Setting Mechanical Insufflation-Exsufflation (MI-E) Pressures for Amyotrophic Lateral Sclerosis (ALS) Patients to Improve Atelectasis and Reduce Risk of Pneumothorax: A Case Report.

Mechanical insufflation-exsufflation (MI-E) has been used to supplement the ability to cough and expel pulmonary secretions in patients with neuromuscular disease who have a reduced ability to cough. The manufacturer's guidelines for MI-E recommend a setting of inspiratory pressure of +40 cmH2O and expiratory pressure of -40 cmH2O. However, patients with small stature and restricted ventilatory impairment are prone to pneumothorax, so the manufacturer's recommendations are not used as is, and should be adjusted for the physical and pulmonary characteristics of each patient. Here, we report a case in which MI-E was used for an amyotrophic lateral sclerosis (ALS) patient with short height, low BMI, and restricted lung capacity at inspiratory and expiratory pressures lower than the manufacturer's recommendations. In adjusting MI-E pressure, physical observations such as chest auscultation, visual chest dilation, and observation of secretion movement toward the tracheal tube were performed to avoid unnecessary pressure. As a result, the pressure level set was lower than the manufacturer's recommendation (25 cmH2O) but sufficient to improve atelectasis and no pneumothorax occurred. The method we practiced in this study is feasible in any clinical setting. We also believe that MI-E, when performed in conjunction with treatment response observation, can be expected to improve at lower pressures than generally recommended, thereby reducing the risk of lung injury and providing safer treatment.

Discordance between subjective and objective evaluations of cognitive function in old Japanese patients with heart failure.

OBJECTIVES: Although cognitive impairment is common among patients with chronic heart failure (HF), the accuracy with which caregivers can recognize it is unknown. This study aimed to examine the degree to which subjective and objective evaluations coincide. METHODS: Cognitive function was evaluated subjectively and objectively in 184 hospitalized patients aged 65 or older (82 ± 7.2 years old and 49% male) with HF, who were divided into three groups: (i) normal; (ii) mild cognitive impairment; and (iii) severe cognitive impairment. RESULTS: The intrapatient agreement of the results of subjective and objective evaluations was tested, and weighted κ coefficients showed poor agreement (0.54, 95% confidence interval: 0.42-0.66, P < 0.001). CONCLUSION: Subjective and objective cognitive function evaluations in older patients with HF are poorly concordant.