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Respir Care. 2019 Apr;64(4):372-383. doi: 10.4187/respcare.06076. Epub 2019 Jan 8.

An Artificial Cough Maneuver to Remove Secretions From Below the Endotracheal Tube Cuff.

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Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Milan, Italy.
Dipartimento di Anestesia, Rianimazione ed Emergenza Urgenza, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy.
Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Milan, Italy.
Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy; he is also affiliated with the Lung Biology Group, Regenerative Medicine Institute at CÚRAM Centre for Research in Medical Devices and the Discipline of Anaesthesia at the National University of Ireland, Galway, Ireland, as well as the Department of Anaesthesia and Intensive Care Medicine, Galway University Hospitals, SAOLTA University Health Group, Galway, Ireland.
IRCCS-Istituto di Ricerche Farmacologiche "Mario Negri," Milan, Italy.



Endotracheal suctioning is mandatory to prevent complications caused by the retention of tracheal secretions. Endotracheal suctioning is often performed late, when patients show signs of respiratory and hemodynamic alterations. We conceived a prototype device that, when synchronized with the ventilator, automatically removes secretions collected below the endotracheal tube (ETT) cuff, thus avoiding endotracheal suctioning. The aim of our investigation was to assess the performance of this novel prototype in vitro.


Three studies were performed to examine the characteristics of the prototype. We tested device's ability to generate an effective artificial cough flow (artificial cough maneuver) > 1 L/s by rapidly deflating the ETT cuff within the time of a sustained inflation (at 30 and at 40 cm H2O) (cough flow study). We also tested the prototype's ability to remove the fluid positioned below the ETT cuff using saline dye (fluid removal study), and to prevent the aspiration of saline dye from above the ETT cuff during the deflation phase of the ETT cuff (aspiration study). The trachea model was positioned at 45° in the aspiration study, and horizontally in the other two studies.


In the cough flow study, the prototype provided an effective artificial cough maneuver, with a mean ± SD of 1.78 ± 0.19 L/s (range, 1.42-2.14 L/s). The tracheal pressure after ETT cuff deflation never decreased below the PEEP level. In the fluid removal study, the prototype cleared the fluid from below the ETT cuff and the experimental trachea. No fluid was aspirated from the area above the ETT cuff toward the lower airways.


We conceived an system capable of automatically expelling fluid from below the ETT cuff outside an experimental trachea by generating an artificial cough maneuver. This system may decrease the use of endotracheal suctioning and its complications. Future in vivo studies are needed to confirm this first in vitro evaluation.


cough; in vitro; intubation; mechanical ventilation; ventilator-associated pneumonia


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