MANUAL IN-EXSUFFLATION (MI:E) PHILIPS E70
Guidelines for MI:E (Philips E70) in Adult Patients
Guideline Profile
Version 1.1
Respiratory Physiotherapy Team (Vicky Mummery / Daisy
Author
Cosker)
Executive sponsor Patrice Hill, Director of Therapies
Executive sponsor sign off July 2016
Target audience Physiotherapists
Date issued Aug 2016
Review date Aug 2018
Consultation and approval
Nikki Webster Principal
Dates
June 2016
Physiotherapist
Patricia Hill, AHP Lead and
Dates
June 2016
Key individuals and Director of Therapies
committees consulted Alison Gordon, Clinical
during drafting Specialist Physiotherapist
Dates
July 2016
UCLH
Dates
Dates
Ratification
Ratification Committee Therapies Clinical Governance Group
Date Aug 2016
Document History
Version
Date
Review date
Reason for change
Page 1 of 17
Contents
1
Introduction .................................................................................................................... 4
2
Purpose ......................................................................................................................... 4
3
Scope ............................................................................................................................ 4
4
Roles and Responsibilities ............................................................................................. 4
4.1
Staff ........................................................................................................................ 4
4.2
Respiratory Physiotherapy Team ............................................................................ 5
5
Indications and Contraindications .................................................................................. 6
5.1
Indications for Use .................................................................................................. 6
5.2
Absolute Contraindications ..................................................................................... 6
5.3
Relative Contraindications ...................................................................................... 7
6
Equipment...................................................................................................................... 8
6.1
Location of Equipment ............................................................................................ 8
6.2
Equipment Setup .................................................................................................... 9
6.3
Cleaning ................................................................................................................. 9
6.4
Home Screen ........................................................................................................ 10
6.5
Modes ................................................................................................................... 10
7
Procedure .................................................................................................................... 11
8
Development and implementation ................................................................................ 13
8.1
Development......................................................................................................... 13
8.2
Implementation ..................................................................................................... 13
9
Monitoring compliance ................................................................................................. 13
10
References ............................................................................................................... 14
11
Appendix I MI:E (E70) Competency Assessment ..................................................... 16
Page 2 of 17
Executive Summary
This guideline identifies the expected standard of care at St George’s University Hospital
NHS Foundation Trust for the use of Philips E70 MI:E with adult patients. It identifies:

Indications for use

Contraindications

Setup of device

Documentation

Competency
The guideline was constructed and reviewed by the Respiratory Physiotherapy Team. It
covers all clinical areas where an adult patient may visit. The target patient group includes
adult patients requiring an MI:E device. The target professional group is any respiratory
competent physiotherapist.
Page 3 of 17
1
Introduction
Mechanical Insufflation-Exsufflation (MI:E) is the use of gradual increase in positive
airway pressure which rapidly changes to negative pressure. The rapid shift in
pressure produces a high expiratory flow, simulating a natural cough. The E70 Cough
Assistor Device can be used to augment the patient’s ability to cough and therefore
assist bronchopulmonary secretion clearance.
Some patients are unable to cough or clear airway secretions effectively due to
reduced peak cough flow (<270l/m). MI:E is an alternative to suctioning providing
decreased mucosal trauma and increased patient comfort.
The E70 is typically used in neuromuscular disease however it can be used in the
management of any patient in which cough effectiveness has been reduced and who
are at risk of developing further respiratory complications.
2
Purpose
 To standardise practise across St George’s Healthcare NHS Trust
 To ensure a safe, evidence based rationale and procedure for Manual
Hyperinflation
 To provide Staff with the information necessary to become trained and competent
in the use of the E70 for MI:E
3
Scope
This guideline applies to all staff (temporary and permanent) working in any of the
locations registered by St. George’s Healthcare NHS Trust with the Care Quality
Commission (CQC) to provide regulated activities. Locations are not necessarily
geographically based or determined. Therefore, the term locations does not just refer
to Trust buildings; it is the term used by the CQC to describe the hub of operations for
a service or range of services and so includes all activities being performed in the
course of performing one’s role.
4
4.1
Roles and Responsibilities
Staff
Staff who undertake the administration of MI:E must be employed in a clinical post
within the Trust. They must be supported by their manager and be confident and
willing to undertake this activity as a key part of their role.
Page 4 of 17
Staff should be aware of the guidelines and how to implement them accordingly. It is
the staff members’ responsibility to remain up to date with these local policies and
guidelines for the use of MI:E in the adult patient. Be familiar with and demonstrate a
working knowledge of policies and procedures relating to MI:E, its complications and
patient assessment.
Staff members using MI:E must provide evidence of continued competency in
knowledge and skills through regular practice or attendance at competency training
days. Competency will be assessed and recorded using the standardised MI:E
Competency Assessment Form (Appendix I).
Staff members using MI:E must accept appropriate accountability/responsibility for
their practice.
It is the responsibility of staff members using MI:E as a treatment method to
document all care provided in the patient’s clinical records.
4.2
Respiratory Physiotherapy Team
It is the responsibility of the Respiratory Physiotherapy Team to ensure annual MI:E
competency training is available to all Physiotherapists on call at St George’s
Heathcare NHS Trust.
It is also the responsibility of the Respiratory Physiotherapy Team to the review and
update these guidelines accordingly
Page 5 of 17
5
Indications and Contraindications
These are guidelines only and clinicians should use their clinical judgement in their
interpretation and application. The rationale for the use of a MI:E device should be
clearly documented in the patient’s medical notes. As with any therapeutic
management, there are indications and contraindications that must be taken into
consideration.
5.1
Indications for Use
Sputum retention, typically due to:

Respiratory muscle weakness (RMW)

Reduced Peak Cough Flow (PCF) <270lpm

Bulbar muscle involvement preventing the ability to breath-stack
Typical patients requiring MI:E present with the following conditions:
5.2

Motor Neurone Disease

Spinal muscular atrophy

Muscular dystrophy

Myasthenia gravis

Post-Polio Syndrome

Spinal cord injuries

CVA

Chronic respiratory disease e.g. bronchiectasis, cystic fibrosis
Absolute Contraindications

Undrained pneumothorax

Severe bronchospasm

Head injury with ICP > 25mmHg

Severe arterial hypotension

Trache-oesophageal fistula

Significant haemoptysis
Page 6 of 17
5.3
Relative Contraindications

Proximal bronchial
tumor/obstruction
Risk of gas trapping or causing trauma

Emphysematous Bullae
Increases risk of pneumothorax

Recent oesophageal or lung
surgery e.g.
lobectomy/pneumonectomy
High airway pressure may compromise the
anastamosis. Check with surgeons regarding
stump pressure

Spinal instability
Risk/benefit must be assessed and consent to
treat from treating Consultant required.
Use of MI:E must be justified and other potential
treatments exhausted prior to use.
Full spinal immobilization (Miami J/head
hold/thoracic counter pressure, etc.) required
throughout treatment

Severe exacerbation of Chronic
Obstructive Pulmonary Disease
(COPD) / Bronchospasm
Increased airway pressure will increase airway
irritation and inflammatory response

Acute Respiratory Distress
Syndrome (ARDS) / Acute Lung
Injury / contusions
Increases risk of pneumothorax/barotrauma

Raised intracranial pressure
(ICP)
Increasing intrathoracic pressure compromises
mean arterial pressure leading to compromised
cerebral perfusion pressure

Hypotension (Systolic <80)
Increased intrathoracic pressure compromises
venous return – reduces cardiac output

Cardiovascular (CVS)
instability/arrhythmias
Reduces venous return - further increases effort
required to maintain adequate tissue perfusion

Acute Head Injury
See raised ICP

Unexplained haemoptysis
May be indicative of acute trauma to the lung
parenchyma

Extreme tachypnea
Difficult to co-ordinate the technique

Subcutaneous Emphysema
May indicate the presence of a pneumothorax

Recent meal / gastric distension
May induce vomiting

Undrained pleural effusion
May cause barotrauma to lung parenchyma

Recent facial fractures, maxfax
surgery or burns
Precludes the use of a facemask

Unclipped cerebral aneurysm
Vigourous coughing can cause rupture
Page 7 of 17
6
6.1
Equipment

Philips E70® Cough Assistor

Power cable

Smoothbore tubing (1.5m)

Entrainment connector if required

Suitable interface (anaesthesia
facemask or catheter mount)
Ensure the mask fits your patient
appropriately to avoid unnecessary air
leaks and maximise efficiency of
treatment
Location of Equipment
The E70 is stored in the Respiratory store cupboard located in the Physiotherapy
Department St. James’ Wing
Anaesthesia masks are usually located at each of the Intensive Care Units. Please
speak to a nurse in charge in order to obtain one.
Page 8 of 17
6.2
Equipment Setup
6.3
Cleaning
A bacterial filter should be placed between patient circuit and device. If you are
treating a patient with suspected H1N1, a filter should be placed at the device end
and also at the distal end of the circuit before the interface to double-filter and protect
the device.
Tubing, masks and filters are single patient use and therefore should be disposed of
as per infection control Policy.
After each patient use, the exterior of the machine may be washed with a mild
detergent and water, or with a bactericidal cleaning solution such as 70% isopropyl
alcohol as per infection control Policy and stored in its appropriate bag.
A green Clinell® green sticker should be applied to demonstrate that the device has
been sanitised.
Page 9 of 17
6.4
Home Screen
3
4
1
5
2
1. Left Button
Allows selection of certain actions specified on-screen
2. Up/Down Button
Allows navigation of the display menu and editing of device settings
3. Manual Switch
Switch activates the exhale and inhale phases. Press right (+) to
activate the inhale phase; press left (-) activates the exhale phase.
Leaving the switch in the middle activates the pause phase
4. Power On/Off
Turns the device on or off
5. Right Button
Allows selection of certain actions specified on-screen
6.5
Modes
Manual
Insufflation / Exsufflation is controlled manually by treating therapist
Auto
Insufflation / Exsufflation is auto cycled. Inhale time, exhale time and pause
time can all be set
CoughTrak
Can be added to Auto mode. Insufflation / Exsufflation is automated but
triggered by the patietns insirpatory effort. Inhale time, exhale time and
pause time can all be set
Osscillation Can be added to Auto and Manual modes either during inhale, exhale or
both phases to mobilize and increase the benefits of therapy
Page 10 of 17
7
Procedure
PREPARATION
Action
1. Perform a thorough assessment of the
patient to ascertain whether MI:E is
indicated
2. Wash hands and apply suitable PPE
3. Assemble equipment and complete
safety checks including machine filter
check (back of unit)
4. Select appropriate interface and
ensure good fit if using facemask
5. Select appropriate Mode (Manual /
Auto / CoughTrak)
6. Set up machine to desired settings
(Insufflation Pressure, Exsufflation
Pressure, Inhale Flow and if in Auto
Mode: Inhale Time, Exhale Time and
Pause Time)
7. Explain the procedure to the patient
and the rationale behind it
Familiarise patient with mask,
especially if unfamiliar with positive
pressure therapy
8. Position the patient to optimise
treatment i.e; lung to be treated should
be uppermost to aid postural drainage
Rationale
MI:E has the potential to be distressing for
patients therefore only use an indicated
Infection Control
Ensure the equipment is undamaged and
correctly configured for use
To prevent leaks
Set Exsufflation to at least 10cmH2O below
the equivalent insufflation pressure, e.g.
Insufflation pressure 30cm H2O
Exsufflation pressure - 40cm H2O
To gain informed consent and improve
tolerance of the technique
Some patients like to feel the mask on their
face prior to use
MI:E is best performed in the sitting position,
although it may be performed supine if
necessary, particularly if postural drainage is
expected to aid secretion clearance
PERFORMING MI:E
Page 11 of 17
Action
Rationale
1. Apply appropriate interface allowing time for
patient to become accustomed to it
Ensure a tight seal is made by lips or facemask
To improve tolerance of the
technique
To reduce leak
2. Start with a low pressure insufflation (usually 1015cm H2O) until the patient has accommodated
and gradually build up to the maximum
inspiratory pressure tolerated
MANUAL: insufflation is achieved through
pushing the manual control lever to
the inhalation phase (left) for as long
as the patient can tolerate (2-3 secs)
AUTO:
push the therapy button and device
will cycle automatically
3. Release the lever and allow patient to passively
exhale, whilst keeping mask on
4. Repeat for 3-6 inhalation breaths or as required
Observing the patient’s chest
raising or expanding while
receiving MI:E will provide visual
cue as for the effectiveness of our
treatment
For lung volume recruitment
5. Following final inhalation, rapidly switch lever to
exhalation phase (right) whilst encouraging
patient to cough
6. Apply suction if required
7. Once tolerating, treat in cycles of 5-6 breaths
allowing patient to rest for a short period between
Best Practice
If cough remains inadequate, combine exsufflation with Manually Assisted Cough
Consider combining MI:E with medication to lose secretions to facilitate sputum clearance
8. Deliver re-recruitment breaths post treatment
MI:E can cause derecruitment
9. Monitor patient’s reaction, comfort, and response
to the treatment.
MonitoringSpO2, HR, RR and BP required
In order to review settings or
continue/discontinue treatment
To ascertain clinical changes
Note:
Consider RR and breath ratio when determining the times for Insufflation and Exsufflation.
Some patients will like simple sequences of Insufflation-Exsufflation; others will prefer
longer Insufflation periods before the Exsufflation
Considerations for use with trache patients
Tracheostomy cuff should be inflated during therapy
Higher exhalation pressures may be required to overcome the increased resistance of the
tracheostomy tube
Ensure that suction is available; the patient can be suctioned through the tracheostomy
mount or mount removed and suctioned straight into the tracheostomy
Page 12 of 17
8
8.1
Development and implementation
Development
The following guideline has been constructed by systematically reviewing the
current, available literature, together with advice and discussion with expert
colleagues, both in medical, physiotherapy and nursing professions. Where the
evidence exists to support clinical practice it has been used and cited:
 Embase (1998-2016)
 Cochrane database of systematic reviews
 AMED (1985-2016)
8.2
Implementation
Training will be provided by staff competent in the procedure.
The Competency Checklist (Appendix I) will be used by the trainer when assessing
competence and acts as a record of competency gained
9
Monitoring compliance
This guideline will be monitored on an on-going basis through data collected via the
Trust’s Adverse Incident Reporting Policy and through audit.
Any adverse incidents relating to the E70 will be escalated and where appropriate,
investigated under the Trust’s Serious Incident Policy (SI) with conclusions formed as
to how the incident occurred and recommendations for change. This guideline will be
updated accordingly to reflect any recommendations made.
The table below outlines the process for monitoring compliance with this document
Page 13 of 17
10 References
Phillips, Respironics. ‘Cough Assist E70 – mechanical insufflator exsufflator’ Brochure
Available online at:
http://www.philips.co.uk/healthcare/product/HC1098159/coughassist-e70-mechanicalinsufflatorexsufflator
Chatwin, Michelle (2008) ‘How to use a mechanical insufflator-exsufflator’ Breathe Vol
4 No 4 pp 321-329 Available online at:
http://breathe.ersjournals.com/content/breathe/4/4/320.full.pdf
National Institute of Clinical Excellence (2016) ‘Motor neurone disease: assessment
and management’ Available online at: https://www.nice.org.uk/guidance/ng42
Homnick, D. (2007) ‘Manual insufflation-exsufflation for airway mucus clearance’
Respiratory Care Vol 52 No 10 pp 1296-1307 Available online at:
http://rc.rcjournal.com/content/52/10/1296.full.pdf
Toussaint, M. (2011) ‘The use of mechanical insufflation-exsufflation via artificial
airways’ Respiratory Care Vol 56 No 8 pp 1217-1219 Available online at:
http://rc.rcjournal.com/content/56/8/1217.full
Chatwin M, Ross E, Hart N, Nickol AH, Polkey MI, Simonds AK (2003) ‘Cough
augmentation with mechanical insufflation/exsufflation in patients with neuromuscular
weakness’
Eur
Respir
J
21
pp
502-508
Available
online
at:
http://www.ncbi.nlm.nih.gov/pubmed/12662009
Winck JC, Goncalves MR, Lourenco C, Viana P, Almeida J, Bach JR (2004) ‘Effects of
mechanical insufflation-exsufflation on respiratory parameters for patients with chronic
airway secretion encumbrance’ Chest 126 pp 774-780 Available online at:
http://www.ncbi.nlm.nih.gov/pubmed/15364756
Page 14 of 17
Monitoring compliance and effectiveness table – must be completed prior to ratification
Element/ Activity
being monitored
Lead/role
Methodology to be used for
monitoring
Frequency of monitoring and
Reporting arrangements
Acting on recommendations
and Leads
Change in practice and
lessons to be shared
Correct use of E70 for
MI:E
The Principal Cardiorespiratory
Physiotherapist will lead on all
aspects of monitoring
This guideline will be monitored on
an on-going basis through data
collected via the Trust’s Adverse
Incident Reporting Policy and
through audit.
This guidelines will be reviewed a
minimum of two yearly
The Respiratory Physiotherapy
Team will undertake subsequent
recommendations / action
planning for any or all
deficiencies and
recommendations within
reasonable timeframe
Required changes to practice
will be identified and actioned
within a specific timeframe. The
Principal Cardiorespiratory
Physiotherapist take each
change forward where
appropriate. Lessons will be
shared with all the relevant
stakeholders.
.
Any adverse incidents relating to
E70 will be escalated and where
appropriate, investigated under the
Trust’s Serious Incident Policy (SI)
with conclusions formed as to how
the incident occurred and
recommendations for change. This
guideline will then be updated
accordingly to reflect any
recommendations made.
The lead or committee is
expected to read and interrogate
the report to identify deficiencies
in the system and act upon them.
Required actions will be
identified and completed in a
specified timeframe.
Page 15 of 17
11 Appendix I
MI:E (E70) Competency Assessment
The following statements are designed to indicate competence to use this device.
Responsibility for use remains with the user, so if you are in any doubt regarding your
competence to use the device, you should seek education to bring about improvement
You must meet all applicable criteria before competence is confirmed
Circle the answer appropriate to each criterion to verify the competence of the subject
Surname:
Forename(s):
Title:
Job Title/Designation:
Division
Team / department
Risk Category:
High Risk
Assessment Date:
High Risk devices must be assessed by an Authorised Trainer.
You hold individual responsibility for ensuring your continuing competence
Circle the answer appropriate to each criterion to verify the competence of the subject
THEORY and RATIONALE
a. Able to identify indications for using MI:E
Met
Not met
b. Able to explain physiology of technique
Met
Not met
c.
Able to identify patient groups likely to benefit from MI:E
Met
Not met
d. Able to identify contraindications and precautions of use
Met
Not met
e. Identify appropriate outcome measures to evaluate treatment
Met
Not met
Met
Not met
g. Apply appropriate modes / settings for MI:E and discuss rationale
Met
Not met
h. Apply any relevant infection control precautions
Met
Not met
i.
Apply the technique correctly
Met
Not met
j.
Adjust settings according to patient tolerance / clinical presentation
Met
Not met
Ability to perform INTERVENTION appropriately
f.
Set up E70 correctly including O2 entrainment if necessary
MONITORING and REASSESSMENT
k.
Appropriate monitoring of patient observations during treatment
Met
Not met
l.
Appropriate outcomes re-assessed
Met
Not met
m. Accurate and timely documentation
Met
Not met
Signed Assesse
Signed Assessor
Page 16 of 17
Notes for MI:E (E70) Competency Assessor
Assessment Statement
Rationale
a.
Sputum retention
typically due to:

Respiratory muscle weakness

Reduced PCF

Bulbar muscle involvement preventing
the ability to breath-stack
b.
Be able to explain definition as utilising a gradual increase
in positive airway pressure which rapidly changes to
negative pressure. The rapid shift in pressure produces a
high expiratory flow, simulating a natural cough
Motor Neurone Disease
Spinal muscular atrophy
Muscular dystrophy
Myasthenia gravis
Post-Polio Syndrome
Spinal cord injuries
Acute Exacerbations of CLD where cough is ineffective
due to severe fatigue
Relative Contraindications

Proximal Tumor/obstruction

Emphysematous Bullae

Recent oesophageal or lung surgery e.g.
lobectomy/pneumonectomy

Spinal instability

Severe exacerbation COPD/ Bronchospasm

ARDS

Raised ICP

Hypotension / CVS instability / arrhythmias

Acute Head Injury

Unexplained haemoptysis

High respiratory rate

Subcutaneous Emphysema

Recent meal

Undrained pleural effusion

Recent facial fractures, maxfax surgery / burns
c.
d.
e.
f.
g.
Absolute Contraindications

Undrained pneumothorax

Severe bronchospasm

Head injury with ICP > 25mmHg

Severe arterial hypotension

Trache-oesophageal fistula

Significant haemoptysis
Sputum volume
SpO2
Ausc
Correct assembly of circuit without prompts
Correct selection and adjustment of settings without
prompts
Gloves and gown (visor optional)
Appropriate techniques demonstrated with senior present
Can discuss rationale behind potential adjustments
required to settings
k. Appropriate monitoring throughout Rx
l. Description of assessed outcome measures selected at
point d.
m. SOAP notes in line with trust and CSP standards
Correctly attaches oxygen entrainment and
bacterial filter. Correct selection of
appropriate interface
Mode, Insufflation Pressure, Exsufflation
Pressure, Inhale Flow and if in Auto Mode:
Inhale Time, Exhale Time and Pause Time
h.
i.
j.
Patient safety
Legal requirement
Page 17 of 17