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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4566_Библиотеки_им_академика_М_И_Перельмана
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Indications for tracheostomy
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Table 1. Indications for tracheostomy
Dependence on ventilation for >16 h a day, not satisfactorily managed by NIV
Aspiration of secretions leading to chest infections
Diculties with airway secretion clearance
Upper airway obstruction or non-patency, e.g. due to tumour, laryngectomy,
mucopolysaccharidosis
Inability to control arterial blood gas tensions using NIV
Problems tolerating NIV, e.g. due to interface issues, age (neonate/infant)
Patient preference
than in adults. Use of cough assist devices together with experienced physiotherapists
can optimise secretion clearance noninvasively in many situations. This means the
combination of eective NIV, secretion clearance and PEG (percutaneous endoscopic
gastrostomy) feeding can oen obviate the need for a tracheostomy in older children
and adults.
The elective or semi-elective progression to a tracheostomy should always be
discussed carefully with the patient, and family/carers wherever possible, outlining
the pros and cons. Advances in tracheostomy management mean that speaking and
feeding are now more feasible, but risk management and the care package required
is by necessity more complex.
The outcome of T-IPPV is largely determined by the underlying condition. Marchese
et al. (2008) showed a median survival of 26 months in COPD patients, which was
even lower than for patients with amyotrophic lateral sclerosis (ALS) at a median of
49 months. Hospital readmissions were highest in those with pulmonary disease, but
the tracheostomy complication rate was low at 2.6%.
Patient satisfaction and health-related quality of life (HRQoL) oen depends on the
circumstances in which the tracheostomy is performed. Life satisfaction and quality of
life (QoL) has been shown to be poor in patients in whom tracheostomy was performed
for prolonged weaning diculties aer acute decompensation and was significantly
worse in those with COPD compared to those with NMD. Important determinants
of QoL were the negative impact of T-IPPV on the ability to communicate, mobility,
social contact and autonomy.
However, for patients with slowly progressive NMD, Delorme et al. (2023) showed
good or excellent QoL in around two-thirds of patients on home mechanical ventilation
and, in fact, HRQoL for T-IPPV users was better than for those on NIV. About a third
had received a tracheostomy as an emergency. The dierence here is that this survey
Table 2. Planning for long-term T-IPPV
Choice of tracheostomy tube: cued, uncued
Medical equipment: ventilator with back-up, suction machine and catheters, and cough
assist devices, all with replacement, service and breakdown plans
Skills training of carers/family including management of acute emergencies
(e.g. mucus plug, displacement of tracheostomy tube, electrical power failure) and
performance of CPR
Access to a multidisciplinary medical team for regular follow-up and acute care
Support for family and carers
Advance care plan
CPR: cardiopulmonary resuscitation.
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ERS Handbook: Respiratory Sleep Medicine
Indications for tracheostomy
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was carried out aer an average of 18 years with T-IPPV, so the patients represent a
stable survivorship who have progressed well and have adapted to T-IPPV. There is a
further discussion of the use of NIV versus T-IPPV in chapter 13.1 of this Handbook,
‘Noninvasive ventilation’.
The considerations for initiating long-term T-IPPV and discharge home are outlined
in table 2. Planning, skills training of family and carers, and risk management are
essential components of a successful long-term care plan. More detailed accounts are
given elsewhere (see: Escarrabill, 2015; Amar-Dolan et al., 2020).
Further reading
• Amar-Dolan LG, et al. (2020). “This is how hard it is”. Family experience of hospital-to-home
transition with a tracheostomy. Ann Am Thorac Soc; 17: 860–868.
• Bradley P, et al. (2018). Long-term tracheostomy ventilation in the community: characteristics
of a UK cohort. Eur Respir J; 52: Suppl. 62, PA1673.
• Delorme M, et al. (2023). Quality of life in patients with slowly progressive neuromuscular
disorders dependent on mechanical ventilation. Thorax; 78: 92–96.
• Escarrabill J (2015). Patient and carer education, and risk management. In: Simonds AK, ed.
ERS Practical Handbook of Noninvasive Ventilation. Sheeld, European Respiratory Society;
pp. 282–288.
• Huttman SE, et al. (2018). Quality of life and life satisfaction are severely impaired in patients
with long term invasive ventilation following ICU treatment and unsuccessful weaning. Ann
Intensive Care; 8: 38.
• Marchese S, et al. (2008). Outcomes and attitudes towards home tracheostomy ventilation of
consecutive patients: a 10-year experience. Respir Med; 102: 430–436.
• Winck JC (2019). Long-term tracheostomy ventilation in Portugal: survey based on home care
providers. Pulmonology; 25: 180.
295ERS Handbook: Respiratory Sleep Medicine
Cough augmentation
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techniques
Tiina Andersen and Michel Toussaint
Cough as a function
The cough is the body’s strongest physiological reflex. It removes airway secretions
from the central airways and is a crucial element in sustaining a healthy respiratory
system. An eective cough depends on three phases, illustrated in figure 1. If one or
more of the phases is disturbed, the patient’s cough might become weak and they are
at an increased risk of secretion accumulation and complications such as dyspnoea
and pneumonia.
An eective cough has the capacity to clear mucus or debris out of the airways during
a cough eort. It is largely dependent on the magnitude of the cough peak flow (CPF)
generated during the expulsive phase of the cough. In addition, measurements of
FVC, maximal inspiratory pressure (P
can detect a weak cough and guide the clinician to choose a suitable manual or
mechanical cough augmentation technique.
) and maximal expiratory pressure (P
Imax
Emax
)
Cough augmentation in specific hypoventilation syndromes
In the hypoventilation subgroups with no airway secretion clearance problems, cough
augmentation is not necessary to prevent chest infections. However, an acute viral
Key points
• In patients with muscular weakness, customised cough techniques are
needed to prevent and treat the accumulation of secretions, as well as
complications like dyspnoea and pneumonia.
• ‘Hypoventilation syndrome’ covers a wide range of subgroups, not all of which
require cough augmentation techniques.
• Cough augmentation is recommended when CPF is <270 L·min−1 and/or FVC
is <50% of the predicted capacity when stable.
• One of the following techniques can be selected, depending on the objective
measurements: MI-E, manually assisted cough, air stacking, LVR or
glossopharyngeal breathing.
• Individualisation of cough augmentation is an important factor of success.
296
ERS Handbook: Respiratory Sleep Medicine
3) Forceful expiration
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Sucient expiratory airflow to move
the secretions
The patient coughs; if necessary,
combine with a manually assisted cough
The patient actively coughs
The patient actively coughs; if
necessary, combine with a manually
assisted cough
Cough expiratory compression is applied;
Cough augmentation techniques
0
2
15–20
cmH
1.0–2.0 s
Start with:
Time
Pressure
Exsuation
the direction of the compression is in line
with the expiratory chest wall movement
Alter the settings according
to individual responses
If necessary, combine with
manually assisted cough
cough is stronger
• Better cough audibility
• Secretions up to the mouth
• A feeling in the patient that their
• Increased CPF
Cough phase and aim
2) Glottic closure
Enhance the expulsion of the
airflow
The patient holds their breath between each
pistoning
1) Deep inspiration
Sucient inspiratory volume for an
eective cough
Pistoning of small amounts of air
(usually 6–12 times) into the lungs using
Techniques
When insuated, coordinate the opening to
expiratory eort
the glossopharyngeal muscles (mouth,
tongue, pharynx and larynx)
breathing
Glossopharyngeal
The patient holds their breath between each
stacking
When insuated, coordinate the opening to
expiratory eort
Instruct the patient to coordinate glottis
closure aer the inspiration phase, opening
quickly when giving a manually
assisted cough
The lung volume gradually increases until the
patient is unable to inhale more air
A series of breaths in (usually 3–4 times) with a
manual resuscitator or ventilator without the
patient breathing out, until the patient is unable to
inhale more air
The patient takes a deep breath; if necessary, use
glossopharyngeal breathing or air stacking
Air
stacking
cough
Manually assisted
• In bulbar patients, this is not oen possible
Consider individually how to instruct the patient
With instruction, most non-bulbar
patients manage to coordinate glottis closure
and opening with the pressure swing from
positive to negative
0
2
On
1.5–2.5 s
Low (bulbar)
10–15 cmH
High (no bulbar)
Start with:
Time
(flow)
Pressure
Risetime
Triggering
Insuation
Alter the settings in accordance
with individual responses
If possible, the patient takes a
breath to start the insuation;
if not, triggering should be o
Mechanical
exsuation
insuation-
glottis, followed by rapid opening
• In non-bulbar patients: firm closure of the
• Increased volume
deep breath in
• Good chest wall expansion
• A feeling in the patient that they can take a
achieve:
be tirated to
Techniques should
Figure 1. The clinical titration of cough augmentation is a dynamic process, which involves patient interaction and addresses all three cough phases.
297ERS Handbook: Respiratory Sleep Medicine
Cough augmentation techniques
https://t.me/medicina_free
illness can further weaken the patient by decreasing their inspiratory and expiratory
muscle strength, leading to an even more reduced vital capacity and a less eective
cough. Where there is increased production of airway mucus and obstruction in the
airways, additional peripheral airway clearance techniques may be warranted to
mobilise secretions.
Cough augmentation helps most patients with neuromuscular diseases (NMDs).
Techniques that ensure lung recruitment and augment coughing to increase the CPF
are recommended in order to prevent chest infection. In rapidly progressing diseases,
such as amyotrophic lateral sclerosis (ALS), the pathological processes may evolve so
quickly that the respiratory management becomes responsive to already-established
pulmonary complications. Early respiratory interventions are therefore beneficial in
these patients.
Cough augmentation can be more challenging in subjects with bulbar innervated
muscular dysfunction, where synchronisation of the glottic movements in a cough
is disturbed. With additionally weakened inspiratory and expiratory muscles, all
of the cough phases become inadequate. In some challenging patients, laryngeal
visualisation during dynamic cough augmentation titration might be useful, where
clinical reasoning alone does not lead to success.
Patients with severe kyphoscoliosis are another challenging subgroup, where the rigid
thorax prevents good chest expansion and reversion, and it is hard to increase the CPF.
Cough augmentation techniques
Cough augmentation techniques should aim to increase either the inspiratory volume
or the expiratory flow depending on the patient’s individual needs. Some of the
manually and mechanically assisted techniques used are described below and are
presented in figures 1 and 2.
Inspiratory support
Cough eectiveness is connected to the deep breath that precedes the cough. If
the patient is unable to take a deep breath, the air stacking technique (repeated
inspirations without breathing out) can be used to assist insuation, with a manual
resuscitator or mechanical device delivering positive pressure. Glossopharyngeal
breathing can also help self-insuation.
Air stacking manually assists inspiration by increasing the inspiratory volume of the
lung to its maximum extent. This results in an enhanced expiratory flow through a
combination of static recoil and expiratory muscle recruitment.
The advantages of air stacking include its low cost and its availability.
Expiratory support
Expiratory support techniques aim to: assist the expiratory muscles that are incapable
of increasing intra-abdominal and intra-thoracic pressure; and/or increase the
expiratory flow generated during the cough manoeuvre.
Expiratory support can be provided either through manually assisted cough (i.e.
the therapist administers thoracoabdominal thrusts that are coordinated with the
patient’s cough eort during the exhalation phase) or through mechanical exsuation
of the lungs. Assistance may also be achieved by a self-induced thrust to the abdomen
from a stationary object such as a table.
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ERS Handbook: Respiratory Sleep Medicine
Cough augmentation techniques
FVC, % pred
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of
Amount
provided
assistance
Cost
GPB
MAC
alone
alone
Insuation
+MAC
MI-E Insuation
MI-E
+MAC
Self-
Assisted
insuation
insuation
GPB
MAC
alone
Assisted
insuation
alone
(LVR, AS)
+
MAC
MI-E
possible
possible
MI-E+MAC
first
MI-E
choice
first
choice
MI-E+MAC
100
450
400
350
4.0
3.5
3.0
No need
for assisted cough
75
250
300
–1
Consider need
CPF, L·min
FVC, L
2.0
2.5
for assisted cough
50
200
1.5
100
150
0.5
1.0
Need for
assisted cough
25
Figure 2. The published literature regarding the critical values FVC % predicted, FVC L and CPF, the relative cost and the amount of assistance required for the
initiation of cough augmentation techniques. MAC: manually assisted cough; LVR: lung volume recruitment; AS: air stacking; GPB: glossopharyngeal breathing.
Reproduced and modified from Toussaint et al. (2018) with permission.
299ERS Handbook: Respiratory Sleep Medicine
Cough augmentation techniques
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Mechanically assisted cough
Mechanical insuation-exsuation (MI-E) is a mechanical technique used to assist
cough by combining both inspiratory and expiratory support. When the patient
inhales, MI-E supports the inspiration by delivering a positive pressure (insuation)
that contributes to better expansion of the lungs. This is followed by a rapid switch
to a negative pressure, supporting the expiration (exsuation) of the patient’s lungs.
These positive and negative pressure swings are applied sequentially, with the aim of
simulating the airflow changes that occur during normal cough, potentially facilitating
secretion clearance. This cyclical process is repeated several times or until secretions
are substantially expelled.
MI-E is considered a safe method for cough clearance. It is much more expensive than
air stacking, and use of the procedure is not reimbursed in all countries. Studies have
not suciently demonstrated the benefits of MI-E in terms of mortality, morbidity
and quality of life. Despite these limitations, most recent and relevant international
guidelines recommend the use of MI-E, supporting the view that ‘absence of evidence
of the eect is not evidence of absence of the eect’.
Individualisation
As the group of patients requiring cough support is heterogeneous, respiratory
physiotherapists can individualise the way the techniques are used (figure 1). The
chosen technique and the way it is used should be both eective and tolerated by the
patient. It is important to build up good chest expansion by using the techniques that
assist inspiration, and to subsequently adjust the expiratory phase of cough support
so that the audible quality of the cough reaches a desired and adequate level.
Respiratory muscles become increasingly weak as diseases progress, meaning more
supportive techniques will be needed compensate (figure 2).
Daily respiratory treatment usually takes place at the patient’s home and is performed
by personal caregivers, according to individually tailored procedures that have been
planned for home use.
Further reading
• Andersen TM, et al. (2021). Upper airway assessment and responses during mechanically
assisted cough. Respir Care; 66: 1196–1213.
• Auger C, et al. (2017). Use of mechanical insuation-exsuation devices for airway clearance
in subjects with neuromuscular disease. Respir Care; 62: 236–245.
• Benditt JO (2018). Pathophysiology of neuromuscular respiratory diseases. Clin Chest Med;
39: 297–308.
• Chatwin M, et al. (2018). Airway clearance techniques in neuromuscular disorders: a state of
the art review. Respir Med; 136: 98–110.
• Georges M, et al. (2022). Proposals from a French expert panel for respiratory care in ALS
patients. Respir Med Res; 81: 100901.
• Homnick DN (2007). Mechanical insuation-exsuation for airway mucus clearance. Respir
Care; 52: 1296–1305.
• Morrow B, et al. (2013). Mechanical insuation-exsuation for people with neuromuscular
disorders. Cochrane Database Syst Rev; 12: CD010044.
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ERS Handbook: Respiratory Sleep Medicine
Cough augmentation techniques
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• Morrow B, et al. (2021). Cough augmentation techniques for people with chronic
neuromuscular disorders. Cochrane Database Syst Rev; 4: CD013170.
• Rose L, et al. (2022). Health care use, costs, and survival trajectory of home mechanical
insuation-exsuation. Respir Care; 67: 191–200.
• Sheers N, et al. (2019). Respiratory adjuncts to NIV in neuromuscular disease. Respirology;
24: 512–520.
• Toussaint M, et al. (2016). Cough augmentation in subjects with Duchenne muscular
dystrophy: comparison of air stacking via a resuscitator bag versus mechanical ventilation.
Respir Care; 61: 61–67.
• Toussaint M, et al. (2018). 228th ENMC International Workshop: airway clearance techniques
in neuromuscular disorders Naarden, The Netherlands, 3–5 March, 2017. Neuromuscul
Disord; 28: 289–298.
301ERS Handbook: Respiratory Sleep Medicine
Indications for additional
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oxygen treatment
Anita K. Simonds
Criteria for long-term oxygen therapy in patients with chronic hypoxaemia due to
COPD and other conditions such as interstitial lung disease (ILD) and cystic fibrosis
are well established. In these situations, the cause of hypoxaemia is primarily oxygen
diusion limitation and a failure of gas exchange.
In alveolar hypoventilation, especially in patients with daytime hypercapnia, oxygen
treatment is not first-line therapy, and may worsen hypercapnia due to suppression of
hypoxic ventilatory drive. A rise in carbon dioxide tension (P
by a reduction in hypoxic vasoconstriction caused by uncontrolled oxygen leading to
ventilation/perfusion mismatch; and the Haldane eect (whereby oxygen induces a
right shi of the carbon dioxide (CO2) dissociation curve, displacing CO2) is also a
contributor to an increase in hypercapnia.
For these reasons, oxygen should be always be added with careful monitoring of
S
and P
aO
2
hypoxaemia in patients with hypoventilation in whom the current ventilatory support
. However, additional oxygen therapy is indicated to correct residual
CO
2
for hypoventilation has been optimised as far as possible. In practice, supplemental
oxygen therapy may be required acutely (box 1), or on a long-term basis to address
hypoxaemia. These situations can be dierentiated by the clinical scenario and
measurement of arterial blood gases. Patients with acute ventilatory failure will have
a low P
chronic ventilatory failure will have a low P
but relatively normal pH if compensation has occurred.
, low pH and bicarbonate level, and elevated P
aO
2
, elevated P
aO
2
) may also be explained
CO
2
. Patients with acute-on-
CO
2
, raised bicarbonate level,
aCO
2
Key points
• In patients with alveolar hypoventilation, oxygen should be added where
indicated with careful monitoring of S
• The cause of hypoxaemia should always be identified and addressed where
possible, and the management of hypoventilation should be optimised before
the supplemental oxygen flow rate is titrated.
• Additional oxygen therapy can provoke a rise in P
hypoventilation, caused by a number of mechanisms: loss of hypoxic
vasoconstriction, depression of hypoxic ventilatory drive, and the Haldane eect.
• Oxygen should be prescribed to a target S
302
aO
2
and P
.
CO
2
in patients with alveolar
CO
2
level.
aO
2
ERS Handbook: Respiratory Sleep Medicine
Indications for additional oxygen treatment
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Box 1. Acute indications for additional oxygen therapy in hypoxaemic
patients
Acute indications for oxygen supplementation:
• During an acute chest infection
• During an episode of pulmonary oedema
• For hypoxaemia due to intercurrent illness such as PE, pleural eusion,
pneumothorax
It should be noted that the cause of acute, or acute-on-chronic hypoxaemia
should always be identified and treated. In patients with neuromuscular disease
and reduced cough ecacy, a very common cause of hypoxaemia is an increase in
pulmonary secretions, which should be addressed promptly using physiotherapy and
secretion clearance techniques such as mechanical insuation–exsuation. Clinical
examination and chest radiography will indicate if there is pneumonic consolidation,
pneumothorax, pulmonary oedema or pleural eusion present. A computed
tomography scan should be performed if there is a moderate or high risk of pulmonary
embolism (PE). An increase in IPAP may be required in some situations, e.g. pulmonary
atelectasis, and a small increase in EPAP may aid alveolar recruitment and reduce
work of breathing. However in the presence of a pneumothorax, NIV settings should
be changed with caution, and the need for NIV carefully reviewed. A low threshold for
pneumothorax drainage is advised in patients in whom continued NIV is essential.
Chronic indications
Patients with chronic lung disease as a cause of chronic ventilatory failure (e.g.
COPD, bronchiectasis, ILD) may require supplemental oxygen therapy with NIV
or tracheostomy ventilation due to persisting hypoxaemia. In all cases, ventilatory
settings (particularly IPAP and back-up rate) should be optimised to control P
If, despite CO2 control, S
should be added and flow rate titrated to aim for a mean S
Monitoring of S
optimised. In some ventilators, oxygen is entrained into the device; in others, oxygen
aO
2
and P
during ventilation remains <90% on air, oxygen therapy
aO
2
will enable ventilator settings and oxygen flow rate to be
tcCO
2
of 88–92%.
aO
2
aCO
2
should be entrained into the circuit as proximally to the patient as possible, just
before the expiratory port. The delivered inspired oxygen fraction will be influenced
by IPAP and EPAP levels, as well as flow rate and position of entrainment into the
ventilatory circuit. Flow rate should always be prescribed to achieve a target S
The continued need for oxygen supplementation should be reviewed particularly aer
aO
2
value.
an acute-on-chronic exacerbation has resolved.
It should be noted that oxygen therapy is not a treatment for breathlessness in
non-hypoxaemic patients. It may be prescribed for symptom palliation in end-stage
lung disease.
Daytime oxygen therapy
This is rarely required in patients with neuromuscular disease when breathing
spontaneously, but may be necessary in those with chronic hypoxaemia due to COPD
or primary lung disease. Flow rates can be titrated to S
walk test or 6-min walk test. In patients with mobility problems, oxygen flow rate can
using a standard shuttle
aO
2
be assessed pragmatically during activities of daily living.
.
303ERS Handbook: Respiratory Sleep Medicine
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