Pneumologie
-
The electromechanical insufflator-exsufflator (Emerson CoughAssist) was developed as an aid for patients with neuromuscular disorders suffering from impaired cough. The insufflator-exsufflator simulates and supports physiological cough by supporting inspiration with positive pressure and shifting this positive pressure rapidly into a negative pressure that supports exsufflation and thus bronchial clearance. Maximum pressures are +/- 60 cm H2O, pressures between 30 and 50 cm H2O are sufficient to produce assisted cough in adults with neuromuscular disease. ⋯ An anaesthetic facemask is used as interface, alternatively, a mouthpiece can be used in combination with a nose strap. It is also possible to use the insufflator-exsufflator in patients with tracheostomy. We present in this article detailed information about the technical principles and practical use of the electromechanical insufflator-exsufflator.
-
Many patients with neuromuscular diseases suffer from a weak cough. Due to infection or aspiration a life-threatening situation may occur. There are different options for the therapists to improve secretion clearance from the airways in the patient with a weak cough. Furthermore, there are indications that consequent practice of techniques to ameliorate bronchial clearance may also improve the prognosis of patients with neuromuscular diseases. ⋯ The early diagnosis of a weak cough in NMD patients is important for the timely start of existing and effective measures for improving the capacity of elimination of secretions--air stacking, manually assisted cough and mechanically assisted cough. Although there is no high degree of evidence, we believe that morbidity and possibly mortality can be affected in a positive manner.
-
The use of non-invasive ventilation (NIV) to improve physical activity in COPD patients has been addressed in several clinical investigations in the past. In general, NIV can be applied directly during exercise, but also intermittently when used for long-term treatment thereby aiming at improving physical activity during spontaneous breathing. There is increasing evidence that NIV enhances exercise capacity in COPD patients with a reduction of exercise-induced dyspnea when applied during exertion. ⋯ Therefore, it is still unclear how to define the best technique for NIV to be used in order to enhance exercise capability in COPD patients. Future studies are needed to define which subgroup of patients benefit from NIV in view of its effects on exercise. Further studies should also be aimed at clarifying which mode and which ventilator settings are most beneficial in improving exercise capability in COPD patients.
-
Pulmonary complications are the most common causes of mortality in patients with severe inspiratory and/or expiratory muscle weakness. An inspiratory tidal volume below 1500 ml and a peak cough flow below 160 L/min result in mucus retention and increase the risk of pneumonia. An intact cough function is pivotal for airway clearance during acute and chronic airway infections with increased mucus production as well as for protection against endotracheal aspirations. ⋯ Non-invasive assistance of inspiration can be provided by manual hyperinflation, air stacking, glossopharyngeal breathing or mechanical insufflation. Safe and effective methods of expiration assistance include manual thorax and abdominal compression, manual self-assistance as well as mechanical insufflation-exsufflation. The use of these non-invasive inspiratory and expiratory muscle aids can decrease the risk of pulmonary complications in patients with severe ventilatory muscle weakness.
-
Although life-saving, mechanical ventilation is associated with numerous complications. Recently, it was shown in animal models that controlled mechanical ventilation (CMV) can cause the so-called ventilator-induced diaphragmatic dysfunction (VIDD). The decrease in diaphragmatic strength proceeds along with prolonged mechanical ventilation. ⋯ Since VIDD is particularly caused by comorbidity, a series of other factors may lead to diaphragmatic dysfunction. Whether or not VIDD causes weaning failure is difficult to decide since other reasons may also cause respiratory muscle weakness. However, based on pathophysiology, treatment options may be assisted mechanical ventilation, administration of antioxidative agents or stimulation of the phrenic nerve.