Cough assist care

What is it?

Coughing is a natural process that the body uses to rid itself of irritating substances, such as secretions that are present in the respiratory tract.
But in order for a cough to be effective, one must:
- be able to take a deep breath,
- be able to control the muscles that allow us to speak or make sounds,
- have sufficient force of the thoracic muscles (chest) and of the abdominal muscles (stomach).
If one of these conditions is absent or modified because of illness or a health problem, coughing becomes ineffective causing an accumulation of secretions in the lungs.
This accumulation of secretions can lead to respiratory infections and difficulty in breathing.
Weakness or the ineffective functioning of the muscles that aid in breathing (larynx, thorax and the abdomen), or of the diaphragm (thin, dome shaped muscle that separates the chest from the abdomen) can also reduce the quality and the quantity of air that enters the lungs.
The reduction of these volumes of air can cause a reduction of thoracic cage mobility that further compromises cough efficiency.

To avoid these complications, your child must cough strongly enough to eliminate or prevent the accumulation of secretions in the lungs. Different cough assist techniques can be used to help your child cough effectively.
Your child’s healthcare team will provide you with information regarding the cough assistance techniques most appropriate to your child’s condition and specific test results.

How does it work?

Cough assist techniques help to strengthen and increase the effectiveness of your child’s cough when applied during one of the two phases of breathing: that is during inspiration (when air is taken into the lungs), expiration (when air leaves the lungs), or both. Cough assist techniques help clear secretions from the respiratory tract and also help your child spit out secretions (expectoration).
One inspiratory aid technique is lung volume recruitment (also called breath stacking or manual hyperinflation therapy) using a modified ventilatory bag adapted with a one way valve and a series of connectors. Once adapted with a one way valve, this modified ventilatory bag, should never be used for resuscitation techniques.
This technique helps your child take a big breath (inspiration) and increase the volume of air in the lungs. It also helps the diaphragm and thoracic muscles aid your child with a greater force during a cough.
Lung volume recruitment is possible in children whether other methods of cough assistance are used or not.
It is rarely used in children with tracheostomy.
The technique requires the use of a facial mask or a mouthpiece.

Manual expiratory aid techniques help your child cough during expiration. They are applied when the lungs are full of air. The external application of manual abdominal or thoracic compressions during expiration aid your child in coughing and clearing secretions. Manual expiratory assistant techniques include:
- abdominal thrusts or compressions
- thoracic or thoracic lateral compressions (chest or side of chest compressions)
- directed cough assist (or auto cough assist or independent cough assist or auto cough assistance).

Mechanical inspiratory and expiratory aid techniques require the use of an insufflation / exsufflation (in-exsufflator) device (eg, Cough Assist®, E-70 or CA-3000).
These pressure generating devices quickly fill the lungs to the fullest capacity possible, and then quickly switch to a negative pressure to withdraw the air from the lungs on expiration.
This rapid movement of positive/negative pressure helps to mobilize pulmonary secretions towards the back of your child’s throat where they can be either expectorated (spit out) or if required, suctioned.
This cough assist technique can be used in children receiving ventilatory assistance or not.
It can be used on children with or without a tracheostomy.
The technique requires the use of a facial mask, a mouthpiece or a tracheal cannula adapter.

Cough assist techniques can be used regularly to prevent complications but also to treat pulmonary infections.
They do not cause pain but do require a certain adaptation period by your child. In younger children, consider the use of medical play to help your child adapt.
The duration of each treatment session will vary from one child to another depending on the quantity of secretions, the effort required and the technique used.
Based on your child’s condition and the results of tests, your child’s healthcare team can recommend the use of one or more cough assist techniques used simultaneously to help your child cough better.

Refer to your child’s healthcare team if other cough assist techniques (eg, inflating vest) are recommended for your child or if the medical devices used are different from the ones described in the methods of care here.

Your healthcare team will take the opportunity during your child’s follow-up appointments to answer any questions you may have or, if needed, make other recommendations.

FAQ – Cough assist care

When to consult your healthcare team

Respiration/respiratory muscles

Your child experiences chest/abdominal pain during lung volume recruitment technique or manual thrusts.
You are unable to clear your child’s secretions.
Your child’s abdomen does not move outwards during lung volume recruitment technique or insufflation/exsufflation technique.

Equipment

A leak around the mouthpiece or through the nose that persists during lung volume recruitment technique or insufflation/exsufflation technique.

Health

Your child experiences severe dizziness that lasts after 2 consecutive sessions of cough assist.
Your child’s abdomen remains bloated and/or your child burps after lung volume recruitment technique or insufflation/exsufflation technique

Your child’s healthcare team will verify your cough assist techniques, the equipment used and any adjustments that may be required, during your child’s follow-up appointment.

Do not hesitate to contact your healthcare team with any specific questions concerning your child.

PLEASE NOTE: The information in this section is meant as a general guide to help parents and caregivers with common issues and is not intended to replace the care provided by your child’s healthcare team.

Discuss your child’s unique needs with the healthcare team, including WHO and WHEN to contact when problems arise.

Stomach upset during lung volume recruitment technique or insufflation/exsufflation technique

Possible cause(s)

The technique was applied during or immediately following a meal

What to do?

Stop the technique immediately unless your child is really congested with secretions.
Avoid applying the technique within 2 hours before or after a meal.
If needed, suction the secretions.

Chest/abdominal discomfort or pain during lung volume recruitment (breath stacking) or insufflation/exsufflation technique

Possible cause(s)

Sore chest or abdominal muscles
Too much air in the lungs

What to do?

It is normal that your child feels a slight pulling of the chest muscles when the therapy is first started. This discomfort will gradually disappear.

If he feels pain:

Stop the technique immediately.
Contact the healthcare team as soon as possible.

Dizziness or fatigue

Possible cause(s)

Less than 10 minutes between each session
Session is too long

What to do?

Let your child rest.
Wait 10 minutes between each session.

If the dizziness is severe:

Stop the technique immediately.
If the symptoms reappear again, contact the healthcare team.

Bloating of the abdomen with burping after lung volume recruitment technique or insufflation/exsufflation technique

Possible cause(s)

Air is entering the stomach instead of the lungs

What to do?

Remind your child to relax during the insufflations of air; he must not resist air entry.

If the discomfort persists:

Stop the technique immediately.
Quickly contact the healthcare team.

Inability to expectorate (clear) the secretions

Possible cause(s)

Poor technique
Thicker secretions
More secretions than usual

What to do?

Review the technique.
Combine more than one technique at a time (ex, pulmonary hyperinflation with abdominal thrusts) in order to increase the efficacy of secretion clearance.
Make sure that the humidity level is adequate.
If the problem persists, contact the healthcare team as soon as possible.

Leak around the mouthpiece during lung volume recruitment technique or insufflation/exsufflation technique

Possible cause(s)

Poor seal around the mouthpiece

What to do?

Make sure that your child closes his mouth firmly around the mouthpiece.
Make sure that the mouthpiece is properly inserted in the modified ventilatory bag.
If needed, use a facial mask.
If the problem persists, contact the healthcare team.

Leak from the nose during lung volume recruitment technique or insufflation/exsufflation technique

Possible cause(s)

The air is leaking through the nose rather than going to the lungs

What to do?

Use a nose clip.
If the problem persists, use a facial mask.
If the problem continues to persist, contact the healthcare team.

Abdomen does not move outwardly during lung volume recruitment technique or insufflation/exsufflation technique

Possible cause(s)

Poor technique
Lack of collaboration by your child

What to do?

Review the technique.
Make sure that there is no leak (mouthpiece, facial mask, tubing).
Make sure that your child is relaxed.
If the problem persists, contact the healthcare team.

For specific advice on your child or any other questions, do not hesitate to contact your child’s healthcare team.

Everyday tips

Clothing

If your child has a tracheostomy, refer to the appropriate section.

Bathing and swimming

If your child has a tracheostomy, refer to the appropriate section.

Mouth care:

It’s important to clean your child’s mouth at least twice a day.
If your child has no teeth, use a small face cloth or a gauze dampened with water and rolled around your index finger, to gently rub your child’s gums front to back.
Once teeth start to appear, it is important to brush your child’s teeth after each meal and at bedtime. Since young children have a tendency to swallow toothpaste instead of spitting it out, use only the size of a small grain of rice in children under 2 years old and the size of a small pea in children up to 6 years old. Use this time to also gently massage their gums with the toothbrush.
Have your child rinse their mouth with warm water or use a low alcohol content mouthwash if recommended by your child’s healthcare team.
Apply, if required, a hydrating product for the lips if they are chapped and dry.

Nose care:

Whether your child is a nose breather or not, secretions, possibly with viruses and bacteria, will accumulate. Since the nose is connected to the lungs via the trachea, it is important to keep the nose clean if your child is incapable of blowing his own nose effectively. This action will decrease the risk of infection and improve breathing.
The nose may be kept clean through a combination of suctioning and rinsing the nose with a salt water (saline solution). There are a variety of devices available for these purposes. Talk to your child’s healthcare team to find the method most appropriate for your child, including the preparation of homemade saline solution and the proper storage of this solution.

Sleeping

If your child has a tracheostomy, refer to the appropriate section.

Nutrition and hydration

Place your child in the most comfortable position to facilitate breathing, according to your child’s condition.
If your child has a tracheostomy, refer to the appropriate section.

Activities

If your child has a tracheostomy, refer to the appropriate section.

Travel and transportation

If your child has a tracheostomy, refer to the appropriate section.
Always have on hand a “travel kit” containing the essential items required for the cough assist technique used for your child, (interface, modified ventilatory bag, in-exsufflator device, anti-bacterial filters, tubing, suction device, catheters, wipes, cushions, pillows, paper tissues). Keep a list of the contents of your travel kit so that it is easy to restock when needed. Confirm with your healthcare team how often you should verify supply and status, including expiry dates of equipment, materials, medications and solutions.
Keep a list of key contacts close at hand with the names and telephone numbers of the hospital, doctors, other members of your child’s healthcare team and equipment providers. Make sure you know how to reach these contacts outside of regular hours and on holidays.
Before leaving on a trip:
- make sure you have a document from the healthcare team describing your child’s condition and tracheostomy care needs and a complete list of medication.
- bring enough supplies to last for the duration of the trip and several extra days;
- make sure to ask if equipment providers and other resources are available at your destination in the event of equipment failure or other healthcare needs;
- take the climate of the region you will be visiting into consideration because the relative humidity of the ambient air could modify the quantity and the consistency of your child’s secretions.
For travel by airplane:
- make sure to contact the airline company to inquire about their policy concerning the transport of medical equipment;
- keep all medical equipment, supplies and medication with you in the cabin.

Others

Cardio Pulmonary Resuscitation (CPR): make sure all of your child’s caregivers are trained in CPR. Consult your child’s healthcare team regarding training and renewal of training requirements.

Emergencies:

If your child has a tracheostomy, refer to the appropriate section.
Always have a telephone nearby in case of an emergency. Make sure your cell phone is charged at all times. When you go out, bring what you need to charge the phone, when necessary (cable with charger and portable Power Bank charger).
Alert utility and emergency care providers that your child has special medical needs.
Discuss with your child’s healthcare team whether your child requires monitoring by a trained and competent individual capable of intervening, as needed; during the day, night or at all times.
Discuss with your child’s healthcare team the need for a medical alert bracelet (eg, MedicAlert bracelet) containing key medical information.

Humidity:

If your child has a tracheostomy, refer to the appropriate section.
Your child needs to live in an environment that is sufficiently humidified so that the secretions can be easily cleared.
Avoid overheating the home in the winter and using an air conditioner in the summer so that the air in your home is not too dry.
The recommended relative humidity in the home, measured with a special device called a hygrometer, should be between 40 to 50%.
If your home is too humid (55% and more), install a dehumidifier and clean it every week in order to prevent the presence of mold in the air that your child breathes.
On the other hand, if there is not enough humidity in your home, some daily habits can increase the level humidity in your home such as:
- minimize use of the kitchen exhaust fan when you boil water;
- avoid using an air conditioner in the summer;
- keep the bathroom door open when you use the shower;
- minimize the use of electric heaters, wood burning stoves and fireplaces during the winter;
- eliminate carpeting and rugs in the home.
Talk with your child’s healthcare team for more suggestions on how the humidity in your home can be optimized.

Air quality:

Avoid all exposure to traditional or electronic cigarette smoke or vapor, especially at home.
Regularly clean or change the filters on the air conditioners.
Avoid places where there is:
- accumulation of dust, presence of rugs, upholstered furniture and home accessories that are difficult to clean (eg, heavy drapery,
- dust from renovations,
- wood burning heating systems (stove or fireplace),
- excessive pollution (eg, smog, heavy traffic, strong winds),
In your child’s room:
- avoid the presence of toys and stuffed animals in your child’s bed,
- use pillows cases, sheets, and blankets made of washable synthetic material (hypo-allergenic),
- sheets that are very soft and fluffy with fibres (eg, flannel sheets) are not recommended: they attract dust and may release fine fibres that can enter your child’s tracheal cannula,
- wash bedding in hot water every week in order to destroy dust mites,
- dry bedding in a dryer if your child is allergic to pollen.
If your child has a tracheostomy, refer to the appropriate section.

Infection prevention:

If your child has a tracheostomy, refer to the appropriate section.
Before providing care to your child, always wash your hands.
Prevention of respiratory infections:
- If you have a cold, the flu or another respiratory infection, use non sterile gloves and wear a mask when providing care to your child.
- Avoid exposing your child to anyone that has a cold, the flu or other respiratory infection with or without a cough.
- Depending upon your child’s specific needs and following the advice of your child’s healthcare team, consider avoiding areas such as shopping malls or daycare to minimize the risk of exposure to infections.
- Consider annual vaccination against the flu for your child and the entire family. Make sure that your child’s immunizations are up to date. Follow the recommendations of your child’s healthcare team.

Maintenance and cleaning of medical supplies and equipment:

The ventilatory interfaces (mask, mouthpiece) and the tracheal cannula adapter should generally be cleaned once per week or more frequently if soiled.
Cleaning of the nose clip should be done as needed.
Below is a suggested method that can serve as a guide.
Always wash your hands, before starting.
- Clean the sink: wash it with dishwashing soap and warm water, then disinfect it with bleach and then rinse thoroughly with running tap water or use a large bowl/tub reserved only for the cleaning of your child’s medical equipment. If you use a tub, clean with soap and warm water before each use.
- Disassemble all the equipment (according to the manufacturer’s recommendations) so that all the parts can be cleaned thoroughly.
- Rinse all the parts under warm tap water so as to remove any debris (eg, secretions, blood).
- Soak all parts in the sink or in a tub filled with warm water and non-perfumed dish soap (not antibacterial) (eg, Sunlight™) for 10 minutes.
- Never use bleach, alcohol or hydrogen peroxide to clean equipment; these products may damage the equipment.
- If needed, brush the interior and exterior of the parts that remain soiled with a soft baby bottle brush.
- Rinse all parts with warm water.
- Shake off excess water as much as possible from all the parts that were rinsed.
- Allow all parts to dry on a clean towel placing them in such a fashion that will allow water to drain away from them.
Modified ventilatory bag: clean the exterior surface with a damp cloth and a mild soap if needed.
In-exsufflator device and components:
- clean the device exterior with a damp cloth and a mild soap once a week.
- anti-bacterial filter: change the filter every month or more often, if soiled.
- other components: clean according to the manufacturer or the healthcare team recommendations.

Daycare and school:

Your child’s healthcare team will evaluate your child’s needs and will support you in the planning of integration to daycare or to school.
Advise school staff of the treatment and care that your child requires.

Methods of care

Methods of care : Inspiratory aid

Indications

Pulmonary (lung) hyperinflation (or pulmonary insufflation, or alveolar recruitment, or pulmonary volume recruitment, or pulmonary volume augmentation) is a technique that helps a child increase their lung volume by the insufflation of air to the lungs using a modified ventilatory bag.

This technique can be used regularly to prevent complications from retained secretions and also to treat pulmonary infections.
The steps in the method below may serve as a guide; speak to your healthcare team about the specific equipment that your child uses.

Considerations:

Pulmonary hyperinflation provides the child with a volume of air large enough to produce an effective cough that will in turn help clear secretions.
This technique is possible in ventilated and non-ventilated children.
This technique is rarely used on children with a tracheostomy. If this is the case with your child, consult the healthcare team for specific instructions.
Based on your child’s condition and the results of tests (pulmonary function tests), your healthcare team can recommend the use of this technique alone or with expiratory aid techniques used simultaneously to help your child cough better.
Good handwashing is essential before and after providing care to your child.
Ensure the comfort of your child during care by using different positioning techniques and distraction techniques.

Frequency

3 to 5 maneuvers per session (1 maneuver = 1 inspiration with bag/1 expiration/1 abdominal thrust or 1 thoracic compression), if appropriate.
If the secretions are not sufficiently cleared: 5 to 8 maneuvers or until your child clears their secretions with an effective cough.
2 to 4 sessions per day regularly or more if needed, according to your child’s healthcare team.
It is suggested that each session not last more than 10 minutes in order to avoid hyperventilation and dizziness.
It is suggested that you wait 10 minutes between each session.
Apply the technique before meals or at least 2 hours after a meal in order to avoid stomach discomfort and vomiting.

Required materials

Modified ventilatory bag with connecting tubing, adapted with a one way valve, a second one way valve with the latex flap valve removed that serves simply as a connector and where a sticker that reads “Do not use for resuscitation” is applied
Interface adapter
Ventilatory interface: mask or mouthpiece
Nose clip if necessary
Paper tissues (Kleenex™)
Towels, pillows, cushions
Suction device and catheters (if required)

Refer to your healthcare team if the material used or the sequence of steps taught is different from what is described in the method of care.

Step 1: Anticipation

See the full description here

Summary:

Collaborate and form a team with your child. When you invest the time to form a strong team, children feel more comfortable and less anxious – this will help you complete the care with less stress – for you and your child.

Use these tips, from the start, to set the stage for a positive care procedure:

Create the right moment: integrate the care in a routine.
Alert your child to the needed care and communicate together.
Form a team with your child: Encourage autonomy by offering realistic choices such as the method of distraction. Stay tuned to your child. Manage pain and anxiety, using distraction and positioning for comfort.

Step 2: Preparation

See the full description here

Summary:

Prepare the environment: Identify a routine place for care. Close windows, doors and fans. Wash and dry the work surface and gather the needed materials for the care and to distract your child.
Prepare your child: Get help if needed. Position your child for comfort to receive the care and start to use the selected distraction method.
Prepare yourself: Find the right time when you are ready to provide the care safely. Review the list of care steps. Wash your hands.

Now that you are ready to start the care procedure, take the opportunity to encourage and praise your child.

Step 3: Procedure

See the full description here

Summary 3 key concepts:

Safety: Carefully follow the care practice steps as you have been taught.
Flexibility: Be ready to adjust according to your child’s reactions during the procedure. As needed, reposition or select an alternative distraction strategy. Follow your child’s pace and rhythm.
Collaboration: Reassure your child, verbally and non-verbally. Acknowledge your child’s emotions and reactions. Help your child differentiate between the different sensations during a procedure.

Step 4: Prepare the equipment

Use a properly cleaned table.
Gather the necessary supplies.
Make sure that the equipment is clean and correctly assembled: the connecting tubing, one way valves (one with, the other without the latex flap valve), and the interface adapter should all be assembled on the self-inflating manual resuscitator.
Make sure that the latex flap valve has been removed from the second one way valve used as a connecting adapter, next to the interface adapter.
Verify the state of the interface (mask or mouthpiece).
Connect the interface to the adapter.
Verify that all parts are properly assembled and adjusted.

Why ?

This step ensures proper assembly of the equipment.

Step 5: Position your child

Place your child, if possible, in a sitting or semi sitting position.
Make sure that your child’s head is well positioned and supported by using either rolled up towels, pillows, or cushions, as discussed with the healthcare team.
If your child cannot be placed in a sitting position, place on his back, with the head of the bed slightly raised.
If your child is in a wheelchair and abdominal thrusts or thoracic compressions are also applied during the cough assist technique, be sure to secure the wheelchair against a wall and apply the brakes.

Why ?

A sitting position optimizes coughing.

Step 6: If possible, establish a signal with your child

If your child’s capacity permits collaboration, establish a signal with your child to indicate when your child feels that his lungs are filled to full capacity and that he is ready to exhale and cough (eg, a wink, bending of head to one side, raising a hand).
Respect this signal at all times during the technique.

Why ?

This step ensures that the technique will be safely applied and encourages teamwork with your child.

Step 7: Place the interface on your child’s face

If your child has a tracheostomy, consult with the healthcare team as to the adjustments required in applying the following steps.

Mouthpiece:
- insert the mouthpiece into your child’s mouth, making sure that he firmly seals his lips around it;
- use a nose clip if recommended by the healthcare team.
Mask:
- place the mask over your child’s face, making sure to form a good seal with no leaks.

Why ?

This step permits connection of your child to the equipment.

The nose clip prevents air leaks through the nose when using a mouthpiece.

Step 8: Squeeze the modified ventilatory bag

Ask your child to relax and let the air enter his lungs without resistance, as your child takes the deepest breath possible.
At the same time your child takes in a deep breath, gently squeeze the modified ventilatory bag as you coordinate with each inspiratory effort made by your child. The number of breaths you give via the manual resuscitator must respect the volume of air to be given that is recommended by the healthcare team.
It is important that your child does NOT exhale during this phase of the technique.
Observe for rising of your child’s chest during this maneuver.
Repeat this maneuver until you have given a certain volume of air and your child signals you that his lungs are full.
Pay attention to the signal given by your child once he is ready to exhale.

Why ?

This step permits the filling of your child’s lungs with a certain volume of air.

Step 9: Encourage your child to cough

Once your child is ready to exhale, remove the interface and encourage your child to cough as he breathes out.
If recommended by the healthcare team, apply abdominal thrusts, thoracic (chest) or thoracic lateral compressions as your child coughs.
Have your child spit out the secretions and wipe with a tissue.

Why ?

This step permits your child to clear his secretions from his lungs.

Step 10: Suction secretions as needed

If your child has difficulty clearing secretions from the nose, mouth or the back of the throat, suction as needed.
For your child’s comfort, remove the nose clip when suctioning.

Why ?

This step helps your child clear his secretions completely from the respiratory tract.

Step 11: Repeat as needed

Complete the session by repeating the maneuver (1 inspiration/1 exhalation/cough/1 abdominal thrust or lateral thoracic compression or thoracic compressions) until your child has coughed effectively enough to clear the lungs of secretions.
Repeat the session 5 to 8 times if the secretions are difficult to clear.
Wait at least 10 minutes before starting another session.

Why ?

This step helps your child clear his secretions completely from his respiratory tract.

A delay of 10 minutes between each session will prevent your child from getting too tired or dizzy.

Step 12: Clean and store the equipment

Cleaning tips

Mask, mouthpiece and nose clip, if needed:
- clean with soapy water,
- rinse in warm water
- let dry.
Modified ventilatory bag:
- clean the exterior with a damp cloth and mild soap if required.
Store the equipment in a clean container protected from dust until next use.

Why ?

This step is required to prevent infections and maintain equipment.

Step 13: Recovery

See the full description here

Summary:

The treatment is finished. Wash your hands again.

Be prepared to recognize the challenges faced and to provide positive feedback. Help your child recognize his/her strengths. Acknowledge the collaborative teamwork.

Listen to what your child says about the parts of the procedure that were difficult or painful.
Comfort your child and recognize your child’s collaboration with positive feedback.
Highlight your child’s specific strengths that helped make the procedure positive.
Discuss with your child what might be done the same or differently the next time the care is needed.
Keep your promises if you have promised a reward, follow through.
Reward yourself too.