Assisted Coughing: Difference between revisions
No edit summary |
Kim Jackson (talk | contribs) No edit summary |
||
| (9 intermediate revisions by 3 users not shown) | |||
| Line 1: | Line 1: | ||
<div class="editorbox"> | <div class="editorbox"> | ||
'''Original Editor '''- | '''Original Editor '''- [[User:George Prudden|George Prudden]] | ||
'''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}} | '''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}} | ||
| Line 6: | Line 6: | ||
== Description == | == Description == | ||
The cough assist helps to clear secretions by applying a positive pressure to fill the lungs, then quickly switching to a negative pressure to produce a high expiratory flow rate and simulate a cough.<ref>Finder J. Overview of airway clearance technologies. July 2006. Available at: <nowiki>http://www.rtmagazine.com/issues/</nowiki> articles/2006-07_06.asp. Accessed August 12, 2007</ref> It is known as ‘manual insufflation-exsufflation’ and can be applied via a mask, mouthpiece, endotracheal or tracheostomy tube.<ref>Bach JR. Mechanical insufflation/exsufflation: has it come of age? A commentary. Eur Respir J. 2003;21:385-386.</ref> | |||
The cough assist helps to clear secretions by applying a positive pressure to fill the lungs, then quickly switching to a negative pressure to produce a high expiratory flow rate and simulate a cough.<ref>Finder J. Overview of airway clearance technologies. July 2006. Available at: <nowiki>http://www.rtmagazine.com/issues/</nowiki> articles/2006-07_06.asp. Accessed August 12, 2007</ref> It is known as ‘manual insufflation-exsufflation’ and | |||
It is most useful in patients with an ineffective cough due to muscle weakness, in conditions such as [[ | It is most useful in patients with an ineffective cough due to muscle weakness, in conditions such as [[Muscular Dystrophy|muscular dystrophies]], [[Myasthenia Gravis|myasthenia gravis]], SMA, [[Spinal Cord Injury|Spinal cord lesions]], [[Motor Neurone Disease MND|MND]] etc.<ref>Finder JD, Birnkrant D, Farber CJ, et al. Respiratory care of the patient with Duchenne muscular dystrophy: ATS consensus statement. Am J Respir Crit Care Med. 2004;170:456-465.</ref><ref>Chatwin M, Ross E, Hart N, Nickol AH, Polkey MI, Simonds AK. Cough augmentation with mechanical insufflation/exsufflation in patients with neuromuscular weakness. Eur Respir J. 2003;21:502-508.</ref><ref>Sancho J, Servera E, Vergara P, Marin J. Mechanical insufflation-exsufflation vs tracheal suctioning via tracheostomy tubes for patients with amyotrophic lateral sclerosis. Am J Phys Med Rehabil 2003;82(10750-753.</ref> | ||
In conditions such as [[Spinal Cord Injury|spinal cord injury]] or neuromuscular disease an individual may require assistance to cough using manual techniques or a medical device.<ref>Vianello A, Corrado A, Arcaro G, Gallan F, Ori C, Minuzzo M, Bevilacqua M. Mechanical insufflation-exsufflation improves outcomes for neuromuscular disease in patients with respiratory tract infections. Am J Phys Med Rehabil 2005;84:83-88.</ref> <ref>Garstang SV, Kirshblum SC, Wood KE. Patient preference for in-exsufflation for secretion management with spinal cord injury. J Spinal Cord Med 2000;23(2)80-85.</ref>Manual assisted cough is the compression of the diaphragm by another person to replace the work of abdominal muscles in order to facilitate a cough. A medical device can be used to assist coughing effort by a positive pressure breath followed by a rapid change to negative pressure.<ref name=":0">Harden, B. (2004). ''Emergency physiotherapy: An on-call survival guide''. 1st ed. Edinburgh: Churchill Livingstone.</ref> | In conditions such as [[Spinal Cord Injury|spinal cord injury]] or [[Neuromuscular Disorders|neuromuscular disease]], an individual may require assistance to cough using manual techniques or a medical device.<ref>Vianello A, Corrado A, Arcaro G, Gallan F, Ori C, Minuzzo M, Bevilacqua M. Mechanical insufflation-exsufflation improves outcomes for neuromuscular disease in patients with respiratory tract infections. Am J Phys Med Rehabil 2005;84:83-88.</ref> <ref>Garstang SV, Kirshblum SC, Wood KE. Patient preference for in-exsufflation for secretion management with spinal cord injury. J Spinal Cord Med 2000;23(2)80-85.</ref> | ||
# Manual assisted cough is the compression of the diaphragm by another person to replace the work of [[Abdominal Muscles|abdominal muscles]] in order to facilitate a cough. | |||
# A medical device can be used to assist coughing effort by a positive pressure breath followed by a rapid change to negative pressure.<ref name=":0">Harden, B. (2004). ''Emergency physiotherapy: An on-call survival guide''. 1st ed. Edinburgh: Churchill Livingstone.</ref> | |||
== Indication == | == Indication == | ||
* A patient unable to clear secretions effectively due to muscle weakness | * A patient unable to clear secretions effectively due to muscle weakness | ||
* Peak cough flows of | * Peak cough flows of <180 L/min are unlikely to be effective at clearing secretions | ||
* Can be useful in preventing respiratory complications due to secretion retention and poor tidal volumes<ref>Tzeng AC, Bach JR. Prevention of pulmonary morbidity for patients with neuromuscular disease. Chest. 2000;118:1390-1396.</ref> | * Can be useful in preventing respiratory complications due to secretion retention and poor tidal volumes<ref>Tzeng AC, Bach JR. Prevention of pulmonary morbidity for patients with neuromuscular disease. Chest. 2000;118:1390-1396.</ref> | ||
== Clinical | == Clinical Presentation == | ||
* Subjectively 'chesty' | * Subjectively 'chesty' | ||
* Audible secretions at the mouth | * Audible secretions at the mouth | ||
| Line 24: | Line 25: | ||
* Tactile fremitus | * Tactile fremitus | ||
* [[Hypoxaemia|Hypoxemia]] | * [[Hypoxaemia|Hypoxemia]] | ||
* Non productive cough | * Non-productive cough | ||
* Poor inspiratory efforts | * Poor inspiratory efforts | ||
| Line 65: | Line 66: | ||
Undrained pneumothorax | Undrained pneumothorax | ||
[[Osteoporosis]] | |||
Pain | Pain | ||
| Line 73: | Line 74: | ||
Bronchospasm | Bronchospasm | ||
Emphysema | [[Emphysema]] | ||
Patient | Patient compliance | ||
Airway obstruction | Airway obstruction | ||
| Line 85: | Line 86: | ||
* Coagulopathy | * Coagulopathy | ||
* High Oxygen requirements | * High Oxygen requirements | ||
* Asthma or air trapping | * [[Asthma]] or air trapping | ||
* Full tummy! | * Full tummy! | ||
== Side | == Side Effects == | ||
* Abdominal distension | * Abdominal distension | ||
* Chest soreness | * Chest soreness | ||
| Line 94: | Line 95: | ||
* Oxygen desaturation | * Oxygen desaturation | ||
== Setting | == Setting Up the Cough Assist == | ||
* Plug in the cough assist and ensure it is on a flat, stable surface | * Plug in the cough assist and ensure it is on a flat, stable surface | ||
* Set up the circuit – machine, filter, tubing, mask | * Set up the circuit – machine, filter, tubing, mask | ||
| Line 101: | Line 102: | ||
* Turn on the machine and set to MANUAL | * Turn on the machine and set to MANUAL | ||
* Occlude the tubing with your gloved hand and push the manual control to EXHALATION | * Occlude the tubing with your gloved hand and push the manual control to EXHALATION | ||
* Observe pressure gauge and adjust to desired level using the main PRESSURE CONTROL | * Observe pressure gauge and adjust to the desired level using the main PRESSURE CONTROL | ||
'''Next, set the inspiratory pressure''' | '''Next, set the inspiratory pressure''' | ||
* Inspiratory pressure matches the Expiratory pressure when the INHALE PRESSURE dial is turned to the far right. | * Inspiratory pressure matches the Expiratory pressure when the INHALE PRESSURE dial is turned to the far right. | ||
| Line 133: | Line 134: | ||
* Gain consent | * Gain consent | ||
* Carry out any chest physio techniques prior to cough assist to optimise treatment and position patient as indicated. | * Carry out any chest physio techniques prior to cough assist to optimise treatment and position patient as indicated. | ||
* Explain procedure and accustom patient to mask with machine off. | * Explain the procedure and accustom patient to mask with machine off. | ||
* Switch machine on and allow patient to feel with their hand | * Switch the machine on and allow the patient to feel with their hand | ||
* Set pressures low to begin with (10-15cmH2O) to allow patient to acclimatise | * Set pressures low to begin with (10-15cmH2O) to allow the patient to acclimatise | ||
* Choose manual or automatic mode and build up pressures as tolerated to gain adequate secretion removal. Always start with the inspiratory phase | * Choose manual or automatic mode and build up pressures as tolerated to gain adequate secretion removal. Always start with the inspiratory phase | ||
* Oxygen can be entrained via nasal specs or t-piece if needed. | * Oxygen can be entrained via nasal specs or t-piece if needed. | ||
* Encourage patient to cough with the breath out | * Encourage patient to cough with the breath out | ||
* 5 breaths in and out at a time followed by 30-60 sec rest. Repeat up to 10 times as needed. Usually 3-5 ‘cycles’ are enough to produce a cough | * 5 breaths in and out at a time followed by 30-60 sec rest. Repeat up to 10 times as needed. Usually, 3-5 ‘cycles’ are enough to produce a cough | ||
* Cough assist is for intermittent use and should not be used for >5 mins | * Cough assist is for intermittent use and should not be used for >5 mins | ||
* Observe post treatment and reassess for improvement | * Observe post-treatment and reassess for improvement | ||
* Document treatment details and effects | * Document treatment details and effects | ||
== Cough | == Cough Assist Device Troubleshooting == | ||
Please also see [[Non Invasive Ventilation|non-invasive ventilation]] for more information on positive pressure devices | Please also see [[Non Invasive Ventilation|non-invasive ventilation]] for more information on positive pressure devices | ||
| Line 165: | Line 166: | ||
[[Category:Cardiopulmonary]] | [[Category:Cardiopulmonary]] | ||
[[Category:Primary Contact]] | [[Category:Primary Contact]] | ||
[[Category:Respiratory Disease - Interventions]] | |||
[[Category:Interventions]] | |||
[[Category:Respiratory]] | |||
[[Category:Respiratory Disease]] | |||
[[Category:Cardiopulmonary - Interventions]] | |||
[[Category:Technology]] | |||
Latest revision as of 08:19, 26 April 2024
Original Editor - George Prudden
Top Contributors - Kim Jackson, George Prudden, Adam Vallely Farrell, Rachael Lowe, Lucinda hampton, Laura Ritchie, Claire Knott and Angeliki Chorti
Description[edit | edit source]
The cough assist helps to clear secretions by applying a positive pressure to fill the lungs, then quickly switching to a negative pressure to produce a high expiratory flow rate and simulate a cough.[1] It is known as ‘manual insufflation-exsufflation’ and can be applied via a mask, mouthpiece, endotracheal or tracheostomy tube.[2]
It is most useful in patients with an ineffective cough due to muscle weakness, in conditions such as muscular dystrophies, myasthenia gravis, SMA, Spinal cord lesions, MND etc.[3][4][5]
In conditions such as spinal cord injury or neuromuscular disease, an individual may require assistance to cough using manual techniques or a medical device.[6] [7]
- Manual assisted cough is the compression of the diaphragm by another person to replace the work of abdominal muscles in order to facilitate a cough.
- A medical device can be used to assist coughing effort by a positive pressure breath followed by a rapid change to negative pressure.[8]
Indication[edit | edit source]
- A patient unable to clear secretions effectively due to muscle weakness
- Peak cough flows of <180 L/min are unlikely to be effective at clearing secretions
- Can be useful in preventing respiratory complications due to secretion retention and poor tidal volumes[9]
Clinical Presentation[edit | edit source]
- Subjectively 'chesty'
- Audible secretions at the mouth
- Crackles heard on auscultation
- Tactile fremitus
- Hypoxemia
- Non-productive cough
- Poor inspiratory efforts
Contraindications[edit | edit source]
| Manual assisted cough | Cough assist device |
|---|---|
| Direct pressure should be avoided to rib fractures or surgical sites. | Undrained pneumothorax
Frank haemoptysis Vomiting Facial fractures CVS instability Raised intracranial pressure (ICP) Recent upper GI surgery Lung abscess |
Precautions[edit | edit source]
| Manual assisted cough | Cough assist device |
|---|---|
| Immediately following surgery
Paralytic ileus Rib fractures Raised ICP Undrained pneumothorax Pain Unstable spine |
Oxygen dependency
Bronchospasm Patient compliance Airway obstruction |
Cautions[edit | edit source]
- Cardiovascular instability
- Coagulopathy
- High Oxygen requirements
- Asthma or air trapping
- Full tummy!
Side Effects[edit | edit source]
- Abdominal distension
- Chest soreness
- Fatigue
- Oxygen desaturation
Setting Up the Cough Assist[edit | edit source]
- Plug in the cough assist and ensure it is on a flat, stable surface
- Set up the circuit – machine, filter, tubing, mask
- Position patient as needed
First, set the expiratory pressure
- Turn on the machine and set to MANUAL
- Occlude the tubing with your gloved hand and push the manual control to EXHALATION
- Observe pressure gauge and adjust to the desired level using the main PRESSURE CONTROL
Next, set the inspiratory pressure
- Inspiratory pressure matches the Expiratory pressure when the INHALE PRESSURE dial is turned to the far right.
- To reduce the inhale pressure, occlude the tubing and push the manual control to the right (inhalation phase)
- Gently turn the inhale pressure dial to the left. When fully to the left, it will be 50% of the set expiratory pressure
| Guide to pressures: | |
|---|---|
| Adult | Up to 40 cmH2O |
| Age 5-12 | 20 – 30 cmH2O |
| Child<5 | Up to 20cmH2O |
Set the Flow Rate
- The inhale flow rate can be adjusted for comfort and effectiveness. Turned to the left is maximum flow rate and to the right is slower
Finally, set the cycle timing
- The cough assist can be used in Automatic or Manual modes.
- Manual mode is operated by moving the switch from inhale to exhale manually, coordinating with the patient's breathing
- Automatic mode allows the machine to cycle automatically through inspiration, expiration and pause
Technique/Treatment[edit | edit source]
- Gain consent
- Carry out any chest physio techniques prior to cough assist to optimise treatment and position patient as indicated.
- Explain the procedure and accustom patient to mask with machine off.
- Switch the machine on and allow the patient to feel with their hand
- Set pressures low to begin with (10-15cmH2O) to allow the patient to acclimatise
- Choose manual or automatic mode and build up pressures as tolerated to gain adequate secretion removal. Always start with the inspiratory phase
- Oxygen can be entrained via nasal specs or t-piece if needed.
- Encourage patient to cough with the breath out
- 5 breaths in and out at a time followed by 30-60 sec rest. Repeat up to 10 times as needed. Usually, 3-5 ‘cycles’ are enough to produce a cough
- Cough assist is for intermittent use and should not be used for >5 mins
- Observe post-treatment and reassess for improvement
- Document treatment details and effects
Cough Assist Device Troubleshooting[edit | edit source]
Please also see non-invasive ventilation for more information on positive pressure devices
Resources[edit | edit source]
http://www.icid.salisbury.nhs.uk/ClinicalManagement/SpinalInjuries/Pages/AssistedCoughing.aspx
References[edit | edit source]
- ↑ Finder J. Overview of airway clearance technologies. July 2006. Available at: http://www.rtmagazine.com/issues/ articles/2006-07_06.asp. Accessed August 12, 2007
- ↑ Bach JR. Mechanical insufflation/exsufflation: has it come of age? A commentary. Eur Respir J. 2003;21:385-386.
- ↑ Finder JD, Birnkrant D, Farber CJ, et al. Respiratory care of the patient with Duchenne muscular dystrophy: ATS consensus statement. Am J Respir Crit Care Med. 2004;170:456-465.
- ↑ Chatwin M, Ross E, Hart N, Nickol AH, Polkey MI, Simonds AK. Cough augmentation with mechanical insufflation/exsufflation in patients with neuromuscular weakness. Eur Respir J. 2003;21:502-508.
- ↑ Sancho J, Servera E, Vergara P, Marin J. Mechanical insufflation-exsufflation vs tracheal suctioning via tracheostomy tubes for patients with amyotrophic lateral sclerosis. Am J Phys Med Rehabil 2003;82(10750-753.
- ↑ Vianello A, Corrado A, Arcaro G, Gallan F, Ori C, Minuzzo M, Bevilacqua M. Mechanical insufflation-exsufflation improves outcomes for neuromuscular disease in patients with respiratory tract infections. Am J Phys Med Rehabil 2005;84:83-88.
- ↑ Garstang SV, Kirshblum SC, Wood KE. Patient preference for in-exsufflation for secretion management with spinal cord injury. J Spinal Cord Med 2000;23(2)80-85.
- ↑ 8.0 8.1 8.2 Harden, B. (2004). Emergency physiotherapy: An on-call survival guide. 1st ed. Edinburgh: Churchill Livingstone.
- ↑ Tzeng AC, Bach JR. Prevention of pulmonary morbidity for patients with neuromuscular disease. Chest. 2000;118:1390-1396.
- ↑ Miske LJ, Hickey EM, Kolb SM, Weiner DJ, Panitch HB. Use of the mechanical in-exsufflator in pediatric patients with neuromuscular disease and impaired cough. Chest. 2004;125:1406-1412.
