Triburter versus threshold device in a post COVID-19 patient

ABSTRACT

BACKGROUND AND PURPOSE: Respiratory muscle training (RMT) may be beneficial for patients with COVID-19. A variety of devices exist but none provide combined inspiratory and expiratory muscle training (IMT and EMT, respectively) with expiratory vibration from water filling the Triburter device (TD) which may facilitate the removal of pulmonary secretions as well as strengthening of the respiratory muscles. The purpose of this case study was to examine the effects of RMT with the TD in a patient recovering from COVID-19 complications. CASE DESCRIPTION The case study subject was a 57-year-old female who was diagnosed with COVID-19 in July 2020 and again in December 2020. The subject's past medical history includes gastroesophageal reflux, pneumonia, hypertension, interstitial lung disease, hypoxemic respiratory failure and the use of supplemental O2 (2 L/min via nasal cannula at rest and with exercise and 24% FiO2 via ventimask adapter with IMT). At the start of cardiopulmonary rehabilitation (CPR) in March 2021, the subject showed signs of paradoxical breathing and extensive use of accessory muscles, decreased endurance, and dyspnea at rest with bronchospasms following full inhalations and exercise that resulted in coughing and prolonged dyspnea. The subject was given a Threshold IMT device to use during CPR sessions and as part of her home exercise program, but she was not compliant with Threshold IMT. In July 2021 the patient used the TD in CPR and performed 30 repetitions with 4 cm of water in the TD representing a resistance of approximately 30% of her current maximal inspiratory pressure. OUTCOMES: While performing RMT with the Triburter in CPR the patient's heart rate, oxygen saturation, modified BORG dyspnea and blood pressure ranged from 90-93 bpm, 96-97% on room air, 3-4/10 and approximately 120/80 mmHg, respectively. The patient reported greater adherence as well as less coughing and dyspnea with the TD vs Threshold device, but reported difficulty closing the TD after adding water. Also, the resistance during IMT with the TD may have been less than that with the Threshold device since the IMT and EMT resistance parameters are not clearly defined with the TD. Compared to the initial evaluation in March 2021, the number of 6-minute walk test (6MWT) rests and rest durations as well as total distance walked in late July 2021 improved (2 rests for a total of 46 seconds and distance of 370 m vs 4 rests for a total of 132 seconds and distance of 229 m). DISCUSSION: The improvement in 6MWT performance in a post-COVID-19 patient is noteworthy highlighting the important role of RMT and CPR in this patient population. The TD device appeared to elicit greater compliance and more tolerable RMT than that from the Threshold device due possibly to combined IMT and EMT and vibration with exhalation. Patients recovering from COVID19 with retained pulmonary secretions and weak respiratory muscles may benefit from the TD, but further investigation of it is needed.