Geiseler J, Karg O
Klinik für Intensivmedizin und Langzeitbeatmung, Asklepios Fachkliniken München-Gauting.
Pneumologie. 2008 Mar;62 Suppl 1:S43-8. doi: 10.1055/s-2008-1038098.
Many patients with neuromuscular diseases suffer from a weak cough. Due to infection or aspiration a life-threatening situation may occur. There are different options for the therapists to improve secretion clearance from the airways in the patient with a weak cough. Furthermore, there are indications that consequent practice of techniques to ameliorate bronchial clearance may also improve the prognosis of patients with neuromuscular diseases.
The management of secretions in neuromuscular disorders does not consist of single actions but is rather a complex programme. Diagnostics and several therapeutic measures have to be performed intensely and regularly. The diagnosis of a weak cough flow is based on anamnestic data, e. g., increase in secretions or dysphagia, physical examination, e. g., paradoxical breathing, and easily measured lung function parameters like vital capacity and peak cough flow (PCF). The diagnosis of an accumulation of secretions in the airways can be made easily by means of a pulse oximetry: while breathing room air the oxygen saturation in the case of a healthy lung and clean airways will be better than 95 %. A decline can, among others, be induced by amounts of secretions in the airways. The consequence should be measures to improve secretion expectoration (so-called oximetry-feedback protocol). To assist in secretion elimination from the airways several means are available like air stacking, manually assisted cough and mechanical assisted coughing--e. g., mechanical insufflator-exsufflator. Which of these techniques should be used depends on the extent of the disease: with preserved facial and bulbar muscles, air stacking alone or in combination with manually assisted coughing may be adequate and effective in the home care of the patient. In case of failure of these means, e. g., in bulbar paralysis, there is the possibility to apply mechanically assisted coughing by means of the mechanical insufflator-exsufflator. In case of tracheostomy, air stacking or mechanical assisted coughing has to be combined with tracheal suctioning. Acute infections of the lower airways are a special challenge: personnel intensive application of a combination of different secretion eliminating techniques, e. g., bronchoscopy in the hospital, manually assisted coughing and mechanically assisted coughing have to be performed in high intensity to avoid intubation.
The early diagnosis of a weak cough in NMD patients is important for the timely start of existing and effective measures for improving the capacity of elimination of secretions--air stacking, manually assisted cough and mechanically assisted cough. Although there is no high degree of evidence, we believe that morbidity and possibly mortality can be affected in a positive manner.
许多神经肌肉疾病患者存在咳嗽无力的情况。由于感染或误吸，可能会出现危及生命的状况。对于治疗师而言，有多种方法可用于改善咳嗽无力患者气道分泌物的清除。此外，有迹象表明，持续练习改善支气管清除的技术也可能改善神经肌肉疾病患者的预后。
神经肌肉疾病中分泌物的管理并非单一行动，而是一个复杂的方案。必须密集且定期地进行诊断和多种治疗措施。咳嗽气流微弱的诊断基于病史资料，例如分泌物增多或吞咽困难，体格检查，例如矛盾呼吸，以及易于测量的肺功能参数，如肺活量和峰值咳嗽流量（PCF）。通过脉搏血氧饱和度仪可轻松诊断气道分泌物积聚：在呼吸室内空气时，健康肺部且气道清洁的情况下，血氧饱和度将高于95%。气道分泌物增多等情况可导致血氧饱和度下降。相应的应对措施应为改善痰液咳出的方法（所谓的血氧饱和度反馈方案）。为协助气道分泌物排出，有多种方法可供选择，如气体堆叠、人工辅助咳嗽和机械辅助咳嗽——例如，机械吸气-呼气器。应使用哪种技术取决于疾病的严重程度：面部和延髓肌肉功能保留时，单独使用气体堆叠或与人工辅助咳嗽联合使用，在患者家庭护理中可能就足够且有效。如果这些方法失败，例如在延髓麻痹的情况下，可通过机械吸气-呼气器进行机械辅助咳嗽。如果进行了气管切开术，气体堆叠或机械辅助咳嗽必须与气管抽吸相结合。下呼吸道急性感染是一项特殊挑战：必须高强度地密集应用不同的分泌物清除技术组合，例如在医院进行支气管镜检查、人工辅助咳嗽和机械辅助咳嗽，以避免插管。
对神经肌肉疾病患者咳嗽无力进行早期诊断，对于及时启动现有的有效措施来提高分泌物清除能力（气体堆叠、人工辅助咳嗽和机械辅助咳嗽）很重要。尽管证据程度不高，但我们认为发病率以及可能的死亡率能够得到积极影响。
