Empilhamento de ar e compressão torácica aumentam o pico de fluxo da tosse em pacientes com distrofia muscular de Duchenne

Abstract

Objective: To evaluate cough efficiency using two manually-assisted cough techniques. Methods: We selected 28 patients with Duchenne muscular dystrophy. The patients were receiving noninvasive nocturnal ventilatory support and presented FVC values < 60% of predicted. Peak cough flow (PCF) was measured, with the patient seated, at four time points: at baseline, during a spontaneous maximal expiratory effort (MEE); during an MEE while receiving chest compression; during an MEE after air stacking with a manual resuscitation bag; and during an MEE with air stacking and compression (combined technique). The last three measurements were conducted in random order. The results were compared using Pearson's correlation test and ANOVA with repeated measures, followed by Tukey's post-hoc test (p < 0.05). Results: The mean age of the patients was 20 ± 4 years, and the mean FVC was 29 ± 12%. Mean PCF at baseline, with chest compression, after air stacking and with the use of the combined technique was 171 ± 67, 231 ± 81, 225 ± 80, and 292 ± 86 L/min, respectively. The results obtained with the use of the combined technique were significantly better than were those obtained with the use of either technique alone (F[3.69] = 67.07; p < 0.001). Conclusions: Both chest compression and air stacking techniques were efficient in increasing PCF. However, the combination of these two techniques had a significant additional effect (p < 0.0001).Keywords: Muscular dystrophy, Duchenne; Intermittent positive-pressure ventilation; Cough; Insufflation; Peak expiratory flow rate. ResumoObjetivo: Avaliar a eficiência da tosse através do uso de duas manobras manuais de auxílio à tosse. Métodos: Foram selecionados 28 pacientes portadores de distrofia muscular de Duchenne em uso de ventilação mecânica não-invasiva noturna e CVF < 60% do previsto. O pico de fluxo da tosse (PFT) foi medido, com o paciente sentado, em quatro momentos: com esforço expiratório máximo (EEM) de forma espontânea (basal), EEM associado à compressão torácica, EEM após empilhamento de ar com bolsa de ventilação e EEM com o uso dessas duas técnicas (técnica combinada). As três últimas medições foram realizadas em ordem aleatória. Os resultados foram comparados usando o teste de correlação de Pearson e ANOVA para medidas repetidas, seguido do teste post hoc de Tukey (p < 0,05). Resultados: A idade média dos pacientes foi de 20 ± 4 anos, e a CVF média foi de 29 ± 12%. A média de PFT basal, com compressão torácica, com empilhamento de ar e com o uso da técnica combinada foi 171± 67, 231 ± 81, 225 ± 80, e 292 ±86 L/min, respectivamente. Os resultados com o uso da técnica combinada foram maiores que aqueles com o uso das duas técnicas separadamente [F(3,69) = 67,07; p < 0,001]. Conclusões: As técnicas de compressão torácica e de empilhamento de ar foram eficientes para aumentar o PFT. No entanto, a combinação dessas manobras teve um efeito aditivo significativo (p < 0,0001).Descritores: Distrofia muscular de Duchenne; Ventilação com pressão positiva intermitente; Tosse; I...

Lung function monitoring in patients with duchenne muscular dystrophy on steroid therapy

“…However, we did not determine how frequently the maneuver was performed or the influence of the maneuver on pulmonary parameters. The “air stacking” maneuver is reported to have positive effects only in peak flow of cough and maximum insufflation capacity [22,23]. The CVF continued to decline independently of the use of this maneuver [23].…”

A Review on Cough Augmentation Techniques: Assisted Inspiration, Assisted Expiration and Their Combination

“…Additionally, there was no increase in the CPF in four patients with respiratory muscle weakness with scoliosis, although there was an increase in the patients with respiratory muscle weakness without scoliosis (Sivasothy et al 2001, Chatwin et al 2003. In contrast, a small study in patients with Duchenne muscular dystrophy did not show a significant difference between the patients who had kyphoscoliosis and those who did not, although this was again a study with higher risk of bias (Brito et al 2009).…”

“…This improvement is higher compared to assisted inspiration techniques alone and lower than when the techniques of assisted inspiration and expiration are combined. A study in 28 patients with Duchenne muscular dystrophy showed that CPF (mean ± SD) is higher with the combination of the MAC with manual hyperinflation using a resuscitation bag (292±86 l/min), compared to the techniques alone, MAC (231±81 l/min), hyperinflation (225±80 l/min), and unassisted cough (171±67 l/min) (Brito et al 2009). In mechanically ventilated patients, CPF was also higher when MAC was applied with an increased positive end-expiratory pressure and inspiratory time compared to MAC alone (112.3±15.6 l/min versus 95.8±18.3 l/m, p <0.05) (Silva et al 2012).…”

The Expansion of the Pulmonary Rib Cage during Breath Stacking Is Influenced by Age in Obese Women

“…These authors found that the decrease in lung volume after surgery was smaller in the patients treated with breath stacking and that this maneuver allowed greater lung expansion and greater maintenance of inspiratory volume. Breath stacking has also been proposed, in a modified form using a manual resuscitation bag, a one-way valve and a mask or mouthpiece, to increase the maximum inspiratory capacity and expiratory flow to improve cough in patients with neuromuscular disorders or spontaneously breathing intubated [32]–[34].…”