SESSION TITLE: Respiratory Care SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Patients with diaphragmatic weakness present unique challenges to airway clearance, mobilizing secretions and preventing frequent hospitalizations due to respiratory failure. CASE PRESENTATION: We present the case of a 68-year-old male with a past medical history of chronic respiratory failure due to very severe chronic obstructive pulmonary disease (COPD), obstructive sleep apnea, congestive heart failure (CHF) and aortic root repair complicated by bilateral diaphragmatic paralysis. Over six months, the patient had eight hospitalizations with acute on chronic respiratory failure related to recurrent pneumonia in the right lower lobe as well as COPD and CHF exacerbations. Respiratory cultures were positive for Serratia marcescens and Achromobacter xylosoxidans. Attempts at aggressive airway clearance therapies including nebulizers, hand-held oscillating positive pressure device, chest physiotherapy, average volume assured pressure support ventilation and multiple antibiotic courses were unsuccessful. Radiographic imaging via chest X-ray and non-contrast computed tomography (CT) of the chest demonstrated progressive right lower lobe consolidation and bronchiectatic changes. In an attempt to augment cough efforts and secretion clearance, a mechanical insufflation-exsufflation (MI-E) with oscillatory function was added to his daily regimen. Following this therapeutic intervention, a significant symptomatic and radiographic improvement in his chronic lung consolidation was noted in one month on follow up of chest-CT; he has since only been hospitalized for exacerbation of heart failure due to dietary indiscretion. DISCUSSION: Diaphragmatic paralysis has different etiologies including myopathic syndromes, connective tissue disorders or direct damage to the phrenic nerve. Patients are at high risk for hypoventilation resulting in chronic hypercapnia and difficulty clearing secretions. Rates of recurrent pneumonia and acute on chronic respiratory failure are proportionally increased. Both cough assist and oscillatory devices have documented success in helping to mobilize secretions in patients with various neuromuscular disorders. MI-E devices have been shown to augment cough efficacy and secretion clearance. The efficacy of combining such therapy with an oscillatory component into one device is not as clear. Our case illustrates the impact of such a device resulting in immediate subjective and objective response to therapy. Likewise, we would note the positive impact on health care utilization costs; the high upfront cost (∼$4,000 dollars) of this device may have prevented the above hospitalizations saving significant costs. CONCLUSIONS: The introduction of a combined insufflation-exsufflation and oscillatory device to patients with significant diaphragmatic weakness has the potential to more effectively augment airway clearance and be a valuable tool in decreasing health service use. 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 Feb;84(2):83-8 Reference #2: Mahede T, Davis G, Rutkay A, et. al. Use of mechanical airway clearance devices in the home by people with neuromuscular disorders: effects on health service use and lifestyle benefits. Orphanet J Rare Dis. 2015 May 6;10:54 Reference #3: Auger C, Hernando V, Galmiche H. Use of Mechanical Insufflation-Exsufflation Devices for Airway Clearance in Subjects With Neuromuscular Disease. Respir Care. 2017 Feb;62(2):236-245 DISCLOSURES: No relevant relationships by Muhammad Ali, source=Web Response No relevant relationships by Andreea Anton, source=Web Response No relevant relationships by Mark Barash, source=Web Response No relevant relationships by Aasim Mohammed, source=Web Response