Table 1.

Secretion mobilization techniques

• Manually-assisted coughing (“quad coughing”). ○ Insufflation using bag-valve-mask (eg, AmbuBag) or glossopharyngeal breathing before quad coughing will increase the peak cough flow. ○ Contraindications: inferior vena caval filter, recent abdominal surgery, rib fractures. • Mechanical insufflation-exsufflation (CoughAssist; J.H. Emerson Co.; Cambridge, MA; www.coughassist.com). ○ Contraindications: bullous emphysema, susceptibility to pneumothorax or pneumomediastinum, or recent barotraumas. ○ Effective cough at inspiratory/expiratory pressures of + 40/−40 cm H2O; for patient using device for first time, begin with pressures of 15 cm H2O to familiarize patient with procedure. ○ Typical cough settings: 3 second inhalation phase, 2 second exhalation phase, then pause for 5 seconds. ○ Perform cycle of 4 or 5 assisted coughs, then rest (spontaneously breathing or back on mechanical ventilator) for 30 seconds. Repeat cycle of coughs and rest up to 6 times as needed. Monitor patient symptoms, oxygen saturation, and secretions retrieved to determine when to terminate treatment. •Percussion (manual percussion; hand-held mechanical percussor). •Postural drainage. •Suctioning. •Bronchoscopy. •Intrapulmonary percussive ventilation. •High-frequency chest wall oscillation (The Vest™; Hill-Rom, Inc.; Batesville, Indiana). •Inhaled mucolytics or hydrating agents for thick, tenacious secretions.