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This review article describes definitive noninvasive respiratory management of respiratory muscle dysfunction to eliminate need to resort to tracheotomy. In 2010 clinicians from 22 centers in 18 countries reported 1,623 spinal muscular atrophy type 1 (SMA1), Duchenne muscular dystrophy (DMD), and amyotrophic lateral sclerosis users of noninvasive ventilatory support (NVS) of whom 760 required it continuously (CNVS). The CNVS sustained their lives by over 3,000 patient-years without resort to indwelling tracheostomy tubes. These centers have now extubated at least 74 consecutive ventilator unweanable patients with DMD, over 95% of CNVS-dependent patients with SMA1, and hundreds of others with advanced neuromuscular disorders (NMDs) without resort to tracheotomy. Two centers reported a 99% success rate at extubating 258 ventilator unweanable patients without resort to tracheotomy. Patients with myopathic or lower motor neuron disorders can be managed noninvasively by up to CNVS, indefinitely, despite having little or no measurable vital capacity, with the use of physical medicine respiratory muscle aids. Ventilator-dependent patients can be decannulated of their tracheostomy tubes.
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To assess cough reflex sensitivity using the simplified cough test (SCT) and to evaluate the usefulness of SCT to screen for silent aspiration.
The healthy control group was divided into two subgroups: the young (n=29, 33.44±9.99 years) and the elderly (n=30, 63.66±4.37 years). The dysphagic elderly group (n=101, 72.95±9.19 years) consisted of patients with dysphagia, who suffered from a disease involving central nervous system (ischemic stroke 47, intracerebral hemorrhage 27, traumatic brain injury 11, encephalitis 5, hypoxic brain damage 3, and Parkinson disease 8). The SCT was performed using the mist of a 1% citric acid from a portable nebulizer. The time from the start of the inhalation to the first cough was measured as the cough latency. All the dysphagic patients underwent the videofluoroscopic swallowing study.
The cough latency was more significantly prolonged in the healthy elderly group than in the healthy young group (p<0.001), and in the dysphagic elderly group than in the healthy elderly group (p<0.001). The sensitivity and specificity of SCT were 73.8% and 72.5% for detecting aspiration in the dysphagic patients, and 87.1% and 66.7% for detecting silent aspiration in the aspirated patients.
Cough latency measured with the SCT reflects the impairment of cough reflex in healthy elderly and dysphasic subjects. The results of this study show that the SCT test can be a valuable method of screening aspiration with or without cough in dysphasic patients.
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Method: Thirty-one patients with DMD were investigated. The vital capacity (VC), maximum insufflation capacity (MIC), maximal inspiratory (MIP), and expiratory pressure (MEP) were measured. Unassisted peak cough flow (UPCF) and assisted PCF at three different conditions were evaluated.
Results: The mean value of MICs (1,873⁑644 cc) was higher than that of VCs (1,509⁑640 cc). MIP and MEP were 48.8⁑21.4% and 29.5⁑19.5% of predicted normal value respectively. MIP was correlated with UPCFs as well as MEP. All of three assisted cough methods showed significantly higher value than unassisted method (p＜0.01). The manual assisted PCFs at MIC significantly exceeded those produced by manual assisted or PCFs at MIC. The positive correlation between the MIC-VC difference and PCF at MIC-UPCF difference was seen (p＜0.01).
Conclusion: Inspiratory muscle strength and the preservation of pulmonary compliance is important for the development of effective cough as well as expiratory muscle power. Thus, the clinical implication of the inspiratory phase in assisting a cough should be emphasized. (J Korean Acad Rehab Med 2003; 27: 43-48)
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