breathing at ease - michigan society for respiratory care clearance consists of both mobilization of...

Breathing at Ease

A Guide to Cough-Assist and Secretion Management

University of Michigan Medical CenterAdult Assisted Ventilation Clinic

Armando Kurili, BS, CRT

Respiratory System: A Brief Review

• Lungs as vital organs of gas exchange

– Trachea– Bronchial Tube– Bronchioles– Alveoli

They Don’t Work Alone

• Respiratory muscles

– Internal/External Intercostal– Diaphragm– Scalene– Sternomastoids– Abdominal muscles

When Breathing is Interrupted

• Restrictive diseases– Weakened chest wall muscles or abnormalities in

the chest wall• Obstructive disease

– The obstruction or narrowing of the small airways in the lungs, often characterized by difficulty exhaling

• Obesity hypoventilation syndrome (OHS)– Defined by a combination of obesity and a high

level of CO2 in the blood

Finding Solutions for Different Respiratory Conditions

• Airway Clearance• NPPV (Non-Invasive Positive Pressure

Ventilation)• IN (Invasive Ventilation)

Airway Clearance

Secretion clearance

Mucociliary clearance

(mobilization)

Cough clearance

(removal)

High-frequency chest-wall compression

Oscillation devices

Positive expiratory pressure

CoughAssist MI-EBreathing techniques

SuctioningManual assisted cough

Chest physiotherapy

5

Secretion Removal Techniques and Devices

• Suction

• Manually-assisted cough

• Cough-Assist

Suctioning

• Invasive procedure

• Misses left main stem bronchus 90% of the time

• Tracheal trauma, suctioning induced hypoxemia, hypertension, cardiac arrhythmias and raised intracranial pressure have all been associated with suctioning

• Can be a painful • Anxiety-provoking procedure

Manually-assisted cough

8

A Normal Cough?Requires 3 Phases of Operation

• Inspiration phase85 to 90% of TLC and a cough volume of 2.5 L

• Compression phaseGlottic closure for about 0.2 s. Prevents outflow of inhaled air

• Expulsion phaseContractions of expiratory muscles while glottis is open

Is indispensable for clearing airway secretions and bronchial mucus plugs.

The Cough Assist can be used for two things:

• For Coughing • Can’t generate sufficient flow

• Expanding the Lungs• Unable to air stack• Low Vital Capacity

Life-saving value of Cough-Assist

• Late-1940s, Henry Seeler working for US Air Force

• In 1952, Barach. Mechanical Cough Chamber

• In 1953, Cof-Flator. First portable device

• In 1993 FDA, Approved In-Exsufflator, JH Emerson CO,

Application of Cough-Assist

• Patients with an ineffective cough due to neuromuscular disorders

• Patients with paralysis of the respiratory muscles such as a high spinal cord injury

• Patients that have an ineffective cough due to respiratory fatigue associated with intrinsic lung disease

• Patients in respiratory failure due to neuromuscular disease and in the acute and chronic care setting

– Avoid intubation– Decrease hospitalization and complications from pneumonia and

respiratory infection– Facilitate extubation and decannulation– Prevent post-extubation failure

Inhale + Exhale + Pause = Cycle

Suggested Cough-Assist T70 MI-E Treatment

Repeat cycle 4-6 times

Rest 20-30 seconds

Repeat sequence 4-6 times

Patients that may benefit from a Cough Assist are

• Muscular Dystrophy• Spinal Muscular Atrophy• Amyotrophic Lateral Sclerosis• Spinal Cord Injuries• Myasthenia Gravis• Post Polio• COPD patients with a weak and ineffective cough

Summary• Used via:

• facemask, mouthpiece, endotracheal or trach

• Maximal effectiveness:• at pressures of 40 to -40 cm H2O

• Increase peak cough expiratory flows:• more than 80%1

• Recommended use to:• reduce recurrent respiratory infections

• Patients prefer Cough-Assist to suctioning for comfort and effectiveness

Questions?