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.