Mechanical insufflation-exsufflation for invasively ventilated critically ill patients: a focus group study

INTRODUCTION: Mechanical Insufflation-Exsufflation (MI-E) is used as an airway clearance intervention in primary care (home ventilation), long-term care (prolonged rehabilitation after intensive care, neuromuscular diseases, and spinal cord injury), and increasingly in acute care in intensive care units (ICU).

AIM: We sought to develop in-depth understanding of factors influencing decision-making processes of health care professionals regarding initiation, escalation, de-escalation, and discontinuation of MI-E for invasively ventilated patients including perceived barriers and facilitators to use.

METHODS: We conducted focus groups (3 in the Netherlands; 1 with participants from four European countries) with clinicians representing the ICU interprofessional team and with variable experience of MI-E. The semi-structured interview guide was informed by the Theoretical Domains Framework (TDF). Two researchers independently coded data for directed content analysis using codes developed from the TDF.

RESULTS: A purposive sample of 35 health care professionals participated. Experience varied from infrequent to several years of frequent MI-E use in different patient populations. We identified four main themes: (1) knowledge; (2) beliefs; (3) clinical decision-making; and (4) future adoption.

CONCLUSION: Interprofessional knowledge and expertise of MI-E in invasively ventilated patients is limited due to minimal available evidence and adoption. Participants believed MI-E a potentially useful intervention for airway clearance and inclusion in weaning protocols when more evidence is available.

RELEVANCE TO CLINICAL PRACTICE: This focus group study provides an overview of current practice, knowledge and expertise, and barriers and facilitators to using MI-E in mechanically ventilated patients. From these data, it is evident there is a need to develop further clinical expertise and evidence of efficacy to further understand the role of MI-E as an airway clearance technique for ventilated patients.