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Meta-Analysis
. 2021 Apr 22;4(4):CD013170.
doi: 10.1002/14651858.CD013170.pub2.

Cough augmentation techniques for people with chronic neuromuscular disorders

Brenda Morrow  1 , Andrew Argent  2 , Marco Zampoli  3 , Anri Human  4 , Lieselotte Corten  5 , Michel Toussaint  6
Affiliations
Meta-Analysis

Cough augmentation techniques for people with chronic neuromuscular disorders

Brenda Morrow et al. Cochrane Database Syst Rev. .

Abstract

Background: People with neuromuscular disorders may have a weak, ineffective cough predisposing them to respiratory complications. Cough augmentation techniques aim to improve cough effectiveness and mucous clearance, reduce the frequency and duration of respiratory infections requiring hospital admission, and improve quality of life.

Objectives: To determine the efficacy and safety of cough augmentation techniques in adults and children with chronic neuromuscular disorders.

Search methods: On 13 April 2020, we searched the Cochrane Neuromuscular Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL, and ClinicalTrials.gov for randomised controlled trials (RCTs), quasi-RCTs, and randomised cross-over trials.

Selection criteria: We included trials of cough augmentation techniques compared to no treatment, alternative techniques, or combinations thereof, in adults and children with chronic neuromuscular disorders.

Data collection and analysis: Two review authors independently assessed trial eligibility, extracted data, and assessed risk of bias. The primary outcomes were the number and duration of unscheduled hospitalisations for acute respiratory exacerbations. We assessed the certainty of evidence using GRADE.

Main results: The review included 11 studies involving 287 adults and children, aged three to 73 years. Inadequately reported cross-over studies and the limited additional information provided by authors severely restricted the number of analyses that could be performed. Studies compared manually assisted cough, mechanical insufflation, manual and mechanical breathstacking, mechanical insufflation-exsufflation, glossopharyngeal breathing, and combination techniques to unassisted cough and alternative or sham interventions. None of the included studies reported on the primary outcomes of this review (number and duration of unscheduled hospital admissions) or listed 'adverse events' as primary or secondary outcome measures. The evidence suggests that a range of cough augmentation techniques may increase peak cough flow compared to unassisted cough (199 participants, 8 RCTs), but the evidence is very uncertain. There may be little to no difference in peak cough flow outcomes between alternative cough augmentation techniques (216 participants, 9 RCTs). There was insufficient evidence to determine the effect of interventions on measures of gaseous exchange, pulmonary function, quality of life, general function, or participant preference and satisfaction.

Authors' conclusions: We are very uncertain about the safety and efficacy of cough augmentation techniques in adults and children with chronic neuromuscular disorders and further studies are needed.

Trial registration: ClinicalTrials.gov NCT01999075 NCT01518439 NCT04081116.

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Conflict of interest statement

BM: has no particular conflict of interest to declare in respect of this review. She received an equipment grant from the University of Cape Town, which supported the purchase of a "Nippy" mechanical In‐exsufflation device as well as an unconditional donation of consumables for this device from Bakoni Medical company for an ongoing clinical trial of MI‐E (PACTR201506001171421). BM is principal investigator of this trial, which may be eligible for inclusion in later versions of this review, in which case, she will recuse herself from that data extraction and analysis.

AA: is a specialist (paediatric critical care) physician and manages patients with a variety of conditions. He has no particular conflicts of interest to declare in respect of this review.

MZ: is a specialist (paediatric pulmonology) and manages patients with a variety of conditions, including NMD. He has no particular conflicts of interest to declare in respect of this review.

AH: as student investigator of the ongoing PACTR201506001171421trial, AH was also a recipient of an equipment grant from the University of Cape Town, which supported the purchase of a Nippy mechanical In‐exsufflation device as well as an unconditional donation of consumables for this device from Bakoni Medical company. This trial may be eligible for inclusion in later versions of this review, in which case, she will recuse herself from that data extraction and analysis.

LC: is a physiotherapist and lecturer. She has no conflicts of interest to declare in respect of this review.

MT: is the first author of a study included in this review (Toussaint 2016), as well as two excluded studies (Toussaint 2003; Toussaint 2009); however, he did not participate in any methodological or analytical processes related to these studies. He has no other conflicts of interest to declare in respect of this review.

Figures

1
1
Study flow diagram.
2
2
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
3
3
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
1.1
1.1. Analysis
Comparison 1: Manual versus mechanical breathstacking (BS), Outcome 1: Peak cough flow
1.2
1.2. Analysis
Comparison 1: Manual versus mechanical breathstacking (BS), Outcome 2: Maximal insufflation capacity
2.1
2.1. Analysis
Comparison 2: Glossopharyngeal breathing (GPB) versus manual breathstacking (BS), Outcome 1: Peak cough flow
2.2
2.2. Analysis
Comparison 2: Glossopharyngeal breathing (GPB) versus manual breathstacking (BS), Outcome 2: Inspiratory capacity
3.1
3.1. Analysis
Comparison 3: Mechanical insufflation‐exsufflation (MI‐E) versus mechanical insufflation (MI) plus manually assisted cough (MAC), Outcome 1: Peak cough flow
3.2
3.2. Analysis
Comparison 3: Mechanical insufflation‐exsufflation (MI‐E) versus mechanical insufflation (MI) plus manually assisted cough (MAC), Outcome 2: Inspiratory capacity
4.1
4.1. Analysis
Comparison 4: Mechanical insufflation‐exsufflation (MI‐E) versus mechanical insufflation‐exsufflation (MI‐E) plus manually assisted cough (MAC), Outcome 1: Peak cough flow
4.2
4.2. Analysis
Comparison 4: Mechanical insufflation‐exsufflation (MI‐E) versus mechanical insufflation‐exsufflation (MI‐E) plus manually assisted cough (MAC), Outcome 2: Inspiratory capacity
5.1
5.1. Analysis
Comparison 5: Mechanical insufflation (MI) plus manually assisted cough (MAC) versus mechanical insufflation‐exsufflation (MI‐E) plus MAC, Outcome 1: Peak cough flow
5.2
5.2. Analysis
Comparison 5: Mechanical insufflation (MI) plus manually assisted cough (MAC) versus mechanical insufflation‐exsufflation (MI‐E) plus MAC, Outcome 2: Inspiratory capacity
See this image and copyright information in PMC

Update of

References

References to studies included in this review

Brito 2009 {published data only}
    1. Brito MF, Moreira GA, Pradella-Hallinan M, Tufik S. Air stacking and chest compression increase peak cough flow in patients with Duchenne muscular dystrophy. Jornal Brasileiro de Pneumologia 2009;35(10):973-9. [PMID: ] - PubMed
Chatwin 2003 {published data only}
    1. Chatwin M, Ross E, Hart N, Nickol AH, Polkey MI, Simonds AK. Cough augmentation with mechanical insufflation/exsufflation in patients with neuromuscular weakness. European Respiratory Journal 2003;21(3):502-8. [PMID: ] - PubMed
Chatwin 2009 {published data only}
    1. Chatwin M, Simonds AK. The addition of mechanical insufflation/exsufflation shortens airway-clearance sessions in neuromuscular patients with chest infection. Respiratory Care 2009;54(11):1473-9. [PMID: ] - PubMed
Del Amo Castrillo 2019 {published data only}
    1. Del Amo Castrillo L, Lacombe M, Boré A, Vaugier I, Falaize L, Orlikowski D, et al. Comparison of two cough-augmentation techniques delivered by a home ventilator in subjects with neuromuscular disease. Respiratory Care 2019;64(3):255-61. [PMID: ] - PubMed
Jenkins 2014 {published data only}
    1. Jenkins HM, Stocki A, Kriellaars D, Pasterkamp H. Breath stacking in children with neuromuscular disorders. Pediatric Pulmonology 2014;49(6):544-53. [PMID: ] - PubMed
Katz 2019 {published data only}
    1. Katz S, Momoli F, Barrowman N, Bijelic V, Mah J, McMillan H, et al. Stacking exercises attenuate the decline in FVC and sick time (STEADFAST). Chest 2019;156(4 Suppl):A245-6.
Kim 2016 {published data only}
    1. Kim SM, Choi WA, Won YH, Kang SW. A comparison of cough assistance techniques in patients with respiratory muscle weakness. Yonsei Medical Journal 2016;57(6):1488-93. [DOI: 10.3349/ymj.2016.57.6.1488] [PMID: ] - DOI - PMC - PubMed
Lacombe 2014 {published data only}
    1. Lacombe M, Castrillo LD, Boré A, Chapeua D, Horvat E, Vaugier I, et al. Comparison of three cough-augmentation techniques in neuromuscular patients: mechanical insufflation combined with manually assisted cough, insufflation-exsufflation alone and insufflation-exsufflation combined with manually assisted cough. Respiration 2014;88(3):215-22. [PMID: ] - PubMed
Sivasothy 2001 {published data only}
    1. Sivasothy P, Brown L, Smith IE, Shneerson JM. Effect of manually assisted cough and mechanical insufflation on cough flow of normal subjects, patients with chronic obstructive pulmonary disease (COPD), and patients with respiratory muscle weakness. Thorax 2001;56(6):438-44. [PMID: ] - PMC - PubMed
Torres‐Castro 2016 {published data only}
    1. Torres-Castro R, Vilaró J, Vera-Uribe R, Vasconcello L, Puppo H. Acute effects of air stacking versus glossopharyngeal breathing in patients with neuromuscular disease. British Journal of Medicine and Medical Research 2016;14(3):1-8.
Toussaint 2016 {published data only}
    1. Toussaint M, Pernet K, Steens M, Haan J, Sheers N. Cough augmentation in subjects with Duchenne muscular dystrophy: comparison of air stacking via a resuscitator bag versus mechanical ventilation. Respiratory Care 2016;61(1):61-7. [DOI: 10.4187/respcare.04033] [PMID: ] - DOI - PubMed

References to studies excluded from this review

Bianchi 2014 {published data only}
    1. Bianchi C, Carrara R, Khirani S, Tuccio MC. Independent cough flow augmentation by glossopharyngeal breathing plus table thrust in muscular dystrophy. American Journal of Physical Medicine and Rehabilitation 2014;93(1):43-8. [PMID: ] - PubMed
Kang 2000 {published data only}
    1. Kang SW, Bach JR. Maximum insufflation capacity: vital capacity and cough flows in neuromuscular disease. American Journal of Physical Medicine & Rehabilitation 2000;79(3):222-7. [PMID: ] - PubMed
Silva 2012 {published data only}
    1. Silva AR, Fluhr SA, Bezerra AL, Correia MA Jr, Franca EE, Andrade FM. Expiratory peak flow and respiratory system resistance in mechanically ventilated patients undergoing two different forms of manually assisted cough. Revista Brasileira de Terapia Intensiva 2012;24(1):58-63. [PMID: ] - PubMed
Toussaint 2003 {published data only}
    1. Toussaint M, De Win H, Steens M, Soudon P. Effect of intrapulmonary percussive ventilation on mucus clearance in Duchenne muscular dystrophy patients: a preliminary report. Respiratory Care 2003;48(10):940-7. [PMID: ] - PubMed
Toussaint 2009 {published data only}
    1. Toussaint M, Boitano LJ, Gathot V, Steens M, Soudon P. Limits of effective cough-augmentation techniques in patients with neuromuscular disease. Respiratory Care 2009;54(3):359-66. [PMID: 19245730 ] - PubMed
Winck 2004 {published data only}
    1. Winck JC, Goncalves MR, Lourenco C, Viana P, Almeida J, Bach JR. Effects of mechanical insufflation-exsufflation on respiratory parameters for patients with chronic airway secretion encumbrance. Chest 2004;126(3):774-80. [PMID: ] - PubMed

References to ongoing studies

NCT01518439 {published data only}
    1. NCT01518439. Instrumental and manual increase of couch in neuromuscular patients (OPTICOUGH). clinicaltrials.gov/ct2/show/NCT01518439 (first received 26 January 2012).
NCT02651805 {published data only (unpublished sought but not used)}
    1. NCT02651805. Mechanical insufflator-exsufflator to control mucus hypersecretion in patients in palliative care – a feasibility study. clinicaltrials.gov/ct2/show/NCT02651805 (first received 11 January 2016).
NCT03355105 {published data only (unpublished sought but not used)}
    1. NCT03355105. Comparison of two methods of adjusting the mechanical in-exsuflation in neuromuscular adult patients (EXSUFLOW). clinicaltrials.gov/ct2/show/NCT03355105 (first received 28 November 2017).
NCT04081116 {published data only}
    1. NCT04081116. Mechanical insufflation-exsufflation in children with NMD and weak cough. clinicaltrials.gov/ct2/show/NCT04081116 (first received 9 September 2019).
PACTR201506001171421 {published and unpublished data}
    1. PACTR201506001171421. The effect of cough assist and inspiratory muscle training in patients with NMD. pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=1171 (first received 10 June 2015).

Additional references

Albuali 2007
    1. Albuali WH, Singh RN, Fraser DD, Seabrook JA, Kavanagh BP, Parshuram CS, et al. Have changes in ventilation practice improved outcome in children with acute lung injury? Pediatric Critical Care Medicine 2007;8(4):324-30. - PubMed
Altman 2005
    1. Altman DG, Bland MJ. Statistic notes: treatment allocation by minimisation. BMJ 2005;330:843. - PMC - PubMed
Anderson 2005
    1. Anderson JL, Hasney KM, Beaumont NE. Systematic review of techniques to enhance peak cough flow and maintain vital capacity in neuromuscular disease: the case for mechanical insufflation-exsufflation. Physical Therapy Reviews 2005;10(1):25-33.
Bach 1996
    1. Bach JR, Saporito LR. Criteria for extubation and tracheostomy tube removal for patients with ventilatory failure. A different approach to weaning. Chest 1996;110(6):1566-71. - PubMed
Bach 1997
    1. Bach JR, Ishikawa Y, Kim H. Prevention of pulmonary morbidity for patients with Duchenne muscular dystrophy. Chest 1997;112(4):1024-8. - PubMed
Bach 2003
    1. Bach JR. Mechanical insufflation/exsufflation: has it come of age? A commentary. European Respiratory Journal 2003;21(3):385-6. [PMID: ] - PubMed
Bach 2007
    1. Bach JR, Bianchi C, Vidigal-Lopes M, Turi S, Felisari G. Lung inflation by glossopharyngeal breathing and "air stacking" in Duchenne muscular dystrophy. American Journal of Physical Medicine & Rehabilitation 2007;86(4):295-300. [PMID: ] - PubMed
Bianchi 2008
    1. Bianchi C, Baiardi P. Cough peak flows: standard values for children and adolescents. American Journal of Physical Medicine & Rehabilitation 2008;87(6):461-7. [PMID: ] - PubMed
Boentert 2017
    1. Boentert M, Wenninger S, Sansone VA. Respiratory involvement in neuromuscular disorders. Current Opinion in Neurology 2017;30(5):529-37. - PubMed
Boitano 2006
    1. Boitano LJ. Management of airway clearance in neuromuscular disease. Respiratory Care 2006;51(8):913-22; discussion 922-4. [PMID: ] - PubMed
Bott 2009
    1. Bott J, Blumenthal S, Buxton M, Ellum S, Falconer C, Garrod R, et al. Guidelines for the physiotherapy management of the adult, medical, spontaneously breathing patient. Thorax 2009;64(Suppl 1):i1-51. [PMID: ] - PubMed
Chatwin 2018
    1. Chatwin M, Toussaint M, Goncalvez MR, Sheers N, Mellies U, Gonzales-Bermejo J, et al. Airway clearance techniques in neuromuscular disorders: a state of the art review. Respiratory Medicine 2018;136:98-110. - PubMed
Covidence [Computer program]
    1. Covidence. Melbourne, Australia: Veritas Health Innovation, accessed March 2020. Available at covidence.org.
Deeks 2017
    1. Deeks JJ, Higgins JP, Altman DG. Chapter 9: Analysing data and undertaking meta-analyses. In: Higgins JP, Churchill R, Chandler J, Cumpston MS, editor(s). Cochrane Handbook for Systematic Reviews of Interventions Version 5.2.0 (updated June 2017). Cochrane, 2017. Available from training.cochrane.org/handbook/archive/v5.2.
Dohna‐Schwake 2006
    1. Dohna-Schwake C, Ragette R, Teschler H, Voit T, Mellies U. IPPB-assisted coughing in neuromuscular disorders. Pediatric Pulmonology 2006;41(6):551-7. [PMID: ] - PubMed
Douglas 1981
    1. Douglas NJ, Drummond GB, Sudlow MF. Breathing at low lung volumes and chest strapping: a comparison of lung mechanics. Journal of Applied Physiology 1981;50:650-7. - PubMed
Elbourne 2002
    1. Elbourne DR, Altman DG, Higgins JP, Curtin F, Worthington HV, Vail A. Meta-analyses involving cross-over trials: methodological issues. International Journal of Epidemiology 2002;31(1):140-9. - PubMed
Farrero 2013
    1. Farrero E, Antonio A, Egeac CJ, Almaraz MJ, Masae JF, Utraboe I, et al. Guidelines for the management of respiratory complications in patients with neuromuscular disease. Archivos de Bronconeumologia 2013;49(7):306-13. - PubMed
Fauroux 2008
    1. Fauroux B, Guillemot N, Aubertin G, Nathan N, Labit A, Clement A, et al. Physiologic benefits of mechanical insufflation-exsufflation in children with neuromuscular diseases. Chest 2008;133(1):161-8. [PMID: ] - PubMed
Finder 2004
    1. Finder JD, Birnkrant D, Carl J, Farber HJ, Gozal D, Iannaccone ST, et al. Respiratory care of the patient with Duchenne muscular dystrophy: ATS consensus statement. American Journal of Respiratory and Critical Care Medicine 2004;170(4):456-65. [PMID: ] - PubMed
Finder 2010
    1. Finder JD. Airway clearance modalities in neuromuscular disease. Paediatric Respiratory Reviews 2010;11(1):31-4. [PMID: ] - PubMed
Gattinoni 2003
    1. Gattinoni L, Carlesso E, Cadringher P, Valenza F, Vagginelli F, Chiumello D. Physical and biological triggers of ventilator-induced lung injury and its prevention. European Respiratory Journal 2003;22(47 Suppl):15s-25s. - PubMed
Gattinoni 2010
    1. Gattinoni L, Protti A, Caironi P, Carlesso E. Ventilator-induced lung injury: the anatomical and physiological framework. Critical Care Medicine 2010;38(10 Suppl):S539-48. - PubMed
Gozal 2000
    1. Gozal D. Pulmonary manifestations of neuromuscular disease with special reference to Duchenne muscular dystrophy and spinal muscular atrophy. Pediatric Pulmonology 2000;29(2):141-50. [PMID: ] - PubMed
Higgins 2020a
    1. Higgins JP, Savović J, Page MJ, Elbers RG, Sterne JA. Chapter 8: Assessing risk of bias in a randomized trial. In: Cochrane Handbook for Systematic Reviews of Interventions Version 6.1 (updated September 2020). Cochrane, 2020. Available from training.cochrane.org/handbook.
Higgins 2020b
    1. Higgins JP, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, Welch VA, editor(s). Cochrane Handbook for Systematic Reviews of Interventions Version 6.1 (updated September 2020). Cochrane, 2020. Available from training.cochrane.org/handbook.
Homnick 2007
    1. Homnick DN. Mechanical insufflation-exsufflation for airway mucus clearance. Respiratory Care 2007;52(10):1296-305; discussion 1306-7. [PMID: ] - PubMed
Hull 2012
    1. Hull J, Aniapravan R, Chan E, Chatwin M, Forton J, Gallagher J, et al. British Thoracic Society guideline for respiratory management of children with neuromuscular weakness. Thorax 2012;67(1):1-40. - PubMed
Iannaccone 2007
    1. Iannaccone ST. Modern management of spinal muscular atrophy. Journal of Child Neurology 2007;22(8):974-8. [PMID: ] - PubMed
Leiner 1963
    1. Leiner GC, Brramowitz S, Small MJ, Stenby VB, Lewis WA. Expiratory peak flow rate. Standard values for normal subjects. Use as a clinical test of ventilatory function. American Review of Respiratory Disease 1963;88:644-51. - PubMed
Marques 2014
    1. Marques TB, Neves Jde C, Portes LA, Salge JM, Zanoteli E, Reed UC. Air stacking: effects on pulmonary function in patients with spinal muscular atrophy and in patients with congenital muscular dystrophy. Jornal Brasileiro de Pneumologia 2014;40(5):528-34. - PMC - PubMed
Marques 2020
    1. Marques L, Freitas Fregonezi GA, Santos IP, Marcelino AA, Medeiros da Fonsêca JD, Dourado-Júnior ME, et al. Effects of positioning on cough peak flow and muscular electromyographic activation in Duchenne muscular dystrophy. Respiratory Care 2020;65(11):1668-77. - PubMed
Mayer 2017
    1. Mayer OH, Henricson EK, McDonald CM, Buyse GM. Advances in pulmonary care in Duchenne muscular dystrophy. US Neurology 2017;13(1):35-41.
McCool 2006
    1. McCool FD, Rosen MJ. Nonpharmacologic airway clearance therapies: ACCP evidence-based clinical practice guidelines. Chest 2006;129(1 Suppl):250S-9S. [PMID: ] - PubMed
Mills 2009
    1. Mills EJ, Chan AW, Wu P, Vail A, Guyatt GH, Altman DG. Design, analysis, and presentation of crossover trials. Trials 2009;10(27):1-6. - PMC - PubMed
Moher 2009
    1. Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group. Preferred reporting items for systematic reviews and metaanalyses: the PRISMA statement. PLoS Medicine 2009;6(7):e1000097. [DOI: 10.1371/journal.pmed1000097] - DOI - PMC - PubMed
Morrow 2013
    1. Morrow B, Zampoli M, Van Aswegen H, Argent A. Mechanical insufflation-exsufflation for people with neuromuscular disorders. Cochrane Database of Systematic Reviews 2013, Issue 12. Art. No: CD010044. [DOI: 10.1002/14651858.CD010044.pub2] - DOI - PubMed
Nolan 2016
    1. Nolan SJ, Hambleton I, Dwan K. The use and reporting of the cross-over study design in clinical trials and systematic reviews: a systematic assessment. PloS One 2016;11(7):e0159014. - PMC - PubMed
Nygren‐Bonnier 2009
    1. Nygren-Bonnier M, Markström A, Lindholm P, Mattsson E, Klefbeck B. Glossopharyngeal pistoning for lung insufflation in children with spinal muscular atrophy type II. Acta Paediatrica 2009;98:1324–8. - PubMed
Panitch 2009
    1. Panitch HB. The pathophysiology of respiratory impairment in pediatric neuromuscular diseases. Pediatrics 2009;123(Suppl 4):S215-8. [PMID: ] - PubMed
Panitch 2017
    1. Panitch HB. Respiratory implications of pediatric neuromuscular disease. Respiratory Care 2017;62(6):826-48. - PubMed
Papastamelos 1996
    1. Papastamelos C, Panitch HB, Allen JL. Chest wall compliance in infants and children with neuromuscular disease. American Journal of Respiratory and Critical Care Medicine 1996;154(4 Pt 1):1045-8. [PMID: ] - PubMed
Quanjer 2012
    1. Quanjer PH, Stanojevic S, Cole TJ, Baur X, Hall GL, Culver BH, et al, ERS Globalet al Lung Function Initiative. Multi-ethnic reference values for spirometry for the 3-95-yr age range: the global lung function 2012 equations. European Respiratory Journal 2012;40(6):1324-43. - PMC - PubMed
Review Manager 2020 [Computer program]
    1. Review Manager (RevMan). Version 5.4. Copenhagen: Nordic Cochrane Centre, The Cochrane Collaboration, 2020.
Rokadia 2015
    1. Rokadia HK, Adams JR, McCarthy K, Aboussouan LS, Mireles-Cabodevila E. Cough augmentation in a patient with neuromuscular disease. Annals of the American Thoracic Society 2015;12(12):1888-91. - PubMed
Rosière 2009
    1. Rosière J, Vader JP, Cavin MS, Grant K, Larcinese A, Voellinger R, et al. Appropriateness of respiratory care: evidence-based guidelines. Swiss Medical Weekly 2009;139(27-28):387-92. - PubMed
Saharan 2010
    1. Saharan S, Lodha R, Kabra SK. Management of acute lung injury/ARDS. Indian Journal of Pediatrics 2010;77(11):1296-302. - PubMed
Schünemann 2017a
    1. Schünemann HJ, Oxman AD, Higgins JP, Vist GE, Glasziou P, Akl E, et al. Chapter 11: Completing 'Summary of findings' tables and grading the confidence in or quality of the evidence. In: Higgins JP, Churchill R, Chandler J, Cumpston MS, editor(s). Cochrane Handbook for Systematic Reviews of Interventions Version 5.2.0 (updated June 2017). Cochrane, 2017. Available from training.cochrane.org/handbook/archive/v5.2.
Schünemann 2017b
    1. Schünemann HJ, Oxman AD, Vist GE, Higgins JP, Deeks JJ, Glasziou P, et al. Chapter 12: Interpreting results and drawing conclusions. In: Higgins JP, Churchill R, Chandler J, Cumpston MS, editor(s). Cochrane Handbook for Systematic Reviews of Interventions Version 5.2.0 (updated June 2017). Cochrane, 2017. Available from training.cochrane.org/handbook/archive/v5.2.
Suri 2008
    1. Suri P, Burns SP, Bach JR. Pneumothorax associated with mechanical insufflation-exsufflation and related factors. American Journal of Physical Medicine & Rehabilitation 2008;87(11):951-5. [PMID: ] - PubMed
Toussaint 2018
    1. Toussaint M, Chatwin M, Gonzalez J, Berlowitz DJ, the ENMC Respiratory Therapy Consortium. Airway clearance techniques in neuromuscular disorders. Neuromuscular Disorders 2018;28:289-98. - PubMed
Trebbia 2005
    1. Trebbia G, Lacombe M, Fermanian C, Falaize L, Lejaille M, Louis A, et al. Cough determinants in patients with neuromuscular disease. Respiratory Physiology and Neurobiology 2005;146(2-3):291-300. - PubMed
Tzeng 2000
    1. Tzeng AC, Bach JR. Prevention of pulmonary morbidity for patients with neuromuscular disease. Chest 2000;118(5):1390-6. [PMID: ] - PubMed
Vianello 2004
    1. Vianello A, Arcaro G, Gallan F, Ori C, Bevilacqua M. Pneumothorax associated with long-term non-invasive positive pressure ventilation in Duchenne muscular dystrophy. Neuromuscular Disorders 2004;14(6):353-5. - PubMed
Wang 2007
    1. Wang CH, Finkel RS, Bertini ES, Schroth M, Simonds A, Wong B, et al, Participants of the International Conference on SMA Standard of Care. Consensus statement for standard of care in spinal muscular atrophy. Journal of Child Neurology 2007;22(8):1027-49. - PubMed
Wang 2010
    1. Wang CH, Bonnemann CG, Rutkowski A, Sejersen T, Bellini J, Battista V, et al. Consensus statement on standard of care for congenital muscular dystrophies. Journal of Child Neurology 2010;25(12):1559-81. [PMID: ] - PMC - PubMed
Westermann 2013
    1. Westermann EJ, Jans M, Gaytant MA, Bach JR, Kampelmacher MJ. Pneumothorax as a complication of lung volume recruitment. Jornal Brasileiro Pneumologia 2013;39(3):382-6. - PMC - PubMed

References to other published versions of this review

Morrow 2018
    1. Morrow B, Argent A, Zampoli M, Human A, Corten L, Toussaint M. Cough augmentation techniques for people with chronic neuromuscular disorders. Cochrane Database of Systematic Reviews 2018, Issue 11. Art. No: CD013170. [DOI: 10.1002/14651858.CD013170] - DOI - PMC - PubMed

Associated data