Cough Assist and Clearing the Air on Secretion Management.txt
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What is the definition of the cough assist
Mechanical Insufflator-ExsufflatorCoughAssist is a noninvasive therapy that safely and consistently removes secretions in patients with an ineffective ability to cough
What typical patients use the CoughAssist?
- Amyotrophic lateral sclerosis
- Spinal muscular atrophy
- Muscular dystrophy
- Myasthenia gravis
- Spinal cord injuries
When should cough assist be used?
peak cough flow <270 l/m
How does CoughAssist works?
CoughAssist 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
What are the benefits of the CoughAssist?
- Removes secretions from the lungs
- Reduces the occurrence of respiratory infections
- Safe, noninvasive alternative to suctioning
- Easy for patients and caregivers to operate
What are the Indications for CoughAssist?
- Reduced Peak Cough Flow (pcf) < 270 lpm necessary to clear bronchial secretions during an infection
- PCF can be measured by pneumotach or by simple peak flow meter adapted to a facemask.
- A maximum expiratory pressure < 60 cm H20
What are the Contraidications for CoughAssist?
- Any patient with a history of bullous emphysema
- Susceptibility to pneumothorax or pnuemo-mediastinum
- Recent barotrauma, should be carefully considered before use
Attach CoughAssist user circuit to the CoughAssist output including a bacterial/viral filter, smoothbore tubing and an appropriate interface: mask, mouthpiece or trach adapter. If a mask is used, it should be of appropriate size to provide for a tight seal
Implementation of CoughAssist
Begin with inspiratory pressures between +10 and +15 cm H20 and expiratory pressures of between -10 and -15 cm H20 to allow an introduction / acclimation period to the device
Implementation of CoughAssist
Verify initial pressures or any changes in pressure requirements by occluding the circuit in a clean manner and cycling from inhale to exhale.
This should be done several times while viewing the pressure gauge
Implementation of CoughAssist
What is Patient Acclimation for CoughAssist?
- Acclimate the patient to CoughAssist by starting with low pressures (i.e., 5 to 10 cm H2O).
- Let him or her feel the air first before attaching a patient interface. This is especially important when working with children.
- Agree on signal to stop TX
- Start with positive pressure only then move to positive and negative pressures
What are the different patient interfaces for CoughAssist?
- Face Masks and Mouthpieces
- - When using a mouthpiece, nose clips may be required
- Trached Patients
- - If the patient has a cuffed tracheostomy tube, inflate the tube cuff.
- - For patients with an uncuffed trach, the first option is to use the trach tube and have the patient try to maintain closure at the glottis. If this is not possible, closure of the mouth and nose may be required.
When starting CoughAssist in Manual Mode you should...
slide the manual toggle from inhale to exhale 4-6 times holding the inhale pressure for 2-3 sec, enough time to deliver a full deep breath, then rapidly to exhale for 2-3 sec
When starting CoughAssist in Auto Mode you should...
slide to the Auto mode. Set the inhale time to 2-3 sec. and the exhale time to 2-3 sec
How should CoughAssist be adjusted after beginning the therapy?
increased 5 cm H20 each cycle on 4-6 breaths until optimal pressures are reached to clear secretions
What are typical inhale pressures?
15 cm H20 to 40 cm H20
What are optimal exhale pressures?
35cm H20 and 45 cm H20
What are common settings for inhale and exhale pressures for adults?
inhalation pressure of 30 to 40 cm H2O and an exhalation pressure of 35 to 45 cm H2O
CoughAssist on intubated or trached patients should have higher or lower inhalation pressures?
higher exhalation pressures may be required due to the increased restriction of the narrow artificial airway
When should the clinician switch to exhalation when using CoughAssist?
patients signals they have received a full deep breath
Patients with unstable upper airways, infants, and children should have what type of flow setting?
A standard treatment consists of how many consecutive cycles of insufflation/exsufflation?
How long should the patient rest during Tx?
What is the usual recommended starting setting for patients?
Patients who are ordered CoughAssist usually under go how many TX's per day?
2 to 4 CoughAssist treatments per day (1 treatment = 4-6 sequences; 1 sequence = 4-6 cycles; 1 cycle = 1 insufflation and 1 exsufflation)
When should CoughAssist be used?
- - Signs of retained secretions including drops in oxygen saturations
- - During infections
- - To improve chest wall mobility and vital capacity as well as prevent atelectasis
What two methods are used for airway clearance?
- - Secretion Mobilization:
- Techniques design to loosen and mobilize secretions from the lower airway to the upper airway
- - Secretion Removal:
- Techniques that mobilize and remove secretions from the lungs
What Groups at Risk for Retaining Secretions?
- - Intrinsic Lung Disease:
- Cystic Fibrosis (CF), COPD, Bronchiectasis
- - Restrictive Lung Diseases:
- ALS, muscular dystrophy, post polio, multiple sclerosis, spinal muscular atrophy
- Spinal cord injury, stroke
What is Intrinsic Lung Disease characterized by?
have the muscle strength for strong coughing but have thick secretions causing the mucociliary transport not to function effectively
What is Restrictive Lung Disease characterized
- Lack of respiratory muscle strength
- Impaired ability to cough
- - patient have an impaired ability to eliminate secretions
What are the secretion mobilization techniques?
- 1. Intrapulmonary percussive ventilation (IPV)
- 2. Manual chest physiotherapy and postural drainage
- 3. Positive expiratory pressure devices (PEP)
- 4. High frequency chest wall oscillation (HFCWO)
- 5. Aerosol therapy
What 3 types of therapy does Intrapulmonary Percussive Ventilation (IPV) provide?
- 1. Percussive oscillatory vibrations which loosen secretions
- 2. High density aerosol delivery to help thin viscous secretions
- 3. Positive expiratory pressure (PEP)
What are the four phases of a cough?
- 1. Irritation
- 2. Inspiratory
- 3. Compressive
- 4. Expulsive
What is the normal range for Peak Cough Flow (PCF)?
Normal: 6-12 L/s or 360-720 L/m
Maximum Expiratory Pressure (MEP), which isolates cough muscle strenght, has a normal range of?
60 cmH2O and higher
If a Peak Cough Flow (PCF) is <160 L/Min, then it is?
an Ineffective Cough
What risks are associated with an Ineffective Cough?
- Increases risk of respiratory infection
- Introduces risk of chronic lung damage as a result of recurring lung infection
- Increases risk of pneumonia and resulting hospitalizations
If a patient has a Peak Cough Flow between 160 L/min and 270 L/min, what are they identified to benefit from?
Assisted Cough Techniques
What are the 3 Secretion Clearing/Removal Techniques?
- 1. Suctioning
- 2. Manually-assisted cough (MAC)
- 3. Mechanical insufflation-exsufflation
What can be done that is noninvasive and applies pressure to the abdomen, pleural space, and airway to increase PCF?
a Manually Assisted Cough
What is the most important part of Manually Assisted Cough?
air stacking or maximal insufflation to deep lung volume prior to the MAC
Besides being labor intensive and caregiver inconsistency, what other limitation is assosiciated with Manually Assisted Cough (MAC)?
At best, increase PCF to the minimum needed to clear secretions (270 L/Min)
What does Mechanical Insufflation-Exsufflation (MI-E) do?
Applies a positive pressure to the airway (insufflation) followed by a rapid shift to a negative pressure (exsufflation) simulating a cough
What are the indications for Mechanical Insufflation-Exsufflation (MI-E)?
Any patient unable to cough or clear secretions effectively due to reduced peak cough expiratory flow < 270 L/min
What are the contraindications for Mechanical Insufflation-Exsufflation (MI-E)?
- History of bullous emphysema
- Known susceptibility to pneumothorax or pneumo-mediastinum
- Recent barotrauma
What are some benefits of insufflation?
- Neuromuscular disease - reduced VC and Vt and an inability to sigh that result in developing atelectasis and pneumonia1
- Provides normal hyperinflation - has been shown to combat loss of chest wall compliance and microatelectasis2
What are some benefits of exsufflation?
- - Flow simulates a natural expiratory cough flow (6-10 L/sec)
- - More effective than invasive suctioning since suctioning has been shown to miss the left mainstem bronchus 90% of the time1
- - Potentially eliminates the need for invasive suctioning
What settings should be used with MI-E?
- Pressures (positive and negative)
- - Start low, 10 to 15 cm H20
- - Get patient acclimated to device
- - Increase pressures as tolerated, 35 to 45 cm H20 ideally1
- Times (Inhale, Exhale and Pause)
- - Small Children: 1 to 2 sec
- - Adults: 2 to 3 sec
What are the goals of Mechanical Insufflation-Exsufflation (MI-E)?
- - Hyper-expansion from inspiratory pressure
- - Replace a good expiratory cough flow from expiratory pressure
How do you achieve the most effective cough flows?
by combining MI-E and MAC
In-exsufflator cough machine improves _________________ flow rates
peak cough expiratory
Secretion mobilization techniques assist the _______, but they do not assist what
mucociliary escalator; cough
What is the principle mechanism for clearing the airways?
Patients who have an impaired cough mechanism require what to done?
secretions be removed
When choosing airway clearance therapy, ______ and ______ needs must be considered
What steps should be taken while performing an MI-E?
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