Ventilator-Assisted Living©

Spring 2002, Vol. 16, No. 1

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Airway Clearance Therapy for Neuromuscular Patients with Respiratory Compromise

Louis Boitano, MS, RRT, and Joshua Benditt, MD, Departments of Pulmonary and Critical Care Medicine and Respiratory Care, University of Washington Medical Center, Northwest Assistive Breathing Center, Seattle, Washington

Recently, IVUN asked for our advice on answering this query, “I have Duchenne muscular dystrophy, and I have heard about two machines that will help me cough: The Vest™ and the CoughAssist™ device. Which would be best for me?”

This question has arisen as the result of the new direction Advanced Respiratory Company (Saint Paul, Minnesota; 800-426-4224; www.thevest.com) has taken in marketing their airway clearance device, The Vest™, as an effective means of assisting cough and preventing respiratory infection in neuromuscular patients with respiratory compromise.

The Vest™ consists of an inflatable vest worn by the individual that is connected by air hoses to an air pulse generator. During therapy, the vest inflates and deflates rapidly, applying gentle pressure to the chest wall to loosen and thin mucus and move it to the central airways to be cleared by coughing or suctioning.

A number of short-term clinical studies have shown The Vest™ to be as effective as other forms of airway clearance therapy for patients with intrinsic lung disease, such as cystic fibrosis, that result in retained secretions. Although The Vest™ can effectively mobilize retained mucous secretions, there are no clinical studies that show this device to be effective in augmenting peak cough flow in neuromuscular patients at risk for complications of pulmonary infection due to a weakened cough strength.

Most neuromuscular patients with respiratory compromise are limited by weakened inspiratory and/or expiratory muscle strength, but not by intrinsic lung disease. The mucociliary systems are functional and able to move pulmonary secretions to the larger airways. The problem is that cough is ineffective, and secretions cannot be expelled from the larger airways.

The CoughAssist™ (J.H. Emerson Company, Cambridge, Massachusetts; 800-252-1414) was specifically designed to augment weakened cough function by mechanically replicating the cough maneuver. This device, in either manual or automatic mode, provides an inspiratory pressure support breath followed by a rapid change to expiratory flow that can generate enough peak air flow to clear proximal mucous secretions that may not otherwise be cleared by the neuromuscular patient with an ineffective cough strength.

The onset of chronic pulmonary infections in these individuals is often the result of deteriorating ventilatory function that results in chronic atelectasis (collapse of the lung). A weakened cough can further complicate pulmonary infection if the individual cannot adequately clear the increased mucous secretions associated with infection. The individual may be at risk for acute respiratory failure, because his/her al-ready limited ventilatory strength is taxed by chronic ineffective cough and increasing pulmonary congestion. The support of the CoughAssist™ may prevent the development of pulmonary congestion, and possibly avoid hospitalization and potential acute respiratory failure.

Although antibiotics and airway clearance therapy such as The Vest™ may be warranted for acute pulmonary infection, this management only treats the pulmonary insult and not the underlying cause of the problem. A preventive maintenance regimen of airway clearance therapy alone cannot prevent the reoccurrence of pulmonary infections in neuromuscular patients with chronic progressive underventilation and weakened cough strength.

The onset of pulmonary infections may signal a need to start ventilatory support in order to maintain adequate lung inflation. An assessment of the patient’s pulmonary vital capacity and peak cough flow can help to identify whether ventilation and/or cough strength is the limiting factor that may be contributing to the development of chronic pulmonary infections.

Implementing noninvasive ventilation that supports adequate ventilation and cough assist therapy that supports adequate ventilation and cough function can provide adequate pulmonary maintenance and significantly decrease the potential for pulmonary infection. A respiratory management plan and progressive support of both ventilation and cough strength can help to maintain a high level of quality of life for the neuromuscular patient with developing respiratory compromise.

Editor’s Note: The CoughAssist™, distributed through Respironics, Inc., received a Medicare HCPCS code (E0482) for reimbursement in January 2002. The cost for the automatic model ranges approximately $4,500 to $6,000 and higher, depending on whether it is sold to a hospital or a home care company.

The Vest™ has no Medicare code. It is available through a lifetime lease over 15 months, amounting to $15,900. When the lease is paid, the equipment belongs to the company but the individual has the use of it for life. (A one-time payment discount of 10% is also offered.) Individuals can try The Vest™ at no cost or obligation before paperwork is submitted to the insurance company. Advanced Respiratory promises complete reimbursement services, and a lifetime warranty.

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