Initiation of NIV

Cough optimisation 

Oropharyngeal and respiratory secretions are a major barrier to effective NIV tolerance and ventilation. This section discusses the optimisation of cough and respiratory secretions.

The importance of poor cough in MND

Excessive respiratory secretions occur in MND as a patient’s cough deteriorates due to respiratory muscle weakness and poor bulbar function. Inspiratory and expiratory muscle weakness causes reduced lung volumes and bulbar dysfunction results in poor cough, lung atelectasis and failure to clear respiratory secretions.

Poor bulbar function also causes aspiration of oropharyngeal secretions, food and fluids as well as poor oral hygiene. These problems can be a major barrier to NIV use resulting in ineffective ventilation as well as pneumonia and distressing symptoms due to pooling of secretions in the lungs.

It is important to address both respiratory and oropharyngeal secretions together as both contribute to respiratory secretions. In addition, the treatment of oropharyngeal secretions to dry up the mouth with anticholinergic medication (eg hyoscine, glycopyrollate) can thicken respiratory secretions.

In the following video, Rosie Whitehead, a Respiratory Physiotherapist, explains how she approaches poor cough and excessive secretions, including describing what Cough Assist is.

Video transcript

How to manage bulbar weakness and excessive secretions

Rosie Whitehead

“Some patients, if they are struggling with their secretions or they have bulbar management problems, we might discuss with their neurologist about medications to help clear their chest. Or we might discuss with the respiratory team about a cough assist machine because if they are not clearing their secretions they won’t be able to ventilate effectively.

A cough assist machine is a machine than can give you a big breath in, then it helps you clear your secretions so it gives you a negative pressure to cough out. So when your respiratory muscles get weaker the idea is that it can do the effort of you taking a big breath in and then the clearing of, coughing out. So the idea is that it clears your chest more effectively and gets rid of your secretions so hopefully you can ventilate better with your NIV.

Generally we would give a Cough Assist to anyone who aren’t able to clear their secretions as well or might have a cough that is borderline weak or they feel like they are not able to clear their chest effectively or they are having recurrent chest infections.”

Conservative management of poor cough

On all patients, conservative measures should be considered.

Medical management of poor cough

Other measures that should be considered in people with poor cough:

Cough assist machine

Mechanical cough assist

Mechanical cough assist can be particularly helpful for people with:

In the following video, Katie Flowers, a Respiratory Physiotherapist, explains to people living with motor neurone disease what options there are for keeping their chest clear.

Suction machine

Good practice points

Additional resources

For more information relating to secretion management and cough optimisation, go to our Resources page or see the following guidance and information sheets:

Healthcare professional pathway:

South Wales MND Care Network saliva management pathway

Patient information:

Managing saliva problems in motor neurone disease

Oral suction for motor neurone disease