title: Comparison of three cough-augmentation techniques in neuromuscular patients: mechanical insufflation combined with manually assisted cough, insufflation-exsufflation alone and insufflation-exsufflation combined with manually assisted cough.
abstract: BACKGROUND
  Mechanical insufflation-exsufflation (MI-E), more commonly known as 'cough assist therapy', is a method which produces inspiratory and expiratory assistance to improve cough performances. However, other alternatives or combinations are possible.
  
  
  OBJECTIVE
  The objective was to compare the effects of mechanical insufflation combined with manually assisted coughing (MAC), insufflation-exsufflation alone and insufflation-exsufflation combined with MAC in neuromuscular patients requiring cough assistance.
  
  
  METHODS
  Eighteen neuromuscular patients with severe respiratory muscle dysfunction and peak cough flow (PCF) lower than 3 liters/s or maximal expiratory pressure (MEP) lower than +45 cm H2O were studied. Patients were studied under three cough-assisted conditions, which were used in random order: insufflation by intermittent positive-pressure breathing (IPPB) combined with MAC, MI-E and MI-E + MAC.
  
  
  RESULTS
  Overall, PCF was higher with IPPB + MAC than with MI-E + MAC or MI-E alone. Among the 12 patients who had higher PCF values with IPPB + MAC than with the two other techniques, 9 exhibited mask pressure swings during MI-E exsufflation, with a transient positive-pressure value due to the expiratory flow produced by the combined patient cough effort and MAC. Each of these 9 patients had higher PCF values (>5 liters/s) than did the other 9 patients when using IPPB + MAC.
  
  
  CONCLUSIONS
  Our results indicate that adding the MI-E device to MAC is unhelpful in patients whose PCF with an insufflation technique and MAC exceeds 5 liters/s. This is because the expiratory flow produced by the patient's effort and MAC transitorily exceeds the vacuum capacity of the MI-E device, which therefore becomes a transient load against the PCF.
authors.affiliation: Réanimation Médicale, Physiologie - Explorations Fonctionnelles, Centre d'Innovations Technologiques UMR 805, Hôpital Raymond Poincaré, AP-HP, Garches, and EA 4497, Université de Versailles Saint-Quentin-en-Yvelines, Versailles, France.
authors.forename: Matthieu
authors.initials: M
authors.lastname: Lacombe
authors.forename: Lorena
authors.initials: L
authors.lastname: Del Amo Castrillo
authors.forename: Aurélien
authors.initials: A
authors.lastname: Boré
authors.forename: David
authors.initials: D
authors.lastname: Chapeau
authors.forename: Eric
authors.initials: E
authors.lastname: Horvat
authors.forename: Isabelle
authors.initials: I
authors.lastname: Vaugier
authors.forename: Michelle
authors.initials: M
authors.lastname: Lejaille
authors.forename: David
authors.initials: D
authors.lastname: Orlikowski
authors.forename: Hélène
authors.initials: H
authors.lastname: Prigent
authors.forename: Frédéric
authors.initials: F
authors.lastname: Lofaso
mesh_terms: D000328:Adult; D000368:Aged; D003371:Cough; D018592:Cross-Over Studies; D005260:Female; D006801:Humans; D007327:Insufflation / Q000379:methods*; D007384:Intermittent Positive-Pressure Breathing / Q000379:methods*; D008297:Male; D008661:Metabolism, Inborn Errors / Q000150:complications; D008875:Middle Aged; D009134:Muscular Atrophy, Spinal / Q000150:complications; D009136:Muscular Dystrophies / Q000150:complications; D009468:Neuromuscular Diseases / Q000150:complications; D012131:Respiratory Insufficiency / Q000209:etiology / Q000628:therapy*; D012133:Respiratory Paralysis / Q000209:etiology / Q000628:therapy*; D012138:Respiratory Therapy / Q000379:methods*; D016896:Treatment Outcome; D055815:Young Adult