Mechanical Insufflation-Exsufflation for Patients With Bronchiectasis and After Tracheal Stenting

Abstract

SESSION TITLE: Airways Global Case Reports I SESSION TYPE: Global Case Report Poster PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM INTRODUCTION: Mechanical insufflation-exsufflation (MI-E) is primarily used in patients with neuromuscular disease with reduced sputum expectoration strength. Although patients with bronchiectasis and those after airway stenting retain strength for sputum expectoration, the presence of abundant and viscous sputum and reduced ciliary motility of the airway epithelium make sputum expectoration difficult. The efficacy of MI-E for these diseases is yet to be ascertained. CASE PRESENTATION: Case 1: An 83-year-old woman presented with advanced bronchiectasis and showed colonization of mucoid-type Pseudomonas aeruginosa. Her hospitalization frequency had increased owing to increased sputum and respiratory discomfort, and long-term antibiotic administration had resulted in drug-resistant Pseudomonas aeruginosa infection. We introduced MI-E (CoughAsist E70® Philips Respironics, Japan) with the aim of improving the symptoms through sputum expectoration. The MI-E pressure was +20/-35 cm H2O; oscillations (10 Hz, ±5 cm H2O) were simultaneously used during exhalation. The peak cough flow (PCF) was 190 L/min. A large amount of sputum was easily expectorated, and she showed improved percutaneous arterial O2 saturation after MI-E. Her fever pattern also gradually improved along with a decrease in the sputum volume. On day 19, her neutrophil count normalized, and the C-reactive protein also decreased to pre-hospitalization levels. The required oxygen level also decreased to 3L from 5L before hospitalization, and her P/F ratio improved from 170 to 320. The patient was discharged at day 22 after MI-E introduction and continued undergoing MI-E at home. Case 2: A 58-year-old man with airway narrowing due to advanced lung cancer was hospitalized after severe dyspnea progression. Subsequently, a Y-type silicon stent was placed in the tracheal bifurcation. The day after stenting, his dyspnea improved significantly; however, his sputum production increased and he experienced expectoration difficulties. Hence, MI-E was introduced. The MI-E pressure was +30/-40 cm H2O; oscillations (10 Hz, ±5cm H2O) were used simultaneously during exhalation. The PCF was about 170 L/min. Sputum was easily expectorated and his dyspnea improved. Once the patient was accustomed to the technique, he began operating the MI-E himself and was able to expectorate his sputum with appropriate timing. DISCUSSION: The MI-E was shown to be effective in patients with decreased sputum expectoration strength, such as those with neuromuscular disease. However, both patients in our report were able to effectively expectorate sputum at a lower PCF than is recommended in cases with neuromuscular diseases, probably because the CoughAsist E70® device we used had an oscillatory function and improvement in maintenance of a constant airway pressure may have enabled sputum elimination from a more peripheral airway region. In Case 1, the efficacy of home usage was brief, but the patient was elderly and may have therefore found it difficult to comprehend the usage of the MI-E leading to poor implementation. CONCLUSIONS: This is the first study to report the effectiveness of MI-E in patients with bronchiectasis and airway stenting. MI-E was useful for the removal of large amounts of viscous sputum in patients with bronchiectasis and in those after airway stenting. The results of this study suggest that sputum elimination may lead to improvement in clinical symptoms. Future studies are warranted to conduct prospective investigation on the usefulness of MI-E in patients with various chronic respiratory diseases. Reference #1: Vianello A, Corrado A, Arcaro G,et al. Mechanical insufflation-exsufflation improves outcomes for neuromuscular disease patients with respiratory tract infections. Am J Phys Med Rehabil. 2005 ;84 :83-88 Reference #2: Winck JC, Gonçalves MR, Lourenço C,et al. Effects of mechanical insufflation-exsufflation on respiratory parameters for patients with chronic airway secretion encumbrance. Chest. 2004 ;126 :774-780. Reference #3: Chatwin M, Ross E, Hart N,et al.Cough augmentation with mechanical insufflation/exsufflation in patients with neuromuscular weakness. Eur Respir J. 2003 ;21 :502-508. DISCLOSURE: The following authors have nothing to disclose: Hibiki Kanda, Shuichi Yano, Shinichi Iwamoto, Emiko Nishikawa, Toru Kadowaki, Kanako Kobayashi, Masahiro Kimura, Toshikazu Ikeda No Product/Research Disclosure Information