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

Abstract

Many neuromuscular disease patient populations suffer from a weak, inadequate cough, which may lead to respiratory tract infections, respiratory failure, and increased mortality. Hospitalized neuromuscular disease patients are often treated with a mechanical insufflation-exsufflation (MI-E) machine to improve lung volume, promote mucociliary clearance and improve their respiratory health. Many of these patients require MI-E within their homes to maintain the benefits achieved in hospitals. Currently, a resource paper that outlines provincial funding avenues for home MI-E machines does not exist. Accordingly, Canadian Respiratory Health Professionals (CRHP) Leadership Council members formed a working group to propose and collate recommendations and resources for using MI-E in neuromuscular populations at home.

RÉSUMÉ

De nombreuses populations de patients atteints de maladies neuromusculaires souffrent d'une toux faible et inadéquate, ce qui peut entraîner des infections des voies respiratoires, une insuffisance respiratoire et une mortalité accrue. Les patients hospitalisés atteints d'une maladie neuromusculaire sont souvent traités avec un appareil d'insufflation- exsufflation mécanique (IE-M) pour améliorer leur volume pulmonaire, favoriser la clairance mucociliaire et améliorer leur santé respiratoire. Un grand nombre de ces patients ont besoin d’IE-M à domicile pour maintenir les bienfaits obtenus dans les hôpitaux. À l'heure actuelle, il n'existe pas de document de référence décrivant les possibilités de financement provincial pour les appareils d’IE-M à domicile. Par conséquent, les membres du Conseil de direction des Professionnels canadiens en santé respiratoire (PCSR) ont formé un groupe de travail pour proposer et assembler des recommandations et des ressources pour l'utilisation de l’IE-M chez les populations neuromusculaires à domicile.

Summary of key messages

1) Consensus machine settings for the mechanical insufflation-exsufflation (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 peak cough flow (PCF) of ≧270 L/min, which produces an effective cough. We suggest combining MI-E with manually assisted cough techniques to increase PCF further if required. 2) Patients with amyotrophic lateral sclerosis 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 amyotrophic lateral sclerosis due to the risk of upper airway collapse. 3) MI-E use in patients with Duchenne Muscular Dystrophy is recommended to improve the short-term sense of breathlessness and helps prevent the need for hospitalization, intubation and tracheostomy. 4) The use of MI-E in individuals with spinal cord injury 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. 5) The use of MI-E in generalized neuromuscular disorder 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 generalized neuromuscular disorder patients. 6) We recommend using home MI-E by non-professional caregivers with generalized neuromuscular disorder patients as it is found to be safe and effective with adequate training. The precise amount and nature of training are unclear. 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. 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.

CONCLUSION: Available evidence supports the use of MI-E for multiple neuromuscular patient populations with a weak cough to prevent respiratory complications, including intubation, tracheostomy and hospitalizations. Such patients should have access to home-based MI-E.

Keywords:

• Cough assist
• mechanical insufflator-exsufflator
• secretion clearance
• neuromuscular diseases
• cough
• insufflation
• respiratory insufficiency
• artificial respiration

Acknowledgments

The authors would like to thank CTS Executive and the CTS Canadian Respiratory Guidelines Committee (Sanjay Mehta) for their input and guidance. We would like to acknowledge with sincere appreciation our expert reviewers: Douglas A. McKim, Medical Director, CANVent Respiratory Rehabilitation Services, The Ottawa Hospital Rehabilitation Centre and the Executive Members of the CRHP Leadership Council.

Disclosure statement

KH, LNP, and MZ report no conflicts of interest. Please reach out to the authors of this paper if you are interested in support to create a MI-E funding program in your provincial/territorial government.