COUGH ASSIST - Norco Inc.

COUGH ASSIST 

Mechanical insufflation-exsufflation (MI-E) is a high-risk procedure and may generate 

droplets exposing staff to respiratory pathogens. Appropriate Personal Protective 

Equipment (PPE) must be applied to reduce exposure to respiratory secretions. 

MI-E may: 

• Recruit lung volumes 

• Treat and prevent atelectasis 

• Improve cough effectiveness 

• Increase mechanical compliance 

• Optimize thoracic range of motion 

• Increase speaking volume 

PCF: 

Peak Cough Flow (PCF) is measured by using a peak flow meter. The PCF is the 

velocity of air expelled from the lungs during a cough maneuver. This measurement 

can be expressed in L/min or L/sec (L/min divided by 60) 

It is useful to measure: 

• Spontaneous PCF (PCF sp) 

• PCF from a MIC (Maximum Insufflation Capacity) (PCF with a bag, PCF with 

a ventilator or PCF with Glossopharyngeal Breathing (GPB) 

• PCF from MIC with an assisted cough, timed with the cough (PCF bag and 

assisted cough, PCF vent and assisted cough or PCF GPB and assist assisted 

cough) 

The PCF correlates well with the actual FEF Max (maximum Forced Expiratory 

Flow rate) [L/sec] measurement commonly measured with the spirometer. 

Multiply your FEF value times 60 to obtain a PCF measurement in l/min. 

CRITERIA 

The patient must be alert, cooperative with respiratory maneuvers and able to 

communicate. 

Note: Taken from “Mechanical Insufflation-Exsufflation for Paralytic/Restrictive Disorders” by The 

Ottawa Hospital Page 1

CLINICAL INDICATIONS 

• An established diagnosis as paralytic/restrictive disorder. (Please see policy 

statement) 

• Patient is unable to cough or clear secretions effectively with a PCF less than 

180 L/min using LVR (Lung Volume Recruitment) with bag, GPB or volume 

ventilator (and assisted cough maneuver when indicated). 

• Patient is overly fatigued when performing LVR with the resuscitation bag, GPB 

or volume ventilator. 

Policy Statement: 

A physician order is required before initiating the MI-E device. The MI-E 

is an alternative to traditional suctioning providing decreased mucosal 

trauma and increased patient comfort. Principally, the MI-E is for 

patients who are unable to cough or clear secretions effectively due to 

reduced peak cough flow (less than 3 liters per second or 180 L/min) 

resulting from spinal cord injuries (SCI) and neuromuscular diseases 

such as ALS, GBS, myasthenia gravis, muscular dystrophy, multiple 

sclerosis, post polio, kypho-scoliosis, and syringomyelia. 

ABSOLUTE CONTRA-INDICATIONS 

Supplemental oxygen should not be bled into the MI-E circuit. Oxygen will pass through 

the fan system during the exsufflation phase resulting in a potential fire hazard. 

• Presence of hemoptysis, untreated or recent pneumothorax, bullous 

emphysema, nausea and emesis, severe COPD, severe asthma and recent 

lobectomy. 

• Increased intra cranial pressure (ICP) including ventricular drains 

• Impaired consciousness/inability to communicate. 

RELATIVE CONTRA-INDICATIONS 

• Therapy immediately following meals 

• Tachypnea 

• History of COPD and pheumothorax 

• Large pleural effusion 

• Cervical spinal injury unclear 

• Hemodynamic instability 



The use of the MI-E in patients with intrinsic lung diseases (such as 

chronic obstructive pulmonary disease (COPD), bronchiectasis, cystic 

fibrosis (CF) pulmonary fibrosis, and asthma) where secretions may be 

abundant should be introduced with caution and at times may not be 

indicated. The efficacy of the treatment in this instance must be 

monitored by a physician specialized in lung physiology such as a staff 

pulmonologist or intensivist. 

The use of the MI-E in other conditions not specified in the policy should be 

discussed with the care team. 

PRECAUTIONS 

• Patients known to have cardiac instability should be monitored for 

arrhythmias, oximetry (SpO2), dyspnea, vital signs and symptoms. 

• Patients with a combination of intrinsic diseases and paralytic/restrictive 

disorders must be referred to a staff pulmonologist or intensivist for 

consultation (the MI-E may cause early closure in flaccid airways such as 

COPD, CF, bronchiectasis). 

• Patients with long-standing thoracic cage restriction (who may have severely 

reduced thoracic compliance) will require slow incremental insufflations during 

the initial introductory period. 

• Notify physician if chest pain is present. 

PROCEDURE 

The MI-E is best performed in the sitting or semi-recumbent position however, can be 

done in supine. C-spine stabilization must be assessed and the head and neck must 

always be supported (appropriate brace or collar) if an assisted cough maneuver is 

performed in coordination with the exsufflation phase. 

MI-E sessions are usually performed: 

• QID, and PRN, to a maximum of Q10 minutes to avoid hyperventilation 

• Ideally in the morning upon awakening, before meals and at bedtime. 

• With assisted cough BID and PRN when indicated. 

The MI-E can be applied via mask, tracheostomy or endotracheal tube. 



PRE-THERAPY ASSESSMENT 

• Perform a general respiratory assessment / confirm pulmonary restriction / 

exclude significant obstructive disease 

• Baseline spirometry and spirometry with the LVR (lung volume recruitment) 

bag 

• SpO2, pulse rate 

• Optional: MIP / MEP and for non-intubated patients. PCF with LVR and PCF 

with LVR and assisted cough maneuver where applicable. 

NOTE: 

In an emergency, perform modified respiratory assessment, and monitor 

the SpO2 and pulse rate. Other objective measures should be performed 

at the first available opportunity when the circumstance is no longer 

urgent. 

• Initial suggested pressures should be set 5-10 cm H2O above the patient’s 

maximum MIP (to minimize the over-stretching of the chest wall soft tissues 

and muscles). Gradually increase the pressures over the first 48 to 72 hours by 

5-10 cmH2O until the ordered level is reached. In an acute condition the 

pressure should be increased within a few sessions, however, in emergent 

situations, utilize minimal effective pressure of +/-30 cmH2O from the onset 

(unless otherwise prescribed by physician). 

• Minimal effective pressures are +/-30 cmH2O and the most common 

therapeutic range is +/- 40 to 50 cmH2O. 

• The exsufflation pressure (absolute number) should never be less than the 

insufflation pressure. 

• When initiating the MI-E it is important to maintain LVR with the bag on a 

daily basis, minimum twice a day, (AM and PM) and PRN thereafter. This 

ensures the patient will be able to resume LVR with the bag once the MI-E is 

discontinued. 

• Patients requiring supplemental oxygen can be oxygenated with the 

resuscitation bag between MI-E treatments. 



EQUIPMENT 

• Appropriate PPE; 

• Cough Assist 

• Breathing filter 

• 6-foot disposable smooth bore tubing; 

• 10 – 6-inch flex tube with 15 mm connector for trached or intubated patients; 

• Transparent mask (preferred option); 

• Trach / endotracheal connector; 

• Mouthpiece and nose clip (optional) for exceptional circumstances; 

• Suction source on stand-by for patients with artificial airways and as clinically 

indicated for other patients (in-line suction where indicated in isolation cases). 

EMERSON COUGHASSIST Model CA 3200) 

Manual Mode 

Always verify pressure settings before starting each treatment. 

1. Turn power ON 

2. Turn the Inhale Pressure Control Knob (top right) clockwise to maximum 

position (varies the inspiratory pressure between 50-100% of the exhale 

pressure). 

3. Set the initial insufflation/exsufflation pressure by occluding the end of the 

circuit with your gloved thumb while holding the Manual Control Lever in the 

inhale/exhale for a minimum of 2 seconds for each position. At the same time, 

adjust the Pressure Adjustment Knob (below Manual Control Lever) to the 

desired prescribed pressure while watching the manometer on the display panel. 

Release the Manual Control Level to ensure the pressure returns to 0cmH2O. 

4. Apply the facemask interface securely and adjust to eliminate leak. 

5. Coordinate therapy with patient breathing pattern. 

6. Slide the Manual Control Level to the (+) as the patient is breathing in. Hold for 

3 seconds and vocalize IN-ONE THOUSAND, TWO-ONE THOUSAND, and 

THREE-ONE THOUSAND. 

7. Rapidly slide the Manual Control Level from the (+) to the (-). Hold for 2-3 

seconds and vocalize COUGH ONE-THOUSAND, TWO-ONE THOUSAND (and 

THREE-ONE THOUSAND). An assisted cough maneuver may be added where 

indicated at the onset of the COUGH command. 



Remember to rapidly shift the lever from (+) to the (-). This sudden 

change promotes the greatest pressure gradient and a maximum 

expiratory flow. 

8. Repeat the inhale/exhale cycle 5 times. 

9. Remove the facemask to clear the secretions from the airway. 

10. Rest 30 seconds to avoid hyperventilation between treatments. 

11. One treatment is equal to 3 - 5 cycles and one session is equal to 3 - 5 

treatments. 

12. Suction should be on standby if clinically indicated. Suctioning beyond the 

tracheostomy and endotracheal tube is rarely indicated. 

13. Assess treatment efficacy including weekly spirometry to assess PCF. 

Remark: Unequal pressures such as +30, -35 cmH2O may be prescribed 

to maximize the exsufflation phase while minimizing the stretch to the 

intercostals muscles during the insufflation phase. Turn the Inhale 

Pressure Control Knob (top right) to decrease the inhalation pressure. 

EMERSON COUGHASSIST Model CA 3200) 

Automated Mode 

Always verify pressure settings before starting each treatment. 

1. Turn power ON 

2. Turn the Inhale Pressure Control Knob (top right) clockwise to maximum 

position (varies the inspiratory pressure between 50-100% of the exhale 

pressure). 

3. Set the initial insufflation/exsufflation pressure by occluding the end of the 

circuit with your gloved thumb while holding the Manual Control Lever in the 

inhale/exhale for a minimum of 2 seconds for each position. At the same time, 

adjust the Pressure Adjustment Knob (below Manual Control Lever) to the 

desired prescribed pressure while watching the manometer on the display panel. 

Release the Manual Control Level to ensure the pressure returns to 0cmH2O. 

4. Set the therapy mode switch to AUTO. 

5. Set the Inhale Time to 3 seconds, Exhale Time 2-3 seconds and Pause Time 

between 3-5 seconds. Set the Inhale Flow toggle switch to patient comfort. Note: 

patients with long standing thoracic cage restriction will require slow 

incremental insufflations during the initial introductory period. 



6. Apply the facemask and coordinate therapy with patient effort. 

7. Give five breaths on the Automatic Mode (this is one cycle). Remove the mask to 

clear secretions from the airway. 

8. Rest 30-60 seconds to avoid hyperventilation. Repeat (5-breath cycles) 3 to 5 

times. 

9. Suction should be available if clinically indicated. Suctioning beyond the 

tracheostomy / endotracheal tube is rarely indicated. 

10. Assess treatment efficacy including weekly spirometry to assess PCF. 

HELPFUL HINTS 

MI-E with trachs and endotracheal tubes 

• Suction equipment must always be available 

• Connectors must have a snug fit 

• May require higher pressures due to the narrowing of artificial airway 

• Best to have trach with cuff inflated to allow for in-exsufflation via trach 

• For a cuffless trachs, cork the trach and use the MI-E via mask/mouth, a 

tight stoma is required and if the stoma is not tight you should consider 

having the trach changed to cuffed trach tube 

• In-exsufflation may be achieved via the trach site with a cuffless trach 

however, the patient must have excellent control of the upper airway 

• Discard the six-inch tube with 15 mm connector after each use when 

sputum present. 

EXCELLENT REFERENCE: 

http://www.doctorbach.com 



REFERENCE 

1. Bach JR – Management of Patients with Neuromuscular Disease: Hanley & Belfus 

Inc. Philadelphia, Pg. 260-265, 2004. 

2. Bach JR – Guide to the Evaluation and Management of Neuromuscular Disease: 

Hanley & Belfus Inc. Philadelphia, 1999. 

3. Bach JR – Pulmonary Rehabilitation – the Obstructive and Paralytic Conditions. 

Pg. 285-352, 1996. 

4. Bach JR – Mechanical Insufflation-Exsufflation. Comparison of Peak Expiratory 

Flows with Manually Assisted and Unassisted Coughing Techniques. Chest 1993 

Nov; 104(5):1553-62 

5. Tzeng AC, Bach JR – Prevention of Pulmonary Morbidity for Patients with 

Neuromuscular Disease. Chest 2000 Nov;118(5):1390-6 

6. Bach JR, Niranjan V, Weaver B – Spinal Muscular Atrophy Type 1: A Noninvasive 

Respiratory Management Approach. Chest 2000 Apr;117(4):1100-5. 

7. Hardy KA, Anderson BD – Noninvasive Clearance of Airway Secretions. Respir 

Care Clin N Am 1996 Jun;2(2):323-45. 

8. Dean S, Bach JR – The Use of Noninvasive Respiratory Muscle Aids in the 

Management of Patients with Progressive Neuromuscular Diseases. Respir Care 

Clin N Am 1996 Jun;2(2):223-4. 

9. Marchant WA, Fox R – Postoperative Use of a Cough-Assist Device in Avoiding 

Prolonged Intubation. Br J Anest 2002;89(4):644-647. 

10. McKim D, LeBlanc C, Walker K – Determinants of Peak Cough Flow in Patients 

With Amyotrophic Lateral Sclerosis. Chest 1998 Oct; 114(5):292S 

11. Boitano L, Dobrozsi J, Hilsen M & al – Resource Manual Noninvasive Mechanical 

Ventilation: University of Washington Medical Center Dept of Respiratory Care 

Services. 

12. http://www.irrd.ca/education/slide.asp?slideid=20 

13. http://www.irrd.ca/education/slide.asp?slideid=1 

14. http://www.coughassist.com/coughassist.htm 

Policy developed by: 

Carole LeBlanc RRCP/RRT, COPD Educator Douglas A McKim MD, FRCPC, FCCP, D,ABSM 

Professional Practice Leader, Respiratory Therapy Medical Director, Respiratory Rehabilitation Services 

The Rehabilitation Centre/The Ottawa Hospital Associate Professor, Department of Medicine 

University of Ottawa 

Respiratory Therapy Leaders 

The Ottawa Hospital

COUGH ASSIST - Norco Inc.

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