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An Overview of Cough & Cough Assessment Sally Cozens Respiratory Specialist Physiotherapy

An Overview of Cough & Cough Assessment Sally Cozens Respiratory Specialist Physiotherapy. Objectives. Revision of normal cough function Why assess cough? How to assess cough the components of cough When to introduce airway clearance methods Understanding Airway Clearance Techniques

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An Overview of Cough & Cough Assessment Sally Cozens Respiratory Specialist Physiotherapy

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  1. An Overview of Cough & Cough Assessment Sally Cozens Respiratory Specialist Physiotherapy

  2. Objectives • Revision of normal cough function • Why assess cough? • How to assess cough the components of cough • When to introduce airway clearance methods • Understanding Airway Clearance Techniques • An introduction to MI-E Specialists in Ventilation & Airway Clearance

  3. Normal Physiological Cough Specialists in Ventilation & Airway Clearance

  4. Normal Cough • ‘‘Cough is a forced expulsive manoeuvre, usually against a closed glottis and which is associated with a characteristic sound.’’ • (BTS 2006) • Coughing and support from the mucocilliary escalator protects the respiratory system by clearing it of irritants and secretions Specialists in Ventilation & Airway Clearance

  5. Stages in a Normal Physiological Cough (Yanagihara et al. 1966) Specialists in Ventilation & Airway Clearance

  6. Requirements For A Normal Cough Specialists in Ventilation & Airway Clearance

  7. Glottis Arytenoid Cartilage Glottis Trachea Vocal Folds/ Cords Epiglottis Specialists in Ventilation & Airway Clearance

  8. An Effective Cough • (Leith 1985) Inspiratory Phase Compressive Phase Expiratory Phase Specialists in Ventilation & Airway Clearance

  9. Normal Cough Specialists in Ventilation & Airway Clearance

  10. Why Assess Cough? Specialists in Ventilation & Airway Clearance

  11. General muscle weakness Respiratory muscle weakness Decreased chest wall compliance Ineffective cough REM related nocturnal hypoventilation Recurrent chest infections Shortening of respiratory muscles & Chest wall deformity NREM and REM related hypoventilation Decreased tidal volumes Daytime hypercapnic respiratory failure Disease Progression

  12. Impact Of Impaired Cough • Effective cough is a protective mechanism against respiratory tract infections, which are the commonest cause of hospital admission in patients with respiratory muscle weakness due to neuromuscular disease. • (Chatwin et al 2003) Specialists in Ventilation & Airway Clearance

  13. Impact Of Impaired Cough 90% of episodes of respiratory failure develop because of inability to clear the airways in NMD (Gomez-Merino et al 2002) Specialists in Ventilation & Airway Clearance

  14. What Numbers Are Significant? • If PCF does not exceed 270-300L/min, Patients when they are unwell are at risk of a decline in their PCF < 160L/min • (Bach et al, 1997, Chest) Specialists in Ventilation & Airway Clearance

  15. Impaired Cough Specialists in Ventilation & Airway Clearance

  16. NMD Patient – The Reality Specialists in Ventilation & Airway Clearance

  17. CoughAssessment Specialists in Ventilation & Airway Clearance

  18. How Do We Assess The 3 Cough Phases? Specialists in Ventilation & Airway Clearance

  19. Normal Values Specialists in Ventilation & Airway Clearance

  20. Stacatto Expiration Specialists in Ventilation & Airway Clearance

  21. Cough Assessment – How ? • Assessing PCF is a quick and easy way of measuring expiratory muscle function • The greater the PCF, the less risk of respiratory complications (Kang & Bach 2000 Specialists in Ventilation & Airway Clearance

  22. Implications of Reduced PCF • Recurrent chest infections • Risk of aspiration • Hospital Admissions • Reduced QoL • Respiratory Failure & Mortality Specialists in Ventilation & Airway Clearance

  23. Which Patients May Be At Risk? (Canadian HMV Guidelines 2011) Specialists in Ventilation & Airway Clearance

  24. Introducing Airway Clearance Techniques Specialists in Ventilation & Airway Clearance

  25. When To Introduce Methods PCF <270 l min Select MAC or MIC techniques PCF < 245 l min Combine MAC and MIC PCF < 160 l min MI- E Consider MI-E with MAC Chatwin 2009 Specialists in Ventilation & Airway Clearance

  26. Maximum Insufflation Capacity The Maximum Insufflation Capacity (MIC) is a measurement in litres, and is the maximum volume of air stacked within the patient’s lungs beyond spontaneous vital capacity. MIC is attained when the patient takes a deep breath, holds their breath, followed by breath stacking applied using a LVR resuscitation bag, a volume ventilator or glossopharyngeal breathing (GPB). (LeBlanc & McKim 2007) Specialists in Ventilation & Airway Clearance

  27. Manual Assisted Cough A manually Assisted Cough Manoeuvre involves the application of an abdominal thrust or costal lateral compression using various hand placements after an adequate spontaneous inspiration or maximal insufflation. (LeBlanc & McKim 2007) Specialists in Ventilation & Airway Clearance

  28. An introduction to MI-E Specialists in Ventilation & Airway Clearance

  29. The History of Mechanical Insufflation-Exsufflation MI-E is not a new therapy, it was developed in 1948 by AlvanBarach as a result of the polio epidemic Specialists in Ventilation & Airway Clearance

  30. The History of Mechanical Insufflation-Exsufflation • It was in 1953 that various portable devices were manufactured to deliver MI-E • First publication of the use of MI-E was in 1954. The Beck & Barachreported successful and immediate elimination of large amounts of purulent secretions in a patient with poliomyelitis. Specialists in Ventilation & Airway Clearance

  31. The History of Mechanical Insufflation-Exsufflation • Emerson launched the “Cofflator” in 1950’s which weighed 9kg Specialists in Ventilation & Airway Clearance

  32. How Does MI-E Work? • MI-E devices clear secretions by applying a positive pressure to the airway – Insufflation • Followed by a rapid shift to negative pressure – Exsufflation • It is the rapid shift in pressure which results in a high expiratory flow (PEF) stimulating a cough • Flows produced need to be sufficient to produce an effective PCF with no effort Specialists in Ventilation & Airway Clearance

  33. Outcomes of MI-E • Assisting secretion mobilisation • Lung volume recruitment • Increasing inspiratory and expiratory force • Cough augmentation Reduced Chest Infections… Reduced Admissions Reduced Cost of Care … Improved QoL Specialists in Ventilation & Airway Clearance

  34. Thank You Any Questions ? Specialists in Ventilation & Airway Clearance

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