Waves of Precision: A Practical Guide for Reviewing New Tools to Evaluate Mechanical In-Exsufflation Efficacy in Neuromuscular Disorders

Author:

Chatwin Michelle12,Sancho Jesus34,Lujan Manel56ORCID,Andersen Tiina78ORCID,Winck Joao-Carlos910ORCID

Affiliation:

1. Neuromuscular Complex Care Centre, The National Hospital for Neurology and Neurosurgery, University College London Hospitals Foundation Trust, London WC1N 3BG, UK

2. Clinical and Academic Department of Sleep and Breathing, Royal Brompton Hospital, Part of Guys and St Thomas’ NHS Foundation Trust, London SW3 6NP, UK

3. Respiratory Medicine Department, Hospital Clínico Universitario, 46010 Valencia, Spain

4. Institute of Health Research INCLIVA, 46010 Valencia, Spain

5. Servei de Pneumologia, Parc Taulí Hospital Universitari, Institut d’Investigació i Innovació Parc Taulí (I3PT-CERCA), Universitat Autònoma de Barcelona, 08208 Sabadell, Spain

6. Centro de Investigación Biomédica en Red (CIBERES), 28029 Madrid, Spain

7. Norwegian Advisory Unit on Home Mechanical Ventilation, Thoracic Department, Haukeland University Hospital, 5021 Bergen, Norway

8. The Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, 5063 Bergen, Norway

9. Cardiovascular R&D Centre (UniC), Faculdade de Medicina da Universidade do Porto, 4200-319 Porto, Portugal

10. Pulmonology Unit, Instituto CUF, 4460-188 Porto, Portugal

Abstract

Mechanical insufflation-exsufflation (MI-E) is essential for secretion clearance, especially in neuromuscular disorders. For the best outcomes, initiation of MI-E should be started at the correct time with regular evaluation to the response to treatment. Typically, cough peak flow has been used to evaluate cough effectiveness with and without MI-E. This review highlights the limitations of this and discussed other tools to evaluate MI-E efficacy in this rapidly developing field. Such tools include the interpretation of parameters (like pressure, flow and volumes) that derive from the MI-E device and external methods to evaluate upper airway closure. In this review we pinpoint the differences between different devices in the market and discuss new tools to better titrate MI-E and detect pathological responses of the upper airway. We discuss the importance of point of care ultrasound (POCUS), transnasal fiberoptic laryngoscopy and wave form analysis in this setting. To improve clinical practice newer generation MI-E devices should allow real-time evaluation of waveforms and standardize some of the derived parameters.

Publisher

MDPI AG

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