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Reply to “Misconceptions in the assessment of cough peak flow measurements for extubation or decanulation protocols”
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Chiou, J.R. Bach, M.R. Gonçalves, L. Vudayagiri" "autores" => array:4 [ 0 => array:2 [ "Iniciales" => "M." "apellidos" => "Chiou" ] 1 => array:2 [ "Iniciales" => "J.R." "apellidos" => "Bach" ] 2 => array:2 [ "Iniciales" => "M.R." "apellidos" => "Gonçalves" ] 3 => array:2 [ "Iniciales" => "L." 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"apellidos" => "Winck" "email" => array:1 [ 0 => "jcwinck@mail.telepac.pt" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "C." "apellidos" => "LeBlanc" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 2 => array:3 [ "nombre" => "J.L." "apellidos" => "Soto" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] 3 => array:3 [ "nombre" => "F." "apellidos" => "Plano" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Department of Pulmonology, Faculdade de Medicina, Universidade do Porto, Portugal" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Linde Healthcare, Pullach, Germany" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Ottawa Hospital Rehabilitation Centre, Canada" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "REMEO<span class="elsevierStyleSup">®</span> Centre el Pilar, Linde Group, Argentina" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">We thank very much the comments of Chiou M et al. about our paper entitled “The value of cough peak flow measurements in the assessment of extubation or decannulation readiness” recently published in the Portuguese Journal of Pulmonology.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We agree with the authors that intubated patients cannot reproduce a true cough maneuver because they cannot close their glottises; so we explain that in our article saying that the “Cough PEF measured in intubated patients may be considered a “huff” or, perhaps, a peak expiratory flow maneuver and not a true peak cough flow”, so we clearly differentiate a Cough Peak Expiratory Flow (PEF) to a true Peak Cough Flow (CPF). In the conclusions we also state that: “Only when the measurement is obtained with an active glottis should we call it cough peak flow, otherwise it should be termed cough PEF”. So we believe that in our paper we contributed to the clarification of the concept and to the standardization of the measurements. Moreover in Table I we summarized the papers designed to evaluate cough strength in the extubation or decannulation phases, differentiating each setting and the population is predominantly of critically ill. The context of neuromuscular patients is somewhat different and the measurements should also include CPF's obtained with enhancing maneuvers.</p><p id="par0015" class="elsevierStylePara elsevierViewall">We agree with Chiou M et al. that the distinction between unassisted and assisted CPF is important and in fact Dr Bach's group was one of the first to propose in this setting the measurement of assisted CPF with an abdominal thrust timed to glottic opening.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> In our review paper we also acknowledge this by saying that “if a spontaneous CPF of more than 160<span class="elsevierStyleHsp" style=""></span>L/min is not achieved a manually assisted CPF or lung volume recruitment CPF should be evaluated”.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> Unfortunately, only 4 papers published so far refer to this manually assisted coughing maneuver, and not all systematically report the values of assisted versus unassisted CPF.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">2–5</span></a> The fact that in these papers values are measured normally through the mouth and within 3<span class="elsevierStyleHsp" style=""></span>h of extubation/decannulation, render comparisons more difficult.</p><p id="par0020" class="elsevierStylePara elsevierViewall">However we would like to emphasize that measuring CPF should be seen as a important topic in this setting and all the professionals should follow the guidelines as they do it when evaluating a patient in a lung function lab. In our review we aimed to propose some recommendations for set-up and measurement of this parameter which is lacking in the current respiratory function manuals.</p><p id="par0025" class="elsevierStylePara elsevierViewall">What Chiou M et al. state about decannulation protocols and cuffless tubes was really beyond our revision. However as we state in our article when measuring CPF, professionals should acknowledge the status of the tube, as the measurement can be different depending on if the tube is cuffed or uncuffed. Definitely, in tracheostomized patients the measurement of Cough PEF should be done with the cuff deflated.</p><p id="par0030" class="elsevierStylePara elsevierViewall">With our paper, the final goal was to draw the attention of the pulmonologists as well as the intensivists to the importance of including cough strength measurements in the evaluation of extubation or decannulation readiness following a more homogeneous and standardized manner. New data is absolutely welcomed.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0035" 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:5 [ 0 => array:3 [ "identificador" => "bib0030" "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" => "bib0035" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Extubation of unweanable patients with neuromuscular weakness: a new management paradigm" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "J.R. Bach" 1 => "M.R. Gonçalves" 2 => "I. Hamdani" 3 => "J.C. 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Saporito" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Chest" "fecha" => "1996" "volumen" => "110" "paginaInicial" => "1566" "paginaFinal" => "1570" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8989078" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0045" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Tracheostomy decannulation and cough peak flows in patients with neuromuscular weakness" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "D.A. McKim" 1 => "A. Hendin" 2 => "C. LeBlanc" 3 => "J. King" 4 => "C.R. Brown" 5 => "A. Woolnough" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/PHM.0b013e31825597b8" "Revista" => array:6 [ "tituloSerie" => "Am J Phys Med Rehabil" "fecha" => "2012" "volumen" => "91" "paginaInicial" => "666" "paginaFinal" => "667" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22561386" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0050" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Decanulation of patients with severe respiratory muscle insufficiency: efficacy of mechanical insufflation-exsufflation" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "J.R. Bach" 1 => "L.R. Saporito" 2 => "H.R. Shah" 3 => "D. Sinquee" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.2340/16501977-1874" "Revista" => array:6 [ "tituloSerie" => "J Rehabil Med" "fecha" => "2014" "volumen" => "46" "paginaInicial" => "1037" "paginaFinal" => "1041" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25096928" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/21735115/0000002100000005/v3_201605090007/S2173511515001165/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/S2173511515001165/v3_201605090007/en/main.pdf?idApp=UINPBA00004E&text.app=https://journalpulmonology.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173511515001165?idApp=UINPBA00004E" ]
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