Manually assisted coughing

Secretion clearance is addressed in detail elsewhere in the text. However, physical therapy and careful hydration are the cornerstones of management. Mucupurulent secretions are often noted in acute respiratory failure. Administration of acetylcysteine 600 mg/day will decrease sputum viscosity hut its value in NIV patients has been less well studied. In patients with NMD, manually assisted coughing, air stacking, and mechanical devices can all be used in patients with a facial mask. On rare occasions, bronchial lavage under local anesthesia can be carried out during NIV. Secretion clearance reduces the ventilation pressures required to overcome the impedance to airflow. 

Consider if NIV (nocturnal) is required Consider need for assistance with airway clearance (chest physical therapy, manual assisted coughing)... 

Approaches to preventing airway secretion retention include pharmacotherapy to reduce mucus hypersecretion or to liquefy secretions, and the application of chest physiotherapy (CPT) techniques. (CPT) can be defined as the external application of a combination of forces to increase mucus transport that include PD, special breathing exercises, manual chest vibration and percussion, autonomous instmmental techniques, and manually assisted coughing. 

Figure 8 Manually assisted cough with abdominal thrust to measure PCF in sitting position. Abbreviation. PCF, peak cough flow.

Manually assisted coughing and MIC maneuver require a cooperative patient, good coordination between the patient and the caregiver, adequate physical effort, and often frequent application by the family caregiver (Figs. 9 and 10). It is usually ineffective in... 

Figure 9 Air stacking and manually assisted cough in a patient with neuromuscular disease, performed by the family caregiver.

Abdominal compressions should not be used for 1 to 1.5 hours following a meal, however, chest compressions can be used to augment PCF. Chest thrusting techniques must be performed with caution in the case of an osteoporotic rib cage. Unfortunately, since it is not widely taught to health care professionals, manually assisted coughing is underutilized (67). 

The use of MI-E has been demonstrated to be very important in extubating NMD patients following general anesthesia, despite their lack of any breathing tolerance, and managing them with NIV (8,9,60). It is also permitted to avoid intubation or to quickly extubate NMD patients in acute ventilatory failure with no breathing tolerance and profuse airway secretions due to intercurrent chest infections (37,83,84). MI-E in a protocol with manually assisted coughing, oximetry feedback, and home use of noninvasive intermittent positive pressure ventilation was shown to effectively decrease hospitalizations and respiratory complications, and mortality for patients with NMD (7,85). 

Sivasothy P, Brown L, Smith IE, et al. 2001. Effects of manually assisted cough and mechanical insufflation on cough flow of normal subjects, patients with chronic obstructive pulmonary disease (COPD), and patients with respiratory muscle weakness. Thorax 56 438 44. 

Chest physiotherapy MH Percusssion/vibration Manually or mechanically assisted cough suctioning... 

Because of their young age, intact mental status, and bulbar musculature, high-level tetraplegic patients are perfect candidates for NIV (136). Patients with lesions below Cl can be managed with NIV, respiratory aids, and manual plus mechanically assisted coughing, provided their assisted PCF > 160 L/min (98). 

The ability to generate a PCF, whether unassisted or manually assisted, > 160 L/min is considered critical for successful extubation and adequacy of long-term NIV. The threshold criteria are higher for elective, noninvasive respiratory management, non-invasive ventilation, volume recruitment, and assisted coughing of neuromuscular ventilatory failure (49). Intubated patients with a PCF <60 L/min (measured through the ETT) have a fivefold reduction in successful extubation and are up to 19 times more likely to die in hospital (35). 

Bach JR. Mechanical insufflation-exsufflation. Comparison of peak expiratory flows with manually assisted and unassisted coughing techniques. Chest 1993 104(5) 1553-1562. 

In 1995 he requested tracheal decannulation, which occurred without problems. Volume ventilation with nasal pillows was established as a backup. He remains in the community, works and goes on vacation, enjoying good health. On two occasions he required out patient chest physiotherapy and in-exsufflation to assist with secretion clearance, associated with a lower respiratory infection. On these occasions, he was not satisfied that his secretions were being cleared completely by his manual resuscitator assisted cough or by GPB. 

The patient with partial or eomplete abdominal muscle paralysis is unable to produce an effeetive eough. The abdominal thrust is an assisted coughing technique that consists of the assoeiation of two teehniques the costophrenic compression and the Heimlich maneuver. The eombination of deep lung insufflations to the MIC followed by the manually assisted eough with abdominal thrust (Fig. 8) has been shown to increase significantly PCF s values in restrietive patients (47,64). 

Whereas the mucociliary elevator is the primary mechanism for clearing the peripheral 21 divisions of the airway, coughing clears the most central 6 divisions. Chest percussion and vibration can help mobilize peripheral airway secretions but they are not substitutes for coughing and, unlike for assisted coughing, have never been shown to decrease pulmonary morbidity and mortality. Cough can be assisted by manual and mechanical means. 

Respiratory muscle assistance involves the manual or mechanical application of forces to the body or pressure changes to the airway to assist inspiratory or expiratory muscle function. Negative pressure applied to the airway during expiration assists the expiratory muscles for coughing, just as positive pressure applied to the airway during inhalation (noninvasive IPPV) assists inspiratory function. 

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