Systematic review of techniques to enhance peak cough flow and maintain vital capacity in neuromuscular disease: the case for mechanical insufflation–exsufflation

Abstract

Patients with neuromuscular disease risk developing chest infections due to the inability to cough effectively and to maintain adequate lung volume. This systematic review aimed to evaluate the comparative effectiveness of techniques used in the respiratory management of these patients. Articles evaluating peak cough flow measurements and maintenance of lung volumes only were selected to retain a specific focus for comparison. A database search was performed using the Cochrane controlled register, AMED, Cinahl, Medline and PEDro. Various techniques improved cough efficacy in neuromuscular disease by increasing peak cough flow values and maintaining lung volume. Mechanical insufflation-exsufflation is a technique used to augment cough strength, producing the greatest increase in peak cough flow compared with other techniques. These findings highlight the treatment options for the patient with neuromuscular disease in order to maintain respiratory muscle length, prevent infection and augment peak cough flow.

Guidelines for the physiotherapy management of the adult, medical, spontaneously breathing patient

“…Independent airway clearance techniques are ineffective in patients with compromised respiratory muscles. Conventional techniques such as postural drainage are unlikely to be effective in this client group,340 and suction is neither well tolerated nor therefore successful 325 330 340 342. Thus patients with compromised respiratory muscles require assisted coughing, non-invasive assistance and aids for airway clearance.…”

“…For a fuller description, please see the section with this title under Spinal cord injury. A systematic review of mechanical in-exsufflation342 includes three controlled trials comparing mechanical in-exsufflation with other assisted cough techniques in mixed stable patient populations with neuromuscular disease 333 335 358. Two of these studies335 358 found that the mean peak cough flow of included subjects increased to levels greater than the 270 l/min stable threshold, which was not the case for the third 333…”

Use of Mechanical Insufflation-Exsufflation Devices for Airway Clearance in Subjects With Neuromuscular Disease

“…This is the first systematic review including observational studies and the first literature update available on MI-E devices used for airway clearance in patients with neuromuscular disease since the work of Anderson et al 27 in 2005. Our review underlines the lack of robust data on MI-E use for airway clearance in neuromuscular disease.…”

“…The availability of MI-E devices in Europe since 2002 has increased the number of studies initiated. 25,26 The first team that performed a systematic review on MI-E was Anderson et al 27 in 2005. Their systematic review included 4 controlled trials, with a total of 98 subjects with neuromuscular disease.…”

Laryngeal Responses to Mechanically Assisted Cough in Progressing Amyotrophic Lateral Sclerosis

“…Until recently, high MI-E pressure settings have generally been considered to be most effective for neuromuscular patients, 34,35 and most studies and clinicians apply settings of Ϯ 40 cm H 2 O or higher. [36][37][38] Our findings indicate that in ALS, high pressures were the most provocative and most likely to cause adverse responses, and that such responses were difficult to predict based on other clinical signs or symptoms. Based on these observations, treatment pressures as high as 50 cm H 2 O should probably be avoided in challenging cases of ALS, especially if fiberoptic laryngoscopy is not available.…”