This document discusses managing respiratory symptoms in advanced multiple sclerosis (MS). It summarizes research showing pulmonary dysfunction correlates with disability level in MS. For patients with normal lung function, expiratory muscle strength may still be reduced. Lung volume recruitment (LVR) and mechanical in-exsufflation (MI-E) are presented as techniques that can help preserve lung function and clear secretions by improving peak cough flow. The combination of LVR and manually assisted coughing is shown to be most effective. Case studies demonstrate MI-E and tracheostomy with ventilation can prevent hospital admissions and be life-saving for some advanced MS patients.
Hypertension is the aptly named silent killer. Therefore, learning more about it and the ways in which one could prevent it could help you avoid this terrible assassin.
Hypertension is the aptly named silent killer. Therefore, learning more about it and the ways in which one could prevent it could help you avoid this terrible assassin.
Please share this slideshow with anyone who may be interested!
In this webinar:
● Marijuana for Medical Purposes Regulations (MMPR)
● Statistics on cannabis usage and results of the CCSN medical cannbis survey
● Differences between licensed producers and dispensaries
● Basic information on medical cannabis usage, adverse effects, potential use and contraindications
● Cannabis varieties
● How to legally access medical cannabis
Contact the presenter:
● Kaivan Talachian: ktalachian@canntrust.ca
View the YouTube video:
http://youtu.be/ZB9-z-pqqTc
Follow our social media accounts:
Twitter - https://twitter.com/survivornetca
Facebook - https://www.facebook.com/CanadianSurvivorNet
Pinterest - https://www.pinterest.com/survivornetwork
YouTube - https://www.youtube.com/user/Survivornetca
The video for this presentation is available on our Youtube channel:
https://youtube.com/allceuseducation A continuing education course for this presentation can be found at https://www.allceus.com/member/cart/index/index?c=
Objectives
Identify the symptoms of marijuana intoxication
Review the research related to the short and long term effects of marijuana on the brain and body
Explore the medical uses of marijuana
Discuss marijuana as a gateway drug
What is It
Marijuana refers to the dried leaves, flowers, stems, and seeds from the hemp plant, Cannabis sativa.
The plant contains the mind-altering chemical delta-9-tetrahydrocannabinol (THC)
Extracts with high amounts of THC can also be made from the cannabis plant
How is it Used
Smoked
Joints
Pipes or water pipes (bongs)
Blunts—emptied cigars that have been partly or completely refilled with marijuana.
Vaporized
Pull the active ingredients from the marijuana and collect their vapor in a storage unit which is inhaled instead of smoke.
Eaten: Brownies, cookies, or candy, or brew it as a tea.
How is it Used
Resins: A newly popular method of use is smoking or eating different forms of THC-rich resins
Smoking THC-rich resins extracted from the marijuana plant is on the rise. Users call this practice dabbing. People are using various forms of these extracts, such as:
hash oil or honey oil—a gooey liquid
wax or budder—a soft solid with a texture like lip balm
shatter—a hard, amber-colored solid
Oral Ingestion
Orally consumed cannabinoids tends to be stronger and last longer (4-6 hours) than inhaled cannabis.
This is because of the way bodies metabolize THC.
When cannabis is inhaled, THC passes rapidly from the lungs to the blood stream and to the brain.
When cannabis is consumed orally, a significant portion of THC is converted into the metabolite 11-hydroxy-THC before reaching the brain.
This metabolite is believed to be slightly more potent than THC and possesses a greater blood-brain penetrability
Short Term Effects
THC effects are felt more slowly when the person eats or drinks it. (30 minutes to 1 hour)
Effects
Altered senses (for example, seeing brighter colors)
Temporary hallucinations
Altered sense of time
Changes in mood
Impaired body movement
Difficulty with thinking and problem-solving
Impaired memory
Breathing problems. Marijuana smoke irritates the lungs
Increased heart rate for up to 3 hours after smoking
FA is a very rare, genetic, recessive disease, affecting 1/50,000 people.
Originates from mutations in the “coding” of the mitochondria.
Discovered by Nicholaus Friedreich in the early 1860’s.
Both parents must have the dominant trait for a 25% chance of an offspring possessing the disease.
Not necessarily a disease that kills you, but eventually a wheelchair and regular assistance will be required.
Onset before age 20-25 year.
Managing Respiratory Symptoms in Advanced MS by Rachael Mosesmiranda olding
Advanced MS & neuromuscular disease cause respiratory problems leading to problems with talking, eating and chest infections, which can be fatal. Rebreathe bags & airway clearance machines / cough machines can enhance quality of life, and prove cost-effective in preventing unplannned hospital admissions for chest infection.
Please share this slideshow with anyone who may be interested!
In this webinar:
● Marijuana for Medical Purposes Regulations (MMPR)
● Statistics on cannabis usage and results of the CCSN medical cannbis survey
● Differences between licensed producers and dispensaries
● Basic information on medical cannabis usage, adverse effects, potential use and contraindications
● Cannabis varieties
● How to legally access medical cannabis
Contact the presenter:
● Kaivan Talachian: ktalachian@canntrust.ca
View the YouTube video:
http://youtu.be/ZB9-z-pqqTc
Follow our social media accounts:
Twitter - https://twitter.com/survivornetca
Facebook - https://www.facebook.com/CanadianSurvivorNet
Pinterest - https://www.pinterest.com/survivornetwork
YouTube - https://www.youtube.com/user/Survivornetca
The video for this presentation is available on our Youtube channel:
https://youtube.com/allceuseducation A continuing education course for this presentation can be found at https://www.allceus.com/member/cart/index/index?c=
Objectives
Identify the symptoms of marijuana intoxication
Review the research related to the short and long term effects of marijuana on the brain and body
Explore the medical uses of marijuana
Discuss marijuana as a gateway drug
What is It
Marijuana refers to the dried leaves, flowers, stems, and seeds from the hemp plant, Cannabis sativa.
The plant contains the mind-altering chemical delta-9-tetrahydrocannabinol (THC)
Extracts with high amounts of THC can also be made from the cannabis plant
How is it Used
Smoked
Joints
Pipes or water pipes (bongs)
Blunts—emptied cigars that have been partly or completely refilled with marijuana.
Vaporized
Pull the active ingredients from the marijuana and collect their vapor in a storage unit which is inhaled instead of smoke.
Eaten: Brownies, cookies, or candy, or brew it as a tea.
How is it Used
Resins: A newly popular method of use is smoking or eating different forms of THC-rich resins
Smoking THC-rich resins extracted from the marijuana plant is on the rise. Users call this practice dabbing. People are using various forms of these extracts, such as:
hash oil or honey oil—a gooey liquid
wax or budder—a soft solid with a texture like lip balm
shatter—a hard, amber-colored solid
Oral Ingestion
Orally consumed cannabinoids tends to be stronger and last longer (4-6 hours) than inhaled cannabis.
This is because of the way bodies metabolize THC.
When cannabis is inhaled, THC passes rapidly from the lungs to the blood stream and to the brain.
When cannabis is consumed orally, a significant portion of THC is converted into the metabolite 11-hydroxy-THC before reaching the brain.
This metabolite is believed to be slightly more potent than THC and possesses a greater blood-brain penetrability
Short Term Effects
THC effects are felt more slowly when the person eats or drinks it. (30 minutes to 1 hour)
Effects
Altered senses (for example, seeing brighter colors)
Temporary hallucinations
Altered sense of time
Changes in mood
Impaired body movement
Difficulty with thinking and problem-solving
Impaired memory
Breathing problems. Marijuana smoke irritates the lungs
Increased heart rate for up to 3 hours after smoking
FA is a very rare, genetic, recessive disease, affecting 1/50,000 people.
Originates from mutations in the “coding” of the mitochondria.
Discovered by Nicholaus Friedreich in the early 1860’s.
Both parents must have the dominant trait for a 25% chance of an offspring possessing the disease.
Not necessarily a disease that kills you, but eventually a wheelchair and regular assistance will be required.
Onset before age 20-25 year.
Managing Respiratory Symptoms in Advanced MS by Rachael Mosesmiranda olding
Advanced MS & neuromuscular disease cause respiratory problems leading to problems with talking, eating and chest infections, which can be fatal. Rebreathe bags & airway clearance machines / cough machines can enhance quality of life, and prove cost-effective in preventing unplannned hospital admissions for chest infection.
MECHANICAL VENTILATION IN NEUROLOGICAL AND NEUROLOGICAL CASES.pptxNeurologyKota
20% of all patients requiring mechanical ventilation suffer from neurological dysfunction.
Major contributor to prolongation of mechanical ventilation in over a third of patients admitted in ICU.
Managing Respiratory Symptoms in Advanced MS - Practical by Rachael MosesMS Trust
Practical guide to managing respiratory symptoms in Advanced MS presented at the MS Trust Annual Conference 2016 buy Consultant Physiotherapist Rachael Moses
A very large proportion of Intensive Care Patients. Discussed in detail about causes diagnosis and management pearls of neuromuscular respiratory failure. Intensive Care Physicians will find this presentation very useful and informative.
Global launch of the Healthy Ageing and Prevention Index 2nd wave – alongside...ILC- UK
The Healthy Ageing and Prevention Index is an online tool created by ILC that ranks countries on six metrics including, life span, health span, work span, income, environmental performance, and happiness. The Index helps us understand how well countries have adapted to longevity and inform decision makers on what must be done to maximise the economic benefits that comes with living well for longer.
Alongside the 77th World Health Assembly in Geneva on 28 May 2024, we launched the second version of our Index, allowing us to track progress and give new insights into what needs to be done to keep populations healthier for longer.
The speakers included:
Professor Orazio Schillaci, Minister of Health, Italy
Dr Hans Groth, Chairman of the Board, World Demographic & Ageing Forum
Professor Ilona Kickbusch, Founder and Chair, Global Health Centre, Geneva Graduate Institute and co-chair, World Health Summit Council
Dr Natasha Azzopardi Muscat, Director, Country Health Policies and Systems Division, World Health Organisation EURO
Dr Marta Lomazzi, Executive Manager, World Federation of Public Health Associations
Dr Shyam Bishen, Head, Centre for Health and Healthcare and Member of the Executive Committee, World Economic Forum
Dr Karin Tegmark Wisell, Director General, Public Health Agency of Sweden
R3 Stem Cells and Kidney Repair A New Horizon in Nephrology.pptxR3 Stem Cell
R3 Stem Cells and Kidney Repair: A New Horizon in Nephrology" explores groundbreaking advancements in the use of R3 stem cells for kidney disease treatment. This insightful piece delves into the potential of these cells to regenerate damaged kidney tissue, offering new hope for patients and reshaping the future of nephrology.
Antibiotic Stewardship by Anushri Srivastava.pptxAnushriSrivastav
Stewardship is the act of taking good care of something.
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
WHO launched the Global Antimicrobial Resistance and Use Surveillance System (GLASS) in 2015 to fill knowledge gaps and inform strategies at all levels.
ACCORDING TO apic.org,
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
ACCORDING TO pewtrusts.org,
Antibiotic stewardship refers to efforts in doctors’ offices, hospitals, long term care facilities, and other health care settings to ensure that antibiotics are used only when necessary and appropriate
According to WHO,
Antimicrobial stewardship is a systematic approach to educate and support health care professionals to follow evidence-based guidelines for prescribing and administering antimicrobials
In 1996, John McGowan and Dale Gerding first applied the term antimicrobial stewardship, where they suggested a causal association between antimicrobial agent use and resistance. They also focused on the urgency of large-scale controlled trials of antimicrobial-use regulation employing sophisticated epidemiologic methods, molecular typing, and precise resistance mechanism analysis.
Antimicrobial Stewardship(AMS) refers to the optimal selection, dosing, and duration of antimicrobial treatment resulting in the best clinical outcome with minimal side effects to the patients and minimal impact on subsequent resistance.
According to the 2019 report, in the US, more than 2.8 million antibiotic-resistant infections occur each year, and more than 35000 people die. In addition to this, it also mentioned that 223,900 cases of Clostridoides difficile occurred in 2017, of which 12800 people died. The report did not include viruses or parasites
VISION
Being proactive
Supporting optimal animal and human health
Exploring ways to reduce overall use of antimicrobials
Using the drugs that prevent and treat disease by killing microscopic organisms in a responsible way
GOAL
to prevent the generation and spread of antimicrobial resistance (AMR). Doing so will preserve the effectiveness of these drugs in animals and humans for years to come.
being to preserve human and animal health and the effectiveness of antimicrobial medications.
to implement a multidisciplinary approach in assembling a stewardship team to include an infectious disease physician, a clinical pharmacist with infectious diseases training, infection preventionist, and a close collaboration with the staff in the clinical microbiology laboratory
to prevent antimicrobial overuse, misuse and abuse.
to minimize the developme
Defecation
Normal defecation begins with movement in the left colon, moving stool toward the anus. When stool reaches the rectum, the distention causes relaxation of the internal sphincter and an awareness of the need to defecate. At the time of defecation, the external sphincter relaxes, and abdominal muscles contract, increasing intrarectal pressure and forcing the stool out
The Valsalva maneuver exerts pressure to expel faeces through a voluntary contraction of the abdominal muscles while maintaining forced expiration against a closed airway. Patients with cardiovascular disease, glaucoma, increased intracranial pressure, or a new surgical wound are at greater risk for cardiac dysrhythmias and elevated blood pressure with the Valsalva maneuver and need to avoid straining to pass the stool.
Normal defecation is painless, resulting in passage of soft, formed stool
CONSTIPATION
Constipation is a symptom, not a disease. Improper diet, reduced fluid intake, lack of exercise, and certain medications can cause constipation. For example, patients receiving opiates for pain after surgery often require a stool softener or laxative to prevent constipation. The signs of constipation include infrequent bowel movements (less than every 3 days), difficulty passing stools, excessive straining, inability to defecate at will, and hard feaces
IMPACTION
Fecal impaction results from unrelieved constipation. It is a collection of hardened feces wedged in the rectum that a person cannot expel. In cases of severe impaction the mass extends up into the sigmoid colon.
DIARRHEA
Diarrhea is an increase in the number of stools and the passage of liquid, unformed feces. It is associated with disorders affecting digestion, absorption, and secretion in the GI tract. Intestinal contents pass through the small and large intestine too quickly to allow for the usual absorption of fluid and nutrients. Irritation within the colon results in increased mucus secretion. As a result, feces become watery, and the patient is unable to control the urge to defecate. Normally an anal bag is safe and effective in long-term treatment of patients with fecal incontinence at home, in hospice, or in the hospital. Fecal incontinence is expensive and a potentially dangerous condition in terms of contamination and risk of skin ulceration
HEMORRHOIDS
Hemorrhoids are dilated, engorged veins in the lining of the rectum. They are either external or internal.
FLATULENCE
As gas accumulates in the lumen of the intestines, the bowel wall stretches and distends (flatulence). It is a common cause of abdominal fullness, pain, and cramping. Normally intestinal gas escapes through the mouth (belching) or the anus (passing of flatus)
FECAL INCONTINENCE
Fecal incontinence is the inability to control passage of feces and gas from the anus. Incontinence harms a patient’s body image
PREPARATION AND GIVING OF LAXATIVESACCORDING TO POTTER AND PERRY,
An enema is the instillation of a solution into the rectum and sig
CHAPTER 1 SEMESTER V PREVENTIVE-PEDIATRICS.pdfSachin Sharma
This content provides an overview of preventive pediatrics. It defines preventive pediatrics as preventing disease and promoting children's physical, mental, and social well-being to achieve positive health. It discusses antenatal, postnatal, and social preventive pediatrics. It also covers various child health programs like immunization, breastfeeding, ICDS, and the roles of organizations like WHO, UNICEF, and nurses in preventive pediatrics.
We understand the unique challenges pickleball players face and are committed to helping you stay healthy and active. In this presentation, we’ll explore the three most common pickleball injuries and provide strategies for prevention and treatment.
CRISPR-Cas9, a revolutionary gene-editing tool, holds immense potential to reshape medicine, agriculture, and our understanding of life. But like any powerful tool, it comes with ethical considerations.
Unveiling CRISPR: This naturally occurring bacterial defense system (crRNA & Cas9 protein) fights viruses. Scientists repurposed it for precise gene editing (correction, deletion, insertion) by targeting specific DNA sequences.
The Promise: CRISPR offers exciting possibilities:
Gene Therapy: Correcting genetic diseases like cystic fibrosis.
Agriculture: Engineering crops resistant to pests and harsh environments.
Research: Studying gene function to unlock new knowledge.
The Peril: Ethical concerns demand attention:
Off-target Effects: Unintended DNA edits can have unforeseen consequences.
Eugenics: Misusing CRISPR for designer babies raises social and ethical questions.
Equity: High costs could limit access to this potentially life-saving technology.
The Path Forward: Responsible development is crucial:
International Collaboration: Clear guidelines are needed for research and human trials.
Public Education: Open discussions ensure informed decisions about CRISPR.
Prioritize Safety and Ethics: Safety and ethical principles must be paramount.
CRISPR offers a powerful tool for a better future, but responsible development and addressing ethical concerns are essential. By prioritizing safety, fostering open dialogue, and ensuring equitable access, we can harness CRISPR's power for the benefit of all. (2998 characters)
Leading the Way in Nephrology: Dr. David Greene's Work with Stem Cells for Ki...Dr. David Greene Arizona
As we watch Dr. Greene's continued efforts and research in Arizona, it's clear that stem cell therapy holds a promising key to unlocking new doors in the treatment of kidney disease. With each study and trial, we step closer to a world where kidney disease is no longer a life sentence but a treatable condition, thanks to pioneers like Dr. David Greene.
Telehealth Psychology Building Trust with Clients.pptxThe Harvest Clinic
Telehealth psychology is a digital approach that offers psychological services and mental health care to clients remotely, using technologies like video conferencing, phone calls, text messaging, and mobile apps for communication.
Jaipur ❤cALL gIRLS 89O1183002 ❤ℂall Girls IN JaiPuR ESCORT SERVICE
Managing respiratory symptoms in advanced MS
1. Managing Respiratory Symptoms in
Advanced MS
Tuesday 10th November 2015
Rachael Moses
Consultant Physiotherapist
Complex Ventilation and Airway Clearance
@rachaelmoses rachael.moses@lthtr.nhs.uk
2. Pulmonary function and dysfunction in
multiple sclerosis.
Smeltzer et al 1988
• Studied pulmonary function in 25 MS patients
with a range of motor impairment.
• Ambulatory patients had normal spirometry
• Wheelchair-bound patients with upper extremity
involvement had reduced spirometry
• Bedridden patients had significantly lower
spirometry results
• Spirometry decline correlated with higher EDS
scores and expiratory muscle weakness occurred
most frequently.
6. Respiratory dysfunction in multiple sclerosis:
A prospective analysis of 60 patients
Buyse et al Eur Respir J, 1997; 10: 139–145
• Sixty patients
• Mean age 48
• EDSS mean score 6.5
• FSS:
o pyramidal 3.4
o brain stem 1.9
o mental 1.3
o cerebellar 2.2
o sphincter 1.8
o visual 1.4
o sensory 2.0
7. Pulmonary Function Tests
Patient Numbers Absolute Value % predicted
VC L 60 3.0 80
TLC L 35 5.6 100
RV L 35 2.1 115
RV/TLC % 35 38 113
FEV1 L 60 2.3 76
FEV1/VC % 60 75 93
PEF L 60 4.6 62
MEP cmH2O 58 48 30
MIP cmH2O 58 47 47
8. Disability score and pulmonary function
EDSS ≥7 EDSS <7
Mean n Mean n p-value
VC % pred 72 26 95 18 <0.001
FEV1 % pred 70 26 91 18 <0.002
PEF % pred 55 26 93 18 <0.001
Duration of disease, pulmonary function and neurological disability scores
Duration of disease
≥18 yrs <18 yrs
Mean n Mean n p-value
EDSS score 7.1 19 6.0 23 <0.05
FSS score
Mental
1.6 19 1.1 29 <0.001
9. Learning points
• For individuals with normal lung function expiratory muscle
strength may be reduced
• Impaired innervation of the upper airway may result in a
diminished awareness of coughing.
• Paralysis in advanced MS tends to ascend slowly from lower
extremities to upper extremities.
• As a result, the first respiratory muscles to be affected are
the abdominal muscles followed by the intercostal muscles.
• The diaphragm, which is innervated by the phrenic nerve
may be expected to be the last to be affected
• Bulbar dysfunction may predispose patients to aspiration
with desaturation, especially at night
10. Learning points
• Reports demonstrating abnormalities of respiratory control
in MS patients may only be observed during acute
exacerbations and therefore reversible
• No significant correlation was found between lung function
and duration of disease
• The prevalence of respiratory muscle dysfunction in MS
patients confirms the almost unpredictable course of the
disease
• This leads to variable respiratory and muscular
involvement.
• Despite marked respiratory muscle dysfunction some MS
patients never complain of pulmonary symptoms, such as
cough or SOB
11. What’s the point?
• MS patients are at risk
• Bulbar dysfunction
• Combination reduced lung volumes,
inspiratory and expiratory muscle weakness
and glottic dysfunction impairs cough
effectiveness
• PCF inversely related to degree of disability,
Chiara et al (2006), Aiello et al (2008)
12. Survival and cause of death in multiple sclerosis: a
prospective population-based study
Hirst et al 2008
• A population-based survey performed in South
Wales in 1985 identified 441 patients with MS
• The most common cause of death was
respiratory disease (47.5%).
• The standardised mortality ratio was 2.79 (95% CI
2.44 to 3.18) so that MS patients were almost
three times more likely to die prematurely
relative to the general population.
13. Sound Familiar?
• EDSS > 7
• Inability to deep breathe
• No cough
• Repeated aspiration pneumonia
• Poor Voice
• SOBAR
• Inability to speak in sentences
14. No real evidence in how to manage
the respiratory symptoms for
people with MS
However….
15. Effect of Upper Respiratory Tract Infection in Patients with
Neuromuscular Disease
Poponick et al 1997
• Insert • Effects of acute URI on
subjects with
neuromuscular disease
• Vital capacity
• Maximal inspiratory
pressures
• Maximal expiratory
pressures
• Transcutaneous oxygen
saturation
• End-tidal PC02
16. Why cant NMD patients cough?
• Reduced lung volumes and weak abdominal
muscles result in an inadequate cough
• Normal peak cough flow (PCF) >360l/min
• The minimum required to remove secretions is
160-200L/min
• The primary cause of respiratory infection in
patients with NMD is the inability to effectively
clear tracheal secretions
• For a patient that has a normal PCF of around
270ml the likelihood is this will deteriorate
17. Deep inspiration
(95% TLC, > 1.5l VC, >2.5l
air inspired)
Epiglottis closes, vocal
cords shut tightly to
entrap air within lung
Abdominal muscles
contract forcefully ,
pushing against the
diaphragm followed by
intercostal contraction
With closed glottis the
intrathoracic pressure rises
> 100cmH20 causing
tracheal narrowing
Rapid opening of vocal
cords and epiglottis with a
large pressure difference
and a narrow trachea
results rapid flow rates
A Cough is stimulated and
air is expelled at around
75-100mph
18.
19. Muscle groups essential for cough
Effective cough is a protective mechanism against respiratory tract infections, which
are the commonest cause of hospital admission in patients with respiratory muscle
weakness due to neuromuscular disease. Chatwin et al 2003
Inspiratory
Muscles
Expiratory
Muscles
Bulbar
Function
26. Assessing expiratory stage of cough
• MEP (maximal expiratory
pressure or PeMax)
• Assessing PCF is a quick and
easy way of measuring
expiratory muscle function
• > 360 l min = Normal Cough
Function
• < 270 l min = Introduce
strategies for assisted
airway clearance
• < 160 l min = Additional
assisted airway clearance
strategies
27. Teach MAC and / or MIC
PCF < 270
PCF < 155
MI-E
+/- MAC
PCF < 245
MI-E
Combine MAC and / or MIC
Michelle Chatwin
29. 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
30. 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=play
er_detailpage&v=Dy1QDIM-rPI
31. 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
32. 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
33. • At LVR initiation, FVC was
21.8 and CPF was 270L
• Annual decline of FVC was
4.7% predicted a year
before LVR and 0.5 percent-
predicted a year after LVR
initiation.
• The difference, 4.2 percent-
predicted a year represents
an 89% improvement in the
annual rate of FVC decline.
• Regular LVR dramatically
improved the rate of FVC
decline in DMD
McKim et al, 2012.
34. 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
• In UK, recommend 2-4 x a day of the
prescribed regime.
35. 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
36. 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)
*in an analysis where the baseline FVC or PCF
respectively were included as covariates to account
for differing baseline values between the groups.
37. Conclusions
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.
38. Combination of MIC and MAC
Lung volume
recruitment
Manual assisted
cough
39. Combination of MIC and MAC
Lung volume
recruitment
Manual assisted
cough
Combining manual hyperinflation with the
abdominal thrust manoeuvre has been shown to
produce a higher peak cough flow than by using
either therapy alone
Trebbia et al 2005
40. 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
42. 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.
43. 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
44. Cough augmentation with mechanical insufflation/exsufflation in
patients with neuromuscular weakness
Chatwin et al, 2003
• Adults and children with NMD exhibit weak
cough and are susceptible to recurrent chest
infections, a major cause of morbidity and
mortality.
• MI-E may improve cough efficacy by
increasing PCF
• It was hypothesised that MI-E would produce
a greater increase in peak cough flow than
other modes of cough augmentation.
45. Cough augmentation with mechanical insufflation/exsufflation in
patients with neuromuscular weakness
Chatwin et al, 2003
• 22 patients (median 21 yrs) with NMD and 19
age-matched controls were studied.
• Spirometry was performed and respiratory
muscle strength measured
• Peak cough flow was recorded during maximal
unassisted coughs, followed in random order by
coughs assisted by physiotherapy, NIV,
insufflation and exsufflation, and exsufflation
alone
• Subjects rated strength of cough, distress and
comfort on a visual analogue scale.
46. Cough augmentation with mechanical insufflation/exsufflation in
patients with neuromuscular weakness
Chatwin et al, 2003
47. The use of MI-E as a cost effective admission avoidance
strategy for patients with advanced multiple sclerosis (MS)
Moses 2015
Diagnosis PCF
Reading
(ml)
Number of
admissions
in 12 months
Average
bed days
Readmissions in 12 months
(following provision of
NIPPY clearway)
Potential
Bed days
saved
Potential
cost
saving (£)
MS 110 4 14 1 42
MS <50 6 9 0 54
MS 100 7 18 0 126
7,600
11,200
32,800
(cost saving is based on a hospital bed day costing £300, minus cost of equipment and consumables) Department of
health https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/213060/2011-12-
reference-costs-publication.pdf
The provision of a MI-E device for patients with MS can prevent future hospital admissions
and is therefore a cost effective admission avoidance strategy for patients with MS
Patients should be offered MI-E devices as part of a planned discharge package.
48. Tracheostomy and Mechanical In-Exsufflation for patients
with advanced Multiple Sclerosis. Should it be a standard
treatment intervention when indicated?
Moses 2015
• Tracheostomies and long term ventilation are now a
recognised treatment for many patients with
neuromuscular disease.
• There is little evidence to support tracheostomy and
mechanical in-exsufflation (MI-E) for patients with
advanced progressive multiple sclerosis (MS) and obvious
ethical implications of both.
• This case study describes the journey of a 50 year old man
with advanced MS who was readmitted with left sided lung
collapse and in severe hypoxic respiratory failure
• His decision to have a tracheostomy saved his life, one he
does not regret
49. Hyperbaric Oxygen Therapy
Anecdotally some people with MS have
reported relief from some symptoms after
HBO therapy, but scientific studies have
repeatedly failed to reproduce these claims
50. Optimal medical management
• Vaccinations
• SALT and nutritional assessment
• Oral secretion management
• Mucolytics
• Reflux management
• Antibiotics
• Early detection of chest infections and use of
rescue packs
• Exercise and prevention
51. The future
• Regular spirometry testing
• PCF measurements
• LVR offered as a standard intervention
• MI-E devices being trialled and offered
• RCTs and prospective studies
• Inclusion into NICE Guidance
• Personal care budgets
• Commissioning
52. 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
53. Managing Respiratory Symptoms in
Advanced MS
Thanks for listening.
Questions?
Email or tweet if you think of something later!
@rachaelmoses rachael.moses@lthtr.nhs.uk
54. 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
55. 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.
56. 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.
57. 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
58. 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.
59. 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