Rescue for a difficult cough

Summary

This educational presentation discusses the use of mechanical insufflator-exsufflator (MIE), or cough assist, for managing difficult coughs, particularly in patients with neuromuscular disorders. It explains the importance of airway clearance techniques, the principles of cough augmentation, and the correct application of MIE devices. The script provides insights on indications, contraindications, and the setup and operation of both older and newer models of cough assist machines, emphasizing the significance of peak cough flow measurements and the benefits of MIE in preventing respiratory complications.

Takeaways

• 🚑 Rescue for a difficult cough includes treatments like nebilization, hydration, medication, and airway clearance techniques (ACTs), which are vital for clearing excess secretions and improving lung function.
• 💡 Airway clearance techniques (ACTs) are non-pharmacological interventions that help reduce airway obstruction and improve gas exchange by mobilizing secretions from smaller to larger airways.
• 🔄 Cough assist, also known as mechanical insufflator exsufflator (MIE), was introduced in 2007 and performs cough augmentation to help patients with ineffective coughs or difficulty in deep breathing due to conditions like muscular dystrophy, spinal muscular atrophy, and spinal cordulations.
• 📈 The use of cough assist requires understanding its principles, efficacy, and application methods. It involves a mechanically applied positive pressure breath followed by a negative pressure to assist in the expulsion of secretions.
• 🏥 Cough assist is particularly beneficial for patients with neuromuscular diseases, children unable to effectively cough, and those with peak cough flow (CPF) less than 160 liters per minute, which is the minimum required for an effective cough.
• ⚠️ Contraindications for cough assist include patients with a history of bullous emphysema, susceptibility to pneumothorax, active hemothorax, high intracranial pressure, impaired consciousness, and low Glasgow Coma Scale scores.
• 🛠️ The cough assist machine has knobs for controlling inspiratory and expiratory times, pressures, and a pause between cycles. It can be used manually or automatically, with settings adjustable for individual patient needs.
• 🔄 Initial treatment settings for cough assist involve setting inspiratory and expiratory pressures and a rest period between cycles. The pressures can be adjusted up to positive or negative 40 cm water, depending on patient tolerance and needs.
• 📊 The standard sequence for cough assist involves 3-6 consecutive cycles for pediatrics and 4-6 for adults, with a 30-second rest period to normalize oxygen levels and allow the patient to recover.
• 🧼 Proper cleaning and maintenance of the cough assist device are crucial, including cleaning the exterior with 70% isopropyl alcohol, washing the air filter with warm water and detergent, and replacing the bacterial filter monthly or as needed.
• 📚 Recent studies and guidelines support the use of cough assist, especially in combination with non-invasive ventilation (NIV) for acute respiratory failure in children with neuromuscular disorders, highlighting the importance of proper device usage and patient assessment.

Q & A

What is the purpose of the presentation on rescue for a difficult cough?

The presentation is for educational purposes only, discussing various treatments to alleviate a difficult cough without endorsing or promoting any specific products or images.

What are the common approaches to alleviate a difficult cough as mentioned in the script?

Common approaches include nebilization, hydration, medication, and airway clearance techniques (ACTs), which are non-pharmacological interventions used to eliminate excess secretions and improve gas exchange.

What is cough assist, and when was it introduced?

Cough assist, also known as a mechanical insufflator exsufflator (MIE), was introduced in 2007. It performs cough augmentation to help patients with ineffective coughs or difficulty in taking deep breaths.

What is the definition of Mechanical Insufflation Exsufflation (MIE)?

MIE is defined as a mechanically applied positive pressure breath followed by negative pressure applied to the airway opening, which helps to augment the patient's tidal volume and assist in the expulsion of secretions.

Which conditions can benefit from the use of MIE?

Conditions such as muscular dystrophy, myasthenia gravis, spinal muscular atrophy (SMA), spinal cordulations, and motor neurone diseases can benefit from MIE, especially in patients with ineffective coughs or muscle weakness.

What is the minimum peak cough flow (PCF) required for an effective cough?

A peak cough flow (PCF) of about 160 liters per minute is required for an effective cough.

What are the contraindications for using cough assist?

Contraindications include a history of bullous emphysema, susceptibility to pneumothorax or pneumomediastinum, active hemoptysis, active masses, high intracranial pressure, impaired consciousness, and low Glasgow Coma Scale (GCS) scores.

How is the cough assist device set up, and what are the initial settings?

The device is set up with inspiratory pressure set at positive 10 to 15 cm water, expiratory pressure at negative 10 to negative 15 cm water, and a pause of 2 to 5 seconds between cycles. The initial settings are color-coded for easy reference.

What is the maximum pressure that can be delivered by the cough assist device, and how is it tolerated by patients?

The device can deliver pressures as high as positive to negative 40 cm water, which has been found to generate good results and is well tolerated by patients.

How should the cough assist treatment be conducted, and what are the post-treatment considerations?

The treatment should be done after all other respiratory treatments, with the patient wearing a mask tightly. The machine is used to do five cuffs in a row, starting with inspiratory face suction. Post-treatment, observe the patient for improvement and ensure they are stabilized before ending the therapy.

What is the recommended cleaning procedure for the cough assist device?

The exterior surface should be cleaned before and after each use with a damp cloth and mild detergent or 70% isopropyl alcohol. The air filter should be washed with warm water and mild detergent, rinsed thoroughly, and air-dried. The bacterial filter should be replaced monthly or when soiled.

Outlines

00:00

😷 Management of Difficult Coughs with Airway Clearance Techniques

This paragraph introduces the topic of managing difficult coughs, emphasizing the educational nature of the presentation and clarifying that the speaker does not endorse any specific products or images. The main focus is on airway clearance techniques (ACTs), which are non-pharmacological interventions aimed at removing excess secretions to reduce airway obstruction and improve lung function. The paragraph also introduces cough assist devices, specifically the Mechanical Insufflator Exsufflator (MIE), which was introduced in 2007 to augment cough in patients with ineffective cough mechanisms due to various conditions such as muscular dystrophy, myasthenia gravis, spinal muscular atrophy, and spinal cord injuries. The use of MIE is discussed in the context of its underlying principles, efficacy, and application methods.

05:02

🔧 How Cough Assist Devices Work and Their Setup

This paragraph delves into the functionality of cough assist devices, explaining how they perform cough augmentation to mobilize secretions from smaller to larger airways for clearance with suctioning. It discusses the prevention of lung infections and treatment of atelectasis through the use of these devices. The paragraph references the AARC Clinical Practice guideline, which supports the use of cough assist techniques in patients with neuromuscular diseases (NMD), particularly when peak cough flow is less than 270 liters per minute. The concept of peak cough flow (CPF) is introduced as a measure of respiratory function in patients with respiratory muscle weakness. The setup of the cough assist machine is described, including the functions of various knobs and levers, and the importance of understanding the device's manual and automatic controls, pressure gauge, and the process of setting inspiratory and expiratory pressures.

10:02

🛠 Initial Settings and Treatment Protocol for Cough Assist Devices

The paragraph outlines the initial settings for a cough assist device, detailing the color-coded system for setting inspiratory and expiratory pressures, as well as the rest period or pause between cycles. It provides specific initial values for these settings and explains the maximum pressures that can be delivered by the device. The paragraph also describes the standard sequence of treatment, which involves a series of consecutive cough cycles with a rest period in between, and emphasizes the importance of post-treatment observation and assessment. The paragraph includes a note on the importance of a good mask fit to prevent leaks and ensure effective treatment delivery.

15:05

🧼 Post-Treatment Care and Recent Studies on Cough Assist Devices

This final paragraph focuses on the post-treatment care for patients using cough assist devices, including the proper disconnection and storage of equipment, as well as cleaning protocols for the device and its components. It stresses the importance of observing patients post-treatment and ensuring their stabilization. The paragraph also highlights recent studies that encourage the use of cough assist devices, particularly in combination with non-invasive ventilation (NIV) for the treatment of acute respiratory failure in children with neuromuscular disorders. It concludes with a reminder to clinicians about the considerations for initiating and daily using cough assist devices to build confidence in their use.

Keywords

💡Rescue for a difficult cough

This term refers to the process of providing relief for a persistent or severe cough, which is the central theme of the video. The script discusses various treatments and techniques aimed at alleviating this condition, emphasizing the importance of proper respiratory care.

💡Nebilitation

Nebilitation, or nebulization, is the process of administering medication in the form of a mist that is inhaled. It is one of the common approaches mentioned in the script for treating a difficult cough by delivering medication directly to the airways.

💡Hydration

Hydration is the state of having adequate water content in the body, which is crucial for maintaining healthy bodily functions, including respiratory health. The script suggests hydration as a common approach to alleviate cough symptoms by keeping the throat and respiratory tract moist.

💡Airway Clearance Techniques (ACTs)

ACTs are non-pharmacological interventions used to remove excess secretions from the respiratory tract. The script describes them as vital for reducing airway obstruction and improving lung function, thus playing a significant role in the management of a difficult cough.

💡Cough Assist

Cough Assist, also known as a mechanical insufflator exsufflator (MIE), is a device introduced in 2007 for cough augmentation. The script explains its function in helping patients with ineffective coughs or those who struggle to take deep breaths due to various conditions.

💡Cough Augmentation

Cough augmentation refers to the process of enhancing the natural cough reflex to expel secretions more effectively. The script mentions that Cough Assist performs this function by applying positive and negative pressures to the airway, which is crucial for patients with respiratory difficulties.

💡Inspiratory Positive Airway Pressure (IPAP)

IPAP is the positive pressure applied to the airway to increase the patient's tidal volume during the inspiratory phase. The script explains that Cough Assist provides IPAP to help patients inhale deeply, which is part of the cough augmentation process.

💡Peak Cough Flow (PCF)

PCF measures the maximum respiratory flow that occurs during a cough. The script uses PCF as an indicator to assess the effectiveness of a cough, particularly in patients with neuromuscular diseases, and as a guide for the use of Cough Assist.

💡Neuromuscular Disorders (NMD)

NMD refers to a group of disorders that affect the nerves and muscles, leading to muscle weakness and other issues. The script highlights that patients with NMD can benefit from Cough Assist due to their impaired respiratory function.

💡Contraindications

Contraindications are conditions or factors that make a particular treatment or procedure inadvisable. The script lists several contraindications for using Cough Assist, such as a history of bullous emphysema or high intracranial pressure, to ensure patient safety.

💡Setup and Operation of Cough Assist

The script provides a detailed explanation of how to set up and operate the Cough Assist device, including the use of knobs for inspiratory and expiratory pressures, the importance of the pause between cycles, and the process of applying the device to patients via a mask or tracheostomy tube.

Highlights

The presentation discusses various treatments for a difficult cough, emphasizing the importance of airway clearance techniques (ACTs).

ACTs are defined as non-pharmacologic interventions aimed at eliminating excess secretions to improve lung function.

Cough assist, introduced in 2007, is a device that performs cough augmentation to help patients with ineffective coughs.

Cough assist uses a combination of positive and negative pressure to augment the patient's tidal volume and assist in secretion expulsion.

Patients with neuromuscular diseases or conditions that affect respiratory muscle strength may benefit from cough assist.

The presentation outlines the indications and contraindications for using cough assist, including conditions that may preclude its use.

Cough peak flow (CPF) is a critical measure used to assess the effectiveness of a cough in patients with respiratory muscle weakness.

A CPF of less than 270 liters per minute is associated with increased risk of infection and secretion retention.

The setup of the cough assist machine includes understanding the functions of various knobs and levers for pressure control.

Digital versions of the cough assist machine offer color-coded settings for easier initial setup and operation.

The initial treatment settings for cough assist are detailed, including inspiratory and expiratory pressures and rest periods.

Cough assist can be applied via a mask, mouthpiece, or tracheostomy tube, with considerations for different patient needs.

The standard sequence for cough assist involves multiple cycles of treatment with rest periods to prevent patient fatigue.

A low cough peak flow of 17 liters per minute is deemed unacceptable, indicating the need for effective cough assist treatment.

The treatment process involves placing the mask securely and using the machine for a series of cough cycles to clear secretions.

Cough assist should be used intermittently and not exceed 5 minutes of continuous use per session.

Post-treatment observation and assessment are crucial to monitor patient improvement and ensure stabilization.

Recent studies support the use of cough assist in combination with non-invasive ventilation for acute respiratory failure in neuromuscular patients.

The presentation concludes with recommendations for clinicians on the initiation and daily use of cough assist to build confidence in the device.

Transcripts

Discuss rescue for a difficult cough

so this presentation is for educational purposes only

and the speaker do not

endorse or promote the products or images featured

or referred to as this Costarian

so rescue for a difficult cough

typically involves treatments to alleviate the cough

so common approaches include nebilization

hydration medication

your area clearance techniques

which generally generates unefficient cough

which is vital for area clearance

air air clearance techniques or ACTs

can be defined as non pharmaclogic intervention

with a variety of different strategies

used to eliminate excess secretions

which aims to reduce area obstruction

cause basic questions and expand the collapse lungs

areas of the lungs

thereby improving the gas exchange and preventing

area inflammation

so study on airway clearance techniques

the right choice for the right patient

um states that postural drainage

manual techniques or PAP systems

well

are like on the background

since the current orientation

is increasingly aimed at devices that can mobilize

or remove secretions like cough assist

so cough assist as popularly known

was introduced in 2007

and also called a short Mie

or your manual insulator exoflator

so cough assist performs um cough augmentation

so appropriate um

use of this technique

requires an understanding of the underlying principles

its relative efficacy and the methods of application

so

MIT

can be defined

as a mechanically applied positive pressure breath

followed by negative pressure

applied to the airway opening

it also provides inspiratory

positive airway pressure to augment

the patient's tidal volume

then switches to a negative pressure

to assist expulsion of secretions

so it can be applied with a mask

a mouthpiece or a trachea a doctor

so your Mie

is most useful in people with an ineffective cough

or who struggle to take a deep breath in

due to muscle weakness

um neurological conditions such as muscular dystrophies

myastina grievous

your SMA or your spinal muscular atrophy

your spinal cordulations

and your mother neurone diseases benefit from your MIT

so who needs it who needs mi

children

unable to effectively cough or clear secretions

a pic

of flow measurement of less than 160 liters per minute

or not able to generate an effective cough

may benefit from Mye

you preventing respiratory complications due to secretion

retention and poor tidal volumes

so knowing who are the children who needs it

the indications and counter indications should be

considered so as measured in previous slide

unable to clear secretions effectively

due to muscle weakness or with an effective cough

reduced pick cough flows

patient with secretions

Christian retention rather and poor tidal volumes

what else chest wall remodeling

stabilization of thoracic cage and spine

pre post surgery contraindications

or as follow

any patient with a history of bullus emphysema

susceptibility to pneumothorox or pneumo medistinium

active hymopthesis active masses

high intracranial pressure

impaired consciousness and low GCs

so now that we know the indication

and contrary indications

now how does your cough assist work

so as I mentioned earlier

your cough assist performs cough augmentation

once cough augmentation is done

secretions are mobilized

from the smaller to the larger airways

therefore

secretions are cleared with the aid of suctioning

once suctioning is done

power we will be able to achieve what

prevention of lung infection

and if your patient has epilepsys

it can be treated and prevented as well

so this has been uh

proven by the AARC Clinical Practice guideline

effectiveness of non pharmacological

air week clearance therapist in hospitalized patients

that for adult and pediatric patients with NMD

or neuromuscular disease

respiratory muscle weakness or impaired cough

cough assist techniques

should be used in patients with NMD

particularly when pick cough flow

is less than 270 liters per minute

so what is big cough flow

or your cough pick flow or CPF

your cup pick flow

or CPF is measured as the pick

respiratory flow that occurs during a cough

so it is used to assess cough

in patients with respiratory muscle weakness

mainly in patients with neuromuscular pathology

so

are supported by a study entitled

the use of cough

big flow in the assessment of respiratory function

in Clinical practice and Narrative literature review

a CPF of about 160 liters per minute is required

for an effective cough

and less than 270 liters per minute

is associated with increased secretion

retention and risk of infection

reduced CPF

or cough big flow can be due to a number of mechanisms

including reduced respiratory muscle strength

lap of coordination

of glotic closure and opening and every obstruction

so

now that we have understood what your cup big flow is

or for its use

now we can set up the cuff assist machine

but before we set it up I have two pictures here

the gray one is the older version of the machine

and the black one is the

the newer version in the market okay

nowadays so of course

let's just familiarize ourselves with the knob

so that will be able to appreciate the digital ones

so on the left side all right

so the three knobs here are the ones um

responsible for your inspiratory time

your expiratory time and your pause

okay this one is the manual and auto control

if you want to do it on a manual side

or auto delivery of the pressures

this one is your power on off

then on this phase is you can see the

the pressure gauge

wherein you will appreciate the negative

and the positive

pressures delivered to your babies or to our patients

so you see it's yellow and it's blue blue

green so this one is the manual lever within you

what if you set the machine into manual

the manual lever is being used to deliver your manual

inspiratory and your manual expiratory pressures

now on the right side of the machine or again

three knobs coping K to the middle

so you have your inspiratory pressure knob

your expiratory pressure knob in the middle

and you have your floor rate for ease of delivery

of the pressures you set it for that

now keep in mind that your inspiratory pressure

the pressure that pushes the air into the lungs

like a big breath

okay

and your respiratory pressure

these are the pressure that pulls the mucus out

of your lungs like a big cough

so inhale deep

so that's your cough big cough

so the pause is the time in seconds between each cycle

of in and out

now before I move into the next slide

I would just like to um tell you that

the mask set up is a bacterial filter with a long tube

here one tube and your inflatable mask okay

so moving on to the next slide

so this is the digital one so again it's color coded

so how do we do the initial setting

so since we know how to set it up now

the initial treatment settings cuff cycle

so one cuff cycle is composed of one inspiration

one expiration and a post face

so the initial settings are color coded

your inspiratory pressure

can be set at positive 10 to positive 15 cm

water with a two second delivery time

the yellow one

your respiratory pressure can be set initially

initial settings photo initially

negative 10 to negative 15 cm water

with a 2 second delivery time

the green one is where you set your rest period

or your pause

so it's two to five seconds between cuff cycles okay

so

how far can you go

with respect to the pressures delivered

you can go as high as positive to negative 40 cm water

and it will generate good results

and it is well tolerated by asking

my patients are done it with

a couple of my patients reach 40

delivered at 3 to 4 seconds

and they're good at it

okay so the standard sequence consist of pediatrics

3 to 6 consecutive cuff cycles

adults 4 to 6 consecutive cuff cycles

rest period 30 seconds where in

this is the time you will have to return your babies

if they are in all to support

so that would normalize a little thing arena oxygen

and if your patients are to customize or ventilated

then you have to put them back to the ventilator

to at least recover for a while

so again if sequences can be repeated

you do it three to six more times

if it is necessary to clear the secretions

okay so

in the picture here

you can see the recording of your big cough

low of 17 liters per minute

so meaning to say that um this low it's not acceptable

so any book

I am problema baka Hindi titan mask become a leak okay

so young boy on my like consider nothing

so we have we know how to set it up

we know the coffee flow importance

we know the initial settings now how do you do

it so how is the treatment done

so do this treatment

after all other respiratory treatments are delivered

so if you have diabetesation

you have chest facial therapy you have um

what's this postrogenage do suctioning

it's okay

do it and then on top of it do your cough assist

so

this treatment can also be done anytime you need help

help coughing so again if your patient is using a mask

put the mask on tight

so the machine can push and pull out the cuff easier

so use the machine to do five cuffs in a row

you always start with the inspiratory face suction

any mucus that you have coughed out

rest if necessary or indicated

and you can repeat this steps

three times until the secretions are cleared

okay so this uh is for via mask

and then if your patients are too customized

make sure that you get an adapter to place it

right on the trick tube

so in the upper right hand corner

a picture of the adapter okay

this one

so you you secure one and then attach it to the tubing

and then you may attach it to the um trachostomy tube

also uh

remember that higher exhale pressures

may be required to overcome the increased resistance

of a trachostomy or your

ETT or your endertracial tube

so if your tract tube is coughed

make sure it is

inflated to protect against secretions of

going up into your oral airway

and also to maintain a good

good pick cough flow or your cough pick flow

so that's how you do simple as it is very easy simple

easy con size

short

to deliver your cuff assist in your patients

or your babies with neuromuscular diseases

so Ganulla book possibly

so once the therapy is completed

of course you have to um

disconnect the patient circuit

along with the bacterial filter

make sure the interface also is placed inside the

set up bag okay

so of course you can clean it up with wipes or your

your your um adapter

YouTube adapter can be cleaned with um um

mild soap and water and then air dry

which is thoroughly and then air dry

so we're done with keeping the patient set up in a bag

now

um of course you have to clean the cough assist device

so the exterior surface should be cleaned

before and after each patient use with

dump and cloth dump and with water in mild detergent

or most common Vienna manpo

we have 70% of supperhyll alcohol

so you can use it

or if you have 10% chlorine beach solution

you may do so but 70% supperhyll alcohol is very handy

so you may use it the air filter should be cleaned

also by washing it with water

and warm water not boiling

warm water with a mild detergent

to have to rinse it thoroughly

to remove all detergent residue

and make sure that it's being air

dried

and the bacterial filter of course

should be replaced once a month

or as they need a rises

so if you see it soiled please do change it

going upon the end and making color black

notordom black for young bacterial filter

so um we're done cleaning the the unit or the device

then I just have some things for you to remember

so oxygen can be entrained by a nasal canola or um

you can breathe in specially committee peaceful by

okay can read in there

so encourage your patients to cough

if doable

do five breaths in and out at a time

followed by a 32 second rest

and repeat up to five to 10 times as needed

so usually

3 to 5 cycles are enough to produce a good cough

and please Cup Assist is for intermittent use

and should not be used for more than 5 minutes

please not more than 5 minutes

and after delivering your cough assist

make sure that you observe the post treatment

and the assess for improvement

if if just in case rule of thumb

follow the triple s rule stop the therapy

return patient to regional resting position

or to your ventilator or to your oxygen

stay with the patient until he or she is stabilized

okay

so and before I add my lecture

would just like to

share with your recent studies to

encourage the use of Mie or your cough assist

so recent study in NIV and

Mie for Acute Respiratory Failure

in children with Neuromuscular Disorders

found out that combined coughing assistance

of your Mie with your NIV

has been recommended to the treatment of acute

neuromuscular respiratory failure okay

and so it's called polygamy

so if you are if you have NIV

we can use the cough assist and of course

for the clinicians

Mie considerations for improving the clinical practice

please make recommendations and the

on the initiation around daily use of our MIT

to build of confidence about the device

so with that um

thank you and let's all breathe in and breathe out

thank you