Download In-Exsuffalators 101

In-Exsufflators 101
A Practical Guide to the Use of an In-Exsufflator (Cough Assist) by Tom Tomko.
In-Exsufflators 101
A Practical Guide to the Use of an In-Exsufflator (Cough Assist) by Tom Tomko
Insurance Issues
Before discussing the use of an in-exsufflator, it should be noted that some insurance companies are still reluctant to
approve payment for one. After falling out of use for many years, the device was only recently reintroduced for use by
individuals with neuromuscular disease. At this point in time, no controlled studies have been done on the use of an
in-exsufflator for this express purpose, and most existing studies and articles were authored by the same individual –
John R. Bach, M.D. Unfortunately, until more supporting studies are performed to confirm Dr. Bach’s findings and
clinical experience, insurance companies may be reluctant to pay for the high cost of the machine.
Nevertheless, it is important to include Dr. Bach’s studies and articles when submitting a letter of justification to the
insurance company. An important article authored by Dr. Bach is titled Prevention of Pulmonary Morbidity for Patients
With Neuromuscular Disease, Chest 2000. A related study, also performed by Dr. Bach, is Mechanical insufflationexsufflation. Comparison of peak expiratory flows with manually assisted and unassisted coughing techniques, Chest
1993.
It is not unusual for an insurance company to reject an initial request for purchase approval. The best way to handle
this is to be patient, persistent and professional while appealing the decision as many times as necessary. Keep a
record of all correspondence, and require that the insurance company provide specific reasons for any denial. Put
pressure on the company to indicate why they feel that an in-exsufflator will not address your child’s needs, and use
these specifics to find pertinent information that may sway their decision. It is also important that you and your
physician work together as a team. The physician’s letter, preferably written or co-written by a pulmonologist, should
focus on the need for frequent assisted coughing, and should include all details pertaining to your child’s pulmonary
function testing (PFT) results. Ask for a copy of the letter, and forward to your child’s physician all correspondence
sent to, and received from, the insurance company.
Of course, none of this will guarantee success, but at least you will sleep better knowing that you did all that you
could. In the meantime, manually assisted coughing, through the use of “abdominal thrusts”, should be performed
whenever necessary. This is accomplished by gently pressing on your child’s diaphragm while they cough, which
helps the child to achieve a more productive cough. (for more information on assisted coughing, see Chest
Physiotherapy)
Effectively Using the Equipment
A typical cough involves a slow, deep inhalation (insufflation), followed by a forceful, quick exhalation (exsufflation).
This action helps to clear our airways of mucous secretions, by moving them up and out. Because your child’s
diaphragm and intercostal muscles are weakened from SMA, however, they are unable to inhale as deeply or exhale
as forcefully. The result is that their airways can become clogged, especially during periods of respiratory distress
due to colds or other illnesses.
Since the in-exsufflator had been decommissioned for so long, many healthcare professionals are either untrained, or
only recently trained, in its use. The result is often confusion over what the proper settings should be. In the absence
of this understanding, technicians are often recommending settings that do not properly simulate a cough. Since each
child is different, I can only provide some general guidelines; you should work together with your child’s physician to
establish the appropriate settings for your child.
There are five primary settings on the typical automatic in-exsufflator: the inhale time, the inhale pressure, the exhale
time, the exhale pressure, and the time to pause between the inhale and exhale phases. These settings should be
adjusted so that they generate a good, productive cough without causing discomfort. Bear in mind that, when
coughing, the exhale pressure is greater than the inhale pressure, so it will take less time to expel the same volume
of air as was inhaled.
If your child seems to be “fighting” the machine, then it is possible that the settings need to be adjusted. For example,
if the inhale time is too long relative to the inhale pressure, your child will want to initiate a cough, but they won’t be
able to do so until the machine stops blowing air in. Similarly, if the exhale time is too long relative to the exhale
pressure, your child will want to breath in, but they won’t be able to do so until the machine stops sucking air out.
It is best to start with low pressure settings until your child becomes comfortable with the feel of mechanically
assisted coughing. To avoid pulling a chest muscle, first time users should not use an inhale pressure that exceeds
their BiPAP or IPPB inhale pressure setting. The inhale pressure can then be gradually increased over the course of
several days if warranted.
A cough cycle involves the inhale phase, the exhale phase, and an optional pause in between. After four or five
cough cycles, the child should take a twenty to thirty second break to allow time for a normal breathing pattern to
return. A full treatment involves repeating the entire process from six to ten times.
To phrase it simply: you need to insufflate until the lungs and chest are fully expanded, and exsufflate until they are
contracted - without patient discomfort. Watching the patient is more important than limiting yourself to numbers from
BiPAP IPAPs. Assisted coughing must be effective to really clear airway secretions. For more details about
recommended guidelines and 'the numbers' for use of the In-Exsufflator, please see Dr. Bach's discussion.
Mask or Mouthpiece
The in-exsufflator can be fitted with either a mask or a mouthpiece. Although your healthcare technician may be
biased toward one or the other, you should resist feeling pressured when choosing which is best for your child. Since
it may be difficult to make a determination, especially after only a brief introduction to the equipment and its operation,
it may be helpful to experiment with both options over the course of a few days.
Involve Your Child’s Physician
Since the in-exsufflator has only recently reentered the healthcare scene, it is possible that your child’s physician will
be unfamiliar with the equipment. For this reason, I recommend that you make sure that you obtain the instruction
manual, and that you send the physician a copy – along with copies of the aforementioned article and clinical study.
Schedule an appointment to go over the instructions with the physician and to mutually arrive at settings that will work
best for your child.
It should be noted that medical equipment suppliers sometimes keep the instructions and only deliver the equipment.
If you do not receive the instruction manual, make sure that you obtain one either through the provider or through the
manufacturer.
It is important that your child’s physician be aware of your use of the machine. Should your child ever require
hospitalization due to respiratory distress, you will likely want to bring the in-exsufflator into the hospital so treatments
can be continued. You may, however, encounter some initial resistance from the hospital staff, and your child’s
physician can serve as an important source of information and direction in determining when and how often to
incorporate the machine’s use in your child’s protocol.
When to In-Exsufflate
The in-exsufflator takes some getting used to, so it is best that your child be familiar with it prior to any bout of illness
that might require its use. Even if your child is healthy, you may nevertheless want to perform periodic treatments to
keep their airways clear and to ensure that they remain comfortable with mechanical in-exsufflation. This will ensure
that, should they become ill, they will be more likely to quickly readapt to the treatment process rather than it
becoming an additional source of agitation during an already stressful time.
You may find it useful to perform a treatment the first thing in the morning. This will help to open up any small mucous
plugs that may have formed overnight as a result of the shallower breathing that occurs when we are fast asleep –
particularly for children with SMA. You may also want to perform a treatment just before bedtime to clear the airways
and lessen the chance of plugging during this shallow nighttime breathing.
During periods of respiratory distress, the in-exsufflator is apt to loosen up a lot of mucous. Although the machine
adequately simulates a cough, it is often helpful during these times to complement the mechanical coughing with
some manually assisted coughing as described earlier. Also, the in-exsufflator is best used to generate controlled
coughing. Should your child begin to cough uncontrollably, it may be helpful to temporarily suspend the treatment and
provide manual assistance until the coughing spell has subsided.
Cleaning
Cleaning the equipment is important, but it can be a real job. Make sure that you don't use longer tubing than you
need, since longer tubing is harder to clean. You can always join two pieces together if you ever need longer tubing
(your equipment provider should be able to get you the connectors).
Conclusion
Used correctly, the in-exsufflator can be a valuable resource in keeping the airways clear while giving a caregiver
some sorely needed assistance. It is not, however, a panacea, and in some instances it may actually increase the
amount of effort required by a caregiver. Often, however, this is a good sign, since it means that the secretions are
flowing, which is the first step in winning the battle against the effects of respiratory illness for a child with SMA.