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Mechanical insufflation-exsufflation (MI-E) is traditionally used in the neuromuscular population. There is growing interest of MI-E use in invasively ventilated critically ill adults. We aimed to map current evidence on MI-E use in invasively ventilated critically ill adults. Two authors independently searched electronic databases MEDLINE, Embase, and CINAHL via the Ovid platform; PROSPERO; Cochrane Library; ISI Web of Science; and International Clinical Trials Registry Platform between January 1990–April 2021. Inclusion criteria were (1) adult critically ill invasively ventilated subjects, (2) use of MI-E, (3) study design with original data, and (4) published from 1990 onward. Data were extracted by 2 authors independently using a bespoke extraction form. We used Mixed Methods Appraisal Tool to appraise risk of bias. Theoretical Domains Framework was used to interpret qualitative data. Of 3,090 citations identified, 28 citations were taken forward for data extraction. Main indications for MI-E use during invasive ventilation were presence of secretions and mucus plugging (13/28, 46%). Perceived contraindications related to use of high levels of positive pressure (18/28, 68%). Protocolized MI-E settings with a pressure of ±40 cm H2O were most commonly used, with detail on timing, flow, and frequency of prescription infrequently reported. Various outcomes were re-intubation rate, wet sputum weight, and pulmonary mechanics. Only 3 studies reported the occurrence of adverse events. From qualitative data, the main barrier to MI-E use in this subject group was lack of knowledge and skills. We concluded that there is little consistency in how MI-E is used and reported, and therefore, recommendations about best practices are not possible.
Er is wereldwijd een groeiende groep milieuvluchtelingen. Voor deze mensen, die vluchten als gevolg van bijvoorbeeld een tsunami, dijkdoorbraak, hoge concentraties vrijkomende giftige stoffen bij een industrieel ongeval, verwoestijning, uitputting van de bodem of langdurige regenval, bestaat nog geen adequaat internationaal beschermingsregime. Ons vorige artikel in Applied Research Today (april 2013) bracht in kaart welke soorten milieuvluchtelingen bestaan, en betoogde dat de bescherming van deze groep plaats kan vinden onder het VN-principe The Responsibility to Protect (R2P). R2P omvat onder andere een integrale aanpak die gericht is op het voorkomen, reageren en opbouwen, waarbij de verantwoordelijkheid is ondergebracht in drie pijlers: 1) een staat is zelf verantwoordelijk voor de bescherming van milieuvluchtelingen, 2) de internationale gemeenschap heeft een verantwoordelijkheid een staat hierbij te assisteren, en 3) de internationale gemeenschap heeft de verantwoordelijkheid om collectief snel en beslissend te reageren indien een staat zelf zijn milieuvluchtelingen niet kan of wil beschermen. Dit vervolgartikel formuleert hoe de integrale aanpak van The Responsibility to Protect kan worden geoperationaliseerd voor de bescherming van milieuvluchtelingen. ABSTRACT The number of environmental refugees is growing. An adequate international legal protection regime is lacking for people who, for example, flee as a result of a tsunami or levee breach; high concentrations of toxic substances from industrial accidents; desertification; soil depletion or prolonged rainfall. Our previous article in Applied Research Today (April 2013) described eight different groups of environmental refugees and argued that the protection of these groups can be ensured under the UN principle the Responsibility to Protect (R2P). R2P offers an integral approach that focuses on prevention, reaction and rebuilding. In first instance, the responsibility to take protective measures lies with the state itself. Secondly, the international community has a responsibility to assist. Lastly, when a state is not able or willing to protect its environmental refugees, the international community has the responsibility to respond in a swift and decisive manner. This follow-up article formulates how the Responsibility to Protect concept could be operationalised to protect environmental refugees.