Cough Insufficiency Research Articles

PULMONARYFUNCTIONINNEUROMUSCULARDISEASES

Respiratory functional assessment in patients with neuromuscular diseases allows us to quantify lung volumes and capacities, cough flows and the effectiveness of of ventilation. Pulse oximetry and non-invasive monitoring of exhaled carbon dioxide are also essential for the non-invasive assessment of hypoventilation associated with ventilatory muscle and cough insufficiency. In this way, it is possible to detect the objective needs for therapeutic assistance and implement health policies appropriate to the needs of this population.

Airway Clearance Strategies and Secretion Management in Amyotrophic Lateral Sclerosis.

Amyotrophic lateral sclerosis (ALS) is a rare, neurodegenerative motor neuron disease that affects voluntary muscle movement. Often, difficulty in coughing, breathing, and swallowing are sequela associated with the condition, and the presence of bulbar muscle predominant weakness results in deleterious effects on airway clearance and secretion management. This narrative review will provide practical guidance for clinicians treating this population. Cough insufficiency in this population typically manifests as a prolonged, slow, weak cough effort that impedes the clearability of secretions and airway protection. Dystussia and dysphagia frequently occur simultaneously in bulbar dysfunction, subsequently impacting respiratory health. Measures of respiratory strength should be obtained and monitored every 3-6 months, preferably in a multidisciplinary clinic setting. Cough augmentation, whether manual or mechanical techniques, should be sought as early in the disease progression as possible to adequately control secretions in the proximal airways. This airway clearance strategy can aid in the prevention and treatment of respiratory tract infections (RTIs), which can pose a significant clinical hurdle to those with ALS. The use of mechanical insufflation-exsufflation may be complicated by severe bulbar dysfunction rendering this technique ineffective. Though peripheral airway clearance strategies, such as high-frequency chest-wall compression, have the advantage of being less impacted by bulbar dysfunction, it is only recommended this modality be used in conjunction with, versus in lieu of, proximal strategies. Salivary secretion management includes the use of anticholinergics, botulinum toxin, and radiation therapy depending on severity and desire for relief.

Airway Care Interventions for Invasively Ventilated Critically Ill Adults—A Dutch National Survey

Airway care interventions may prevent accumulation of airway secretions and promote their evacuation, but evidence is scarce. Interventions include heated humidification, nebulization of mucolytics and/or bronchodilators, manual hyperinflation and use of mechanical insufflation-exsufflation (MI-E). Our aim is to identify current airway care practices for invasively ventilated patients in intensive care units (ICU) in the Netherlands. A self–administered web-based survey was sent to a single pre–appointed representative of all ICUs in the Netherlands. Response rate was 85% (72 ICUs). We found substantial heterogeneity in the intensity and combinations of airway care interventions used. Most (81%) ICUs reported using heated humidification as a routine prophylactic intervention. All (100%) responding ICUs used nebulized mucolytics and/or bronchodilators; however, only 43% ICUs reported nebulization as a routine prophylactic intervention. Most (81%) ICUs used manual hyperinflation, although only initiated with a clinical indication like difficult oxygenation. Few (22%) ICUs used MI-E for invasively ventilated patients. Use was always based on the indication of insufficient cough strength or as a continuation of home use. In the Netherlands, use of routine prophylactic airway care interventions is common despite evidence of no benefit. There is an urgent need for evidence of the benefit of these interventions to inform evidence-based guidelines.

REGISTRIES AND CARE OF NEUROMUSCULAR DISORDERS: P.287Mechanically assisted cough: how to keep it simple

Mechanical insufflation - exsufflation (MI:E) is a life extending method in neuromuscular patients with cough insufficiency. It supports airway clearance to prevent mucous retention, atelectasis and pneumonia. Some neuromuscular centers (NMC) are still unexperienced and hesitant in its use. In our pediatric NMC we have thus developed a standardized approach to facilitate practical use. Initial routine was based on literature and experience of two large centers. We use only one type of device. MI:E is introduced when cough peak flow is <50% of age-related reference, in ventilated patients and in case of clinical obvious cough insufficiency. We preset 3 different modes for home use. Mode 1 provides only insufflation for daily lung volume recruitment in health. In mode 2 in- and exsufflation are preset for airway secretions or SpO2<95%. In mode 3 expiratory oscillation during exsufflation is added for sticky secretions. Durations of in- and exsufflation are increased with age while pressures for in- and exsufflation are fixed at 30-35 cmH2O and -40 cmH2O. Staff, patients and caregivers are trained in MI:E to use modes depending on health condition of the patient and for emergencies. Retraining is performed regularly. This standardization facilitated teaching of staff, patients and caregivers in MI:E in our and other Austrian NMCs. Acceptance was rapid. Only 10% required adaptations to optimize efficacy. Proactive initiation and empowerment of patients and caregivers through training in applying those 3 different modes prevent emergencies. In 60 patients initiated using MI:E during 4 years no pneumothorax occurred. Only 2 SMA 1 patients died due to severe course of disease. This model could be used as a guide for NMCs with limited specialized staff for and expertise in respiratory management. Further investigations regarding the effects on clinical end points like hospitalisation rate and survival are needed.

The impact of lesion location on dysphagia incidence, pattern and complications in acute stroke. Part 2: Oropharyngeal residue, swallow and cough response, and pneumonia.

Dysphagia is a well-known complication of acute stroke. Given the complexity of cerebral swallowing control it is still difficult to predict which patients are likely to develop swallowing dysfunction based on their neuroimaging. In Part 2 of a comprehensive voxel-based imaging study, whether the location of a stroke lesion can be correlated with further dysfunctional swallowing patterns, pulmonary protective reflexes and pneumonia was evaluated. In all, 200 acute stroke cases were investigated applying flexible endoscopic evaluation of swallowing within 96 h from admission. Lesions were mapped using patients' computed tomography/magnetic resonance images and these were registered to a standard space. The percentage of lesioned volume of 137 anatomically defined brain regions was determined on a voxel basis (FSL5.0). Region-specific odds ratios (ORs) were calculated with respect to the presence of oropharyngeal residue, delayed swallow response, insufficient cough reflex and occurrence of pneumonia during hospital stay. Colour-coded lesion location maps of brain regions with significant ORs were created (P < 0.05). Lesion maps for residue and impaired swallow response depicted parietal-temporal areas of the right hemisphere. Limbic structures in the right hemisphere and sensory regions on the left were associated with cough reflex disturbance. There was no overlap of lesion maps for impaired swallow response and insufficient cough reflex or pneumonia, but substantial overlap between the last two conditions. This study gives new insights on the cortical representation of single components of swallowing and airway protection behaviours. The lesion model may help to risk-stratify patients for dysphagia and pneumonia based on their brain scan.

Treatment for Cough: Two Sides to the Story

The role of cough is of interest to speech-language pathologists (SLPs) for two seemingly contradictory reasons: chronic, excessive cough and insufficient cough. Evidence supports the role of the SLP in behavioral strategies for both the reduction and/or elimination of chronic cough, as well as the use of pulmonary exercise to realize improved airway clearance in individuals with a weak, insufficient cough. At both ends of this continuum, anchored at one end by too much coughing and the other end anchored by inadequate cough for airway clearance/pulmonary health, the SLP has an important role.

Respiratory illness in children with disability: a serious problem?

Key pointsChildren with neurocognitive impairment often present with chronic or recurrent respiratory problems.The respiratory problems have an important impact on quality of life and life expectancy.The underlying causes are multiple: risk of aspiration, insufficient cough, upper airway obstruction and progressive kyphoscoliosis.There is often a complex interplay between these known risk factors.The diagnostic and therapeutic approach should be multidisciplinary.Educational aimsTo provide data on the prevalence of respiratory problems in children with disability and to increase awareness on this topic.To provide insight into the complex interplay of the underlying causes and risk factors for chronic lung infection and respiratory failure.To give an overview of the diagnostic approaches relevant in this context.To highlight possible therapeutic approaches.To touch on ethical considerations in this group of vulnerable and complex patients.

Upper airway microbial colonization in patients with neuromuscular disorders.

Inherited neuromuscular disorders (NMD) inevitably result in severe lung volume restriction and cough insufficiency associated with high morbidity and mortality. The aim of this retrospective study was to evaluate whether the airways of patients with NMD are colonized with potential pathogenic microorganisms that might contribute to the pulmonary morbidity in NMD. In this cross-sectional study, cough swabs were obtained and cultured for microbiological analyses from 77 patients with NMD and different degrees of lung volume restriction and cough insufficiency. Upper airway microbial colonization was compared to lung function parameters and cough peak flow values. Upper airway microbial colonization with potential pathogenic pathogens was identified in 39/77 (51%) of the subjects. Upper airway microbial colonization was associated with lower forced vital capacity (% pred.) 26.6 ± 19.7 versus 41.8 ± 20.4, P < 0.001 and cough peak flow (l/min) 125 ± 55 versus 207 ± 100, P < 0.001. In the subgroup colonized with potential pathogenic Gram-negative bacteria or Staphylococcus aureus forced vital capacity and cough peak flow remained significantly lower compared with subjects without upper airway colonization (FVC (% pred.): 22.6 ± 16.5 vs 37.9 ± 21.5, P = 0.003; CPF (l/min): 123 ± 60 vs 179 ± 93, P = 0.013). Severe respiratory compromise in patients with NMD is associated with upper airway microbial airway colonization, which might contribute to respiratory morbidity/insufficiency.

The value of cough peak flow measurements in the assessment of extubation or decannulation readiness

Insufficient cough strength has a major role in extubation and decannulation outcomes.Cough capacity can be easily evaluated by measuring flows during coughing. Values vary depending on whether cough flows are measured through the mouth or through a tracheostomy or endotracheal tube. It is important to standardize these measurements and start using them routinely in the extubation and decannulation processes. Values of cough peak flow >160L/min measured at the mouth or a value of cough PEF >60L/min measured at the endotracheal tube suggest successful decannulation or extubation.

Anesthetic Considerations for Bilateral Lung Transplantation in Mounier-Kuhn Syndrome

OUNIER-KUHN SYNDROME (MKS), or tracheobronchomegaly, is a rare disorder of unknown etiology that is characterized by marked dilation of the trachea and major bronchi, due to severe atrophy and thinning, as well as absence of elastic fibers and smooth muscular fibers of the large airways. 1 This syndrome commonly presents in men in the third or fourth decade of life. It is marked by weakness of the membranous and cartilaginous parts of the trachea and main bronchi leading to an insufficient cough, mucous retention, and tracheobronchial wall collapse during respiration. Symptoms can range from well-preserved lung function to refractory respiratory failure. There are fewer than 100 case reports in the literature with only 2 reports of successful lung transplantation for patients with this syndrome. 1–3 Herein, the authors present a case of a patient diagnosed with MKS presenting for bilateral lung transplantation and describe the one-lung ventilation (OLV) strategies that were attempted and utilized.

Pulmonary Issues in Patients with Chronic Neuromuscular Disease

Patients with chronic neuromuscular diseases such as spinal cord injury, amyotrophic lateral sclerosis, and muscular dystrophies experience respiratory complications that are cared for by the respiratory practitioner. An organized anatomical approach for evaluation and treatment is helpful to provide appropriate clinical care. Effective noninvasive strategies for management of hypoventilation, sleep-disordered breathing, and cough insufficiency are available for these patients.

Cough - another important factor in extubation readiness in critically ill patients

Ling Liu and colleagues [1] found that critically ill patients who fail weaning have impaired ability to convert neuromuscular activity into tidal ventilation, highlighting the eff ect of diaphragm weakness on weaning and extubation from mechanical ventilation. However, it is noteworthy that the insuffi cient cough strength greatly contributes to failed extubation in clinical practice as well, particularly in patients with acute cervical cord injury, or who have undergone major thoracic or abdominal surgery. Some intubated patients with inadequate cough strength can successfully pass the spontaneous breathing trial, but nevertheless might still experience extubation failure afterwards. It is diffi cult for them to clear secretions in airways due to the inability to cough, which leads to increased risk of atelectasis and respiratory infection. Weak cough can be attributable to expiratory muscle dysfunction, inspiratory muscle weakness, and so on; however, expiratory muscle function is crucial for eff ective cough [2]. Th e major expiratory muscles include the muscles of the anterolateral wall of the abdomen, the expiratory intercostal muscle, and the triangularis sterni [3]. Th e neuro-ventilatory effi ciency of these muscles, however, cannot be assessed by diaphragm electrical activity. Expiratory muscle strength became a focus of interest for estimating cough strength. Cough peak expiratory fl ow was used to evaluate cough refl ex, which was considered an indicator for predicting successful extubation of

Myasthenia gravis in an 22 months-old girl - impressing improvement due to early adaequate therapy

Aims: Infantile Myasthenia gravis (MG) is a rare autoimmune disease, antibodies against the nicotinic acetylcholine receptor (AChR) can be found in 50% off all cases. Others as antibodies to muscle-specific kinase (MuSK) are less frequent. The prevalence of MG in infants below 1 year of age is approximately 1.1/106. If antibodies are missing, a congenital myasthenic syndrome (CMS) has to be taken into account. Therapeutical options are the treatment with acetylcholinesterase inhibitors and often also immunosuppression. Depending on clinical severity a plasmapheresis or intravenous immunoglobulin could be indicated. A thymectomy could increase the probability of remission. Methods: We report on a 22-months-old girl with an uneventful neurological development. At the age of 20 months she showed a one-sided ptosis, in further course of both sides with a significant strength reduction in a context of a febrile common cold. First examinations without abnormal results in brain-MRI or blood. No elevation of AChR-antibodies at the beginning. Because of the typical clinical symptoms a therapy with pyridostigmine was started with only mild improvement. A few weeks later slightly elevated temperature due to a common cold, markedly reduced strength, serious ptosis, cough insufficiency; unable to sit, stand or walk. A slightly elevated AChR-antibodies-level was found (0.83 nmol/l), the repetitive nerve stimulation showed a decrement more than 10%. Results: In addition to the treatment with pyridostigmine (5mg/kgBW/day) we started a therapy with steroids and thereafter also with azathioprine. An impressing improvement could be demonstrated even after reduction of steroids. The girl actually shows a stable status. Conclusion: There are only few reports on infantile and juvenile MG patients and their therapy, evidence based recommendations for medical treatment do not exist. However a consequent drug therapy with acetylcholinesterase inhibitors, steroids and azathioprine reached a dramatic improvement in our patient and held it until now. Depending on clinical course and age a thymectomy have to be considered.

Kommentar zu den Leitlinien 2010 zur kardiopulmonalen Reanimation des European Resuscitation Council

Administer chest compressions (minimum 100/min, minimum 5 cm depth) at a ratio of 30:2 with ventilation (tidal volume 500-600 ml, inspiration time 1 s, F(I)O₂ if possible 1.0). Avoid any interruptions in chest compressions. After every single defibrillation attempt (initially biphasic 120-200 J, monophasic 360 J, subsequently with the respective highest energy), chest compressions are initiated again immediately for 2 min independent of the ECG rhythm. Tracheal intubation is the optimal method for securing the airway during resuscitation but should be performed only by experienced airway management providers. Laryngoscopy is performed during ongoing chest compressions; interruption of chest compressions for a maximum of 10 s to pass the tube through the vocal cords. Supraglottic airway devices are alternatives to tracheal intubation. Drug administration routes for adults and children: first choice i.v., second choice intraosseous (i.o.). Vasopressors: 1 mg epinephrine every 3-5 min i.v. After the third unsuccessful defibrillation amiodarone (300 mg i.v.), repetition (150 mg) possible. Sodium bicarbonate (50 ml 8.4%) only for excessive hyperkaliemia, metabolic acidosis, or intoxication with tricyclic antidepressants. Consider aminophylline (5 mg/kgBW). Thrombolysis during spontaneous circulation only for myocardial infarction or massive pulmonary embolism; during on-going cardiopulmonary resuscitation (CPR) only when indications of massive pulmonary embolism. Active compression-decompression (ACD-CPR) and inspiratory threshold valve (ITV-CPR) are not superior to good standard CPR. Most effective improvement of outcome by prevention of full cardiorespiratory arrest. Basic life support: initially five rescue breaths, followed by chest compressions (100-120/min depth about one third of chest diameter), compression-ventilation ratio 15:2. Foreign body airway obstruction with insufficient cough: alternate back blows and chest compressions (infants), or abdominal compressions (children >1 year). Treatment of potentially reversible causes: ("4 Hs and 4 Ts") hypoxia and hypovolaemia, hypokalaemia and hyperkalaemia, hypothermia, and tension pneumothorax, tamponade, toxic/therapeutic disturbances, thrombosis (coronary/pulmonary). Advanced life support: adrenaline (epinephrine) 10 µg/kgBW i.v. or i.o. every 3-5 min. Defibrillation (4 J/kgBW; monophasic or biphasic) followed by 2 min CPR, then ECG and pulse check. NEWBORNS: Initially inflate the lungs with bag-valve mask ventilation (p(AW) 20-40 cmH₂O). If heart rate remains <60/min, start chest compressions (120 chest compressions/min) and ventilation with a ratio 3:1. Maintain normothermia in preterm babies by covering them with foodgrade plastic wrap or similar. POSTRESUSCITATION PHASE: Early protocol-based intensive care stabilization; initiate mild hypothermia early regardless of initial cardiac rhythm [32-34°C for 12-24 h (adults) or 24 h (children); slow rewarming (<0.5°C/h)]. Consider percutaneous coronary intervention (PCI) in patients with presumed cardiac ischemia. Prediction of CPR outcome is not possible at the scene, determine neurological outcome <72 h after cardiac arrest with somatosensory evoked potentials, biochemical tests and neurological examination. ACUTE CORONARY SYNDROME: Even if only a weak suspicion of an acute coronary syndrome is present, record a prehospital 12-lead ECG. In parallel to pain therapy, administer aspirin (160-325 mg p.o. or i.v.) and clopidogrel (75-600 mg depending on strategy); in ST-elevation myocardial infarction (STEMI) and planned PCI also prasugrel (60 mg p.o.). Antithrombins, such as heparin (60 IU/kgBW, max. 4000 IU), enoxaparin, bivalirudin or fondaparinux depending on the diagnosis (STEMI or non-STEMI-ACS) and the planned therapeutic strategy. In STEMI define reperfusion strategy depending on duration of symptoms until PCI, age and location of infarction. TRAUMA: In severe hemorrhagic shock, definitive control of bleeding is the most important goal. For successful CPR of trauma patients a minimal intravascular volume status and management of hypoxia are essential. Aggressive fluid resuscitation, hyperventilation and excessive ventilation pressure may impair outcome in patients with severe hemorrhagic shock. Any CPR training is better than nothing; simplification of contents and processes is the main aim.

Cough insufficiency is more pronounced in spinal muscular atrophy than in Duchenne muscular dystrophy

Cough insufficiency is more pronounced in spinal muscular atrophy than in Duchenne muscular dystrophy

Isolation and insight: practical pillars of revalidation?

The clearance of airway secretions from the lungs is normally supported by the mucociliary escalator and by cough. These protective mechanisms provide an effective means of pulmonary-hygiene maintenance in healthy individuals. Patients with neuromuscular disease that affects the respiratory pump (the muscles of breathing) can experience mild to profound limitation in both ventilation and cough. Neuromuscular respiratory insufficiency, when left untreated, can substantially impact quality of life and life expectancy. In most cases of neuromuscular disease, respiratory failure and pneumonia are the primary causes of death. Invasive mechanical ventilation and tracheal suctioning have been successfully used when needed to support respiratory insufficiency in this population. These modalities, though supportive, have been associated with substantial morbidity when used in patients with neuromuscular disease. The advent of noninvasive ventilation as a means of supporting chronic neuromuscular respiratory insufficiency has spurred the development of noninvasive cough-augmentation therapy to support airway clearance. Unfortunately, the need to support cough clearance is not always addressed, and few guidelines for the management of cough insufficiency have existed until relatively recently. An understanding of neuromuscular respiratory pathophysiology and the modes of effective noninvasive cough support are key in the evaluation and management of neuromuscular diseases. This review is meant to provide a basic understanding of cough mechanics, and the pathophysiology and management of neuromuscular cough insufficiency.

Review Article: Mechanical ventilation in Duchenne patients with chronic respiratory insufficiency: clinical implications of 20 years published experience

Chronic respiratory insufficiency is inevitable in the course of disease progression in patients with Duchenne muscular dystrophy (DMD). Without mechanical ventilation (MV), morbidity and mortality are highly likely towards the end of the second decade of life. The present review reports evidence and clinical implications regarding DMD patients treated with MV. There is no doubt that nocturnal hypercapnia precedes daytime hypercapnia. Historical comparisons have provided evidence that non-invasive intermittent positive pressure ventilation (NIPPV) at night is effective and improves quality of life and survival by 5-10 years. By contrast, the optimal criteria and timing for initiation of NIPPV are inconsistent. A recent randomized study however demonstrated the benefits of commencing NIPPV as soon as nocturnal hypoventilation is detected (Ward S, et al., Randomised controlled trial of non-invasive ventilation (NIV) for nocturnal hypoventilation in neuromuscular and chest wall disease patients with daytime normocapnia. Thorax 2005; 60: 1019-24). The respective role of the three hypotheses of the indirect action of nocturnal NIPPV on daytime blood gases may be complimentary; the main improvement may be due to improved ventilatory response to CO2. The ultimate time to offer full time ventilation with the most advantageous interface is lacking in evidence. Full time NIV is possible with a combination of a nasal mask during the night and a mouthpiece during the day, however tracheostomy may be provided when mechanical techniques of cough-assistance are useless to treat chronic cough insufficiency.

SYMPTOMS, CLINICAL AND PHYSIOLOGICAL FINDINGS MOTIVATING HOME MECHANICAL VENTILATION IN PATIENTS WITH NEUROMUSCULAR DISEASES

To clarify the relationship between symptoms, clinical signs and physiological abnormalities that were motivating the initiation of home mechanical ventilation in patients suffering from neuromuscular diseases. From The Swedish Home Mechanical Ventilation Register we identified 352 patients with neuromuscular diseases and we looked at circumstances (acute vs elective) and clinical motives for starting ventilatory support. Home mechanical ventilation was commenced electively in 268 patients (76%) and among these daytime sleepiness was the most common motive, being reported in 56% of the patients. In the 24 children with spinal muscular atrophy, however, 96% started ventilation electively and cough insufficiency was the most common motive. The patients were moderately hypercapnic (PaCO(2): 7.0 kPa, SD 1.3). None of the clinical motives were related to the PaCO(2) level. Average PaO(2) was above 8 kPa in all groups, but lowest in the patients with post-polio and dystrophia myotonica. Mean vital capacity was close to 40% of predicted, but significantly lower in the Duchenne patients (26% of predicted). Daytime sleepiness was the most common clinical symptom motivating home mechanical ventilation in this group of patients with chronic hypercapnic respiratory insufficiency secondary to neuro/myopathies. Respiratory function testing is therefore suggested to be included in the diagnostic work up of daytime sleepiness in these patients.

Respiratory function assessment and intervention in neuromuscular disorders

Published research on neuromuscular respiratory failure has increased rapidly over the past decade. Progress in the management of respiratory complications and preventive care have improved outcomes and quality of life for many. In particular, noninvasive positive pressure ventilation (NIPPV) is effective in resolving respiratory failure and has dramatically changed the management of these patients. In this review we discuss recent studies assessing the course of respiratory failure, with a focus on non-Duchenne muscular dystrophy; investigating the impact NIPPV has when it is introduced before diurnal respiratory failure develops; and evaluating a device to treat insufficient cough--the mechanical insufflator--exsufflator (MI-E). Studies in children with congenital muscular dystrophies and spinal muscular atrophies detected a high prevalence of respiratory complications and confirmed that respiratory failure can be predicted by measurement of vital capacity. NIPPV is an established treatment that is effective in the long-term management of end-stage diurnal respiratory failure. Additionally, recent studies showed improvement in symptoms, quality of life and prevention of respiratory complications when it is introduced for nocturnal hypoventilation before the development of diurnal respiratory failure. However, data on the efficiency of the MI-E are limited, and studies comparing it with other techniques of assisted coughing are needed. Recent findings stress the importance of regular respiratory assessment in neuromuscular disease, including sleep studies; strongly support the introduction of NIPPV for management of symptomatic nocturnal hypoventilation; and suggest that prospective randomized trials are required to verify the usefulness of the MI-E.

Coughing reflex induced by electrostimulation of the trachea: a pilot study

Introduction: Pulmonary infections and ateleetases are common complications in Intensive Care, neurological and surgical units. One of the main causes of these complications is insufficient cough activity resulting in sputum retention. In order to treat the problem of insufficient coughing and to reduce the disadvantages of the conventional methods, we developed a new method, which induces a coughing reflex by electric stimulation of the trachea. A literature search on the subject revealed no information. In co-operation with the Department of Bioinformatics of the University of Twente an electrode and electrostimulator were developed and tested in animal study. Methods: Ten patients in the intensive care unit with reduced ability to remove sputum by coughing were included in the study. The frequency of coughing caused by mechanical stimulation of the trachea (suction)was observed and compared with coughing caused by the electrode in position without any stimulation and coughing caused by electrical stimulation. Results: During electrostimulation coughing could be induced in all cases with same or better intensity than with mechanical stimulation. A positive effect on sputum evacuation was observed. No side effects were observed on ECG, oxygen saturation and blood pressure; of the six conscious patients one noticed a slight tingling sensation at the location of the electrode. Conclusions: In this pilot study electrostimulation of the trachea appears to be effective in inducing coughing reflexes in patients with a reduced ability to effectively cough. Also a positive effect on sputum evacuation was observed. The method of electrical stimulation may offer a way to reduce the disadvantages of the conventional method. When the method is applied with assistance of computer or timer, a higher frequency of treatment can be archieved and this may offer a way of improved effectiveness. Because less personnel is needed when using this method, and stay on ICU may be shortened, improved cost-effectiveness can be archieved.