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Artificial Coughing, A New Apparatus for Paralyzed Patients*
Artificial Coughing, A New Apparatus for Paralyzed Patients * JUERGEN STOFFREGEN, M .n.
Goettingen, Germany
Patients with respiratory paralysis (for example in poliomyelitis) are unable to cough. Bronchial secretions may accumulate and cause atelectasis, bronchopneumonia, decreased gaseous exchange, blood vessel shunt phenomena, and other undesirable effects. Such complications are responsible for a large percentage of the deaths associated with prolonged artificial respiration. Coughing is the best way to keep the bronchial tree clean and to prevent pulmonary complications. Patients with tracheotomy or endotracheal intubation are unable to cough because they can not close the glottis, and coughing is possible only when contraction of the abdom inal wall works against a closed upper airway. Barach, Beck, Bickerman and co-workers, have recently reported good results with mechanical coughing by means of the "coughing chamber"! (essentially a modified iron lung) and of the "Cof-flator.?" the first real coughing machine. Another coughing apparatus was developed in 1955 by Stoffregen and Oehrnig and reported at the 1955 World Congress of Anesthesia at Scheveningen, Netherlands." Description of Apparatus : This apparatus consists of a manually operated valve, which opens suddenly connecting the bronchial tree to a source of negative pressure. This sudden large pressure difference between the inside of the lungs through the upper airways to the coughing apparatus simulates normal coughing. The required pressure difference is achieved by means of a surgical as-
FIG U HE I: The artificial coughing apparatus. consis t illK of a s ur-gica l a spirator a pistol-like valve.
1I111.1
"Presented at the 2:3nl Annual Meet ing, American College of Chest Physicians. New York City, May 29 to June 2, 1957 .
56
57
ARTIFICIAL COUGHING
Vol. XXXVI
pirator (suction machine) with a vacuum flask of five liters capacity. A relief valve maintains a flask pressure of minus 200 centimeters of water. By means of a new three-way valve and a rubber hose the trachea of the intubated or tracheotomized patient can be exposed suddenly to the vacuum (Fig. 1). This new valve (Fig. 2) is a pistol-like, manually operated instrument, consisting of a trigger mechanism, a blocking lever, and a threeway valve. One arm leads to the room air, to an anesthesia machine, or to a mechanical respirator. When the trigger is pressed, the blocking lever opens the rotary valve in about 0.05 second. The patient's lungs are
FIGURE 2B
FIGURE 2.-\ Figl//'(' ! :
The pistol-like valve,
Translation: Drehschieber
zum Patienten zum Vakuumbehaltcr verstellbarer Bypass Abzugsbiigel Sperre
+
about 3 sec.
- rotary valve - to the patient - -to the vacuum flask - varia bel bypass - trigger - blocking level'
'>
QI--If---------:::::::......- RIGHT
ATRIUM
TRACHEAL PRESSURE 9 o(J1 CII CIl
o Fl(1~JRE
3:
P!'~!J5ures
in the trachea and in the right atrium during artificial coughing.
5H
.JUf<:RGEN STOFFREGEK
.I"ly . 191>9
now suddenly connected to the suction apparatus and artificial coughing is produced . It might appear that a preliminary insufflation of the lungs in order to dilate the bronchial tree would give a more efficient cough. However, experiments proved this to be unnecessary, the coughing by means of negative pressure only is practically as good. Figure 3 shows the pressure changes in the trachea and in the right atrium, measured by means of a cardiac catheter. The difference in the pressures and in the time is due to various resistances, mainly the elasticity of the lungs and thoracic wall. Figure 4 are pneurnotachograms showing that the artificial coughing is practically identical with spontaneous cough. The danger of pulmonary edema as a result of repeated negative pressure was feared by Scandinavian clinicians who hesitated to apply even much
I/see. COUGHING
10
8
SPONTANEOUS
ARTIFICIAL
6
4
2 O""""---....c....------~--_:..-------=--
7.9 l zsec . 8.1 l /sec. PNEUMOTACHOGRAM
FIG U RE 4 : The curves for spontaneous and artificial coughing arc prnctically identical.
FIGURE 5A, left: X-ray of the chest of an anesthetized , intubated, curarized dog, The right middle and lower lobes are filled with a contrast medium .-FIGURE 58 • ..iy h f : The contrast medium has been removed by artificial coug-hing. The ;;,1]11e findings have been demonstrated by r-inematog raphical technique.
Vol. XXXVI
ARTIFICIAL COUGHING
59
less suction than this apparatus uses during artificial breathing. Fortunately, this complication has not appeared. Hoernicke and Stoffregen 14 tested the present instrument on a large number of guinea pigs, and produced brief endotracheal pressures up to 300 em. H~O suction. In some cases, this was repeated 20 times in 10 minutes. No change of the lungs are found by histological examination and estimations of the fluid content in the lungs by weighing and dessication. This technique of artificial coughing was also used in a few hundred patients, in poliomyelitis, and in curarized tetanus patients but mainly during or at the end of anesthesia. No sign of pulmonary edema was found in any of these patients. SUMMARY A new artificial coughing device is described. It removes secretions from the lungs of intubated or tracheotomized patients. The device consists of a pistol-iike valve connected to a vacuum source and is efficient, inexpensive, and easy to operate.* *This artificial coughing device is now manufactured by the Draegerwerk Luebeck, West Germany, under the name "Tussomat." N ot e : Figures 2 and 5 are published with the permission of Springer-Verlag, Heidelberg, German)'. RESUME L'auteur decrit un nouvel appareil provoquant la toux artificielle. II permet ainsi d'evacuer les secretions des poumons chez les malades intubes ou tracheotomlses. L'appareil consiste en une valve semblable it un pistolet reliee it une source de vide; c'est un appareil efficace, peu couteux et facile it manier. ZUSAMMENFASSUNG Beschreibung einer neuen kiinstlichen Hustenvorrichtung. Sie entfernt das Sekret aus Lungen von intubierten oder tracheotomierten Kranken. Die Vorrichtung besteht aus einer mit einem Vakuum-Erzeuger verbundenen revolverartigen Klappe und ist von guter Wirksamkeit, preiswert und leicht zu handhaben. REFERENCES 1 Barach, A. L., Beck, G. J., Bickerman, H. A. and Seanor, H. E .: "Use of Physical Methods Simulating Cough Mechanisms in Poliomyelitis, Bronchial Asthma, Pulmonary Emphysema and Bronchiectasis," J . Amer. Med. Ass., 150 :1380, 1952. 2 Barach, A. L., Beck, G. J. and Smith, W.: "Mechanical Production of Expiratory Flow Rates Surpassing the Capacity of Human Coughing," Am. J . Med. Sci., 226 :241, 1953. 3 Beck , G. J. and Barach, A. L.: "Value of Mechanical Aids to Breathing. Case Report of Poliomyelitis." Ann. Int. Med., 40: 1081, 1954. 4 Beck, G. J. and Scarrone, L. A.: "Physiological Effects of Exsuffiation with Negative Pressure (E.W.N.P.)," Dis. Che st , 29:80, 1956. 5 Bickerman, H. A., Beck, G. J ., Gordon, Ch., Barach, A. L. and Itkin, S.: "Physical Methods Simulating Mechanisms of the Human Cough: Elimination of Radiopaque Material From the Bronchi of Dogs, " J . Appl. Physiol., 5 :92, 1952. 6 Bickerman, H. A. and Itkin, S.: "Exsuffiation with Negative Pressure (E.W.N.P.)," Arch. Int. Med., 93 :698, 1954. 7 Bruener, H., Hoernicke, H. and Stoffregen, J.: "Eiserne Lunge und Kreislauf. Die Einwirkung verschiedener Beatmungsverfahren, insbesondere der Eisernen Lunge, auf den Kreislauf," Dtsch. med. Wschr., 80 :484, 1955. 8 Hoernicke, H.: "Konnen mechanische Hustengeriite die Lungen schiidigen?" Virchows A rchiv, 328 :576, 1956. 9 Ross, B. B., Cramiak, R. and Rahn, H .: "Physical Dynamics of the Cough Mechanism," J. Appl. Physiol., 8 :264, 1955. 10 Stoffregen, J .: "tiber ein neues Geriit zur Erzielung kiinstlicher Hustenstosse," Lanpenbecks Archiv 11. Dtsch. Z. cu-; 284 :452, 1956. 11 Stoffregen, J. and Oehmig, H.: "A New Apparatus to Induce Coughing and Expectoration. Current Researches in Anesth. a . Analges," Proceedings W odd Congress of Anesthesiologists Scheveningen, The Netherlands, Sept. 5-10, 1955. P. 49, 1956.
Goettingen, Germany
Patients with respiratory paralysis (for example in poliomyelitis) are unable to cough. Bronchial secretions may accumulate and cause atelectasis, bronchopneumonia, decreased gaseous exchange, blood vessel shunt phenomena, and other undesirable effects. Such complications are responsible for a large percentage of the deaths associated with prolonged artificial respiration. Coughing is the best way to keep the bronchial tree clean and to prevent pulmonary complications. Patients with tracheotomy or endotracheal intubation are unable to cough because they can not close the glottis, and coughing is possible only when contraction of the abdom inal wall works against a closed upper airway. Barach, Beck, Bickerman and co-workers, have recently reported good results with mechanical coughing by means of the "coughing chamber"! (essentially a modified iron lung) and of the "Cof-flator.?" the first real coughing machine. Another coughing apparatus was developed in 1955 by Stoffregen and Oehrnig and reported at the 1955 World Congress of Anesthesia at Scheveningen, Netherlands." Description of Apparatus : This apparatus consists of a manually operated valve, which opens suddenly connecting the bronchial tree to a source of negative pressure. This sudden large pressure difference between the inside of the lungs through the upper airways to the coughing apparatus simulates normal coughing. The required pressure difference is achieved by means of a surgical as-
FIG U HE I: The artificial coughing apparatus. consis t illK of a s ur-gica l a spirator a pistol-like valve.
1I111.1
"Presented at the 2:3nl Annual Meet ing, American College of Chest Physicians. New York City, May 29 to June 2, 1957 .
56
57
ARTIFICIAL COUGHING
Vol. XXXVI
pirator (suction machine) with a vacuum flask of five liters capacity. A relief valve maintains a flask pressure of minus 200 centimeters of water. By means of a new three-way valve and a rubber hose the trachea of the intubated or tracheotomized patient can be exposed suddenly to the vacuum (Fig. 1). This new valve (Fig. 2) is a pistol-like, manually operated instrument, consisting of a trigger mechanism, a blocking lever, and a threeway valve. One arm leads to the room air, to an anesthesia machine, or to a mechanical respirator. When the trigger is pressed, the blocking lever opens the rotary valve in about 0.05 second. The patient's lungs are
FIGURE 2B
FIGURE 2.-\ Figl//'(' ! :
The pistol-like valve,
Translation: Drehschieber
zum Patienten zum Vakuumbehaltcr verstellbarer Bypass Abzugsbiigel Sperre
+
about 3 sec.
- rotary valve - to the patient - -to the vacuum flask - varia bel bypass - trigger - blocking level'
'>
QI--If---------:::::::......- RIGHT
ATRIUM
TRACHEAL PRESSURE 9 o(J1 CII CIl
o Fl(1~JRE
3:
P!'~!J5ures
in the trachea and in the right atrium during artificial coughing.
5H
.JUf<:RGEN STOFFREGEK
.I"ly . 191>9
now suddenly connected to the suction apparatus and artificial coughing is produced . It might appear that a preliminary insufflation of the lungs in order to dilate the bronchial tree would give a more efficient cough. However, experiments proved this to be unnecessary, the coughing by means of negative pressure only is practically as good. Figure 3 shows the pressure changes in the trachea and in the right atrium, measured by means of a cardiac catheter. The difference in the pressures and in the time is due to various resistances, mainly the elasticity of the lungs and thoracic wall. Figure 4 are pneurnotachograms showing that the artificial coughing is practically identical with spontaneous cough. The danger of pulmonary edema as a result of repeated negative pressure was feared by Scandinavian clinicians who hesitated to apply even much
I/see. COUGHING
10
8
SPONTANEOUS
ARTIFICIAL
6
4
2 O""""---....c....------~--_:..-------=--
7.9 l zsec . 8.1 l /sec. PNEUMOTACHOGRAM
FIG U RE 4 : The curves for spontaneous and artificial coughing arc prnctically identical.
FIGURE 5A, left: X-ray of the chest of an anesthetized , intubated, curarized dog, The right middle and lower lobes are filled with a contrast medium .-FIGURE 58 • ..iy h f : The contrast medium has been removed by artificial coug-hing. The ;;,1]11e findings have been demonstrated by r-inematog raphical technique.
Vol. XXXVI
ARTIFICIAL COUGHING
59
less suction than this apparatus uses during artificial breathing. Fortunately, this complication has not appeared. Hoernicke and Stoffregen 14 tested the present instrument on a large number of guinea pigs, and produced brief endotracheal pressures up to 300 em. H~O suction. In some cases, this was repeated 20 times in 10 minutes. No change of the lungs are found by histological examination and estimations of the fluid content in the lungs by weighing and dessication. This technique of artificial coughing was also used in a few hundred patients, in poliomyelitis, and in curarized tetanus patients but mainly during or at the end of anesthesia. No sign of pulmonary edema was found in any of these patients. SUMMARY A new artificial coughing device is described. It removes secretions from the lungs of intubated or tracheotomized patients. The device consists of a pistol-iike valve connected to a vacuum source and is efficient, inexpensive, and easy to operate.* *This artificial coughing device is now manufactured by the Draegerwerk Luebeck, West Germany, under the name "Tussomat." N ot e : Figures 2 and 5 are published with the permission of Springer-Verlag, Heidelberg, German)'. RESUME L'auteur decrit un nouvel appareil provoquant la toux artificielle. II permet ainsi d'evacuer les secretions des poumons chez les malades intubes ou tracheotomlses. L'appareil consiste en une valve semblable it un pistolet reliee it une source de vide; c'est un appareil efficace, peu couteux et facile it manier. ZUSAMMENFASSUNG Beschreibung einer neuen kiinstlichen Hustenvorrichtung. Sie entfernt das Sekret aus Lungen von intubierten oder tracheotomierten Kranken. Die Vorrichtung besteht aus einer mit einem Vakuum-Erzeuger verbundenen revolverartigen Klappe und ist von guter Wirksamkeit, preiswert und leicht zu handhaben. REFERENCES 1 Barach, A. L., Beck, G. J., Bickerman, H. A. and Seanor, H. E .: "Use of Physical Methods Simulating Cough Mechanisms in Poliomyelitis, Bronchial Asthma, Pulmonary Emphysema and Bronchiectasis," J . Amer. Med. Ass., 150 :1380, 1952. 2 Barach, A. L., Beck, G. J. and Smith, W.: "Mechanical Production of Expiratory Flow Rates Surpassing the Capacity of Human Coughing," Am. J . Med. Sci., 226 :241, 1953. 3 Beck , G. J. and Barach, A. L.: "Value of Mechanical Aids to Breathing. Case Report of Poliomyelitis." Ann. Int. Med., 40: 1081, 1954. 4 Beck, G. J. and Scarrone, L. A.: "Physiological Effects of Exsuffiation with Negative Pressure (E.W.N.P.)," Dis. Che st , 29:80, 1956. 5 Bickerman, H. A., Beck, G. J ., Gordon, Ch., Barach, A. L. and Itkin, S.: "Physical Methods Simulating Mechanisms of the Human Cough: Elimination of Radiopaque Material From the Bronchi of Dogs, " J . Appl. Physiol., 5 :92, 1952. 6 Bickerman, H. A. and Itkin, S.: "Exsuffiation with Negative Pressure (E.W.N.P.)," Arch. Int. Med., 93 :698, 1954. 7 Bruener, H., Hoernicke, H. and Stoffregen, J.: "Eiserne Lunge und Kreislauf. Die Einwirkung verschiedener Beatmungsverfahren, insbesondere der Eisernen Lunge, auf den Kreislauf," Dtsch. med. Wschr., 80 :484, 1955. 8 Hoernicke, H.: "Konnen mechanische Hustengeriite die Lungen schiidigen?" Virchows A rchiv, 328 :576, 1956. 9 Ross, B. B., Cramiak, R. and Rahn, H .: "Physical Dynamics of the Cough Mechanism," J. Appl. Physiol., 8 :264, 1955. 10 Stoffregen, J .: "tiber ein neues Geriit zur Erzielung kiinstlicher Hustenstosse," Lanpenbecks Archiv 11. Dtsch. Z. cu-; 284 :452, 1956. 11 Stoffregen, J. and Oehmig, H.: "A New Apparatus to Induce Coughing and Expectoration. Current Researches in Anesth. a . Analges," Proceedings W odd Congress of Anesthesiologists Scheveningen, The Netherlands, Sept. 5-10, 1955. P. 49, 1956.