Letter to the Editor
Misconceptions in the assessment of cough peak flow measurements for extubation or decanulation protocols
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Winck, C. LeBlanc, J.L. Soto, F. Plano" "autores" => array:4 [ 0 => array:2 [ "Iniciales" => "J.C." "apellidos" => "Winck" ] 1 => array:2 [ "Iniciales" => "C." "apellidos" => "LeBlanc" ] 2 => array:2 [ "Iniciales" => "J.L." "apellidos" => "Soto" ] 3 => array:2 [ "Iniciales" => "F." 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"apellidos" => "Chiou" "email" => array:1 [ 0 => "chioumi@njms.rutgers.edu" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "J.R." "apellidos" => "Bach" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "M.R." "apellidos" => "Gonçalves" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "L." "apellidos" => "Vudayagiri" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, NJ, USA" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Department of Pulmonology, University Hospital of S. João, Faculty of Medicine, University of Porto, Portugal" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Winck et al. proposed routine use of cough peak flow (CPF) measurements in the assessment of extubation and decanulation readiness.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">1</span></a> However, intubated patients cannot cough because they cannot close their glottis to hold pressure, and the paper the authors cited suggesting that 90<span class="elsevierStyleHsp" style=""></span>L/m predicts successful extubation<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">2</span></a> is irrelevant for patients with neuromuscular respiratory muscle weakness since they can almost always be successfully extubated even when their unassisted CPF and vital capacities are unmeasurable.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">3,4</span></a> The paper that the authors referred to that used 160<span class="elsevierStyleHsp" style=""></span>L/m as a reference reported the need for maximum unassisted or assisted CPF to reach 160<span class="elsevierStyleHsp" style=""></span>L/m after extubation.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">5</span></a> Assisted CPFs are attained by patients air stacking to the maximum lung volumes that can be held by the glottis and then an abdominal thrust is applied to generate CPF.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">6</span></a> It is the maximum flow that can be generated through the upper airways that is important and not whether the patient can generate that flow him/herself because the greater the flow, the greater the patency of the airways, and the more effective mechanical insufflation–exsufflation (MIE) will be in eliminating airway secretions via an oronasal interface once the tube is out.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">4</span></a> Thus, the distinction between unassisted and assisted CPF is important. The fact is that in a recent report, many patients (e.g. babies with spinal muscular atrophy type 1) could generate no measurable flows via the upper airway, but were almost invariably successfully extubated anyway because following extubation, MIE generated effective flows to clear the airways.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Decanulation protocols begin by transitioning from cuffed to cuffless fenestrated tracheostomy tubes or tracheostomy buttons so that the patient can practice CNVS and MIE and speak without the tube obstructing the upper airways. Failure to permit verbal communication almost invariably results in severe reactive depression.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">7</span></a> The first step in the process of decannulation to noninvasive management is cuff deflation. We have seen numerous other tragic examples of failure to deflate the cuff, and this has been reported.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">7</span></a> Switching patients to cuffless fenestrated tubes does not always clear the upper airway sufficiently to use NVS comfortably because the fenestration can abut against the back wall of the trachea rather than be in the airway. When there is obstruction to the tube, the NVS backs up into the patient's cheeks. Tracheostomy buttons can eliminate this problem by clearing the airway of the tube so that air can leak up through the vocal cords for speech, and the leak is compensated by increasing ventilator settings to maintain normal alveolar ventilation.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0015" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib0040" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The value of cough peak flow measurements in the assessment of extubation or decannulation readiness" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "J.C. Winck" 1 => "C. LeBlanc" 2 => "J.L. Soto" 3 => "F. Plano" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.rppnen.2014.12.002" "Revista" => array:6 [ "tituloSerie" => "Rev Port Pneumol" "fecha" => "2015" "volumen" => "21" "paginaInicial" => "94" "paginaFinal" => "98" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25926373" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0045" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cough peak flows and extubation outcomes" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "M. Smina" 1 => "A. Salam" 2 => "M. Khamiees" 3 => "P. Gada" 4 => "Y. Amoateng-Adjepong" 5 => "C.A. 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Soares" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/PHM.0000000000000112" "Revista" => array:7 [ "tituloSerie" => "Am J Phys Med Rehabil" "fecha" => "2014" "volumen" => "93" "numero" => "8" "paginaInicial" => "719" "paginaFinal" => "723" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24879555" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/21735115/0000002100000005/v3_201605090007/S2173511515000974/v3_201605090007/en/main.assets" "Apartado" => array:4 [ "identificador" => "20584" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21735115/0000002100000005/v3_201605090007/S2173511515000974/v3_201605090007/en/main.pdf?idApp=UINPBA00004E&text.app=https://journalpulmonology.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173511515000974?idApp=UINPBA00004E" ]
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