Mechanical Insufflation / Exsufflation in Restrictive Disorders
Vincent Gathot – Symposium BVRV – 29 March 2019
Outline
What’s clearance?
Limitations of M I/E for patients with bulbar dysfunction
Practice…
What’s the ideal pressure?
Complications with M I/E
Efficacy of M I/E to increase the PCF
When to use M I/E?
M I/E Vs endotracheal suctioning
Physiological benefits of M I/E
What is clearance?
3 parts in clearing airways:
Clearing of the upper respiratory airways
Clearing of secretions from the peripheral airways to the central
respiratory airways.
Ending by clearing of the upper respiratory airways.
Active or assisted coughing
Suctioning, Cough-Assist, Air-stacking,…
IPV, Autogenic drainage, …
What is clearance?
Manually assisted coughing:
Requires lung inflation through air stacking or deep lung
insufflation.
Followed by a thoracal / abdominal thrust applied when the glottis opens.If the VC is < 1,5L, air stacking is especially important before the
abdominal thrust. Kang SW et al. Am J Phys Rehabil 2000
Co-operative patient
Good coordination between the patient and the caregiver
Adequate physical effort and often frequent application by
the caregiver
What is clearance?
For patients with NMD, to prevent:
Hypersecretion
Atelectasis
Pneumonia
Acute respiratory failure
Hospitalisation
M I/E: 2 aspects
Assisted coughing
Lung Volume Recruitement
What is clearance?
Reduction of chest wall compliance…
Inability to fully expandand empty the chest, leads to stiffening of the joints of
the rib cage
Atelectasis resulting from breathing at a low lung
volume and the inability to clear the airways
Lung Volume Recruitement
When to use M I/E
When to use M I/EWhat’s an efficient cough ?
PEF:180 l/min; 3 l/sec
Peak Cough Flow (PCF) < 160 l/min
Indication of an inefficient cough
Servera E et al. Arch Bronconeumol. 2003Homnick DN et al.
Respiratory Care. 2007 Bach JR. Arch Phys
Med Rehabil. 1995
Bach JR et al. Chest 1996
Bach JR. Chest 1993
When to use M I/E
Even a basal PCF < 270 l/min (4,5 l/sec) has been associated with pulmonarycomplications
Servera E et al. Arch Broncopneumol 2003
When to use M I/E
During acute disease, there are additional reductions of the force of the respiratory muscles with an even greater reduction of PCF.
Sancho et al. Am J Respir Crit Care Med. 2007
Mier-Jedrezejowicz et al. Am Rev Respir Dis. 1988
Poponick JM et al. Am J Respir CritCare Med. 1997
When to use M I/E
OximetryDetects a sudden decrease of
oxygen saturation as a consequence of a mucus plug.
The study of Bento J et al. was based on the protocol proposed by Bach et al., that consists in home treatment with a NIV support, oximetry monitoring during
24 hours and the use of M I/E guided by the data from this (SpO2< 95 %).
When to use M I/E
In 1953, the first device for mechanical assistance of coughing was
marketed. Bach J et al. NeuroRehabiliation 1997.
Efficacy of M I/E to increase the PCF
Gomez-Merino Eet al. Am J Phys
Med Rehabil. 2002
Servera E et al. 2003Bach JR. Chest
2002
Chatwin M et al. Eur Respir J 2003
Bach JR. Chest 1993
Bach JR. Eur RespirJ 2003
Vianello A et al. Am J Phys Med Rehabil. 2005
Winck JC et al. Chest 2004
Efficacy of M I/E to increase the PCF
Efficacy of M I/E to increase PCF
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1
2
3
4
5
6
7
8
Unass. Stacking Stack. Ass. Mech. In-Ex
PCF (l/sec)
Mechanical insufflation-exsufflation. Comparison of PEF with manually assisted and unassisted coughing techniques Bach J R; Chest 1993
21 restrictive patients: (10 polio, 5 medullar lesions, 6 NM) Best PEF achieved with ‘Mech. In/Ex’.
Chatwin et al. Eur Respir J 2003 -> Same conclusion
Complicatons with M I/E
Bach et al.Patients with NMD, dependent on NIV that use
M I/E guided by oximetry data can be treated at home without a risk or need of hospitalisation
Homnick DN. Respir Care 2007
No complications related to use of the device. Potential complications are very infrequent but
include:
Abdominal distensionIncrease of gastroesophagealrefluxHaemoptysis
Chest and abdominal discomfortAcute cardiovascular eventsBarotraumasPneumothorax
Complicatons with M I/E
Pneumothorax associated with mechanical insufflation-exsufflation and related factors.
Suri P et al. Am J Phys Med Rehabil. 2008
2 cases of pneumothorax daily use of M I/E
58-yr-old male with C4 ASIA C tetraplegia
26-yr-old male with Duchennemuscular dystrophy
Both patients also used positive-pressure ventilatory assistance.
Although seemingly rare in this patient population, ventilator users also using M I/E who have increasing dyspnea or who require increasing positive inspiratory
pressures when using NIV should be evaluated for pneumothorax.
Complicatons with M I/E
Presence ofpneumothorax
Severe bulbar weakness
Severe uncontrolled asthma
Exclusion criteria
Severe COPD
Complicatons with M I/E
Emphysema
History of pneumothorax
Insufflationpressure: Max
20 cm H2O
Chatwin and Sivasothy have considered that lower pressures
are more comfortable and
involve fewer risks
What’s the ideal pressure?
Chatwin et al. Eur Respir J. 2003
Sivasothy et al. Thorax2001
For NMD-patients, with ‘healthy’ lungs. Actually most studies prescribe
mean pressures of + 40 to - 40 cm H2O
Gomez-Merino E et al. Am J Phys Med Rehabil
2002
Bach JR. Chest 2002
Homnick DN. Respir Care.
2007
Bach JR Chest 1993
Bach JR et al. Chest 1996
GoncalvesMR et al. Am J Phys
Med Rehabil. 2005
Vianello et al. Am J Phys Med Rehabil.
2005
What’s the ideal pressure?
The Addition of Mechanical Insufflation/Exsufflation Shortens Airway-ClearanceSessions in Neuromuscular Patients With Chest Infection.
Michelle Chatwin, Anita Simonds, Respiratory Care, 2009
2-day randomized crossover treatment
With in-exsufflationfor one session
Without in-exsufflation for the
second
Measurements:
Treatment time
Heart rate
Pulse oximetry
Tc CO2
Auscultation score
What’s the ideal pressure?
Results:
Treatment time was significantly shorter with
the in-exsufflation
What’s the ideal pressure?
Significant decrease in auscultation score for both
groups
No difference in mean heart rate, SpO2 or Ptc CO2
Pressures ? + 20 cm / - 20 cm H20Insufflation time: 2-4 s, and exsufflation time: 4-5 s
Physiological benefits of M I/E
Physiologic Benefits of Mechanical Insufflation-Exsufflation in Children WithNeuromuscular Diseases
Brigitte Fauroux et al. Chest 2008
The objectives of this study was to compare
Breathing pattern
VC
SNIP
PEF
Respiratory comfort
Physiological benefits of M I/E
Three M I/E sessionsSix insufflation-
exsufflation cycles
In/Ex pressures were +/- 15 cm H2O, +/- 30 cm H20 and +/- 40
cm H20
Timing of the cycle was 2 s of insufflation, 3 s of exsufflation
30 s rest period between each application
Patients were instructed to let the device make them inhale fully during inspiration and to exhale fully during expiration (not to cough!).
Physiological benefits of M I/E
Mean and maximal inspiratory and expiratory flows during the M I/E applications at the three pressure levels
During the exsufflation, a mean PEF of 114 +/- 84 L/min
could be generated
The patients in this study were not solicited to cough or to produce a forced expiration. So PEF did not
reach a sufficient level.
Physiological benefits of M I/E
Mean V exp during the M I/E applications at the three pressure levels.
Physiological benefits of M I/E
No changes in breathing pattern or SpO2
There was a significant decrease in PET CO2
Physiological benefits of M I/E
A significant increase in the mean SNIP, the mean PEF or PCF and
respiratory comfort
After the 40 cm H20 M I/E application
Physiological benefits of M I/E
Emerson Cough AssistMaximal pressures: +/- 60 cm
H20
Pressure shift from positive to negative: 0.02 sec
The Paw measured on the facial mask during M I/E applications were constantly lower than the inspiratory and expiratory set on the device
M I/E Vs endotracheal suctioning
Endo-trachealsuctioning
Tiring
Irritating
Injury
More secretions
M I/E
Less tiring
Less injuries
Safer / More comfort
As less as possible tracheal suctioning!
Airway suctioning misses the left main stem bronchus +/- 90 % of
the time.
Mechanically assisted cough provides the same exsufflation flows in both left and right
airways.
Practice…
Via an oronasal mask
Via a tracheal tube
Practice…
In our unit 90 % of the patients are treated
with:
Fast or Slow insufflation depending of the patient’s tolerance.
In an automatic mode. This allows us to give manual expiratory assistance.
Practice…
Practice…
When do you apply this technique ?
Sp O2 – drops
Sensation of breathlessness
Sensation of discomfort
An audible sound of accumulation of secretions
In other terms, the same indications when you aspire your patient.
Routine based (clearing)
Practice…
Good habit to have a saturation-measurement during the
intervention
Suctioning tube not further than the tracheal tube
Can be used in permanently ventilated patients
Practice… Coughing with E 70
Practice… Air-Stacking with E 70
Practice…
Always start the maneuver with the insufflation!
Manual control in the exsufflationphase!
Assisted coughing in the exsufflation phase!
In our unit we frequently use thoracic trust because a lot of patients have a PEG-tube. They experience
discomfort when there’s pressure on it.
Internal rotation of the wrists
Upward translation
Practice…
Guérin C. et al., Respiratory Care, August 2011, Vol 56, No 8
180 l/min ?
Limitations of M I/E for patients with bulbar dysfunction
How do you evaluate bulbar dysfunction?
MIC / FVC ratio
Ratio < 1 -> Bulbar dysfunction
Only non-tracheostomised patients
Bento J et al. Arch Bronconeumol 2010
Evaluation by a speech therapist
PCF / PEF ratioSuarez A et al. Am. J. Phys. Med. Rehabil. 2002
Ratio -> 1 : Bulbar dysfunction
Limitations of M I/E for patients with bulbar dysfunction
Limitations of M I/E patients with severe bulbar dysfunctionSancho et al. Efficacy of Mechanical Insufflation/Exsufflation in Medically Stable Patients with Amyotrophic Lateral Sclerosis. Chest 2004
Sancho et al. have identified 2 types of bulbar ALS patients:
Those that only suffer from failure ofglottal closure that cannot entrap airbut in which M I/E can be effective.
Those that present a dynamic collapseof the upper respiratory airways inwhich M I/E is not effective and caneven cause risk.
In the study of Bento et al. ALS is seen as a heterogeneous group: from a non-bulbar disease with inadequate PCF to a severe bulbar disease that requires tracheotomy
Limitations of M I/E for patients with bulbar dysfunction
Bento J. et al. of 2010
10 patients presented severe bulbar dysfunction
5 of them had underwent tracheotomy
5 rejected itIn the progression of the
disease, there’s a moment that it becomes impossible to clear secretions located in the
central airways. It must be considered if tracheotomy is
an option
After extended information about the advantages and the
disadvantages
Limitations of M I/E for patients with bulbar dysfunction
Gomez-Merino et al. Am J Phys Med Rehabil.
2002
Bach JR. Chest 2002
Bach JR. Arch Phys Med
Rehabil. 1995Bach JR. Chest
1993Bach JR et al. Chest 1996
Sancho et al. Am J Respir
Crit Care Med 2007Bach JR et al.
Am J Phys Med Rehabil.
1998Bach JR Eur
Respir J. 2003Farrero E et al. Chest 2005
Bach JR et al. Chest 2004
Goncalves MR et al. AM J Phys Med Rehabil.
2005
Simonds AK. Chest 2006
Magnus T et al. Musle
nerve. 2002 Consensus ?
The almost inevitable progression to bulbar dysfunction is one of the
more negative characteristics of ALS. This is the main reason why, in
contrast to other NMD’s, tracheotomy becomes necessary to
prolong survival.
Limitations of M I/E for patients with bulbar dysfunction
Is tracheostomy still an option in ALS? Reflections of a multidisciplinary work group. Heritier Barras et al. 2013 (Janssens JP)
Current practice in Switzerland and France tends to discourage the use of TPPV in ALS. Fear of a "locked-in syndrome", the high burden placed on caregivers, and unmasking cognitive disorders occurring in the evolution of ALS are some of the caveats when considering TPPV. Most decisions about TPPV are taken in emergency situations in the absence of advance directives. One exception is that of young motivated patients with predominantly bulbar disease who "fail" NIV.