Find out about an effective yet gentle airway secretion clearance technique with the CSP's respiratory management online knowledge partner, Philips Respironics.
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Acute respiratory failure
Respiratory tract infections are the most common cause of hospital admission in patients with neuromuscular disease.(1)
More than 90% of acute respiratory failure episodes in neuromuscular disorder patients are caused by ineffective coughing during chest colds.(2)
Using mechanical insufflation-exsufflation and non-invasive ventilation therapy during periods of acute respiratory failure may decrease pulmonary morbidity and hospitalisation rates.(3)
Cough assist therapy
For those patients unable to cough or effectively clear secretions (peak cough flow <270 L/min(4)), deep suctioning is often used to clear the airway. Unfortunately, invasive suction methods can be uncomfortable for the patient and have been linked to complications such as hypoxia, tissue damage and infection.(5)
Mechanical insufflation-exsufflation, more commonly known as 'cough assist therapy', provides an effective yet remarkably gentle non-invasive alternative for use in the hospital and at home. Cough assist therapy also clears airways for longer periods of time than tracheal suctioning, and with fewer complications.(6)
A cough assist device clears secretions by gradually applying a positive pressure to the airway, then rapidly shifting to negative pressure. The rapid shift in pressure produces a high expiratory flow, simulating a natural cough - whilst avoiding the potential problems associated with more invasive procedures.
Cough assist therapy has been clinically proven to increase peak cough expiratory flows and reduce recurrent respiratory infections.(8 9)
"Cough augmentation with mechanical insufflation-exsufflation produces a significant increase in peak cough flow and facilitates airway secretion clearance in neuromuscular disorders. It has been reported to be successful in avoiding hospitalizations, pneumonias, episodes of respiratory failure, and tracheotomy for patients with Duchenne muscular dystrophy, spinal muscular atrophy, and ALS."
- Winck JC, et al. Chest. 2004;126:774-780.
Use of cough assist therapy in the acute setting
Cough assist has been described as a very efficient technique in the acute setting for neuromuscular diseases patients:
- in the treatment of respiratory failure due to upper respiratory tract infections(10)
- to avoid intubation(11)
- to facilitate extubation and decannulation and to prevent post-extubation failure(12 13)
Additionally, application of cough assist therapy has been successfully described in post-operative sputum retention management, avoiding tracheostomy.(14)
Keeping airways clear makes patients feel better
- Cough assist therapy can lead to improvement in perceived quality of life due to fewer acute illness- related episodes(15)
- Patients report that it feels "easier to breathe" after the use of a cough assist device(16 17 18 19)
"In addition to the medical benefits of enhanced airway clearance, the importance of the psychological benefits to patients with NMD should be considered as well."
- Miske LJ, et al. Chest. 2004;125:1406-1412.
Benefits of using a cough assist device
- Removes secretions from the lungs
- Reduces the occurrence of respiratory infections
- Safe and non-invasive alternative to suctioning
- Easy for patients and caregivers to operate
Typical cough assist therapy patients include those with the following conditions
- Amyotrophic lateral sclerosis
- Spinal muscular atrophy
- Muscular dystrophy
- Myasthenia gravis
- Spinal cord injuries
Find out more
You can also read:
1 Chatwin M, Ross E, Hart N, Nickol AH, Polkey MI, Simonds AK. Cough augmentation with mechanical insufflation/exsufflation in patients with neuromuscular weakness. Eur Respir J. 2003;21:502-508.
2 Tzeng AC, Bach JR. Chest 2000:118;1390-1396.
3 Bach JR et al. Chest 1997; 112:1024-1028 Bach JR et al. Chest 2000; 117:1100-1105
4 Bach JR et al. Chest 1997; 112:1024-1028.
5 AARC Clinical Practice Guideline. Endoctracheal suctioning of mechanically ventilated adults and children with artificial airways. Respiratory Care 1993;38(5)500-504.
6 Sancho J, Servera E. Vergara P, Marin J. Mechanical inexsufflation vs tracheal suctioning via tracheostomy tubes for patients with amyotrophic lateral sclerosis: a pilot study. Am J Phys Med Rehabil 2003;82(10)750-753.
8 Chatwin M, Ross E, Hart N, Nickol AH, Polkey MI, Simmonds AK.Cough Augmentation with Mechanical Insufflation/Exsufflation in Patients with Neuromuscular Weakness. Eur Respir J: March 2003;21(3):502-508.
9 Alice C. Tzeng and John R. Bach. Prevention of Pulmonary Morbidity or Patients with Neuromuscular Disease. Chest 2000;118: 1390-1396. DOI 10. 1378/chest 118.5.1390.
10 Vianello A, Corrado A, Arcaro G, et al. Mechanical insufflation exsufflation improves outcomes for neuromuscular disease patients with respiratory tract infections. Am J Phys Med Rehabil 2005; 84: 83-88.
11 Servera E, Sancho J, Zafra MJ, Catala A, Vergara P Marin J. Alternatives to endotracheal intubation for patients with neuromuscular diseases. Am J Phys Med Rehabil 2005; 84: 851-857.
12 Bach JR, Goncalves M. Ventilator weaning by lung expansion and decannulation. Am J Phys Med Rehabil 2004; 83: 560-568.
13 Bach JR, Saporito LR. Criteria for extubation and tracheostomy tube removal for patients with ventilatory failure. A different approach to weaning. Chest 1996; 110: 1566-1571.
14 Marchant WA, Fox R. Postoperative use of a coughassist device in avoiding prolonged intubation. Br J Anaesth 2002; 89: 644-647.
15 Miske LJ, Hickey EM, Kolb SM, Weiner DJ, Panitch HB. Use of the mechanical inexsufflator in pediatric patients with neuromuscular disease and impaired cough. Chest. 2004;125:1406-1412.
16 Fauroux B, Guillemot N, Aubertin G, Nathan N, Labit A, Clement A, Lofaso F. Physiologic Benefits of Mechanical Insufflation-Exsufflation in Children With Neuromuscular Diseases. Chest. January 2008;133:161-168
17 Chatwin M, Ross E, Hart N, Nickol AH, Polkey MI, Simonds AK. Cough augmentation with mechanical insufflation/exsufflation in patients with neuromuscular weakness. Eur Respir J. 2003;21:502-508.
18 Miske LJ, Hickey EM, Kolb SM, Weiner DJ, Panitch HB. Use of the mechanical inexsufflator in pediatric patients with neuromuscular disease and impaired cough. Chest. 2004;125:1406-1412.
19 Winck JC, Goncalves MR, Lourenco C, Viana P, Almeida J, Bach JR. Effects of mechanical insufflation-exsufflation on respiratory parameters for patients with chronic airway secretion encumbrance. Chest. 2004;126:774-780.