managing respiratory symptoms in advanced ms - practical by rachael moses
TRANSCRIPT
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Managing Respiratory Symptoms in Advanced MS – Practical
Monday 7th November 2016 Rachael Moses
Consultant Physiotherapist Complex Ventilation and Airway Clearance
@rachaelmoses [email protected]
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Ineffective cough as a result of weakness and ensuing restrictive lung
disease
Restrictive lung disease as a result of respiratory
muscle weakness and spinal deformity
Atelectasis as a result of secretion retention and restrictive lung disease
Chronic aspiration as a result of dysphagia and
exacerbated by an ineffective cough
Immobility as a result of muscle weakness or
disco-ordination
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Identify what you need to treat
I cant take a deep breath
I cant cough
I cant talk for long
I’m sick of getting chest
infections
I get short of breath
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Identify what you need to treat
Reduced FVC Reduced MIP
Reduced MEP
Reduced PCF Repeated
chest infections
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Maximum insufflation capacity (MIC)
• The maximum lung volume that can be held by air stacking.
• It requires intact bulbar function
• The Maximum Insufflation Capacity (MIC) measurement (litres) is the maximum volume of air stacked within the patient’s lungs beyond spontaneous vital capacity.
• It is measured after a patient takes a deep breath until maximal capacity is reached and air is then exhaled into a spirometer
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Glossopharangeal Breathing
• This technique uses the glottis to add an inspiratory effort by projecting blouses of air into the lungs.
• The glottis closes with each gulp.
• Individuals find it helps them to have more breath so they can talk for longer/breathe for longer and cough.
http://www.youtube.com/watch?feature=player_detailpage&v=Dy1QDIM-rPI
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Lung Volume Recruitment Bag
• Patients with low lung volume; either from injury or medical condition.
• Has a one way valve to prevent loss of volume.
• Low cost, Versatile, Light weight
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Lung volume recruitment in DMD McKim et al 2012
• 3-5 breaths were delivered over 2-3 seconds to achieve MIC for a total of 3-5 cycles
• Twice daily
• If secretions present a MAC was also performed
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Maintaining pulmonary compliance
• LVR will help to prevent atelectasis and improving chest wall compliance.
• A daily regimen of 8 to 10 hyperinflation manoeuvres has been suggested as a maintenance therapy for pulmonary and chest wall compliance
• This is often repeated 4-6 x in same treatment cycle
• In UK, recommend 2-4 x a day of the prescribed regime.
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Lung Volume Recruitment in Multiple Sclerosis Srour et al 2013
• 10 year study
• LVR was attempted in patients with FVC 80% predicted.
• Regular twice daily LVR was prescribed
• A baseline FVC 80% predicted was present in 82% of patients and 80% of patients had a PCF insufficient for airway clearance.
• There was a significant decline in FVC and PCF over a median follow-up time of 13.4 months
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Conclusions
• The FVC rate of decline was significantly lower in those who had an improvement in PCF with LVR at the first visit than in those without improvement (p<0.0001)
• As was the PCF rate of decline (p = 0.042)
Pulmonary function and cough declines in MS
patients over time LVR is associated with a slower rate of decline in
lung function and peak cough flow.
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Limits of Effective Cough-Augmentation Techniques in Patients With Neuromuscular Disease
Toussaint et al 2012
• Patients with VC > 340 mL and MEP < 34 cm H2O would optimally benefit from the combination of breath-stacking plus manually assisted cough to improve PCF to > 180 L/min
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Mechanical In-Exsufflation (MI-E)
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What is MI-E
• MI-E consists of insufflation of the lungs with positive pressure
• Followed by a rapid change into negative-pressure to give an active exsufflation
• That creates a peak and sustained flow high enough to provide adequate shear and velocity
• Loosen and mobilises secretions toward the mouth for suctioning or expectoration.
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When to consider MI-E
• When combined MIC/MAC fail to produce a PCF > 160
• If MIC/MAC are ineffective in clearing secretions
• If a patient has inadequate carer support to provide regular MIC/MAC
• For patients who have regular hospital admissions with aspiration pneumonia
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Mechanical Insufflation–Exsufflation Improves Outcomes for Neuromuscular Disease Patients with Respiratory Tract Infections
Vianello et al, 2005
Treatment failure (need for minitracheostomy or intubation)
2/11 (p 0.05) 10/16
Treatment
MI-E plus Chest Physio Chest Physio
URTI
11 NMD 16 matched controls
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Cough augmentation with mechanical insufflation/exsufflation in
patients with neuromuscular weakness Chatwin et al, 2003
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Need more help?
• http://www.irrd.ca/default.asp
• http://www.icid.salisbury.nhs.uk/ClinicalManagement/SpinalInjuries/Pages/AssistedCoughing.aspx
• http://www.acprc.org.uk/
• https://www.networks.nhs.uk/nhs-networks/silvah
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Closing thoughts
• People with MS that become immobile will develop respiratory insufficiency with varying degrees
• There is lots of evidence for lung volume recruitment, secretion clearance and optimisation of respiratory function for people with NMD
• The evidence is transferable and may make the lives of people with MS more manageable with a reduction in respiratory side effects, hospital admissions and therefore secondary complications
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Managing Respiratory Symptoms in Advanced MS
Thanks for listening.
Questions?
Email or tweet if you think of something later!
@rachaelmoses [email protected]
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LVR Procedure
• Position patient – preferably in upright sitting and explain procedure • Establish with your patient the signal he/she will use to notify you that
MIC is reached. • With nose clips in place, ask the patient to take a deep breath and hold. • Ask the patient to place lips tightly around the mouthpiece to prevent air
from escaping. • As you gently squeeze the resuscitation bag, coordinate with the patient’s
inspiration. Squeeze the bag 2-5 times until you feel the lungs are full or when the patient sends you a signal that MIC is reached.
• Once the patient’s lungs are full, take the mouthpiece out of the mouth, ask the patient to hold the maximum insufflation for 3 to 5 seconds, and then allow the patient to exhale gently.
• Repeat steps 3 to 5 times.
http://www.irrd.ca/education/policy/LVR-policy.pdf
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References
• Gosselink R, Kovacs L, Decramer M (1999) Respiratory muscle involvement in multiple sclerosis. European Respiratory Journal 13: 449–454.
• Aisen M, Arlt G, Foster S. Diaphragmatic paralysis without bulbar or limb paralysis in multiple sclerosis. Chest 1990; 98: 499–501.
• Balbierz JM, Ellenbergh M, Honet JC. Complete hemidiaphragmatic paralysis in a patient with multiple sclerosis. Am J Phys Med Rehab 1988; 67: 161–165.
• Cooper CB, Trend P St J, Wiles CM. Severe diaphragm weakness in multiple sclerosis. Thorax 1985; 40: 633–634.
• Kuwahira I, Kondo T, Ohta Y, Yamabayashi H. Acute respiratory failure in multiple sclerosis. Chest 1990; 97:246–248.
• Noda S, Umezaki H. Dysarthria due to loss of voluntary respiration (Letter). Arch Neurol 1982; 39: 132.
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References
• Mutluay FK, Gurses HN, Saip S (2005) Effects of multiple sclerosis on respiratory functions. Clinical Rehabilitation 19: 426–432.
• Smeltzer SC, Skurnick JH, Troiano R, Cook SD, Duran W, et al. (1992) Respiratory function in multiple sclerosis. Utility of clinical assessment of respiratory muscle function. Chest 101: 479–484.
• Smeltzer SC, Utell MJ, Rudick RA, Herndon RM (1988) Pulmonary function and dysfunction in multiple sclerosis. Archives of Neurology 45: 1245–1249.
• Altintas A, Demir T, Ikitimur HD, Yildirim N (2007) Pulmonary function in multiple sclerosis without any respiratory complaints. Clinical Neurology & Neurosurgery 109: 242–246.
• Foglio K, Clini E, Facchetti D, Vitacca M, Marangoni S, et al. (1994) Respiratory muscle function and exercise capacity in multiple sclerosis. European Respiratory Journal 7: 23–28.
• Tzelepis , McCool (2015) Respiratory dysfunction in multiple sclerosis. Resp Care.
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References
• Yamamoto T, Imai T, Yamasaki M. Acute ventilatory failure in multiple sclerosis. J Neurol Sci 1989; 89: 313 324.
• Carter JL, Noseworhty JH. Ventilatory dysfunction in multiple sclerosis. Clin Chest Med 1994; 15: 693–703.
• Chiara T, Martin AD, Davenport PW, Bolser DC (2006) Expiratory muscle strength training in persons with multiple sclerosis having mild to moderate disability: effect on maximal expiratory pressure, pulmonary function, and maximal voluntary cough. Arch Phys Med Rehabil 87: 468–473.
• Aiello M, Rampello A, Granella F, Maestrelli M, Tzani P, et al. (2008) Cough efficacy is related to the disability status in patients with multiple sclerosis. Respiration 76: 311–316.
• Trebbia G, Lacombe M, Fermanian C, et al. Cough determinants in patients with neuromuscular disease. Respir Physiol Neurobiol. 2005;146(2–3):291–300
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References
• McKim DA, Katz SL, Barrowman N, Ni A, Leblanc C (2012) Lung Volume Recruitment Slows Pulmonary Function Decline in Duchenne Muscular Dystrophy. Arch Phys Med Rehabil.
• Bach JR, Bianchi C, Vidigal-Lopes M, Turi S, Felisari G (2007) Lung inflation by glossopharyngeal breathing and ‘‘air stacking’’ in Duchenne muscular dystrophy. Am J Phys Med Rehabil 86: 295–300.
• Kang SW, Bach JR (2000) Maximum insufflation capacity. Chest 118: 61–65. • Vitacca M, Paneroni M, Trainini D, Bianchi L, Assoni G, Saleri M, Gile` S,
Winck JC, Gonc¸alves MR: At Home and on Demand Mechanical Cough Assistance Program for Patients With Amyotrophic Lateral Sclerosis. Am J Phys Med Rehabil 2010;89:401–406
• Winck JC, Gonc¸alves MR, Lourenc¸o C, Viana P, Almeida J, Bach JR. Effects of mechanical insufflation-exsufflation on respiratory parameters for patients with chronic airway secretion encumberance. Chest 2004;126(3):774–780.
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References
• Chatwin M and Simonds A. The addition of mechanical insufflation/exsufflation shortens airway-clearance sessions in neuromuscular patients with chest infection. Respir Care 2009;54(11):1473– 1479.
• Vianello A, Corrado A, Arcaro G, Gallan F, Ori C, Minuzzo M, Bevilacqua M. Mechanical insufflation– exsufflation improves outcomes for neuromuscular disease patients with respiratory tract infections. Am J Phys Med Rehabil 2005;84:83–88.
• Chatwin M, Ross E, Hart N, Nickol AH, Polkey MI, Simonds AK. Cough augmentation with mechanical insufflation/exsufflation in patients with neuromuscular weakness. Eur Respir J 2003; 21: 502–508.
• Lung Volume Recruitment in Multiple Sclerosis. Nadim Srour, Carole LeBlanc, Judy King, Douglas A. McKim. 2013. PLOS ONE | www.plosone.org
• Hirst, Swingler, Compston, Ben-Shlomo, Robertson. Survival and cause of death in multiple sclerosis: a prospective population-based study. J Neurol Neurosurg Psychiatry 2008;79:1016-1021