I am practicing as resp.therapy tech. i just want to know your opinion,my question is "it is possible that cough assist is applicable in ventilated pedia patient?,because one doctor ordered cough assist in ventilated patient.. it is possible?
Posts: 1 | Location: qatar | Registered: October 09, 2007
Ealier I posted a link to a Marini article in FOCUS magazine. In it he described how he'll use square wave flow pattern, periodic Peep releases, etc. all to augment secretion clearance. March/April 2007
Respironics now has the Cough Assist as one of their products. We recently had an ALS patient and don't own a cough assist so I checked with my local Respironics rep in an attempt to locate someone I could rent one from. She wasn't able to help me locate a rental unit, but I found she knew very little about this product that is new to her line. She thought the device was only for peds since the only accounts that had made any inquiries since she received the product was a local children's hospital. I was quick to inform her that a very powerful tool had been added to her product line, and it's usefulness was far from limited to ped applications. A few years back I did a brief stint as a clinical coordinator in a SNF based vent program. Half of our vent population was neuro-muscular patients. My staff were very good at ptussive squeeze/augmented cough techniques. With these patients we would IPPB until something broke loose, and then assist exp. flow with abdominal thrust, and rib springs etc. to clear the loosened secretions. We felt we were doing a pretty good job. Most of our patients were on room air or a very low bleed in. We heard about what was at that time called a Cough-a-lator, or something like that. The device we first got a hold of had a horse shoe shaped tube that you manually switched back and for the between vac and blow. Timing was totally manual. I believe you could adjust the peak vac and blow pressure. We used a 6 ft length of corrugated tubing attached to the patient's Ballard for secretion clearance. Using the same sequence of IPPB until something broke loose, but using the Cough Assist for getting out the loosened secretions, we initially had very dramatic results. On patients who were producing moderate volumes of secretions we nearly filled the corrugated tubing, totally overwhelming the Ballard's ability to keep up with the secretions that literally came flying out of our patients. We were able to clear breath sounds on patients who had chronic crackles. We achieved more volume with the IPPB than we had ever been able to previously. We were quickly sold on the device. I have discussed using the cough assist with some quad care purists, and they assert that if you are any good at manually augmenting the neuromuscular patient's cough you don't need the device. That may be true, but if you care for NM patients only rarely, it is a little difficult to keep everybody's skill with the manual techniques sharp enough to do airway clearance on these patients justice. Our ALS patient discharged to home ventilation with never really developing any severe secretion retention issues, so for that patient bag/lavage suction techniques to assist his cough was adequate, but if I were ever to have to care for multiple NM patients, I would really work to access one of these devices for my patients. One caution we found when we were first using the Cough-a-lator was that if the patient has any strength to their own cough, the timing of the insp and exp flows have to be perfectly coordinated with their own efforts. We found this to be almost impossible, and when we tried it with our non-NM pts they would almost always wind up with a pulled intercostals or some other accessory muscle. The newer machines give you the ability to set timing of insp and exp periods, but I don't think there is any sensitivity to the patient, and cycle only by the timing. Ability to sense pt effort to trigger insp and cycling into exp triggered by reaching a pressure threshold would make this an even better device. I have seen families taught to use them with good results. I have also heard of prolonged cough sessions with the devices leading to patient down turn. We usually used 7-10 cycles max until loosened secretions were cleared. We had great patient safety. We did volume expansion with IPs of around 40cwp, and found they tolerated similar IPs with the Cough Assist. The exp pressure we set different for each depending on what worked best.
Thanks for the links Jeff, and as always the thoughts. I will give this some strong consideration for my next NM patient with secretion management issues since I don't think we will get a Cough Assist in the next budget here.
Posts: 142 | Location: Fort Worth Tx | Registered: January 27, 2006
Gary.....The Cough Assist can be rented directly from Respironics. All you need to do is to call customer service with a PO and they will overnight the cough assist directly to you. When you are done, call for a return authorization number and send it back.
There is a nice paper in the recent RC Journal dealing with AW clearance in the geriatric and neuromuscularly compromised PT. It has information you may find useful as well as info on the use of IPV... which is freaking awesome!