Mechanical insufflation-exsufflation and available funding for Canadian adult patients. A Canadian Thoracic Society Position Statement

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Key Message 1:
Consensus machine settings for the MI-E are variable in the literature for adult patient populations. We recommend that clinicians titrate parameters to achieve an increased insufflation time and greater expiratory flow to produce a PCF of ≧270, which produces an effective cough. We suggest combining MI-E with manually assisted cough techniques to increase PCF further, if required.

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Key Message 2:
Patients with ALS who present with a weak cough (PCF <270 L/min) should be administered MI-E to effectively achieve a PCF that is strong enough to clear secretions. However, the application of MI-E may not be effective in bulbar ALS due to the risk of upper airway collapse.

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Key Message 3:
MI-E use in patients with DMD is recommended to improve the short-term sense of breathlessness and helps prevent the need for hospitalization, intubation and tracheostomy.

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Key Message 4:
The use of MI-E in individuals with SCI may be beneficial for improving PCF. The addition of manually assisted cough may further increase cough strength. More research on the applicability of MI-E in this population is needed.

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Key Message 5:
The use of MI-E in generalized NMD patients has been shown to improve PCF and vital capacity compared to other methods of assisted cough. The addition of a manually assisted cough further improves PCF. The use of MI-E also suggests the prevention of hospitalizations in NMD patients.

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Key Message 6:
We recommend using home MI-E by nonprofessional caregivers with generalized NMD patients as it is found to be safe and effective with adequate training. The precise amount and nature of training are unclear.

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Key Message 7:
We recommend using MI-E in mechanically ventilated adult patients (> 18 years) to increase the volume of secretions expectorated compared to standard sterile suctioning techniques.

Table 1. Cost breakdown of MI-E device Cough-Assist E70 and related products.

Item	Cost (CAD)
CoughAssist E70	$5,000
Battery	$400
Bacteria filter	$18
Corrugated tubing (6 ft.)	$2.67 (262 pieces for $700)
Mask	$55
Cough assist kit (including filter, tubing, mask, and adapter)	$55
Estimated initial total	$6228

Abbreviations: MI-E, mechanical insufflation-exsufflation.

Table 2. Coverage for MI-E by province/territory.

Province or Territory	Is MI-E provincially funded?	Who can prescribe?	Name of the funding program	Diagnoses that are funded	Other Criteria
British Columbia	Yes	Respirologist	Provincial Respiratory Outreach Program	NMD or chest wall restriction with hypercapnia, stable condition, normal PCO2 but does have cor pulmonale, nocturnal hypoventilation, severe supine dyspnea, or symptoms of alveolar hypoventilation (requirements for program qualification)	Require home ventilation or BiPAP
Alberta	No
Saskatchewan	Yes	Respirologist, Physiatrist, Pediatrician, Neurologist, Rheumatologist	Saskatchewan Aids to Independent Living	Neuromuscular conditions, post-polio, SCI, or condition with weak respiratory muscles	Either ventilator dependent or at risk of becoming ventilator dependent, PCF of <270 L/min with LVR or manually assisted cough, and not be a resident of a special care home or acute care facility
Manitoba	No
Ontario	Yes, but client is only given an annual grant and will need to pay any extra costs	Physician (preferably a Respirologist)	Ontario’s Ventilator Equipment Pool	NMD, post-polio, SCI or a condition with weak respiratory muscles or paralysis	Individuals who qualify for the Assistive Devices Program, applicant is at risk of becoming ventilator dependent or is ventilator dependent, and has a PCF of <270 L/min with LVR or manually assisted cough
Québec	Yes, if they qualify	Respirologist, Neurologist, Respiratory Therapist, (Under PNAVD collective order)	Programme national d’assistance ventilative à domicile (PNAVD)	NMD, Kyphoscoliosis, Post-Polio Syndrome, SCI	Require home ventilation or BiPAP PCF <270 L/min Inability to perform LVR
Newfoundland/ Labrador	No
Nova Scotia	Yes, if they qualify for social assistance.	Any. (Preferably Respirologists, Neurologists, Physiatrists)	Nova Scotia Department of Community Services	ALS/ MD/ MS	Restrictive pattern and PCF <270 L/min
Prince Edward Island	No
New Brunswick	Yes, if they qualify for social assistance	Physician. Preferably respirologist, intensivist or physiatrist	New Brunswick Social Development Health Services program	ALS / Motor Neuron Disease, DMD, SCI / Tetraplegia, Central Hypoventilation, Kyphoscoliosis, Polio / Post-Polio, Spinal Muscular Atrophy, Other degenerative NMD	PCF <200 L/min
Yukon	No
Northwest Territories	No
Nunavut	No

Abbreviations: MI-E: mechanical insufflation-exsufflation; NMD: neuromuscular disease; SCI: spinal cord injury; ALS: amyotrophic lateral sclerosis; DMD: Duchenne muscular dystrophy; MD: muscular dystrophy; MS: multiple sclerosis; LVR: lung volume recruitment; PCF: peak cough flow; BiPAP: Bilevel Positive Airway Pressure.

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Key Message 8:
We strongly recommend that Canadians have equitable access to MI-E which requires provinces to prioritize available funding for home MI-E. Currently there are large gaps in funding sources throughout the country