CMTNEWS

ASSISTED COUGHING
Knowing what to do when you can't cough
by Linda Crabtree
When it's cold and flu season even those of us who don't have problems breathing can run into trouble when we get so sore and so tired from coughing that we can barely muster up enough energy to get the fluids in our lungs up and out. It is extremely important to clear the lungs and especially so for people with disorders like CMT because some of us may not breathe deeply in the first place and some of us may have partially paralysed or completely paralysed diaphragm muscles.

The following won't apply to everyone with CMT, but if it helps allay the fears of just one person, it is worth printing. It is also something a person can take to the doctor or hospital with them if they get sick enough so that their reflexes don't work or their chest muscles just don't let them cough.

The last time I had what I thought was a bad cold, I sat up for two days and nights with a pillow under my ribs and just concentrated on breathing. Some of that time I could not cough. The reflex simply disappeared. It turned out to be pneumonia in the lower lobes of my lungs, and when I started antibiotics, it began to break up. But, for two days and nights, I couldn't cough and felt as though I was truly drowning. It was very frightening, and no one knew I was in such bad shape except Ron. The tests took longer to come back than the duration of the pneumonia. My doctor guessed at what I had because I told him that when I get pneumonia I have a different taste in my mouth and feel like I have pneumonia. He could also hear rales (an abnormal respiratory sound heard on inspiration or respiration) in the lower lobes of my lungs way down on my back. Sorry to be so graphic here but this is important.

If you get a really bad cough and find you lose the ability to cough, you need help. The fluids in your lungs need to be cleared. The article that follows talks about the Assisted Cough, something you can do at home. There is also suctioning that can be done in hospital on an outpatient basis or at home. Suctioning sounds gruesome but I've heard some speak of it in glowing tones as in, "Oh, what a relief it is!"

Assisted Cough
Benefits & Techniques
A variety of techniques to improve the ability to clear secretions without tracheostomy
Manually-assisted Cough
by Susan Sortor Leger, RRT

An individual's ability to take a good cough will be hindered by not having good chest musculature to compress a big breath, or by not being able to take a deep enough breath.

If an individual can take a good, big breath, but does not have good chest muscles, a respiratory therapist or caregiver trained in the manually-assisted cough technique can help compress that air by placing one hand over the chest and one hand on the abdomen. The individual takes a big breath, and then the therapist or caregiver compresses manually. The person who is helping should be standing in front of the person trying to cough, because he or she needs to see what is happening, and coordination and timing are very important. One must compress just a few seconds before the person exhales, pushing hard against a closed glottis a split second before exhalation. The push should not hurt, and in some cases, a push on only the chest can be effective.

From personal experience, I can tell you that the manually-assisted cough technique can be exhausting for the therapist or caregiver, and does not work for someone who cannot get a big breath to begin with. One way to give a big breath is to use IPPB (intermittent positive pressure breathing) with the volume between 2L-4L.
For that volume with someone with a normal compliant lung, the pressure should be 10 cm for each Litre. For people with scoliosis or rigid chest wall, more pressure is needed, but not enough to burst the lungs and incur barotrauma. Pressure limited at 40 cm is recommended to give a good deep breath. People need to be relaxed and not tense up, to let the air in and let the machine do the work.

Another way ventilator users can get a deep breath is by using a volume ventilator. Manual resuscitators can give breath, but the stroke volume capacity is only 800 cc. This is not enough to cough with, so I teach people to stack their breaths - take a breath, hold it, and stack one breath on top of the next.

The In-Exsufflator Cough Machine
by George Emerson
The In-Exsufflator Cough Machine is a device for helping clear secretions in people who have difficulty with coughing. It has been used for people with post-polio, muscular dystrophy, SCI and ALS. This device is similar to one made in the 1950s called the Cof-flator, designed for polio patients in iron lungs to help clear secretions.

About six years ago, Dr. John Bach came to us because he had a number of post-polio patients still using the old Cof-flator, but the machines were breaking down and were no longer manufactured. He asked if our company could make a new machine, and thus we developed the In-Exsufflator Cough Machine.

The machine operates with a blower and a valve that applies a positive pressure first to give a deep breath in, and then shifts rapidly to negative pressure to create a high expiratory flow, like one has with a normal cough. It can be used on a person with a trach or someone without a trach through a face mask or mouthpiece. The circuit is a bacterial filter, a pressure tap, and a hose to the face mask or adapter to the trach tube. There are two models, one with automatic timing and one manual.
Typically, a session of coughing with the machine involves cycling the unit positive, the negative, in quick succession about five to six times. Then the patient is allowed to rest for a minute in order to prevent hyperventilation which can occur after more than five or six times in a row. This pattern is repeated four to five times. When secretions arise, they come out into the mask or are spit out. The endotracheal tube can be suctioned for a person with a trach.
Pressures should start low, about 10-20 cm as tolerated, and then build up to 40-45 cm to get deep insufflation. The timing for the positive-negative is one to two seconds. The positive and negative pressures are set about the same, though some people like the inspiratory pressure to be slightly less.
A cough session takes about 10-15 minutes for secretion removal. Many therapists are afraid to use higher pressures, but to be effective, pressure should be in the 40-45 cm range. For home use, Dr. Agusta Alba recommends the automatic version, although it is more expensive. Dr. Bach has suggested using the In-Exsufflator in the manual mode along with a manual thrust to combine the effects of the high flow from the machine and the positive buildup from the thrust.
Many patients do not need to use the In-Exsufflator continuously, just for respiratory tract infections. Many have avoided pneumonia that required hospitalization and intubation by using the device. Dr. Alba has advised home health care agencies to stock the machines to be able to rent them out for just such emergencies. She also hopes more hospitals will make them available. She advises people to try the In-Exsufflator before they need it so that they will know what to expect. The In-Exsufflator is available on a weekly rental basis through most of the Respironics Customer Satisfaction Centers. (Call 800-345-6443 for the one nearest you.)
Reprinted from IVUN News. Vol 12, No 1-2, with permission of Gazette International Networking Institute, 4207 Lindell Blvd., #110 St. Louis, MO 63108-2915.