The use of mechanical insufflation-exsufflation via artificial airways.

During the past 20 years, airway clearance techniques have been the subject of increasing scientific interest. Cough augmentation with mechanical insufflation-exsufflation is part of this trend. No fewer than 23 studies, of which 21 were published in the past 10 years, have improved the level of evidence on this technique.1-23 As suggested in Figure 1, the availability of insufflation-exsufflation in Europe since 2002 has increased the number of studies in this field. The addition of knowledge on insufflation-exsufflation recently accelerated, as evidenced by 10 original studies published during the last 4 years.14-23 The particularity of insufflation-exsufflation is that it provides a mechanical assistance to compensate for deficits in both the inspiratory and expulsive phase of cough in patients with low respiratory muscle strength. Often associated with noninvasive mechanical ventilation,1,19,22 insufflation-exsufflation is used in adults, children, and even infants.22 To my knowledge, 3 insufflation-exsufflation devices are available on the market: CoughAssist (Philips Respironics, Murrysville, Pennsylvania); Pegaso (Dima Italia, Bologna, Italia); and Clearway (B&D Electromedical, Warwickshire, United Kingdom). To date, the efficacy, safety, and tolerance of insufflation-exsufflation have been investigated in patients with only one of these 3 devices, the CoughAssist. We must remember that an insufflation-exsufflation device that uses a noninvasive mask does not create a cough ex nihilo. Indeed, assisted cough requires the active participation of the patient who, although very weak, must perform a cough maneuver that includes glottal closure. In this case, weak but existing cough is amplified by the insufflation-exsufflation device. In contrast, when insufflation-exsufflation is used with an invasive interface, the cough maneuver is not essential. The insufflation-exsufflation device can create an artificial cough, even in unconscious, sedated patients.