cord injuries&#41; admitted to a ventilator unit&#46; More recently in a prospective study&#44; Choate et al&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">7</span></a> report decannulation failure rate of 4&#46;8&#37;&#46; Comparison between these studies is difficult because of differences in definitions of decannulation failure&#44; lack of consistency in weaning and decannulation protocols&#44; and differing patient characteristics&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Patients who are decannulated have better survival rates&#46; O&#8217;Connor et al&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">8</span></a> examined the process of decannulation in patients transferred to a long-term acute care hospital&#46; Decannulation was successful in 35&#37; of patients at a median of 45 days following tracheostomy&#46; Patients who failed decannulation had a tracheostomy tube placed earlier and had a shorter stay in the referring acute care hospital&#46; At 3&#46;5 years&#44; 35&#37; of all patients and 62&#37; of decannulated patients were alive&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Where decannulation fails the majority require simple recannulation but others &#40;37&#46;5&#37;&#41; may require translaryngeal intubation&#44;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">7</span></a> and readmission to the ICU&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Cough capacity can be easily evaluated by measuring flows during coughing&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">1&#44;6</span></a> If cough flows are measured through the mouth &#40;with an active glottis&#41; we can call it a true cough peak flow &#40;CPF&#41;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">6</span></a> whereas if measured through a tracheostomy or an endotracheal tube it is more a peak expiratory flow &#40;PEF&#41;&#44; because of bypassing the glottis&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">1</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Cough PEF values during extubation &#40;see also <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;</span><p id="par0040" class="elsevierStylePara elsevierViewall">In a study by Smina et al&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">1</span></a> cough PEF was the strongest predictor of extubation outcome for patients without neuromucular disorders&#46; The mean PEFs were significantly lower in unsuccessful extubations compared with successful extubations &#40;64&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6&#46;8<span class="elsevierStyleHsp" style=""></span>L&#47;min vs 81&#46;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;7<span class="elsevierStyleHsp" style=""></span>L&#47;min&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;03&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">In the Pascal Beuret et al&#46; study&#44;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">9</span></a> which included ICU patients who had successfully passed the spontaneous breathing trial&#44; the optimal cough PEF value to predict extubation failure was &#62;35<span class="elsevierStyleHsp" style=""></span>L&#47;min&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">In patients unable to cooperate voluntarily cough PEF cannot be evaluated&#46; Involuntary cough may be assessed either by instilling normal saline<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">2</span></a> or by advancing a suctioning catheter through the patient&#39;s tracheostomy tube to induce a cough&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">10</span></a> Although not compared directly two different studies using voluntary<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">11</span></a> and involuntary cough PEF<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">2</span></a> have come out with approximately the same cut-off point &#40;60 versus 58&#46;5<span class="elsevierStyleHsp" style=""></span>L&#47;min respectively&#41;</p><p id="par0055" class="elsevierStylePara elsevierViewall">In the Salam et al&#46; study<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">11</span></a> Cough PEFs were measured in all but five patients who were unable to understand instructions or could not attempt a cough&#46; For the remaining 83 patients who attempted to cough&#44; the Cough PEFs ranged from 10 to 200<span class="elsevierStyleHsp" style=""></span>L&#47;min&#59; 41&#37; of the measurements were 60<span class="elsevierStyleHsp" style=""></span>L&#47;min or less&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The study of Smailes<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">12</span></a> demonstrated that patients with a cough PEF of &#8804;60<span class="elsevierStyleHsp" style=""></span>L&#47;min are nine times as likely to fail extubation as those with a CPF<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>60<span class="elsevierStyleHsp" style=""></span>L&#47;min&#46; Smina et al&#46; and Salam et al&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">1&#44;11</span></a> also identified a cough PEF threshold of 60<span class="elsevierStyleHsp" style=""></span>L&#47;min&#46; The study by Beuret et al&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">9</span></a> identified a much lower Cough PEF threshold&#44; which might be due to different patient populations or characteristics of the device used to measure cough&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">In effect the Cough PEF measured in intubated patients may be considered a &#8220;huff&#8221; or&#44; perhaps&#44; a peak expiratory flow maneuver and not a true peak cough flow&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Cough peak flow &#40;CPF&#41; and cough PEF values during decannulation &#40;see also <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;</span><p id="par0070" class="elsevierStylePara elsevierViewall">Bach and Saporito were the first to use CPF to predict decannulation failure&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">6</span></a> They proposed providing maximal insufflations together with an abdominal thrust timed to glottic opening &#40;manually assisted coughing&#41;&#46; In this way assisted CPF of at least 160<span class="elsevierStyleHsp" style=""></span>L&#47;min &#40;immediately after extubation or decannulation&#41; predicted successful extubation or decannulation&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">More recently the same authors<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">13</span></a> challenged the cut-off stating that with great experience in noninvasive management it was possible to extubate and decannulate patients even with CPF<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>160<span class="elsevierStyleHsp" style=""></span>L&#47;min&#59; however&#44; they warned that the less the upper airway patency as suggested by low CPF or mechanical in-exsufflation &#40;MIE&#41; flows&#44; the less effective is MIE in keeping the airways clear after extubation or decannulation and the greater the risk of failing noninvasive management&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">McKim et al&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">14</span></a> measured CPF through the mouth in tracheostomized patients with the cuffs deflated&#44; and cannulas capped&#46; In this study&#44; spontaneous CPF through the mouth in tracheostomized neuromuscular patients was about 35<span class="elsevierStyleHsp" style=""></span>L&#47;min lower than post-decannulation spontaneous CPF&#46; Those authors proposed that with the gain achieved post-decannulation&#44; a spontaneous CPF value of 130<span class="elsevierStyleHsp" style=""></span>L&#47;min may still anticipate a successful decannulation&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Hernandez et al&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">15</span></a> in 151 medical-surgical ICU patients measured cough PEF through the tracheostomy tube and showed that values were higher with the cuff deflated&#46; Moreover they demonstrated that low PEF &#40;percentile 33&#41; was negatively associated with decannulation&#46; Mean PEF in the 87 patients with prolonged weaning was 118<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>77<span class="elsevierStyleHsp" style=""></span>L&#47;min&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Cough flow values&#58; through the tube or through the mouth&#63;</span><p id="par0090" class="elsevierStylePara elsevierViewall">Peak flows through an endotracheal tube are bound to be lower than those in decannulated patients because intubated patients cannot close their glottis&#44; thereby limiting the pressure generated when attempting to cough&#46; Thus&#44; the reason for the lower threshold values described in the studies measuring CPF in intubated patients is a result of the different procedures as these patients perform a &#8220;glotic-free cough PEF&#46;&#8221;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Set-up to measure cough PEF in patients with an endotracheal tube</span><p id="par0095" class="elsevierStylePara elsevierViewall">The peak flow meter&#47;pneumotachograph should be connected to the proximal tip of the tracheal tube via a bacterial&#47;viral filter&#46; The patient&#44; who should be positioned in the semi-recumbent position&#44; should then be instructed to inspire deeply through a three-way connector positioned between the proximal tip of the tracheal tube and the peak flow meter&#46; The external port of the connector should then be occluded&#44; and the patient instructed to cough as strongly as possible through the tracheal tube&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Alternatively&#44; involuntary Cough PEF can be induced by removing the T-piece and dripping 2<span class="elsevierStyleHsp" style=""></span>mL of normal saline into the endotracheal tube at the end-inspiratory point&#44; with the patient in a head-up position at 45&#176; from the horizontal&#46; The end-inspiratory point is chosen to ensure that a full inspiration has occurred&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">The T-piece and flow sensor should be reconnected to the endotracheal tube as soon as possible&#46; The patients should be continuously observed until their breathing becomes smooth and regular&#46; The maximum expiratory flow value detected should be recorded as the involuntary cough PEF&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">2</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Set-up to measure cough flows in patients with a tracheostomy tube</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Measurement through the cannula &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;</span><p id="par0110" class="elsevierStylePara elsevierViewall">In uncooperative patients &#40;e&#46;g&#46; neurosurgical patients&#41;&#44; the patient should be in the supine position with the head of the bed elevated at 30&#176;&#46; Patients with a cuffed tracheotomy tube should have the cuff deflated before measurements are made&#46; Suctioning above the cuff should be done before the cuff is deflated&#46; Oxygen saturation and signs of respiratory distress should be monitored during the measurement process&#46; The cough PEF measurement procedure should be stopped immediately if any of the following occur&#58; respiratory rate greater than 35&#47;min&#59; oxygen saturation&#44; as measured by pulse oximetry&#44; less than 90&#37;&#59; heart rate above 140&#47;min or an increase of more than 20&#37; above resting levels&#46; With sterile conditions&#44; a standardized proportion &#40;12<span class="elsevierStyleHsp" style=""></span>cm&#41; of a 10F suction catheter should be introduced through the suction port of the swivel elbow connector&#46; The swivel connector with the suction catheter partially inserted is then attached to the patient&#39;s tracheotomy tube&#44; which is in turn connected to a viral&#47;bacterial respiratory filter allowing a pneumotachograph-calibrated electronic peak flow meter &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Measurement through the mouth &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;</span><p id="par0115" class="elsevierStylePara elsevierViewall">For cooperative patients the CPF measurements can be done with cuffs deflated&#44; tracheostomy cannulas capped and measured through the mouth<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">14</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0120" class="elsevierStylePara elsevierViewall">Patients should be asked to cough via an oronasal interface into a peak flow meter with the tracheostomy tube covered and cuff deflated&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">13</span></a> If a spontaneous CPF of 160<span class="elsevierStyleHsp" style=""></span>L&#47;min is not achieved then an assisted CPF should be determined by removing the tube&#44; covering the ostomy while ventilating the lungs by mouth piece non-invasive ventilation as needed&#44; and getting the patient to air stack consecutive ventilator-delivered volumes via a mouth piece to a deep lung volume and then coughing into a peak flow meter as an abdominal thrust is applied &#40;called manually assisted CPF&#44; that is the value following lung volume recruitment and manual abdominal trust&#41;&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Alternatively&#44; to measure CPF after lung volume recruitment&#44; breaths can be stacked to approximate the maximum insufflation capacity&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">14</span></a> To achieve a maximum insufflation capacity&#44; the patient is instructed to inhale fully&#44; hold his&#47;her breath&#44; and then place the lips tightly around a mouthpiece through which consecutive volumes of air are delivered using a manual resuscitation bag and held by a closed glottis&#46; The patient is then asked to cough and the flows are measured &#40;called lung volume recruitment CPF&#41;&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Measurements of cough flows&#58; with mechanical peak flow meter&#44; electronic peak flow meter or pneumotachograph&#63; &#40;see also <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;</span><p id="par0130" class="elsevierStylePara elsevierViewall">There is a great variability of devices used in the studies&#58; from a classical mini-Wright Peak flow meter&#44;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">12&#44;14&#44;15</span></a> an Aztech Peak flow meter&#44;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">1&#44;11</span></a> an Access Peak flow meter&#44;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">6&#44;13</span></a> to an electronic peak flow meter<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">9&#44;10</span></a> or a respiratory mechanics monitor&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">2</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">Sancho et al&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">16</span></a> compared CPF measurements with a mechanical peak flow meter &#40;asmaPLAN&#44; Vitalograph&#44; Ennis&#44; Ireland&#41; and pneumotachograph in healthy volunteers and spontaneously breathing neuromuscular disorders patients&#46; In their study PCF measurements made with the peak flow meter were reproducible and reasonably accurate when flows were &#62;270<span class="elsevierStyleHsp" style=""></span>L&#47;min&#46; However&#44; the authors have warned that caution is needed in clinical practice at lower PCF because of the tendency of this portable device to overestimate the lower flows&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">16</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">Electronic PEF meters &#40;like the PiKo-1&#41; can measure PEF in the range of 15 to 999<span class="elsevierStyleHsp" style=""></span>L&#47;min with a 1<span class="elsevierStyleHsp" style=""></span>L&#47;min resolution&#44; an accuracy of 6&#46;5&#37;&#44; and a better agreement with pneumotachograph compared to mechanical PEF meters&#46; Due to its low cost and storage capacity it could be a good alternative to the more expensive pneomotachograph&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">17</span></a></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Analysis of cough flow&#8211;volume curves</span><p id="par0145" class="elsevierStylePara elsevierViewall">Presence of transients of peak flow during cough flow-volume maneuvers may suggest also cough efficiency&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">18</span></a> In fact in a prospective study including 53 spontaneously breathing patients with Amyotrophic lateral sclerosis&#44; the absence of cough spikes in the flow-volume loops was related to an increased mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">19</span></a> So analysis of cough flow&#8211;volume curves with the use of a pneumotachograph may add to the analysis of the absolute CPF values&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Conclusions</span><p id="par0150" class="elsevierStylePara elsevierViewall">Cough flows should become the preferred method of assessing cough strength in patients for whom extubation or decannulation is being planned&#46; Only when the measurement is obtained with an active glottis should we call it cough peak flow&#44; otherwise it should be termed cough PEF&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Although cut-off values for high-risk patients have been defined&#44; different methodologies &#40;set-up and measuring devices&#41; and patient populations involved in the studies suggest some caution in interpreting absolute values&#46; However as a rule of thumb a value of cough peak flow &#62;160<span class="elsevierStyleHsp" style=""></span>L&#47;min measured at the mouth or a value of endotracheal cough PEF &#62;60<span class="elsevierStyleHsp" style=""></span>L&#47;min measured suggests that they are good candidates for decannulation or extubation&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Due to lower cough flow values in this setting&#44; use of more accurate devices like electronic PEF meters should be recommended&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Conflict of interest</span><p id="par0165" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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          "titulo" => "Introduction"
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          "titulo" => "Cough PEF values during extubation &#40;see also Table 1&#41;"
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          "titulo" => "Cough peak flow &#40;CPF&#41; and cough PEF values during decannulation &#40;see also Table 1&#41;"
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        5 => array:2 [
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          "titulo" => "Cough flow values&#58; through the tube or through the mouth&#63;"
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        6 => array:2 [
          "identificador" => "sec0025"
          "titulo" => "Set-up to measure cough PEF in patients with an endotracheal tube"
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          "titulo" => "Set-up to measure cough flows in patients with a tracheostomy tube"
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              "identificador" => "sec0035"
              "titulo" => "Measurement through the cannula &#40;Fig&#46; 1&#41;"
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              "titulo" => "Measurement through the mouth &#40;Fig&#46; 2&#41;"
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          "identificador" => "sec0045"
          "titulo" => "Measurements of cough flows&#58; with mechanical peak flow meter&#44; electronic peak flow meter or pneumotachograph&#63; &#40;see also Table 1&#41;"
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          "identificador" => "sec0050"
          "titulo" => "Analysis of cough flow&#8211;volume curves"
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          "titulo" => "Conclusions"
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          "titulo" => "References"
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            0 => "Cough strength"
            1 => "Extubation"
            2 => "Decannulation"
            3 => "Neuromuscular"
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    "resumen" => array:1 [
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Insufficient cough strength has a major role in extubation and decannulation outcomes&#46;</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Cough capacity can be easily evaluated by measuring flows during coughing&#46; Values vary depending on whether cough flows are measured through the mouth or through a tracheostomy or endotracheal tube&#46; It is important to standardize these measurements and start using them routinely in the extubation and decannulation processes&#46; Values of cough peak flow &#62;160<span class="elsevierStyleHsp" style=""></span>L&#47;min measured at the mouth or a value of cough PEF &#62;60<span class="elsevierStyleHsp" style=""></span>L&#47;min measured at the endotracheal tube suggest successful decannulation or extubation&#46;</p></span>"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Set-up of an electronic peak flow meter &#40;PiKo I&#41; for measuring cough PEF through the tracheal cannula&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Article&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Number of patients&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Diagnosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Measurement via mouth&#47;trach&#47;ET&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Device&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Outcome&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">95&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Critically ill&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ET&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Aztech&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Extubation failure&#44; mortality&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">150&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Critically ill&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ET&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Respiratory mechanics monitor&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Extubation failure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">49&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Neuromuscular&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Mouth&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">HealthScan&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Decannulation failure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">130&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Critically ill&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ET&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Piko-1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Extubation failure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">32&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Neurosurgical&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Trach&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Piko-1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Decannulation failure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">88&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Critically ill&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ET&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Aztech&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Extubation failure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">125&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Burn&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ET&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Mini-Wright&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Extubation failure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">61&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Neuromuscular&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Mouth&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Access&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Post-decannulation&#44; vital capacity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">26&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Neuromuscular&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Mouth&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Mini-Wright&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pre- vs post-decannulation value&#44; decannulation failure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">151&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Prolonged Weaning or Neurological&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Trach&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Mini-Wright&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Time to decannulation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Summary of studies&#46;</p>"
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Original language: English
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Pulmonology

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