Equipment Options for Cough Augmentation, Ventilation, and Noninvasive Interfaces in Neuromuscular Respiratory Management

Abstract

This is a summary of the presentation on equipment options for cough augmentation, ventilation, and noninvasive interfaces in neuromuscular respiratory management presented as part of the program on pulmonary management of pediatric patients with neuromuscular disorders at the 30th annual Carrell-Krusen Neuromuscular Symposium on February 20, 2008. Pediatrics 2009123:S226-S230 T HE WIDESPREAD USE of noninvasive ventilation (NIV) developed with the polio epidemics during the 1940s and 1950s when the iron lung was used to provide negative-pressure ventilation. Although negative-pressure ventilation has been an effective means of supporting neuromuscular respiratory insufficiency, its effectiveness can also be limited by neuromuscular induced upper airway instability that can limit inspiratory flow with negative pressure. Negative-pressure ventilation became a lesser option with the development of positive-pressure ventilation that would support both upper airway stability and provide adequate ventilation by noninvasive means. The first use of positive-pressure ventilation was described by Affeldt 1 in 1953, during which time patients transferred from the iron lung could be supported on intermittent positive pressure via a mouthpiece. The benefit of NIV for the nocturnal support of patients with neuromuscular disorders and respiratory insufficiency by means of both bilevel-pressure-support and volume-cycled ventilation was first described in the late 1980s. [2][3][4][5] The application of home NIV has grown rapidly with the development of bilevel-pressure ventilation technology, noninvasive interface materials technology, and design during the past 20 years. NONINVASIVE BILEVEL-PRESSURE VENTILATIONNoninvasive bilevel-pressure ventilation (NBPV) is based on a flow generator, sensor technology that produces 2 pressure preset levels of airflow through a single-limb ventilator circuit and into a vented nasal, oronasal, or oral interface to provide the user with a desired amount of pressure-support ventilation. The higher inspiratory positive airway pressure (IPAP) is triggered when a change in flow occurs with the patient's inspiratory effort. The flow generator cycles to the lower expiratory positive airway pressure (EPAP) when the circuit flow rate changes with the initiation of expiration. A minimum level of EPAP is necessary to flush out the patient's exhaled gas from the vented interface. The difference between bilevel pressures is the level of pressure support provided to the patient. NBPV provides a means of augmenting the ventilation of patients with respiratory insufficiency. The use of home NBPV to support patients with neuromuscular disorders and chronic respiratory insufficiency has grown rapidly over the past 10 to 15 years. Much of this growth is partly a result of technology-related improvements in bilevel-pressure generator reliability, size, and features that support the patient's use of NBPV in the home (Fig 1 www.pediatrics.org/ content/vol123/Supplement_4). Integrated heated humidificatio...

Use of air stacking and abdominal compression for cough assistance in people with complete tetraplegia

“…13 Trebbia et al 20 conducted a study which demonstrated that MIC contributes 44%, the expiratory reserve volume 13% and the MEP 2% in a PCF increase in patients with neuromuscular diseases. The importance of this low-cost and highly effective technique, as observed in our study, where the PCF with AS-MEE technique was higher compared with the MEE technique, is that it produces a significant increase in PCF of 52%.…”

“…Its greatest efficacy has been reported in patients with neuromuscular diseases, particularly in DMD and SCI. 13 AC has been described as an assisted standard cough whereby the caregiver provides compression posteriorly and in cephalic direction through the abdomen which mimics the normal direction the diaphragm moves during a cough with functioning abdominals. This is preceded by several deep breaths with the assistance of the caregiver as the patient attempts to cough forcibly.…”

Estrategias terapéuticas para aumentar la eficacia de la tos en pacientes con enfermedades neuromusculares

“…La CIM es un indicador indirecto de distensibilidad pulmonar. La técnica clásica está descrita con una bolsa de reanimación manual, una válvula unidireccional, un corrugado entre 20 y 30 cm y en el caso que exista fuga de aire, una pinza nasal 31 . Su mayor eficacia, se ha reportado en pacientes con enfermedades neuromusculares y lesionados medulares 10,32 .…”

Chronic Critical Illness: The Growing Challenge to Health Care

“…30,31 This population also appears to benefit from cough assist devices using positive pressure. 32 There are also a number of small observational and randomized trials of using nocturnal NIV, particularly in stable COPD patients with hypercarbia. 30 Nocturnal NIV in restrictive diseases appears to have a more consistently positive database, and it may help in airway clearance in cystic fibrosis.…”