Ventilator-Assisted Living©

Spring 1998, Vol. 12, No. 1

ISSN 1066-534X

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Read selected articles from this issue ...

Kalle Könkkölä

Assisted Cough: Benefits and Techniques
A variety of techniques to improve the ability to clear secretions without tracheostomy

From the Desk of David Ecker-Russ

Airline Travel with Ventilators

Ventilator Transport: More Than a Little Red Wagon
Gail Anderson

Attendant Care Legislation: MiCASA


Assisted Cough: Benefits and Techniques

A variety of techniques to improve the ability to clear secretions without tracheostomy

Manually-Assisted Cough
Susan Sortor Leger, RRT

An individual's ability to take a good cough will be hindered by not having good chest musculature to compress a big breath, or by not being able to take a deep enough breath.

If an individual can take a good, big breath, but does not have good chest muscles, a respiratory therapist or caregiver trained in the manually-assisted cough technique can help compress that air by placing one hand over the chest and one hand on the abdomen. The individual takes a big breath, and then the therapist or caregiver compresses manually. The person who is helping should be standing in front of the person trying to cough, because he or she needs to see what is happening, and coordination and timing are very important. One must compress just a few seconds before the person exhales, pushing hard against a closed glottis a split second before exhalation. The push should not hurt, and in some cases, a push on only the chest can be effective.

From personal experience, I can tell you that the manually-assisted cough technique can be exhausting for the therapist or caregiver, and does not work for someone who cannot get a big breath to begin with. One way to give a big breath is to use IPPB (intermittent positive pressure breathing) with the volume between 2L- 4L.

For that volume with someone with a normal compliant lung, the pressure should be 10 cm for each L. For people with scoliosis or rigid chest wall, more pressure is needed, but not enough to burst the lungs and incur barotrauma. Pressure limited at 40 cm is recommended to give a good deep breath. People need to be relaxed and not tense up, to let the air in and let the machine do the work.

Another way ventilator users can get a deep breath is by using a volume ventilator. Manual resuscitators can give a breath, but the stroke volume capacity is only 800 cc. This is not enough to cough with, so I teach people to stack their breaths – take a breath, hold it, and stack one breath on top of the next.

Susan Sortor Leger, RRT, ResMed S.A., Saint-Priest, France, www.resmed.com

The In-Exsufflator Cough Machine
George Emerson

The In- Exsufflator Cough Machine is a device for helping clear secretions in people who have difficulty with coughing. It has been used for people with post-polio, muscular dystrophy, SCI, and ALS. This device is similar to one made in the 1950s called the Cofflator, designed for polio patients in iron lungs to help clear secretions. About six years ago, Dr. John Bach came to us because he had a number of post-polio patients still using the old Cofflator, but the machines were breaking down and were no longer manufactured. He asked if our company could make a new machine, and thus we developed the In-Exsufflator Cough Machine.

The machine operates with a blower and a valve that applies a positive pressure first to give a deep breath in, and then shifts rapidly to negative pressure to create a high expiratory flow, like one has with a normal cough. It can be used on a person with a trach or someone without a trach through a face mask or mouthpiece. The circuit is a bacterial filter, a pressure tap, and a hose to the face mask or adapter to the trach tube. There are two models: one with automatic timing and one manual.

Typically, a session of coughing with the machine involves cycling the unit positive, then negative, in quick succession about five to six times. Then the patient is allowed to rest for a minute in order to prevent hyperventilation which can occur after more than five to six times in a row. This pattern is repeated four to five times. When secretions arise, they come out into the mask or are spit out. The endotracheal tube can be suctioned for a patient with a trach.

Pressures should start low, about 10-20 cm as tolerated, and then build up to 40-45 cm to get deep insufflation. The timing for the positive-negative is one to two seconds. The positive and negative pressures are set about the same, though some people like the inspiratory pressure to be slightly less.

A cough session takes about 10-15 minutes for secretion removal. Many therapists are afraid to use higher pressures, but to be effective, pressure should be in the 40-45 cm range. For home use, Dr. Augusta Alba recommends the automatic version, although it is more expensive. Dr. Bach has suggested using the In-Exsufflator in the manual mode along with a manual thrust to combine the effects of the high flow from the machine and the positive pressure buildup from the thrust.

Many patients do not need to use the In-Exsufflator continuously, just for respiratory tract infections. Many have avoided pneumonias that required hospitalization and intubations by using the device. Dr. Alba has advised home health care agencies to stock the machines to be able to rent them out for just such emergencies. She also hopes more hospitals will make them available. She advises people to try the In-Exsufflator before they need it so that they will know what to expect.

The cost for the automatic unit is $3,700; the cost for the manual is $2,860. Medicare does not have a code for the In Exsufflator; Medicaid is more likely to pay for it. Some private insurers will pay.

George Emerson, Vice President, J.H. Emerson Company, 22 Cottage Avenue, Cambridge MA (Massachusetts) 02140 (800-252-1414, (info@jhemerson.com, www.jhemerson.com).

Functional Electrical Stimulation (FES) for Cough
Steven Linder, MD, FCCP

I work on a service with patients with traumatic spinal cord injury (SCI), which is upper motor neuron disease, and tends to be spastic paralysis. Therefore, problems with respiratory insufficiency are different from those in people with post polio because they are problems with spasms in the respiratory muscle. Our respiratory management includes incentive respiratory muscle training, inspiratory spirometry, and visual incentives because the patients cannot feel their chests expanding, but can see the chest and abdomen rising and failing with their inspiratory efforts.

With cervical SCI, there is paralysis of the abdominal wall and ineffective coughing. We see a reduced ability to cough, and therefore patients at increased risk for ventilatory insufficiency and lower respiratory tract infections.

Monitoring the ability to deep breathe and cough and the need for aggressive respiratory therapy (if necessary, tracheostomy) are important parts of our work.

One of the simplest things we can do is to supply these patients with an abdominal binder. When they sit up, we find that their ventilatory insufficiency is worsened. Therefore we encourage them to wear an abdominal binder, because this not only helps them take a deeper breath when they are sitting up, but also helps them cough. We teach our patients assisted cough, and how to teach their attendants to deliver forceful abdominal thrusting to help them cough.

We have measured expiratory pressure (the force of cough) in cervical SCI. We found values of about 200 cm of water pressure with a normal cough, but values of about 30 cm of water pressure when an individual with quadriplega coughs. Several years ago, we looked at ways to restore the ability of these patients to cough, one being functional electrical stimulation (FES) of the abdominal wall. Electrical stimulation had been used before, but it had been surgically implanted in the diaphragm, as a diaphragm pacemaker. This was only for the inspiratory effort, this had nothing to de with cough. Diaphragm pacers are still used in selected cases of high cervical SCI injury as a way of restoring ventilation, but they do not address the issue of cough.

We observed that when we applied electrodes to the abdominal wall, we could stimulate abdominal wall contractions in patients with upper motor neuron disease. (We did not try this with patients with lower motor neuron disease and myopathies, because we did not think it would be as effective.) We placed the unit in conjunction with an abdominal binder and the electrodes, the patients lying on their backs. We measured three cough modes: spontaneous cough, cough using abdominal thrusts, and cough using abdominal wall FES. We delivered the stimulation to four-six electrodes simultaneously. In one patient whose spontaneous cough was only 30 cm of water pressure, FES stimulation in creased the cough to 80 cm, a marked enhancement of the patient's ability to cough. We showed that we could improve expiratory pressure by application of abdominal wall electrical stimulation.

With the unit we have now developed, known as Quik Coff™. the advantage is that patients can use the unit independently. They can take a deep breath, hit the switch with their chin causing abdominal wall stimulation, and cough. The unit is portable, about the size of a pager, and is powered by a 9V battery. Several sites are testing the Quik Coff™; the VA spinal injury unit in Hampton, Virginia, and in California at University of California-Davis and Kaiser Permanente-Vallejo.

The Quik Coff™ is manufactured by B & B Medical Technologies, Inc. 6731 32nd St, North Highlands, CA 95660 (916-331-5221, 800-242-8778, www.BandBmedical.com), and is now available in Europe. Availability in the United States is pending FDA approval. Market price for the unit including all accessories is $1,400.

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