The use of mechanical insufflation-exsufflation in invasively ventilated critically ill children

Invasively ventilated, critically ill children are at risk of retained respiratory secretions, which can obstruct airways, impair gas exchange, and cause lung collapse or ventilator-acquired pneumonia. Endotracheal suctioning partially removes secretions, but additional airway clearance interventions may be required. Mechanical insufflation-exsufflation (MI-E), is a cough augmentation device used to improve secretion clearance in adult intensive care, however it is not well characterised in paediatrics.

To explore MI-E use in invasively ventilated, critically ill children.

This multi-methods study used an anonymous, electronic survey of UK-based paediatric physiotherapists. A scoping review searched seven electronic databases (1995-2025), using key terms ("airway clearance technique*") OR ("mechanical insufflation exsufflation") AND ("mechanical ventilation") OR ("invasive ventilation"). Data were analysed descriptively for both methods, with content analysis for free text survey responses. Mixed-evidence, narrative integration compared and contrasted survey and scoping review findings.

Twenty-nine physiotherapists from across the UK completed the survey, 76% (n = 22/29) were advanced specialists, and all reported access to an MI-E device. Six studies (2010-2024), one prospective, the remaining retrospective or case studies, were identified. Both data sources indicated MI-E was most frequently used with acutely unwell neuromuscular patients, though survey responses described a broader clinical application, including children with complex neurological conditions, general respiratory illnesses, trauma, and post-operative surgical or orthopaedic needs. MI-E settings and outcomes were inconsistently reported. Contraindications aligned across sources.

MI-E appears increasingly accessible within paediatric critical care. Future research should assess MI-E safety in intubated patients and investigate broader critically ill populations.