Chest
Volume 126, Issue 3, September 2004, Pages 774-780
Journal home page for Chest

Clinical Investigations
COPD
Effects of Mechanical Insufflation-Exsufflation on Respiratory Parameters for Patients With Chronic Airway Secretion Encumbrance

https://doi.org/10.1378/chest.126.3.774Get rights and content

Study objectives:

To analyze the physiologic effects and tolerance of mechanical insufflation-exsufflation (MI-E) for patients with chronic ventilatory failure of various etiologies.

Design:

Prospective clinical trial.

Setting:

Rehabilitation unit of a university hospital.

Patients or participants:

Thirteen patients with amyotrophic lateral sclerosis (ALS), 9 patients with severe COPD, and 7 patients with other neuromuscular disorders (oNMDs) with chronic airway secretion encumbrance and decreases in oxyhemoglobin saturation (Spo2).

Interventions:

Pressures of MI-E of 15 cm H2O, 30 cm H2O, and 40 cm H2O were cycled to each patient, with 3 s for insufflation and 4 s for exsufflation. One application was six cycles at each pressure for a total of three applications.

Measurements and results:

We continuously evaluated respiratory inductance plethysmography (RIP) and Spo2 during every application. Peak cough flow (PCF) and dyspnea (Borg Scale) were also measured before the first and after the last application. The technique was well tolerated in all patient groups. Median Spo2 improved significantly (p < 0.005) in all patient groups. Median PCF improved significantly (p < 0.005) in the ALS and oNMD groups from 170 to 200 L/min and from 180 to 220 L/min, respectively, and dyspnea improved significantly in the patients with oNMDs and patients with COPD from 3 to 1 and from 2 to 0.75, respectively. Breathing pattern characteristics (RIP) did not deteriorate after MI-E in any patient groups. Inspiratory flow limitation significantly decreased at the highest MI-E pressures for the ALS group.

Conclusions:

Our results confirm good tolerance and physiologic improvement in patients with restrictive disease and in patients with obstructive disease, suggesting that MI-E may be a potential complement to noninvasive ventilation for a wide variety of patient groups.

Section snippets

Patients

Patients with severe COPD or NMDs were referred to our rehabilitation unit after at least one episode of acute respiratory failure. All who complained of chronic airway congestion and difficulty clearing airway secretions, had decreases in baseline oxyhemoglobin saturation (Spo2), and provided consent satisfied the criteria for inclusion in this study. Exclusion criteria were medical instability, any changes in respiratory management during the 3 prior months, or need for any antibiotic therapy

Results

The oNMD patient group was significantly younger than the ALS and COPD groups (p = 0.024 and p = 0.004, respectively) [Table 1]. Pao2 was significantly lower in the COPD group compared to the oNMD and ALS groups (p = 0.016 and p = 0.001, respectively). Paco2 values were significantly higher and the FEV1 significantly lower in the COPD group compared to the ALS group (p = 0.003 and p = 0.0023, respectively). PCF at baseline was not significantly different between patient groups. In the ALS

Discussion

MI-E was well tolerated, and it significantly improved PCF and Spo2 for patients with NMD and COPD with airway secretion encumbrance, especially when used at pressures of 40 to − 40 cm H2O. It has been demonstrated in Rhesus monkeys that these pressures result in the greatest expiratory flows and result in no airway damage.21 While some patients find MI-E to be most effective at pressures of ≥ 60 cm H2O, the great majority of patients in clinical practice receive it at 40 to − 40 cm H2O. Thus,

Conclusion

This prospective study confirms that MI-E can improve PCF and oxygenation in ALS and other NMDs. In patients with COPD, it improved oxygenation and breathlessness without a significant improvement in PCF, but also without any deterioration in breathing pattern or pulmonary parameters. Taken together, these findings suggest that MI-E may be a potential complement to noninvasive ventilation for a wide variety of patient groups, and may help to reduce the frequency of pulmonary complications

ACKNOWLEDGMENT

The authors thank JH Emerson Company (Cambridge, MA) and Medipro (Grupo Eucon; Madrid, Spain) for supplying the Cough-Assist unit for the study and all the technical support provided.

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