Update And Perspective
on Noninvasive
Muscle Aids*
Part 2: The Expiratory Aids
John
R. Bach,
M.D.,
F.C.C.P.
(Chest
1994,
105:1538-44)
CPAPcontinuous
positive
airway
pressure;
FRCfunction
residual
capacity;
FVCforced
vital
capacity;
HFOhigh
frequency
oscillation;
IAPVintermittent
abdominal
pressure
ventilator;
IPPBintermittent
positive
pressure
breathing;
IPPVintermittent
positive
pressure
ventilation;
IPVintrapulmonary
percussive
ventilation;
MI-Emechanical
insufflation-exsufflation;
PCEFpeak
cough
expiratory
flows;
RTIs
respiratory
tract
infections;
VCvital
capacity
Sir Patrick:
your
fi fteen
made
Don’t
misunderstand
discovery.
years;
last.
Most
and
me,
discoveries
it’s fully
That’s
my
are
a hundred
something
boy,
dequate
clearing
plugs.
This
with airway
ARE
and
of.
tract
infections
and
during
cough
insufflation
to about
85
capacity.’
Glottic
closure
follows
sufficient
intrathoracic
pressures
obtain
peak transient
expiratory
the
volume
AIDS
is expired,
Department
University
Hospital,
Newark,
and Kessler
NJ.
Reprint
requests:
Dr.
University
1538
(VC),
to cough
forced
or PCEF
vital
capacity
are diminished
(FVC),
following
The
attainment
clinical
serious
of adequate
goal and
pulmonary
PCEF
is an
extremely
important
for
complications
in these
patients.5
every
yours
was
NEEDED?
with
bulres-
general
bronchial
inspiration
percent
or
of total
MANUALLY
ASSISTED
COUGHING
lung
Techniques
different
hand
of manually
and arm
assisted
placements
coughing
involve
for expiratory
cycle thrusts
(Fig 1). For patients
with less than 1.5 L
of VC, efficacy
is enhanced
by preceding
the assisted
exsufflation
with a deep
insufflation.
A positive
pressure blower
(Zephyr,
mittent
positive-pressure
or portable
ventilator
insufflation.
Manually
cooperative
patient,
patient
and care
and often
frequent
Lifecare,
Lafayette,
Cob),
interbreathing
(IPPB)
machine,
is useful
for delivering
the deep
assisted
good
coughing
coordination
giver,
and
application
adequate
by the
requires
between
a
the
physical
effort
care giver.
It is
usually
ineffective
in the presence
of significant
scoliosis, and certain
techniques
must be performed
with
caution
in the presence
of an osteoporotic
rib cage.
Unfortunately,
since it is no longer
widely
taught
to
for about
0.2 s and
are generated
to
flows or peak cough
flow
is stopped
of Medicine
of Physical
UMDON-New
Institute
for
Bach,
and
Medicine
Dentistry
Med
and
Rehabilitation,
Medical
West
and
of NJ,
glottic
be repeated
Patients
narrowing
of coughing.
syndromes,
Jersey
Rehabilitation,
Physical
by
This may
expiration.1
of airway
or collapse
during
the expiratory
phase
For patients
with restrictive
pulmonary
the
capacity
flows (PCEF)
exceeding
6 L/s upon glottic
Total
expiratory
volume
during
normal
is about
2.3 ± 0.5 L.’ Before
the first half of
closure
or airway
muscle
activity.
several
times
before
complete
with COPD
have greater
degrees
*From
problem.
George
Bernard
Shaw
Doctor’s
Dilemma”
a precough
to 90
ability
...
(RTIs),
following
other
periods
of
requires
vital
appropriate
preventing
belittling
without
aspiration.
For patients
hypoventilation
and functional
it becomes
a problem
during
hypersecretion.
A normal
expiratory
opening.2’3
coughing
since
the
and
general
anesthesia
and during
RTIs because
of fatigue,
temporary
weakening
of inspiratory
and expiratory
muscles,4
and bronchial
mucus
plugging.
Concomitant
weakness
of oropharyngeal
muscles
exacerbates
the
expiratory
muscle
function
is critical
for
airway
secretions
and bronchial
mucus
may be a continual
problem
for patients
or pulmonary
disease
or with inability
to
swallow
saliva
global
alveolar
bar musculature,
piratory
anesthesia,
MUSCLE
not
regularly
fifty
to be proud
EXPIRATORY
I’m
made
“The
WHY
Respiratory
School,
Orange,
Rehabilitation,
Newark
07103
1.
antertor
FIGURE
and
Manually
chest
assisted
compression
Noninvasive
Downloaded From: http://publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21694/ on 06/19/2017
coughing
after
Respiratory
using
a deep
Muscle
an abdominal
insufflation.
Aids
(John
thrust
R. Bach)
health
care
is greatly
effective
cleaning
ical
professionals,2
manually
underutilized.6
When
assisted
coughing
inadequate,
the
most
alternative
for generating
optimal
PCEF and
deep airway
secretions
is the use of mechan-
insufflation-exsufflation
MECHANICAL
(MI-E).
INSUFFLATION-EXSUFFLATION
The life-saving
value of exsuffiation
with negative
pressure
was made
clear through
the relief of obstructive
dyspnea
as a result of immediate
elimination of lange amounts
of purulent
sputum,
and, in a
second
episode,
by the substantial
clearing
of pulmonany
atelectasis
after 12 hours’ treatment.7
In the late-1940s,
Henry Seeler, working
for the US
Air Force, developed
a mechanical
insufflator-exsufflaton designed
to deliver
alternating
positive
and negative pressures
to ventilate
and exsufflate
patients
suffering
from exposure
to “chemical
weapons”
and
“nerve
gas.”8 In 1951 , Barach
et al9 described
an
exsufflator
attachment
a vacuum
cleaner
attachment
closed,
pressure
the valve
pressure
for
with
to an iron
the
motor
to -40
opened,
in 0.06
iron
motor
lung
developed
mm
Hg.
The
portal.
At peak
causing
device
solenoid
With
a negative
triggering
s and
lungs.
a 5-inch
negative
a return
a passive
used
valve
the
valve
intratank
pressure,
to atmospheric
exsufflation.9
to 0 mm
for
pro-
duced by this device “completely
replaced
bnonchoscopy as a means of keeping
the airway
clean of thick
tenacious
secretions.
“ Another
“patient
would have
required
bronchoscopy
or re-opening
of the tracheotomy if the exsufflator
had not been successful
in
cleaning
the airway.”9
In 1952, Barach
and colleagues’#{176} reported
their
“mechanical
cough chamber.
“ A pressure
change
of
110 mm Hg was induced
25 times per minute.
A
close-fitted
baffle around
the neck split the chamber
into two. A blower
applied
positive
pressure
to the
head chamber.
This resulted
in a higher
pressure
in
the head chamber
than
in the body end of the chamber.
When
the pressure
rose 110 mm Hg above
atmospheric
in the head chamber,
a differential
headbody pressure
gradient
of up to 40 mm Hg caused air
to enter the lungs. The sudden
opening
of the 12.5cm (5 inch) valve in the head compartment
resulted
in a 100 mm Hg explosive
decompression
there
and a
head-body
pressure
differential
shift +40 mm Hg to
about -40 mm Hg creating
a forced exsufflation.
The
expinatory
flows were enhanced
by the perceptible
forward
shift of the body
which
occurred
as the
positive
differential
pressure
in the body compartment
Hg
with
the
return
of atmospheric
pressure
on both sides of the baffle. This approach
created
PCEF comparable
to those of currently
used
portable
MI-E devices.2’11
In 1953, various
portable
devices
were manufactuned to deliver
MI-E directly
to the airway
via a
mouthpiece,
mask,
on endotracheal
tube.”3
Insufflation and exsufflation
pressures
were independently
adjusted
for comfort
and efficacy.
The best known of
these devices
and one which
we use a great deal
although
it is no longer
commercially
available,
Cof-Flator
(OEM
Co, Norwalk,
consists
of a two-stage
ally inflates
the lungs
40
mm
Hg
over
Conn).12
axial
with
a 2-s
The
today,
is the
Cof-Flator
compressor
which
positive
pressures
period.
The
graduof 30 to
pressure
in
the
upper
respiratory
passageway
is then dropped
to 30
mm Hg to 40 mm Hg below atmosphere
in 0.02 s by
the swift opening
of a solenoid
valve connected
to a
negative
pressure
blower.
The negative
pressure
is
maintained
for
1 to 3
1415
In February
1993, a mechanical
insufflator-exsufflaton (In-Exsufflator,
JH Emerson
Co, Cambridge,
Ma)
which
operates
like the Cof-Flaton
except that cycling
between
manually,
istration
This increased
PCEF
in six ventilator-supported
poliomyelitis
patients
from 1 .2 L/s unassisted
to 1 .6 L/s
on 45 percent.
An additional
increase
was obtained
by
timing
an abdominal
compression
with valve opening.’#{176}
These
techniques
were sufficiently
effective
the investigators
to report
that the exsufflation
dropped
manual
positive
and negative
pressure
was approved
by the Federal
must
Drug
and
market.
released
cycling
coordination
flation
for an abdominal
to affix the mask.
tilation.
Five
or
further
secretions
by a period
more
the
as frequently
abdominal
are
are
are expulsed.
as every
are
breath-
given
in one
until
Use can
10 to 60 mm
applied
PCEF
Although
can
insuf-
hypenven-
repeated
no medications
are
during
RTIs.
facilitate
usually
exsufflation
required
users
heated
when
aerosol
secretions
inspissated.
The
efficacy
cally
and
of MI-E
on
animal
was demonstrated
models.’5
At
both
least
for
airways
to effectively
bnis.’7”8
Vital
eliminate
capacity,
oxyhemoglobin
saturation,
immediately
with
MI-E.2”9
An increase
noted
with
immediately
“obstructive
VC
was
noted
respiratory
pulmonary
when
cleaning
tract
flow
rates,
abnormal,
of
mucus
following
treatment
MI-E
by
was
in 67 patients
in
CHEST I 105 I 5 I
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deand
improve
and a 55 percent
following
flow
distal
plugs
in VC of 15 to 42 percent
dyspnea”
clini-
patients
without
significant
obstructive
airway
disease,
generation
is adequate
in both proximal
and
in
An
cycle
expul-
ventilator
using
no
be required
during the exsufflation
and airway
secretion
for effective
MI-E in neuromuscular
with RTIs, liquefaction
of sputum
tneatments
with
of normal
treatments
treatments
thrust
increases
further
expiration
requires
use for 20 to 30 s to avoid
and
sion.’6
and
but
followed
ing or ventilator
sitting,
This
cane giver-patient
an additional
hand
thrust or if one hand is inadequate
One treatment
consists of about five
exsufflation
of MI-E
American
facilitates
of inspiration
and
cycles
on the
feature
be done
Admin-
increase
patients
MAY,
1994
with
1539
blebs
in
Barach
lungs
and
Beck20
and
MI-E
of
following
sputum
area had
complained
of
with
been
relieved.
of transient
MI-E.
This
ease.22’24
our
conditions.2#{176} We
50 percent
improvement
oxyhemoglobin
plugs
for
Significant
strated
by
lowing
15 to
normalization
eliminates
of
Consistent
with
and
hundreds
neuromuscular
PCEF
of
lungs
the
revealed
were
also
a mucin-thorium
of anesthetized
virtually
demon-
poliomyelitis,
emphysema.’4
complete
bronFol-
elimination
and
expiratory
period
resulted
dioxide
dogs, bronof
the
be observed
gradually
choscopically
MI-E
through
in the
to be effective
The
use
tube
in reversing
acute
of
was
atelec-
associated
with productive
airway
secretions
in
1954; however,
PCEF
were noted
to be greater
when
MI-E
was applied
via a mask.2’
Barach
and Beck20
demonstrated
clinical
and radiographic
improvement
in 92 of 103 acutely
ill bronchopulmonary
and neuro-
tions
patients
included
and
for
RTIs
patients
27 with
including
effective
with
72
skeletal
observed
the use of
bronchopulmonary
or neuromuscular
poliomyelitis;7
the latter
than
Colebatch22
with
with
MI-E.
condi-
applying
negative
pres-
or
than
the
Bickerman15
found
age, hemorrhage,
1540
normal
cough,
it is improbable
be more
detrimental
cough
pressure
that this
to the
gradient.
no evidence
of parenchymal
damalveolar
tears,
or emphysematous
of any dein forced
exsufflation
for acute
during
increased
traumatic
exsufflation.
increase
seen
This
during
at peak
inspiratory
including
used.
Hg
unless
The
block
and
found
the
that
85
pressure
difference
bronchioles
occur
pressure
mm
Hg
in patients
drop
with
Downloaded From: http://publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21694/ on 06/19/2017
normal
emphysema,
may
result
the
Respiratory
mm
pressures
during
coughing
and
between
than
is
is 26
during
in an even
alveoli
is normally
The resulting
high alveolar-bronchial
ent may result
in closure
of bronchioles
Noninvasive
in some
anticholinergics
of high intrathoracic
phase
of unassisted
pressure
of
can
with
in intragastric
MI-E
Dayman26
lumen
heart
the
premedication
increase
during
greater
shock,
complete
patients
of 8
pulse
during
reflect
volumes.
in spinal
is
normal
MI-E,
and electrorotation
of the heart
For the acute
high level
severe
bradyarrhythmias
changes
subsequent
can
absence
increase
decrease
increase
the
a normal
The
consistent
H20,
the
cardiographic
lungs
pressure
and
and eliminated
below
the patient’s
can
production
glottic-closure
lungs
Borborygmus
pressure
is increased
an average
and 4 mm Hg in diastole.
The
the
the
during
of
or blood-
coughing.
Blood
mm Hg in systole
coughing.27
negative
by
episodes
of MI-E
were studied
in depth
Peripheral
venous
pressures
as
anterior
cubital
vein
are slightly
cm
one-third
of 40 to 50 mm
Hg is unlikely
to have
any
deleterious
effects
on pulmonary
tissues.
He noted
that since the negative
pressure
applied
to the airways
is analogous
to positive
pressure
on the surface
of the
sure
the
in
ie, 5.8
about
650
of MI-E
effects
measured
raised,
no
observed.
insufflation
and
MI-E
is used
19505.2526
tetraplegic
however,
it was more
for the former.2#{176}
that
Physiologic
early
in over
the immediate
postexsufflation
no sustained
airway
obstruction
As noted
below,
caution
must
in
that
MI-E.’6
and
when
tetraplegics.
disease
were
flows
indicated
from
suspension
after 6 mm of MI-E.’5
The technique
was shown
to be equally
effective
in expulsing
broninserted
foreign
bodies.’5
an indwelling
tracheostomy
use.23 No
disclosed
contents,
increases
chograms
This
of gastric
the
into
muscular
aspiration
of sputum
fact
users,
volume.
suspension
tasis
is the
indeed,
in
seen in a few
bronchial
wall
Immediately
of applications
ventilator
pneumothorax,
streaking
this
reserve
in patients
with
and pulmonary
to be
transient
continued
have been
inspiratory
neuromuscular
have
initial
study,
1 of 19 patients
associated
with
the
crease,
instillation
demonstrated
In one
nausea
“
2)16
ill ventilator-assisted
mucus
MI-E.
of blood-streaked
of mucopurulent
of the atelectatic
distention
are infrequent
insufflation
pressures
MI-E
asthma,
chiectasis,
and
as MI-E
observed
MI-E
the
abdominal
by decreasing
acutely
(Fig
patients
in FVC
saturation
have
with
more
than
6,000
treatments
in over 400 patients
MI-E,
most
of whom
had primarily
lung
dis-
patient-years
neuromuscular
did
that
passed
with
side effects
of damaging
reports
in
patients
noted
the initial
elimination
the profuse
out-pouring
indicated
that “obstruction
sputum,
onset
treated
of blood
streaked
sputum
probably
originated
from the
detachment
of mucus
plugs.
patients
2. Mechanical
insufflation-exsuffiation
applied
to a patient
with Duchenne
muscular
dystrophy
who was extubated
and converted
to 24-h
mouth
and
nasal
intermittent
positive-pressure
ventilation
following
a surgical
procedure
and general
anesthesia.
The In-Exsufflator
OH Emerson
Co, Cambridge,
Mass) is to the right
of the bed.
no
They
appearance
sites
animals
reported
no serious
complications
they treated
with over 2,000 courses
for
discontinued.
FIGURE
of
103 patients
in the
of
the
Muscle
pressure
and
and
present.
gradiobstruc-
Aids (John
R. Bach)
tion
to air exiting
ineffective
MI-E
that
the
for
these
for COPD
high
nacic
alveoli.
Coughing
patients.
patients
expiratory
flows
pressures.2#{176} It was
Part
of cyclical
such
as
ventilation27
and
of the
was
explained
occur
with
suggested
patients
and others
with severe
patient
should
practice
passive
ness should
also be compared
techniques
the
chest
is thus
of
wall
intratho-
ance
lower
for
COPD
and compression
intrapulmonary
high
frequency
ventilation.28
Small amplitude
low
tions and intrapulmonary
percussive
Beck
by the fact
intrinsic
disease,
the
MI-E.24
Its effectivewith
that
of other
expansion
percussive
external
benefit
that
MECHANICAL
often
of
jet
oscillatory
frequency
oscillaventilation
can
oscillation
emphysema
nally to the
One
to be effective
can also
second.38
in the elimination
of contrast
of tenacious
medium
after
sputum
bronchography
in patients
with bronchial
asthma
and bronchiectasis,
and it has been suggested
that MI-E may improve
the
results
of bronchoscopy.2#{176}
Williams
and Holaday29
reported
that MI-E could
effectively
eliminate
airway
secretions
generalized
and
ventilate
anesthesia.
patients
in the minutes
following
They
applied
MI-E
both
to cooperative
and
ported
normalization
patients
studied
nary
emphysema.
sounds,
increased
piratory
rate,
lower
lobe
including
In
MI-E
incidence
either
were
than
in this
during
them
MI-E
enough
lungs.
to permit
It has also
resof right
particular
pa-
and
coughing.
contents
The
extubate
use
little
to the
mucus
was
after
general
on no ventilator-free
use of noninvasive
elimination
alone
IPPV
were
not
them
to effectively
ventilate
permitted
us to avoid
intubation
exsufflaton
was
We
have
abandoned
to refer
been
able
in
RTIs
their
or
acute
with
with
the
,occasionalmedto its effectiveness
to find
chronic
no literature
contradicting
the reports
of effectiveness
on describing
significant
complications.
Even when
used following
abdominal
surgery
and following
extensive
chest wall
surgery,
no disruption
of recently
sutured
wounds
was
noted.29
chest
secretion
clear-
bronchial
asthma
and
in 1966. Oscillation
can be applied
chest wall or abdomen
or directly
exterto the
frequency
positive-pressure
ventilation,
on oscillation
in which
there
are rapid
pressure
swings
above
and below
pressure.37
All of these
techniques
to have some effect
on mucociliany
abdominal
oscillation
in 1988
France)
intermittent
(CIME
Electronique
can operate
very
abdominal
pressure
have
trans-
and
the lower
pant
by
a motor-driven
unit
timing,
thereby
assisting
some
forced
exsufflation.
by
patients
obstructive
Jamil
much
Medicale,
like an
Pro
(IAPV),
but
at several
cycles
which
encircles
per
the
of the thorax.
It is tugged
with
adjustable
ventilation
and
It has been
used
with
pulmonary
the
ventilator
oscillate
the abdomen
It consists
of a corset
abdomen
nantly
device,
cystic
force
and
providing
predomi-
fibrosis
conditions
in
and
other
Europe.39
We
studied
this device
on five IAPV users. With the IAPV
autonomous
tidal
volumes
were
supplemented
by a
mean
of 332 ± 158 ml. The PCEF
during
IAPV
use
were
augmented
by a mean
of 1 .48 ± 0.90 L/s. The
Jamil augmented
mland
PCEF
no measurable
flows
were
respectively,
Jamil’s
by a mean of 221 ± 144
L/s. In one patient
with
tidal volume
and peak
tidal volumes
by 1.13±0.66
VC, the Jamil
less than
50 percent
of those accomplished
mechanical
oscillation
the
chest
wall
or directly
needed
muscle
for patients
insufficiency
assisted
coughing
to be useful
lung disease.
and
58 percent,
by the IAPV.
The
effect,
helpful
for loosening
secretions.
Devices
which
apply
rapidly
of MI-E
has
elective
surgical
extubate
neuromuscular
patients
failure
due
to intercurrent
airway
secretions.
the
No
found
of anesthetized
immediately
incneasingpopulanityoftracheostomy
ical publications
continued
and
for
or in that
having
convert
when
Although
reduced
reversal
spontaneous
patients
despite
quickly
respiratory
profuse
and
of gastric
population29
neuromuscular
and
pulmobreath
result
of MI-E.
Patients
with wounds
on chest
reported
less wound
pain
dogs
treated
with
MI-E.’5
permitted
us to consistently
time
advanced
improved
reported
of aspiration
anesthesia
and reall seven
resonance,
of cyanosis,
collapse
patients
gases
in
two with
addition,
percussion
clearing
tients as a direct
of the abdomen
during
to unconscious
of blood
frequency
bronchial
pont.
developed
Marseille,
and
with
airway
as high
jet ventilation,
small
amplitude
atmospheric
been noted
TECHNIQUES
the use of high
to facilitate
in patients
also be provided,
albeit
less precisely,
by the InExsufflator
(JH Emerson
Co, Cambridge,
Mass).
Mechanical
insufflation-exsufflation
has been noted
before
OsaLLATI0N
first described
changing
to the
with
who
however,
airway
neuromuscular
successfully
or MI-E;
be
pressures
to
may
be
they
not
expiratory
manually
use
however,
for patients
with
The application
may
may
prove
obstructive
or intrinsic
of high frequency
chest
wall compression
at 1 1 to 15 Hz to anesthetized
dogs
was found
to maximize
the tracheal
mucus
clearance
rate.40
The
adjustable
l/E
ratio
of
the
described
Hayek
oscillator
permits
asymmetric
ratory
and expiratony
pressure
changes
(for
+3 to -6 cm
flow velocities
H2O)
which
to optimize
previously
noted,
negative,
mencing
atmospheric,
oscillation
residual
capacity
ican Biosystems,
oscillation
suggested
baseline
pressures
can
be
As
set
at
thus comfunctional
A Thairapy
System
(AmenMinn)
also applies
chest wall
at 10 Hz via a pneumatic
that high-frequency
chest
CHEST
Downloaded From: http://publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21694/ on 06/19/2017
inspiexample
favor
higher
exsufflation
secretion
mobilization.
on positive
values,
above,
at, on below
the
(FRC).
St Paul,
previously
I 105 I
5
vest.
wall
One study
oscillation
1 MAY,
1994
1541
enhanced
tracheal
mucus
clearance,
whereas
flows
was
of 3.8 L/s
greatly
and
peak
inspiratory
flows
method,
appears
when
on high
used
with
airway
head-down
secretion
frequency
posture,
clearance.
jet ventilation,
sis and
The
reported
to be
secretion
effective
Bird
in COPD
Impulsator,
(Percussionaire
than
of postoperative
mobilization
Percussionator,
ratons
more
in the treatment
Conp,
and
Sandpoint,
although
percent
day
of
12
inpatients
and
chest
study
period.
The
majority
Spanker
can
8 outpatients,
patients
do-
sputum
felt
that
helpful.
Several abstracts
and a
recent
publication
also favorably
compared
the use
of IPV with chest percussion
and postural
drainage
for
patients
with COPD
or intrinsic
lung disease;’
however, no studies
have compared
IPV with MI-E,
a
modality
which
can be used at the same pressures
and
frequencies.
Further
study
is needed
to establish
how
the
theoretic
will translate
were
benefits
of HFO
and
related
High
position;
when
can
MUSCLE
also
can
help
stability
abdominal
ASSIST
RESPIRATORY
EFFORT
pattern
Idaho).
of the
for
the
increase
to maintain
these
binder
mildly
PCEF
blood
patients
has also
increased
in this
VC
position.
pressure
and
when
sitting.46
been reported
It
trunk
Use of an
to decrease
the subjective
effort of breathing,
relieve
accessory
neck muscle
and upper
intercostal
respiration,
decrease the respiratory
nate, and increase
tidal air with
a lowering
patients
of
with
the
total
pulmonary
neuromuscular
ventilation
disease
for
or pulmonary
emphysema.7
(4-inch)-wide
or handles
coughing
abdominal
has been
aid.47
When
belt
designed
the
with
shown
the
to increase
mouth
patient
maximum
during
needs
to cough,
spontaneous
coughing
favorably
with
from
to 60 cm
the 80 cm H20
ally assisted
coughing.
determine
if adequate
this
expiratory
coughing
hand
as a postoperative
on she passes one handle
through
the other
with both hands. This instantaneously
applies
to the abdomen
and facilitates
a pain-free
An abdominal
binder
with functional
stimulation
electrodes
has become
availabel
hance
the cough of spinal cord quadniplegics
Coff Belt Company,
Sunnyvale,
Calif).
It
30
H2O
and
pressure
cough.
electrical
to en(Quik
has been
pressure
at
H2O
for
cm
and
obtained
he
pulls
compares
during
manu-
Further
studies
are needed
to
PCEF can be achieved
by using
apparatus.48
DIFFICULTIES
techniques
For patients
with paralyzed
abdominal
musculature
from spinal cord injury,
use of a thonacoabdominal
corset
restricts
the descent
of the diaphragm
and
limits the increase
in FRC which otherwise
usually
increases
significantly
when the patient
assumes
the
upright
position.
Although
it does not assist respiratory
1542
however,
sitting
IN
N0NINvASIvE
WHICH
frequency
pressure
Corp,
Sandpoint,
for the patient
when supine,
when sitting,
it
diaphragm
activity
by permitting
increased
excursion.
It has no significant
effect on PCEF
in the
to humans.
TECHNIQUES
low
assists
Despite
OTHER
amplitude
(Pencussionaire
muscles
grips
Respi-
Idaho)
of the
3.
Percussionator
FIGURE
A 10-cm
patients.
and FVC increased
during regular
use of IPV,
in the case of the latter, the increase
was 6
and only seen with the inpatients
over the 5-
the treatments
1 second
atelecta-
liver aenosolized
medications
while providing
high flow
minibursts
of air to the lungs at a rate of 2 to 7 Hz. In
1 study
volume
0
supine
the
Corporation
(Exeter,
UK) developed
an internal
airway percussor.
This hand-held
device delivers
30 ml
sine wave oscillations
through
a mouthpiece
at 20 Hz.
Overall
tracheobnonchial
clearance
as measured
by
inhaled
nadioaenosol
was improved
significantly
only
by combining
internal
airway
percussion
with physiotherapy.42
Intrapulmonary
percussive
ventilation
(IPV)
(Fig 3)
has been
percussion
20
by
to facilitate
Based
40
of 1.3 L/s
posture.
Mucus
clearance
during
head-down
tilt postural
drainage
was 3.1 ml!
10 mm. it was 3.5 ml/10
mm when using expinatory
biased HFO in the horizontal
position,
and 11 ml/10
mm using expiratory
biased HFO with a head-down
tilt. No clearance
occurred
with inspiratony
biased
HFO during head-down
tilt.27 Thus, although
there is
as yet no good evidence
of clinical efficacy
on humans,
this
affected
cm H20
high
frequency
oscillation
or ventilation
(HFO)
at the
mouth
did not.41
However,
mucociliany
clearance
in anesthetized
sheep receiving
asymmetric
(expiratony
biased) HFO
directly
to the airway
at 15 Hz with peak expiratory
patient
INITIATING
AIDS
and
AND
THE
USE
OF
CONCLUSION
care-giver
preferences
for
noninvasive
approaches,
the ability of these methods
to lower the cost of home mechanical
ventilation,
to
eliminate
the need for hospitalization,
intubation,
and
bronchoscopy
particularly
for neuromusculan/restnictive patients
who develop
global alveolar
hypoventilation,
and
ventilatony
been
their
safety
support
problematic
and
efficacy
and secretion
for physicians
Nonkwase
Downloaded From: http://publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21694/ on 06/19/2017
Respiratory
for
long-term
management,
and
Muscle
medical
Aids (John
it
has
centers
R. Bach)
4
Mier-Jedrzejowicz
weakness
Respir
5
A, Brophy
during
Dis
King
upper
1988;
M, Brock
J
cough.
6 Sortor
[video].
ment
Am
External
Rev
1985;
AL.
of a patient
assisted
mc,
of mechanical
aids
poliomyelitis.
cough
1986
in the
Ann
Intern
Man
in Flight
31
manage-
Med
1954;
Patterson
AFB,
search
Ohio:
AL,
Beck
GJ,
on physical
flow
during
the expiratory
rates
1951;
64:360-63
Barach
AL,
Appl
JR.
Force,
Aerospace
GJ,
Wright-
Medical
1952;
Bull
negative
NY
employing
Barach
Beck
AL,
flow
J
Med
Am
Seanon
of the
rehabilitation
sleep
Bach
JR.
peak
expiratory
(the
GJ,
Smith
RH.
Chest
Mechanical
the capacity
Am
19
Rev
muscular
20 Barach
22
1963;
Rev
Beck
and
GJ.
1954;
GJ,
1964;
values
1955;
43:549-66
Colebatch
HJH.
paralysis.
Australas
23 Cherniack
of
Rehabil
Exsufflation
studies
and
life
by
1992;
with
negative
subjects.
Barach
1954;
AL.
breathing
Effect
44
in poliomyelitis.
Ann
45
methods
46
Med
pressure.
Clin
27
Artificial
J
coughing
Med
1961;
Alcock
for tank
for patients
with
respiratory
10:201-12
bronchial
J
28
Appl
Hayek
1951;
L, Long
Dis
AJW.
The clinical
Z, Ryan
for
Management
muscular
C, Saponito
of
dystrophy.
L, Lee
in the
technics
1964;
J Med
M.
Mouth
management
of
and
for rehabilitation
64:993-1000
emphysema
vibrocompression.
Had
A. High-frequency
1984;
57:135-52
of
rehabilita-
Geriatrics
1966;
BachJR,
Alba
AS. Total
pressure
Jehanne
M, Ythier
C, Gresset
des
Lyon,
DM,
Hopital
Gross
tracheal
wall
King
M, Phillips
A, Morel
dans
compression.
oscillation.
RJD,
Rev
Zidulka
Am
Geddes
oscillation:
DM.
High
Biomed
clearance
by
disease
Mclnturff
SL,
LI,
Care
D,
L.
oscillations
and
43:25-30
P. A new technique
Pencussionaire
for
patients
In: Programme
Hodgkin
percussive
Thangathunia
verses
130:703-06
des
Lyon,
with
Jounn#{233}es
France:
Hopital
1993:27
Shaw
Respin
mucus
wall
1989;
a Domicile.
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the
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support
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bronchique
Programme
King
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Physiol
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in physiologic
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hypoventi-
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de
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alveolar
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3:239-69
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90:637-40
97:52-7
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Chronic
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Saponito
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Muscle
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noninvasive
Med
Holaday
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Acad
Industries
Salomon
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Re-
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high
Assoc
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Portable
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On
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Noninvasive
1993;
by
Phys
Millet
H, Herman
B.
in patients
with acute
103:907-13
muscular
Med
Respiratory
dystrophy
Rehabil
association
1992;
73:179-83
Muscle Aids (John R. Bach)
4
Mier-Jedrzejowicz
weakness
Respir
5
A, Brophy
during
Dis
King
upper
1988;
M, Brock
J
cough.
6 Sortor
[video].
ment
Am
External
Rev
1985;
AL.
of a patient
assisted
mc,
of mechanical
aids
poliomyelitis.
cough
1986
in the
Ann
Intern
Man
in Flight
31
manage-
Med
1954;
Patterson
AFB,
search
Ohio:
AL,
Beck
GJ,
on physical
flow
during
the expiratory
rates
1951;
64:360-63
Barach
AL,
Appl
JR.
Force,
Aerospace
GJ,
Wright-
Medical
1952;
Bull
negative
NY
employing
Barach
Beck
AL,
flow
J
Med
Am
Seanon
of the
rehabilitation
sleep
Bach
JR.
peak
expiratory
(the
GJ,
Smith
RH.
Chest
Mechanical
the capacity
Am
19
Rev
muscular
20 Barach
22
1963;
Rev
Beck
and
GJ.
1954;
GJ,
1964;
values
1955;
43:549-66
Colebatch
HJH.
paralysis.
Australas
23 Cherniack
of
Rehabil
Exsufflation
studies
and
life
by
1992;
with
negative
subjects.
Barach
1954;
AL.
breathing
Effect
44
in poliomyelitis.
Ann
45
methods
46
Med
pressure.
Clin
27
Artificial
J
coughing
Med
1961;
Alcock
for tank
for patients
with
respiratory
10:201-12
bronchial
J
28
Appl
Hayek
1951;
L, Long
Dis
AJW.
The clinical
Z, Ryan
for
Management
muscular
C, Saponito
of
dystrophy.
L, Lee
in the
technics
1964;
J Med
M.
Mouth
management
of
and
for rehabilitation
64:993-1000
emphysema
vibrocompression.
Had
A. High-frequency
1984;
57:135-52
of
rehabilita-
Geriatrics
1966;
BachJR,
Alba
AS. Total
pressure
Jehanne
M, Ythier
C, Gresset
des
Lyon,
DM,
Hopital
Gross
tracheal
wall
King
M, Phillips
A, Morel
dans
compression.
oscillation.
RJD,
Rev
Zidulka
Am
Geddes
oscillation:
DM.
High
Biomed
clearance
by
disease
Mclnturff
SL,
LI,
Care
D,
L.
oscillations
and
43:25-30
P. A new technique
Pencussionaire
for
patients
In: Programme
Hodgkin
percussive
Thangathunia
verses
130:703-06
des
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