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

0

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.

vincent.gathot@inkendaal.be