Rescue for a difficult cough
Summary
TLDRThis 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
- đ 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.
- đĄ 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.
- đ 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.
- đ 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.
- đ„ 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.
- â ïž 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.
- đ ïž 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.
- đ 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.
- đ 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.
- đ§Œ 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.
- đ 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
đ· 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.
đ§ 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.
đ 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.
đ§Œ 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.
Mindmap
Keywords
đĄRescue for a difficult cough
đĄNebilitation
đĄHydration
đĄAirway Clearance Techniques (ACTs)
đĄCough Assist
đĄCough Augmentation
đĄInspiratory Positive Airway Pressure (IPAP)
đĄPeak Cough Flow (PCF)
đĄNeuromuscular Disorders (NMD)
đĄContraindications
đĄSetup and Operation of Cough Assist
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
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