Airway management is important for critically ill patients. Improper airway management can directly threaten the life of patients.[1] Early correct airway assessment and effective airway management can improve patient prognosis.[2] Coughing ability plays an important role in the decision-making process of airway management. Patients with impaired coughing ability have a higher risk of tracheal intubation during treatment. The concept of cough strength was first proposed by Khamiees in 2001,[3] but the evaluation criteria did not include coughing ability. The purpose of this study was to assess patients’ coughing ability through the Delphi method and expert consultation, to provide data support for establishing a cough reflex intensity score and to construct an advanced airway management model for quick and effective evaluation.[4,5]
METHODS
The inclusion criteria of consultation experts were as follows: (1) ten years of experience or more in emergency medicine, intensive care medicine, or other related medical fields; (2) attending physicians or above with at least a bachelor degree; and (3) volunteering to participate in this study and making recommendations to improve the cough reflex intensity scores.
The research team consisted of two chief physicians and three graduate students in emergency medicine. A preliminary scoring system for evaluating the cough reflex intensity was developed based on a literature review and case studies on airway management (supplementary Table 1).[6]
The first round of expert consultation was conducted through questionnaires distributed on site or by email. The scoring system was analyzed and revised according to expert opinions. The expert group discussed the potential inclusion of the new suggestions in the next round of survey. On the basis of literature evidence, each criterion in this study was required to have an approval rating of ≥70%, a mean value of the approval rating >4.0, and a coefficient of variation <0.25.[7]
All statistical analyses were conducted with SPSS version 26.0 (IBM, USA). Descriptive statistics and nonparametric tests were used to calculate the mean, standard deviation, active coefficient, authority coefficient, coordination coefficient, and variation coefficient.
RESULTS AND DISCUSSION
In our study, a total of 30 experts from Class A tertiary hospitals from different provinces, autonomous regions, and municipalities were selected for correspondence. Twenty-three (76.7%) experts had master degree or above, 27 (90.0%) had an associate chief physician title or above, and all 30 experts had worked for more than 10 years, indicating that the experts had rich experience in treating acute and critical illnesses (Table 1).
Table 1. Basic information about recruited experts
| Variables | Number | Percentage |
|---|---|---|
| Age, years | ||
| 30-40 | 9 | 30.0 |
| 41-50 | 14 | 46.7 |
| >51 | 7 | 23.3 |
| Gender | ||
| Male | 22 | 73.3 |
| Female | 8 | 26.7 |
| Education | ||
| Bachelor | 7 | 23.3 |
| Master | 7 | 23.3 |
| Doctor | 16 | 53.3 |
| Working experience, years | ||
| 10-21 | 16 | 53.3 |
| 21-31 | 8 | 26.7 |
| 31-37 | 6 | 20.0 |
| Professional title | ||
| Attending physician | 3 | 10.0 |
| Associate chief physician | 8 | 26.7 |
| Chief physician | 19 | 63.3 |
| Specialties | ||
| Emergency medicine | 26 | 86.7 |
| Intensive care medicine | 4 | 13.3 |
| Other related specialties | 0 | 0 |
Active coefficient of experts
The active coefficient of experts is expressed as the effective response rate of the questionnaire. A response rate of more than 70% was considered good, representing a higher active coefficient. In this study, 30 letters were sent out in each round, and 30 letters were collected, with an effective response rate of 100%. In addition, after the first round of consultation, 15 (50%) experts made 32 suggestions (25 of them were the same or similar). These results indicated that the experts were highly motivated and cooperative and considered this research work very important.
Authority coefficient of experts
The authority coefficient (Cr) is an important indicator that affects the accuracy of evaluation and prediction. It is usually determined by two factors: the judgment basis of the indicators (Ca) and the familiarity with the indicator (Cs). The calculation formula is Cr = (Ca+Cs)/2. The values of Ca and Cs were obtained mainly through the self-evaluation of the experts. The larger the Cr value is, the higher the authoritative coefficient, and Cr ≥ 0.7 is regarded as a high degree of authority coefficient. In this study, the authority coefficients in the two rounds were 0.820 and 0.905, indicating that the experts included in this study obtained a high degree of authority (supplementary Table 2).
Concentration and coordination of expert opinions
The coordination coefficient (W) indicates the coordination degree of expert opinions. In this study, the coordination coefficient of the Delphi method survey in round one was 0.064 (P=0.12), indicating unsatisfactory credibility of the assessment or prediction of expert opinions. However, the coordination coefficient in round two was 0.1 (P=0.02), suggesting high credibility and good coordination of the assessment or prediction of expert opinions (supplementary Table 3).
Modification of entries
The entries with an expert approval rating of <70% were modified as follows. For the decibel of cough sound, most experts believe that the measurement was affected by many interference factors, so this parameter was excluded. Due to the differences in disease type and incidence rate, the Clinical Frailty Scale (CFS) is not applicable to acute and critically ill patients and is also deleted. The Glasgow Coma Scale (GCS) score was applied to patients with a cough intensity score of 1, which required a GCS score of <8, and the phrase “including post-tracheal intubation and tracheotomy” was deleted from the questionnaire. For the detailed indicators with cough intensity scores of 1 and 2, they were listed as a, b, c and a, b and can be scored if one of them is met.
In the second round of investigation, the expert agreement rate for each criterion was >80% (Likert score ≥4 indicated agreement), and the mean value of each item was >4.0 with a variation coefficient <0.25, indicating a convergence of expert opinions (Table 2).
Table 2. The second round of investigation on cough reflex intensity scores
| Grade | Indicators (if one of them is met) | Importance (points) | Variation coefficient |
|---|---|---|---|
| Cough reflex intensity score of 1 (no cough) | a. Conscious and cooperative, but completely incapable of coughing or making coughing noises b. Unconscious state such as coma (GCS score <8) and unable to cough c. No cough reflex under sputum suction tube stimulation, or stimulation by pressing the cricothyroid membrane | 4.53±0.57 | 0.12 |
| Cough reflex intensity score of 2 (with cough, very weak) | a. Cough awareness or cough action, and a weak cough sound, sputum not coughed out of the vocal door b. Cough reflex under the sputum suction tube stimulation, and the sputum sucked out by the sputum suction tube | 4.20±0.76 | 0.15 |
| Cough reflex intensity score of 3 (with cough, strong) | Strong coughing sounds in the absence of sputum suction tube stimulation, most of the sputum coughed out of the vocal cavity, but not out of the mouth | 4.27±0.69 | 0.18 |
| Cough reflex intensity score of 4 (with cough, very strong) | Loud cough sounds and sputum coughed out of the mouth | 4.40±0.68 | 0.12 |
CONCLUSION
Through two rounds of Delphi expert consultation, a cough reflex intensity score system was established, which was featured with good authority, reliability and comprehensiveness. It can provide a reference for effectively assessing the patient’s airway status and disease progress. Nevertheless, this scoring system needs to be further validated in future clinical practice.
Funding: This study was funded by the Autonomous Region Education Reform Project (PT2020023).
Ethical approval: The Ethics Committee of the First Affiliated Hospital of Xinjiang Medical University approved the study (reference number K201908-03).
Conflicts of interest: All authors declare that they have no conflicts of interest.
Contributors: YKL and YL contributed equally to this work. YKL collected and analyzed the data and drafted the manuscript; YKL, YL, and WBJ organized, analyzed, and interpreted the data; YKL designed the study and was responsible for the integrity of the data and the accuracy of the data analysis; JZY and JX provided administrative, technical, and material support and provided the necessary theoretical guidance for this study. YL helped with the statistical analysis, and YKL and YL organized the data and performed the literature search.
All the supplementary files in this paper are available at http://wjem.com.cn.
Reference
Editors’ note: 2021 special issue on airway management
DOI:10.1007/s12630-021-02059-2 [Cited within: 1]
Prehospital advanced life support for out-of-hospital cardiac arrest in blunt trauma patients
DOI:10.1001/jamasurg.2018.4291 PMID:30422252 [Cited within: 1]
Predictors of extubation outcome in patients who have successfully completed a spontaneous breathing trial
DOI:10.1378/chest.120.4.1262
PMID:11591570
[Cited within: 1]
After patients recovering from respiratory failure have successfully completed a spontaneous breathing trial (SBT), clinicians must determine whether an artificial airway is still required. We hypothesized that cough strength and the magnitude of endotracheal secretions affect extubation outcomes.We conducted a prospective study of 91 adult patients treated in medical-cardiac ICUs who were recovering from respiratory failure, had successfully completed an SBT, and were about to be extubated. A number of demographic and physiologic parameters were recorded with the patient receiving full ventilatory support and during the SBT, just prior to extubation. Cough strength on command was measured with a semiobjective scale of 0 to 5, and the magnitude of endotracheal secretions was measured as none, mild, moderate, or abundant by a single observer. In addition, patients were asked to cough onto a white card held 1 to 2 cm from the endotracheal tube; if secretions were propelled onto the card, it was termed a positive white card test (WCT) result. All patients were then extubated from T-piece or continuous positive airway pressure breathing trials. If 72 h elapsed and patients did not require reintubation, they were defined as successfully extubated.Ninety-one patients with a mean (+/- SE) age of 65.2 +/- 1.6 years, ICU admission APACHE (acute physiology and chronic health evaluation) II score of 17.7 +/- 0.7, and duration of mechanical ventilation of 5.0 +/- 0.5 days were studied over 100 extubations. Sixteen patients could not be extubated, and 2 patients underwent two unsuccessful extubation attempts, for a total of 18 unsuccessful extubations. Age, severity of illness, duration of mechanical ventilation, oxygenation, rapid shallow breathing index, and vital signs during SBTs did not differ between patients with successful extubations vs patients with unsuccessful extubations. The WCT result was highly correlated with cough strength. Patients with weak (grade 0 to 2) coughs were four times as likely to have unsuccessful extubations, compared to those with moderate-to-strong (grade 3 to 5) coughs (risk ratio [RR], 4.0; 95% confidence interval [CI],1.8 to 8.9). Patients with moderate-to-abundant secretions were more than eight times as times as likely to have unsuccessful extubations as those with no or mild secretions (RR, 8.7; 95% CI, 2.1 to 35.7). Patients with negative WCT results were three times as likely to have unsuccessful extubations as those with positive WCT results (RR, 3.0; 95% CI, 1.3 to 6.7). Poor cough strength and endotracheal secretions were synergistic in predicting extubation failure (Rothman synergy index, 3.7; RR, 31.9; 95% CI, 4.5 to 225.3). Patients with PaO(2)/fraction of inspired oxygen (P:F) ratios of 120 to 200 (receiving mechanical ventilation) were not less likely to be successfully extubated than those with P:F ratios of > 200, but those with hemoglobin levels < or = 10 g/dL were more than five times as likely to have unsuccessful extubations as those with hemoglobin levels > 10 g/dL.After patients recovering from respiratory failure have successfully completed an SBT, factors affecting airway competence, such as cough strength and amount of endotracheal secretions, may be important predictors of extubation outcomes. Also, a majority (89%) of medically ill patients with P:F ratios of 120 to 200 (four of five patients with P:F ratios from 120 to 150), values sometimes used to preclude weaning, were extubated successfully.
Development of an undergraduate medical education critical care content outline utilizing the Delphi method
DOI:10.1097/CCM.0000000000004086
PMID:31714399
[Cited within: 1]
No consensus exists on a standardized critical care content outline for medical student education. The aim of this research is to develop a national undergraduate medical education critical care content outline.The authors used a Delphi process to reach expert consensus on a content outline that identified the core critical care knowledge topics and procedural skills that medical students should learn prior to entering residency. Over three iterative rounds, the expert panel reached consensus on a critical care content outline.An electronic survey of critical care medical educators, residency program directors, and residents in the United States.The expert panel included three groups as follows: 1) undergraduate medical education critical care educators, 2) residency program directors representing all core specialties, and 3) residents representing their core specialties.None.The expert panel included 28 members. Experts represented the following medical specialties: anesthesiology, emergency medicine, internal medicine, obstetrics and gynecology, pediatrics, and surgery. Seventeen experts had subspecialty training in critical care. The expert panel identified 19 highly recommended critical care knowledge topics and procedural skills. These topics and procedural skills were grouped into five broad categories as follows: 1) neurologic, 2) respiratory, 3) cardiovascular, 4) renal and electrolytes, and 5) supplemental ICU topics. Bag-mask ventilation was the only procedural skill identified as highly recommended.This study provides a national consensus undergraduate medical education critical care content outline. By including experts from multiple specialties, this content outline is meaningful for medical student education, independent of medical specialty. The content outline represents a first step in the development of a national undergraduate medical education critical care curriculum.
Defining priority areas for critical care simulation: a modified Delphi consensus project
Semiquantitative cough strength score and associated outcomes in noninvasive positive pressure ventilation patients with acute exacerbation of chronic obstructive pulmonary disease
PMID:25459451
[Cited within: 1]
Weak cough may result in the failure of noninvasive positive pressure ventilation (NPPV) in patients with AECOPD. However, no detailed descriptions have yet been published for the measurement of cough strength and associated outcomes in AECOPD patients.This study prospectively enrolled 261 AECOPD patients who received NPPV. Semiquantitative cough strength score (SCSS, ranging from 0 = weak to 5 = strong) was recorded before NPPV. Patients who required intubation were defined as NPPV failures.NPPV failed in 55 patients (21.1%). Weak cough (SCSS ≤3, OR = 8.1), high disease severity (APACHE II score >19, OR = 3.8), and malnutrition (total proteins ≤58 g/L, OR = 2.8) were independent risk factors for NPPV failure. Patients with 1, 2, and 3 risk factors were 4.7, 13.6, and 21.6 times more likely, respectively, to experience NPPV failure compared with patients with no risk factors. The NPPV failure rates were 80%, 40%, and 10.2% in patients with SCSS of 0–1, 2–3, and 4–5, respectively (p < 0.001). Compared with NPPV success patients, NPPV failure patients stayed longer in ICU (10.1 ± 7.9 days vs. 6.5 ± 4.6 days, p < 0.001), and they had higher ICU costs (€2986 ± 1906 vs. €5680 ± 3,604, p < 0.001), higher hospital costs (€ 6714 ± 7025 vs. €10,399 ± 9,509, p = 0.009), and higher hospital mortality (72.7% vs. 4.4%, p < 0.001). Moderate accuracy to distinguish NPPV failure by APACHE II score, SCSS, and total proteins was evidenced by ROC curves, with areas under the curve of 0.71, 0.78, and 0.67, respectively. A combination of all three factors reached good accuracy, with an area under the curve of 0.86.AECOPD patients with weak cough had a high risk of NPPV failure. SCSS, APACHE II scores, and total proteins were predictors of NPPV failure. Combined, these factors increased the power to predict NPPV failure.
Applying real-time Delphi METHODS: development of a pain management survey in emergency nursing
DOI:10.1186/s12912-021-00661-9
PMID:34407815
[Cited within: 1]
The modified Delphi technique is widely used to develop consensus on group opinion within health services research. However, digital platforms are offering researchers the capacity to undertake a real-time Delphi, which provides novel opportunities to enhance the process. The aim of this case study is to discuss and reflect on the use of a real-time Delphi method for researchers in emergency nursing and cognate areas of practice. A real-time Delphi method was used to develop a national survey examining knowledge, perceptions and factors influencing pain assessment and management practices among Australian emergency nurses. While designing and completing this real-time Delphi study, a number of areas, emerged that demanded careful consideration and provide guidance to future researchers.© 2021. The Author(s).
