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					                 NHS Lothian - University Hospitals Division – Children’s Services

                         PHYSIOTHERAPY USE OF THE COUGH ASSIST


                            THIS DOCUMENT MUST NOT BE COPIED


1.     Purpose of this document
       To provide guidelines for physiotherapists using the Cough Assist.

2.     Who should use this document
       Physiotherapy, nursing and medical staff.

3.     To whom this document applies
       Physiotherapy staff

4.     Contact point
       Physiotherapy department tel 0131 536 0337
       Respiratory Physiotherapist bleep 9163
       Physiotherapy Service Manager 0131 536 0330

5.     Further reference
       Instruction manual
       Respiratory Care: Alex Hough
       Emergency Physiotherapy – On Call Survival Guide Beverly Harden
       Anderson J.L., Hasney K.M. & Beaumont N.E. Systematic review of techniques to enhance
       peak cough flow and maintain vital capacity in neuromuscular disease: the case for
       mechanical insufflation- exsufflation. Physical Therapy Reviews 2005; 10: 25- 33.

6.     Review group
       Senior 1 Respiratory Physiotherapists
       Senior 11 Physiotherapist

7.     Source
       Physiotherapy Department May 2006

8.     Review Date
       December 2009




Ref No:                         Issue Date: May 2006           Review Date: December 2009
Published by: M Grant           Level:         
Ratified by:                    TB              EMT          DMT            PSD         PN
Issuing Officer: Fiona Gardner  Signature:                     Signature:
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                 NHS Lothian - University Hospitals Division – Children’s Services

                        PHYSIOTHERAPY USE OF THE COUGH ASSIST

The physiotherapy department has Cough assist machines, models CA- 3200.
Please refer to instruction manual attached to the machines.
One is kept in treatment room 4 and the others are in treatment room 5.
Masks and tubing will be kept in the cupboard in treatment room 5.

INDICATIONS
Inability to cough or clear secretions effectively
Reduced peak cough expiratory flow (less than 2 to 3 litres per second)                 ( Harden, 2004 &
Anderson et al, 2005).

CONTRAINDICATIONS
Undrained pneumothorax
Bullous emphysema
Known susceptibility to pneumothorax
Known susceptibility to pneumo-mediastinum
Recent barotraumas ( Harden, 2004).

CARE SHOULD BE TAKEN WITH
Patients with known cardiac instability should have their pulse and oxygen saturations monitored
very closely.
Soreness and/or pain in the chest from a pulled muscle may occur in patients using the Cough
Assist for the first time if the positive pressure used exceeds pressures, which the patient normally
receives during Positive Pressure Therapy e.g. use of a volume ventilator, nasal or mask
ventilation, CPAP or IPPB.

COMPLICATIONS
Fear, pain and poor technique will lead to poor synchrony with the machine (Harden, 2004).

CLEANING
Tubing and mask are single patient use and should be replaced. Spares are available from the
cupboard in treatment room 5.
After each use, the breathing hose and patient interface should be washed thoroughly in soap and
water and left to air dry. These parts must be completely dried before reuse.
The filter should be replaced between each patient to prevent cross contamination. Do not try to
wash the filter. The filter may need to be replaced during individual use if it becomes blocked by
sputum or trapped moisture.
The exterior of the machine may be washed with a mild detergent and water, or with a bactericidal
cleaning solution such as 70% isopropyl alcohol.

TECHNIQUE
Discuss starting use of the cough assist with patient’s doctors.
Explain procedure to patient and let them try holding the mask to their face with the machine
switched off.
Set the inhale flow to full or reduced.
Attach the patient circuit to the unit and block the end of the breathing hose.
The cough assisted can be operated manually or set to automatic.
Chest physio is best done prior to use of the cough assist.


                                                Page 2 of 4
                    Physiotherapy Use of the Cough Assist- Review Date: December 2009
                 NHS Lothian - University Hospitals Division – Children’s Services

                         PHYSIOTHERAPY USE OF THE COUGH ASSIST

Manual Operation
Set the manual/auto switch to manual.
Push the manual control lever to the exhalation phase. Observe the pressure gauge on the device
and adjust the maximum pressure (negative) using the pressure knob to achieve correct reading
on the gauge.
Shift the manual control lever to the inhalation phase. Adjust the pressure reading by turning the
inhale pressure knob to achieve the correct reading on the pressure gauge (clockwise to increase
pressure and counter clockwise to decrease pressure).
Cycle the manual control lever from inhale (positive) to exhale (negative) and back a few times to
ensure that the pressure and suction readings are correct.
Release the manual control lever to ensure that the pressure immediately returns to 0cm H2O. If it
does not, refer to the Maintenance Section of the manual.

Automatic Operation
To operate the unit automatically, set the manual/ auto switch to the auto position.
The unit will cycle from inhale (positive) to exhale (negative) to zero pressure, and back to inhale.
After 4-5 cycles, set the manual/auto switch back to the manual position.
Remove the patient mask from the patient and allow time for a normal breathing pattern to return
(20-30 seconds), or place the patient back on the ventilator if currently in use.
During this resting period, clear secretions that may have become visible in the mouth, throat or
tracheostomy tube.

With both the automatic and manual settings the patient is instructed to cough when the
breath out starts.

The technique can be combined with an assisted cough, which should be done during the exhale
phase of the cough assist.


The patient may need a few inspiratory breaths post coughing to recover.



SETTINGS
It is advisable to begin with lower pressures, such as 10-15cm H2O positive and negative, to
familiarise the patient with the feel of the mechanical insufflattion- exsufflation.
During subsequent treatments, pressures can be increased as necessary to achieve adequate
secretion clearance.
If on NIV start at the level set on the ventilator, initially keeping inspiratory and expiratory pressure
equal.
Increase the expiratory pressure if the patient needs more “suck”.

Maximum positive pressure is 60cm H2O (44 mm Hg)
Maximum negative pressure is 60cm H2O (44 mm Hg)

As there is no CO2 outlet, with both the automatic and manual settings, should cycle for 4-5
breaths and then allow the patient a short rest and time to recover their normal breathing
pattern.


                                                 Page 3 of 4
                     Physiotherapy Use of the Cough Assist- Review Date: December 2009
                 NHS Lothian - University Hospitals Division – Children’s Services

                        PHYSIOTHERAPY USE OF THE COUGH ASSIST

QUICK GUIDE
   If doing other CPT do them prior to using the cough assist
   Set the manual/ auto switch to manual
   Push the lever to exhale
   Turn the pressure knob to set the exhalation pressure
   Push the lever to inhale
   Turn the inhale pressure knob set the inhalation pressure
   Cycle the lever between inhale and exhale to ensure the pressures are correct
   Observe patient’s breathing pattern
   Place the mask on the patient
   Instruct patient to cough or manually assist cough when the breath out starts
   Cycle for 4-5 breaths, then allow patient to rest
   Repeat as required


NOTE
The unit is designed for intermittent operation only and not for continuous use. The device should
not be cycled continuously for more than 5 minutes. After such times, the unit should either be
turned off or left idling with the blower on for at least 5 minutes.
Ensure the Cough Assist is positioned so that the air intake ports on the side and rear of the unit
are not blocked.




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                    Physiotherapy Use of the Cough Assist- Review Date: December 2009

				
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