Overview of “Benefits of interventions for respiratory secretion management in adult palliative care patients — A Systematic Review”

Submitted by: Sean Simpson,
BSc SRT

The main objective of palliative care is to increase quality of life by relieving patients with serious illnesses or diseases of their associated symptoms, including mental and physical stresses (Wallerstedt, Benzein, Schildmeijer & Sandgren, 2018; Vitacca & Comini, 2012). Respiratory mucus production is often increased in patients suffering from cardiovascular disease and various types of cancers (Arcuri, Abarshi, Preston, Brine, & Pires Di Lorenzo, 2016). Cough inefficiency experienced by patients in palliative care due to muscle weakness, poor coordination or neurological diseases, along with increased respiratory secretions, can lead to an accumulation of mucus and may cause difficulty breathing (Arcuri et al., 2016; Vitacca & Comini, 2012; Rogers, 2007). There are an abundance of different treatments that address respiratory secretions, which Arcuri and colleagues (2016) categorize as: therapies to promote expectoration; therapies to facilitate mucus clearance; and therapies to improve cough effectiveness.

Overview of Arcuri et al. (2016) Systematic Review

The systematic review article, “Benefits of interventions for respiratory secretion management in adult palliative care patients—a systematic review” investigates which respiratory secretion management therapies provide the greatest outcomes for effectiveness of intervention and patient comfort during treatment (Arcuri et al., 2016, pp. 2). This study performed a systematic review searching eight different journal databases for randomized controlled trials (RCT), crossover trials, observational and qualitative studies on respiratory secretion management in adults with chronic diseases that met the inclusion criteria (Arcuri et al., 2016, pp. 1). Interventions of mechanical insufflation-exsufflation (MIE), manually assisted cough (MAC), expiratory muscle training, percussive ventilation, positive expiratory pressure (PEP) masks, abdominal muscle electrical stimulation and vibratory vest were investigated in this study (Arcuri et al., 2016, pp. 3).

Findings

Most treatments investigated in this study could be used in a palliative care setting, but it was found that MAC, MIE, and percussive ventilation were the three treatments which best achieved the targeted outcomes (Arcuri et al., 2016, pp. 9).

Therapies to facilitate mucus clearance, such as percussive ventilation, should be performed before therapies to promote expectoration (Arcuri et al., 2016, pp. 7). Compared to other therapies that facilitate mucus clearance, percussive ventilation moved more mucus from peripheral areas of the lung to central airways, where it can be effectively removed by suction or coughing (Arcuri et al., 2016, pp. 7).

Both MAC and MIE are categorized as therapies to promote expectoration (Arcuri et al., 2016, pp. 3). MAC is the most cost effective of these methods, as it does not require any equipment (Arcuri et al., 2016, pp. 3).  MAC was found to increase maximum expiratory pressure and peak cough flow while being considered more comfortable than the other treatments (Arcuri et al., 2016, pp. 3). The disadvantages of MAC are that the patient must be able to coordinate with the manual thrust in order to cough effectively, and that abdominal thrusts can cause pain in certain patients (Arcuri et al., 2016, pp. 3). MIE was found to be more comfortable than suctioning in tracheotomy patients, while being more effective than MAC (Arcuri et al., 2016, pp. 5).

MIE had additional benefits beyond improving peak cough flow, as it improved oxygenation in those with COPD (Winck et al., 2004). A combination treatment of MAC and MIE lead to greater peak cough flows (Spinou, 2020), but there was no comment on how combining these affected patient comfort.

The importance of end of life care is often overlooked in healthcare. I believe palliative care is important in order to maximize quality of life for the patient; they can live as actively as possible, allowing both the patient and their family to enjoy the time they have left together, while their family will be at ease knowing that their loved one is as comfortable as they can be.

References

Arcuri, J. F., Abarshi, E., Preston, N. J., Brine, J., & Pires Di Lorenzo, V. A. (2016). Benefits of interventions for respiratory secretion management in adult palliative care patients – A systematic review. BMC Palliative Care, 15(1), 1–11. https://doi.org/10.1186/s12904-016-0147-y

Rogers, D. F. (2007). Physiology of Airway Mucus Secretion and Pathophysiology of Hypersecretion. Respiratory Care, 52(9), 1134–1146.  Available from http://rc.rcjournal.com/content/52/9/1134.short

Spinou, A. (2020). A Review on Cough Augmentation Techniques: Assisted Inspiration, Assisted Expiration and Their Combination. Physiological Research, 93–103. https://doi.org/10.33549/physiolres.934407

Vitacca, M., & Comini, L. (2012). How do patients die in a rehabilitative unit dedicated to advanced respiratory diseases? Multidisciplinary Respiratory Medicine, 7(1), 1–6. https://doi.org/10.1186/2049-6958-7-18

Wallerstedt, B., Benzein, E., Schildmeijer, K., & Sandgren, A. (2018). What is palliative care? Perceptions of healthcare professionals. Scandinavian Journal of Caring Sciences, 33(1), 77–84. https://doi.org/10.1111/scs.12603

Winck, J. C., Gonçalves, M. R., Lourenço, C., Viana, P., Almeida, J., & Bach, J. R. (2004). Effects of Mechanical Insufflation-Exsufflation on Respiratory Parameters for Patients With Chronic Airway Secretion Encumbrance. Chest, 126(3), 774–780. https://doi.org/10.1378/chest.126.3.774

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