An Overview of Cough PowerPoint Presentation

An Overview of Cough PowerPoint Presentation

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& . 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. ID: 194311

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Slide1

An Overview of Cough & Cough AssessmentSally Cozens Respiratory Specialist Physiotherapy

Slide2

Objectives

Revision of normal cough functionWhy assess cough?How to assess cough the components of coughWhen to introduce airway clearance methodsUnderstanding Airway Clearance TechniquesAn introduction to MI-E

Specialists in Ventilation & Airway Clearance

Slide3

Normal PhysiologicalCough

Specialists in Ventilation & Airway Clearance

Slide4

Normal Cough

Specialists in Ventilation & Airway Clearance

‘‘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

Slide5

Stages in a Normal Physiological Cough

Specialists in Ventilation & Airway Clearance

(

Yanagihara

et al. 1966)

Slide6

Requirements For A Normal Cough

Specialists in Ventilation & Airway Clearance

Slide7

Glottis

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Glottis

Epiglottis

Vocal Folds/ Cords

Arytenoid Cartilage

Trachea

Slide8

An Effective Cough

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(Leith 1985)

Inspiratory Phase

Compressive Phase Expiratory Phase

Slide9

Normal Cough

Specialists in Ventilation & Airway Clearance

Slide10

Why Assess Cough?

Specialists in Ventilation & Airway Clearance

Slide11

General muscle weakness

Respiratory muscle weakness

Decreased chest wall compliance

Shortening of respiratory muscles &Chest wall deformity

Decreased tidal volumes

REM related nocturnal hypoventilation

NREM and REM related hypoventilation

Daytime hypercapnic respiratory failure

Ineffective cough

Recurrent chest infections

Disease Progression

Slide12

Impact Of Impaired Cough

Specialists in Ventilation & Airway Clearance

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)

Slide13

Impact Of Impaired Cough

Specialists in Ventilation & Airway Clearance

90

% of episodes of respiratory failure develop because of inability to clear the airways in NMD

(

Gomez-Merino et al 2002)

Slide14

What Numbers Are Significant?

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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)

Slide15

Impaired Cough

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Slide16

NMD Patient – The Reality

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Slide17

Cough Assessment

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Slide18

How Do We Assess The 3 Cough Phases?

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Slide19

Normal Values

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PIMax

SNIP

PEMax

PCF

Normal

Values

Men > 80 cmH2O

Women >70

cmH2O

(Koulouris et al

1988)

Men >70 cmH2O

Women > 60cmH2O

(Miller et al 1985)

Men

and

Women

>100 cmH2O

(Koulouris et al 1988)

> 360 L/min

Slide20

Stacatto Expiration

Specialists in Ventilation & Airway Clearance

Slide21

Cough Assessment – How ?

Specialists in Ventilation & Airway Clearance

Assessing PCF is a quick and easy way of measuring expiratory muscle functionThe greater the PCF, the less risk of respiratory complications (Kang & Bach 2000

Slide22

Implications of Reduced PCF

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Recurrent chest infections

Risk of aspiration

Hospital Admissions

Reduced

QoL

Respiratory Failure & Mortality

Slide23

Which Patients May Be At Risk?

Specialists in Ventilation & Airway Clearance

(

Canadian HMV Guidelines 2011)

Slide24

Introducing Airway Clearance Techniques

Specialists in Ventilation & Airway Clearance

Slide25

When To Introduce Methods

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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

Slide26

Maximum Insufflation Capacity

Specialists in Ventilation & Airway Clearance

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)

Slide27

Manual Assisted Cough

Specialists in Ventilation & Airway Clearance

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)

Slide28

An introduction to MI-E

Specialists in Ventilation & Airway Clearance

Slide29

The History of Mechanical Insufflation-Exsufflation

MI-E is not a new therapy, it was developed in 1948 by Alvan Barach as a result of the polio epidemic

Specialists in Ventilation & Airway Clearance

Slide30

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 & Barach reported successful and immediate elimination of large amounts of purulent secretions in a patient with poliomyelitis.

Specialists in Ventilation & Airway Clearance

Slide31

The History of Mechanical Insufflation-Exsufflation

Emerson launched the “Cofflator” in 1950’s which weighed 9kg

Specialists in Ventilation & Airway Clearance

Slide32

How Does MI-E Work?

MI-E devices clear secretions by applying a positive pressure to the airway – InsufflationFollowed by a rapid shift to negative pressure – ExsufflationIt is the rapid shift in pressure which results in a high expiratory flow (PEF) stimulating a coughFlows produced need to be sufficient to produce an effective PCF with no effort

Specialists in Ventilation & Airway Clearance

Slide33

Outcomes of MI-E

Assisting secretion mobilisationLung volume recruitmentIncreasing inspiratory and expiratory forceCough augmentation Reduced Chest Infections… Reduced AdmissionsReduced Cost of Care … Improved QoL

Specialists in Ventilation & Airway Clearance

Slide34

Thank YouAny Questions ?

Specialists in Ventilation & Airway Clearance


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