Cough Assist Indications & Benefits
Providing indications without contraindications, and benefits without risks, is irresponsible at best. If the mfr distributed this, there would be a warning letter on its desk as soon as the FDA saw it.
The goal of the Inspiratory Pressure is to expand the lungs, which can correct the closing of the air sacs (alveoli). This may be utilized without the expiratory pressure when feeling short of breath.
Expanding the lungs doesn't "correct the closing of the air sacs" any more than blowing up a balloon corrects damaged rubber. It's almost a non sequitur -- you can't "correct" closing. You can blow in a lot of air that holds them open for longer (for the duration of the breath) but by definition that risks damaging them. Of course, big breaths in without big breaths out retains CO2, which has its own downside and could exacerbate shortness of breath. This isn't a risk-free concept.
As for needing more air, any BiPAP can be adjusted in a couple of seconds to give you more, with a lot more precision, control and thus safety, over a longer period of time than breath by breath. We did this frequently for my husband when he had retained secretions. It helped him get strong enough to get them up or swallow them more completely.
• The expiratory pressure, when used in conjunction with the inspiratory pressure, creates turbulence and helps to move retained secretions upward. This can also help induce a normal cough to help expel secretions.
It simulates a normal cough, but it's not the real thing, as I think all PALS can testify.
• Regular use of the Cough Assist provides normal hyperinflation, which has been shown to combat loss of chest wall compliance, or more simply, flexibility of the chest wall.
In some disease states where the nerves supplying the chest wall are normal but the muscles weak (think muscular dystrophy), this could be true. Not in MND, to the extent that those muscles can't be strengthened. And again, this isn't "normal" hyperinflation. The balloon isn't blowing itself up.
• Using the Cough Assist regularly helps the user adjust to the device, which is very beneficial when secretions do become a problem.
No controlled trials to support this assumption in MND. Just as likely that pressing the dying nerves into action when they aren't needed to work so hard just uses them up faster, and that overstretched muscles [working to bring in more air volume that the pt needs at that moment] lose elasticity faster. Remember how you feel as a PALS when you overdo? CA machine labeling includes a warning, for example, that starting with IPAP greater than the current BiPAP setting (a level likely necessary to affect secretions) can pull muscles so they recommend titrating up if this happens. Do you engage in any other therapy that might pull a muscle?
Also note that diaphragm pacing, which also acts on atrophied muscles, has recently been called into question for PALS. And before you mention BiPAP, the whole point of BiPAP is to support the ideal breath stimulus/duration/size for the pt's lung condition, not to increase it past that point, which is why I am horrified to hear of BiPAPs set too high.
But with CA, to get secretions up, you have to use a breath that is bigger than a natural breath. Since you can't do this 24/7, many of us have found the key to avoiding retained secretions is thinning them out preventively. [It would be nice for this flyer to mention this concept, as a way to minimize the CA pressure necessary and thus safety.]
• Pressure and time settings will vary with each patient, based on effectiveness and tolerance. Adjusting the settings to make the Cough Assist effective is the key to good therapy.
Duh. Settings are also key to safety, which is getting short shrift throughout this communiqué.
• Neuromuscular disease, or other conditions, that reduce lung capacity or lung tidal volume and an inability to “sigh,” may result in the development of atelectasis (closing of lung air sacs) and pneumonia. A sigh is a larger than normal breath of air, which stretches the air sacs in the lung. This “stretching” in turn helps to keep the sacs open or to re-open them.
See above. We don't know if "overstretching" in the name of greater IPAP is prolonging or degrading the ability of the sacs to open, or neither. The MND lung has reduced capacity because of reduced muscle function, not damage to the sacs such as in primary lung disease. While there is no question that clearing retained secretions enables larger breaths and alleviates choking in the short-term, that is the only clear "indication" for the CA. Moreover, a lot of PALS don't have a CA but manage secretions through other means.
This sheet tells me that everyone with a NMD should have a CA.
No. Read the list of contraindications and risks (that include various heart and lung issues). My husband fell into multiple categories of those, so I doubt he was the first and only to have any. We've had at least one member who reported better breathing after stopping CA use.
As I mentioned earlier, I'm not anti-CA for someone who actually needs it. But I would consider it a "last line" (possibly in conjunction w/ the oscillation vest that it can complement) whereas this document presents it as a no-brainer and fails to present "fair balance" among benefits, risks, effectiveness and safety, that especially apply in MND.
