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        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Neuromuscular disease &#40;NMD&#41; patients frequently have impaired cough&#46; Mechanical insufflation-exsufflation &#40;MI-E&#41; has proven efficacy in improving airway clearance&#44; however data related to its long-term home use is lacking&#46; The purpose of this study was to describe indications&#44; safety and compliance of home MI-E in NMD patients&#46;</p> <span class="elsevierStyleSectionTitle">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Four years observational analysis of 21 NMD patients on home MI-E&#46; Diagnosis included bulbar and non-bulbar Amyotrophic Lateral Sclerosis &#40;ALS&#41; and other NMD&#46; Median age was 58 years&#46; Only cooperative patients with unassisted baseline Peak Cough Flow &#40;PCF&#41; &#60; 270 L&#47;min were included&#46; All patients were under continuous mechanical ventilation &#40;6 by tracheostomy&#41;&#46; Pulmonary function before initiation of MI-E &#40;median&#41;&#58; FVC &#61; 0&#46;81 L&#44; MIP &#61; 28 cmH<span class="elsevierStyleInf">2</span>O&#44; MEP &#61; 22 cmH<span class="elsevierStyleInf">2</span>O and PCF &#61; 60 L&#47;min&#46; MI-E was performed by previously trained non-professional caregivers&#44; with an on-call support of a trained health care professional&#46; Patients had pulse oximetry monitorization and applied MI-E whenever SpO<span class="elsevierStyleInf">2</span> &#60; 95 &#37;&#46; Median follow-up was 12 months &#40;3-41 months&#41;&#46;</p> <span class="elsevierStyleSectionTitle">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Ten patients &#40;9 ALS&#41; used MI-E daily&#46; Eleven patients used MI-E intermittently&#44; during exacerbations&#44; and in 8 patients early application of MI-E &#40;guided by oximetry feed-back&#41; avoided hospitalization&#46; All tracheostomized patients used MI-E daily and more times a day than patients under NIV&#46; Four patients &#40;3 bulbar ALS&#41;&#44; were hospitalized due to secretion encumbrance&#46; MI-E was well-tolerated and there were no complications&#46; In general&#44; caregivers considered MI-E effective&#46; During this period&#44; 4 patients died&#44; related to disease progression&#46;</p> <span class="elsevierStyleSectionTitle">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Home MI-E is well tolerated&#44; effective and safe if used by well trained caregivers&#46; MI-E should be considered as a complement to mechanical ventilation&#46;</p>"
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        "resumen" => "<span class="elsevierStyleSectionTitle">Introducci&#243;n</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Con frecuencia&#44; los pacientes con enfermedades neuromusculares &#40;ENM&#41; presentan un deterioro del mecanismo de la tos&#46; Se ha demostrado la eficacia de la insuflaci&#243;n-exuflaci&#243;n mec&#225;nica &#40;IEM&#41; en la mejora del aclaramiento de las v&#237;as respiratorias aunque no se dispone de datos relacionados con su utilizaci&#243;n domiciliaria a largo plazo&#46; El objetivo del presente estudio fue describir las indicaciones&#44; tolerabilidad y cumplimiento con la IEM domiciliaria en pacientes con ENM&#46;</p> <span class="elsevierStyleSectionTitle">M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">An&#225;lisis observacional de 4 a&#241;os de duraci&#243;n de 21 pacientes ENM tratados con IEM domiciliaria&#46; El diagn&#243;stico incluy&#243; esclerosis lateral amiotr&#243;fica &#40;ELA&#41; bulbar y no bulbar y otras ENM&#46; La edad mediana fue de 58 a&#241;os&#46; S&#243;lo se incluyeron pacientes cooperadores con valores de flujo pico de tos basal &#40;FTM&#41; no asistido &#60; 270 l&#47;min&#46; Todos los pacientes estaban sometidos a ventilaci&#243;n mec&#225;nica continua &#40;seis mediante traqueostom&#237;a&#41;&#46; La funci&#243;n pulmonar previa al inicio de la IEM &#40;mediana&#41; era&#58; FVC&#44; 0&#44;81 l&#44; MIP&#44; 28 cmH<span class="elsevierStyleInf">2</span>O&#44; MEP &#61; 22 cmH<span class="elsevierStyleInf">2</span>O y PCF &#61; 60 l&#47;min&#46; Cuidadores no profesionales adiestrados previamente con el apoyo permanente de un profesional sanitario experto efectuaron la IEM&#46; En los pacientes se monitoriz&#243; la pulsioximetr&#237;a y se aplic&#243; IEM siempre que la SpO<span class="elsevierStyleInf">2</span> fue &#60; 95 &#37;&#46; El seguimiento mediano fue de 12 meses &#40;3-41 meses&#41;&#46;</p> <span class="elsevierStyleSectionTitle">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Utilizaron diariamente IEM 10 pacientes &#40;nueve con ELA&#41;&#46; La utilizaron de forma intermitente 11 pacientes durante las exacerbaciones y en 8 la aplicaci&#243;n precoz de IEM &#40;guiada por la informaci&#243;n de la oximetr&#237;a&#41; evit&#243; la hospitalizaci&#243;n&#46; Todos los pacientes traqueostomizados utilizaron la IEM a diario y un mayor n&#250;mero de veces al d&#237;a que los pacientes sometidos a ventilaci&#243;n mec&#225;nica no invasiva &#40;VNI&#41;&#46; Requirieron ingreso hospitalario 4 pacientes &#40;3 ELA bulbar&#41; debido a la acumulaci&#243;n de secreciones&#46; La IEM fue bien tolerada y no se asoci&#243; a complicaciones&#46; En general&#44; los cuidadores la consideraron eficaz&#46; Durante este per&#237;odo&#44; 4 pacientes fallecieron&#44; en relaci&#243;n con la progresi&#243;n de la enfermedad&#46;</p> <span class="elsevierStyleSectionTitle">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La IEM domiciliaria es bien tolerada&#44; eficaz y segura cuando la utilizan cuidadores adiestrados apropiadamente&#46; Debe considerarse un complemento de la ventilaci&#243;n mec&#225;nica&#46;</p>"
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              "identificador" => "bib4"
              "etiqueta" => "4&#46;"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Cough augmentation with mechanical insufflation&#47;exsufflation in patients with neuromuscular weakness"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "M&#46; Chatwin"
                            1 => "E&#46; Ross"
                            2 => "N&#46; Hart"
                            3 => "A&#46;H&#46; Nickol"
                            4 => "M&#46;I&#46; Polkey"
                            5 => "A&#46;K&#46; Simonds"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Eur Respir J"
                        "fecha" => "2003"
                        "volumen" => "21"
                        "paginaInicial" => "502"
                        "paginaFinal" => "508"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12662009"
                            "web" => "Medline"
                          ]
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                      ]
                    ]
                  ]
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib5"
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              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Mechanical insufflation-exsufflation for airways mucus clearance"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "D&#46;N&#46; Homnick"
                          ]
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                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:7 [
                        "tituloSerie" => "Respir Care"
                        "fecha" => "2007"
                        "volumen" => "52"
                        "numero" => "10"
                        "paginaInicial" => "1296"
                        "paginaFinal" => "1305"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17894900"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            5 => array:3 [
              "identificador" => "bib6"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Amyotrophic lateral sclerosis&#58; predictors for prolongation of life by non-invasive respiratory aids"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "J&#46;R&#46; Bach"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Arch Phys Med Rehabil"
                        "fecha" => "1995"
                        "volumen" => "76"
                        "paginaInicial" => "828"
                        "paginaFinal" => "832"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/7668953"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            6 => array:3 [
              "identificador" => "bib7"
              "etiqueta" => "7&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Mechanical insufflation-exsufflation&#46; Comparison of peak expiratory flows with manually assisted and unassisted coughing techniques"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "J&#46;R&#46; Bach"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Chest"
                        "fecha" => "1993"
                        "volumen" => "104"
                        "paginaInicial" => "1553"
                        "paginaFinal" => "1562"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8222823"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            7 => array:3 [
              "identificador" => "bib8"
              "etiqueta" => "8&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Criteria for extubation and tracheostomy tube removal for patients with ventilatory failure&#58; a different approach to weaning"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "J&#46;R&#46; Bach"
                            1 => "L&#46;R&#46; Saporito"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Chest"
                        "fecha" => "1996"
                        "volumen" => "110"
                        "paginaInicial" => "1566"
                        "paginaFinal" => "1571"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8989078"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            8 => array:3 [
              "identificador" => "bib9"
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              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Predictors of ineffective cough during a chest infection in patients with stable amyotrophic lateral sclerosis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "J&#46; Sancho"
                            1 => "E&#46; Servera"
                            2 => "J&#46; Diaz"
                            3 => "J&#46; Marin"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1164/rccm.200612-1841OC"
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Respir Crit Care Med"
                        "fecha" => "2007"
                        "volumen" => "175"
                        "paginaInicial" => "1266"
                        "paginaFinal" => "1271"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17413124"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            9 => array:3 [
              "identificador" => "bib10"
              "etiqueta" => "10&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Respiratory muscle weakness during upper respiratory tract infections"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "A&#46; Mier-Jedrezejowicz"
                            1 => "C&#46; Brophy"
                            2 => "M&#46; Green"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1164/ajrccm/138.1.5"
                      "Revista" => array:6 [
                        "tituloSerie" => "Am Rev Respir Dis"
                        "fecha" => "1988"
                        "volumen" => "138"
                        "paginaInicial" => "5"
                        "paginaFinal" => "7"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/3202399"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            10 => array:3 [
              "identificador" => "bib11"
              "etiqueta" => "11&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Effect of upper respiratory tract infection in patients with neuromuscular disease"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "J&#46;M&#46; Poponick"
                            1 => "I&#46; Jacobs"
                            2 => "G&#46; Supinski"
                            3 => "A&#46;F&#46; DiMarco"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1164/ajrccm.156.2.9611029"
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Respir Crit Care Med"
                        "fecha" => "1997"
                        "volumen" => "156"
                        "paginaInicial" => "659"
                        "paginaFinal" => "664"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9279255"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            11 => array:3 [
              "identificador" => "bib12"
              "etiqueta" => "12&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Neuromuscular ventilatory insufficiency&#58; the effect of home mechanical ventilator use vs oxygen therapy on pneumonia and hospitalization rates"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "J&#46;R&#46; Bach"
                            1 => "R&#46; Rajaraman"
                            2 => "F&#46; Ballanger"
                            3 => "A&#46;C&#46; Tzeng"
                            4 => "Y&#46; Ishikawa"
                            5 => "R&#46; Kulessa"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:7 [
                        "tituloSerie" => "Am J Phys Med Rehabil"
                        "fecha" => "1998"
                        "volumen" => "77"
                        "paginaInicial" => "8"
                        "paginaFinal" => "19"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9482374"
                            "web" => "Medline"
                          ]
                        ]
                        "itemHostRev" => array:3 [
                          "pii" => "S0211139X09002753"
                          "estado" => "S300"
                          "issn" => "0211139X"
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                    ]
                  ]
                ]
              ]
            ]
            12 => array:3 [
              "identificador" => "bib13"
              "etiqueta" => "13&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Mechanical insufflation&#47;exsufflation&#58; has it come of age&#63; A commentary"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "J&#46;R&#46; Bach"
                          ]
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                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Eur Respir J"
                        "fecha" => "2003"
                        "volumen" => "21"
                        "paginaInicial" => "385"
                        "paginaFinal" => "386"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12661989"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            13 => array:3 [
              "identificador" => "bib14"
              "etiqueta" => "14&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Duchenne muscular dystrophy&#58; prolongation of life by noninvasive ventilation and mechanically assisted coughing"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "E&#46; Gomez-Merino"
                            1 => "J&#46;R&#46; Bach"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Phys Med Rehabil"
                        "fecha" => "2002"
                        "volumen" => "81"
                        "paginaInicial" => "411"
                        "paginaFinal" => "415"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12023596"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            14 => array:3 [
              "identificador" => "bib15"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Prevention of pulmonary morbidity for patients with neuromuscular disease"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "A&#46;C&#46; Tzeng"
                            1 => "J&#46;R&#46; Bach"
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                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:7 [
                        "tituloSerie" => "Chest"
                        "fecha" => "2000"
                        "volumen" => "118"
                        "paginaInicial" => "1390"
                        "paginaFinal" => "1396"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11083691"
                            "web" => "Medline"
                          ]
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                          "pii" => "S0959804909000094"
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                          "issn" => "09598049"
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                  ]
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              ]
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            15 => array:3 [
              "identificador" => "bib16"
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              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Survival in amyotrophic lateral sclerosis with home mechanical ventilation&#58; the impact of systematic respiratory assessment and bulbar involvement"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "E&#46; Farrero"
                            1 => "E&#46; Prats"
                            2 => "M&#46; Povedano"
                            3 => "J&#46;A&#46; Martinez-Matos"
                            4 => "F&#46; Manresa"
                            5 => "J&#46; Escarrabill"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1378/chest.127.6.2132"
                      "Revista" => array:6 [
                        "tituloSerie" => "Chest"
                        "fecha" => "2005"
                        "volumen" => "127"
                        "paginaInicial" => "2132"
                        "paginaFinal" => "2138"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15947331"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            16 => array:3 [
              "identificador" => "bib17"
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              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Effect of manually assisted cough and mechanical insufflation on cough flows of normal subjects&#44; patients with chronic obstructive pulmonary disease &#40;COPD&#41; and patients with respiratory muscle weakness"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
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                            1 => "L&#46; Brown"
                            2 => "I&#46;E&#46; Smith"
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                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:7 [
                        "tituloSerie" => "Thorax"
                        "fecha" => "2001"
                        "volumen" => "56"
                        "paginaInicial" => "438"
                        "paginaFinal" => "444"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11359958"
                            "web" => "Medline"
                          ]
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                          "pii" => "S0959804909000094"
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                          "issn" => "09598049"
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                ]
              ]
            ]
            17 => array:3 [
              "identificador" => "bib18"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Series &#8220;ATS&#47;ERS task force&#58; standardisation of lung function testing&#8221;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
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                            3 => "R&#46;O&#46; Crapo"
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                            5 => "R&#46; Casaburi"
                          ]
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                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1183/09031936.05.00035205"
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                        "tituloSerie" => "Eur Respir J"
                        "fecha" => "2005"
                        "volumen" => "26"
                        "paginaInicial" => "948"
                        "paginaFinal" => "968"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16264058"
                            "web" => "Medline"
                          ]
                        ]
                        "itemHostRev" => array:3 [
                          "pii" => "S0300893210001119"
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                          "issn" => "03008932"
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                  ]
                ]
              ]
            ]
            18 => array:3 [
              "identificador" => "bib19"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "ATS&#47;ERS Statement on Respiratory Muscle Testing"
                      "autores" => array:1 [
                        0 => array:2 [
                          "colaboracion" => "American Thoracic Society&#47;European Respiratory Society"
                          "etal" => false
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                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1164/rccm.166.4.518"
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Respir Crit Care Med"
                        "fecha" => "2002"
                        "volumen" => "166"
                        "paginaInicial" => "518"
                        "paginaFinal" => "624"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12186831"
                            "web" => "Medline"
                          ]
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                    ]
                  ]
                ]
              ]
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            19 => array:3 [
              "identificador" => "bib20"
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Disorders of ventilation"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "J&#46;R&#46; Bach"
                            1 => "S&#46;W&#46; Kang"
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                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Chest"
                        "fecha" => "2000"
                        "volumen" => "117"
                        "paginaInicial" => "301"
                        "paginaFinal" => "303"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10669664"
                            "web" => "Medline"
                          ]
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                      ]
                    ]
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                ]
              ]
            ]
            20 => array:3 [
              "identificador" => "bib21"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Mechanical insufflation-exsufflation improves outcomes for neuromuscular disease patients with respiratory tract infections"
                      "autores" => array:1 [
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                          "etal" => true
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                            3 => "F&#46; Gallan"
                            4 => "C&#46; Ori"
                            5 => "M&#46; Minuzzo"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Phys Med Rehabil"
                        "fecha" => "2005"
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                        "paginaInicial" => "83"
                        "paginaFinal" => "88"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15668554"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            21 => array:3 [
              "identificador" => "bib22"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Effects of Mechanical Insufflation-Exsufflation on Respiratory Parameters for patients with chronic airway secretion encumbrance"
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                          "etal" => false
                          "autores" => array:6 [
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                            2 => "C&#46; Louren&#231;o"
                            3 => "P&#46; Viana"
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                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1378/chest.126.3.774"
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                        "tituloSerie" => "Chest"
                        "fecha" => "2004"
                        "volumen" => "126"
                        "paginaInicial" => "774"
                        "paginaFinal" => "780"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15364756"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            22 => array:3 [
              "identificador" => "bib23"
              "etiqueta" => "23&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Oximetry and indications for tracheotomy for amyotrophic lateral sclerosis"
                      "autores" => array:1 [
                        0 => array:2 [
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                          "autores" => array:3 [
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                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
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                        "volumen" => "126"
                        "paginaInicial" => "1502"
                        "paginaFinal" => "1507"
                        "link" => array:1 [
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                ]
              ]
            ]
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              "etiqueta" => "24&#46;"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Mechanical insufflation-exsufflation improves outcomes for neuromuscular disease patients with respiratory tract infections&#46; A step in the right direction"
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                          "autores" => array:2 [
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                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
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                        "fecha" => "2005"
                        "volumen" => "84"
                        "paginaInicial" => "89"
                        "paginaFinal" => "91"
                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "etiqueta" => "25&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Efficacy of Mechanical Insufflation-Exsufflation in Medically Stable Patients with Amyotrophic Lateral Sclerosis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "J&#46; Sancho"
                            1 => "E&#46; Servera"
                            2 => "J&#46; D&#237;az"
                            3 => "J&#46; Mar&#237;n"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Chest"
                        "fecha" => "2004"
                        "volumen" => "125"
                        "paginaInicial" => "1400"
                        "paginaFinal" => "1405"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15078752"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            25 => array:3 [
              "identificador" => "bib26"
              "etiqueta" => "26&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Recent advances in respiratory care for neuromuscular disease"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "A&#46;K&#46; Simonds"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1378/chest.130.6.1879"
                      "Revista" => array:6 [
                        "tituloSerie" => "Chest"
                        "fecha" => "2006"
                        "volumen" => "130"
                        "paginaInicial" => "1879"
                        "paginaFinal" => "1886"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17167012"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            26 => array:3 [
              "identificador" => "bib27"
              "etiqueta" => "27&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Disease progression in amyotrophic lateral sclerosis&#58; predictors of survival"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "T&#46; Magnus"
                            1 => "M&#46; Beck"
                            2 => "R&#46; Giess"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1002/mus.10090"
                      "Revista" => array:6 [
                        "tituloSerie" => "Muscle Nerve"
                        "fecha" => "2002"
                        "volumen" => "25"
                        "paginaInicial" => "709"
                        "paginaFinal" => "714"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11994965"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            27 => array:3 [
              "identificador" => "bib28"
              "etiqueta" => "28&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "A comparison of long-term ventilatory support alternatives from the perspective of the patient and the care giver"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
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                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Chest"
                        "fecha" => "1993"
                        "volumen" => "104"
                        "paginaInicial" => "1702"
                        "paginaFinal" => "1706"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8252946"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Noninvasive respiratory muscle aids&#58; intervention goals and mechanism of action&#46; In Management of patients with neuromuscular disease"
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                          "etal" => false
                          "autores" => array:1 [
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Journal Information
Vol. 46. Issue 8.
Pages 420-425 (January 2010)
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Vol. 46. Issue 8.
Pages 420-425 (January 2010)
Original Article
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Indications and Compliance of Home Mechanical Insufflation-Exsufflation in Patients with Neuromuscular Diseases
Indicaciones y cumplimiento con la insuflación-exuflación mecánica domiciliaria en pacientes con enfermedades neuromusculares
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João Bentoa,
Corresponding author
joao.a.p.bento@gmail.com

Corresponding author.
, Miguel Gonçalvesa,b, Nuno Silvac, Tiago Pintoa, Anabela Marinhoa, João Carlos Wincka,b
a Pulmonology Department, HS João, Oporto, Portugal
b Faculty of Medicine, University of Porto, Oporto, Portugal
c Linde homecare, Oporto, Portugal
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Article information
Abstract
Introduction

Neuromuscular disease (NMD) patients frequently have impaired cough. Mechanical insufflation-exsufflation (MI-E) has proven efficacy in improving airway clearance, however data related to its long-term home use is lacking. The purpose of this study was to describe indications, safety and compliance of home MI-E in NMD patients.

Methods

Four years observational analysis of 21 NMD patients on home MI-E. Diagnosis included bulbar and non-bulbar Amyotrophic Lateral Sclerosis (ALS) and other NMD. Median age was 58 years. Only cooperative patients with unassisted baseline Peak Cough Flow (PCF) < 270 L/min were included. All patients were under continuous mechanical ventilation (6 by tracheostomy). Pulmonary function before initiation of MI-E (median): FVC = 0.81 L, MIP = 28 cmH2O, MEP = 22 cmH2O and PCF = 60 L/min. MI-E was performed by previously trained non-professional caregivers, with an on-call support of a trained health care professional. Patients had pulse oximetry monitorization and applied MI-E whenever SpO2 < 95 %. Median follow-up was 12 months (3-41 months).

Results

Ten patients (9 ALS) used MI-E daily. Eleven patients used MI-E intermittently, during exacerbations, and in 8 patients early application of MI-E (guided by oximetry feed-back) avoided hospitalization. All tracheostomized patients used MI-E daily and more times a day than patients under NIV. Four patients (3 bulbar ALS), were hospitalized due to secretion encumbrance. MI-E was well-tolerated and there were no complications. In general, caregivers considered MI-E effective. During this period, 4 patients died, related to disease progression.

Conclusions

Home MI-E is well tolerated, effective and safe if used by well trained caregivers. MI-E should be considered as a complement to mechanical ventilation.

Keywords:
Mechanical insufflation-exsufflation
Home
Safety
Efficacy
Neuromuscular disease
Resumen
Introducción

Con frecuencia, los pacientes con enfermedades neuromusculares (ENM) presentan un deterioro del mecanismo de la tos. Se ha demostrado la eficacia de la insuflación-exuflación mecánica (IEM) en la mejora del aclaramiento de las vías respiratorias aunque no se dispone de datos relacionados con su utilización domiciliaria a largo plazo. El objetivo del presente estudio fue describir las indicaciones, tolerabilidad y cumplimiento con la IEM domiciliaria en pacientes con ENM.

Métodos

Análisis observacional de 4 años de duración de 21 pacientes ENM tratados con IEM domiciliaria. El diagnóstico incluyó esclerosis lateral amiotrófica (ELA) bulbar y no bulbar y otras ENM. La edad mediana fue de 58 años. Sólo se incluyeron pacientes cooperadores con valores de flujo pico de tos basal (FTM) no asistido < 270 l/min. Todos los pacientes estaban sometidos a ventilación mecánica continua (seis mediante traqueostomía). La función pulmonar previa al inicio de la IEM (mediana) era: FVC, 0,81 l, MIP, 28 cmH2O, MEP = 22 cmH2O y PCF = 60 l/min. Cuidadores no profesionales adiestrados previamente con el apoyo permanente de un profesional sanitario experto efectuaron la IEM. En los pacientes se monitorizó la pulsioximetría y se aplicó IEM siempre que la SpO2 fue < 95 %. El seguimiento mediano fue de 12 meses (3-41 meses).

Resultados

Utilizaron diariamente IEM 10 pacientes (nueve con ELA). La utilizaron de forma intermitente 11 pacientes durante las exacerbaciones y en 8 la aplicación precoz de IEM (guiada por la información de la oximetría) evitó la hospitalización. Todos los pacientes traqueostomizados utilizaron la IEM a diario y un mayor número de veces al día que los pacientes sometidos a ventilación mecánica no invasiva (VNI). Requirieron ingreso hospitalario 4 pacientes (3 ELA bulbar) debido a la acumulación de secreciones. La IEM fue bien tolerada y no se asoció a complicaciones. En general, los cuidadores la consideraron eficaz. Durante este período, 4 pacientes fallecieron, en relación con la progresión de la enfermedad.

Conclusiones

La IEM domiciliaria es bien tolerada, eficaz y segura cuando la utilizan cuidadores adiestrados apropiadamente. Debe considerarse un complemento de la ventilación mecánica.

Palabras clave:
Insuflación-exuflación mecánica
Domicilio
Seguridad
Eficacia
Enfermedad neuromuscular
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References
[1.]
E. Gomez-Merino, J. Sancho, J. Martin.
Mechanical insufflaton-exsufflation: pressure, volume and flow relationships and the adequacy of manufacturer's guidelines.
Am J Phys Med Rehabil, 81 (2002), pp. 579-583
[2.]
E. Servera, J. Sancho, M.J. Zafra.
Cough and neuromuscular diseases. Noninvasive airway secretion management.
Arch Bronconeumol, 39 (2003), pp. 418-427
[3.]
J.R. Bach.
Amyotrophic lateral sclerosis: prolongation of life by non-invasive respiratory aids.
Chest, 122 (2002), pp. 92-98
[4.]
M. Chatwin, E. Ross, N. Hart, A.H. Nickol, M.I. Polkey, A.K. Simonds.
Cough augmentation with mechanical insufflation/exsufflation in patients with neuromuscular weakness.
Eur Respir J, 21 (2003), pp. 502-508
[5.]
D.N. Homnick.
Mechanical insufflation-exsufflation for airways mucus clearance.
Respir Care, 52 (2007), pp. 1296-1305
[6.]
J.R. Bach.
Amyotrophic lateral sclerosis: predictors for prolongation of life by non-invasive respiratory aids.
Arch Phys Med Rehabil, 76 (1995), pp. 828-832
[7.]
J.R. Bach.
Mechanical insufflation-exsufflation. Comparison of peak expiratory flows with manually assisted and unassisted coughing techniques.
Chest, 104 (1993), pp. 1553-1562
[8.]
J.R. Bach, L.R. Saporito.
Criteria for extubation and tracheostomy tube removal for patients with ventilatory failure: a different approach to weaning.
Chest, 110 (1996), pp. 1566-1571
[9.]
J. Sancho, E. Servera, J. Diaz, J. Marin.
Predictors of ineffective cough during a chest infection in patients with stable amyotrophic lateral sclerosis.
Am J Respir Crit Care Med, 175 (2007), pp. 1266-1271
[10.]
A. Mier-Jedrezejowicz, C. Brophy, M. Green.
Respiratory muscle weakness during upper respiratory tract infections.
Am Rev Respir Dis, 138 (1988), pp. 5-7
[11.]
J.M. Poponick, I. Jacobs, G. Supinski, A.F. DiMarco.
Effect of upper respiratory tract infection in patients with neuromuscular disease.
Am J Respir Crit Care Med, 156 (1997), pp. 659-664
[12.]
J.R. Bach, R. Rajaraman, F. Ballanger, A.C. Tzeng, Y. Ishikawa, R. Kulessa, et al.
Neuromuscular ventilatory insufficiency: the effect of home mechanical ventilator use vs oxygen therapy on pneumonia and hospitalization rates.
Am J Phys Med Rehabil, 77 (1998), pp. 8-19
[13.]
J.R. Bach.
Mechanical insufflation/exsufflation: has it come of age? A commentary.
Eur Respir J, 21 (2003), pp. 385-386
[14.]
E. Gomez-Merino, J.R. Bach.
Duchenne muscular dystrophy: prolongation of life by noninvasive ventilation and mechanically assisted coughing.
Am J Phys Med Rehabil, 81 (2002), pp. 411-415
[15.]
A.C. Tzeng, J.R. Bach.
Prevention of pulmonary morbidity for patients with neuromuscular disease.
Chest, 118 (2000), pp. 1390-1396
[16.]
E. Farrero, E. Prats, M. Povedano, J.A. Martinez-Matos, F. Manresa, J. Escarrabill.
Survival in amyotrophic lateral sclerosis with home mechanical ventilation: the impact of systematic respiratory assessment and bulbar involvement.
Chest, 127 (2005), pp. 2132-2138
[17.]
P. Sivasothy, L. Brown, I.E. Smith.
Effect of manually assisted cough and mechanical insufflation on cough flows of normal subjects, patients with chronic obstructive pulmonary disease (COPD) and patients with respiratory muscle weakness.
Thorax, 56 (2001), pp. 438-444
[18.]
R. Pellegrino, G. Viegi, V. Brusasco, R.O. Crapo, F. Burgos, R. Casaburi, et al.
Series “ATS/ERS task force: standardisation of lung function testing”.
Eur Respir J, 26 (2005), pp. 948-968
[19.]
American Thoracic Society/European Respiratory Society.
ATS/ERS Statement on Respiratory Muscle Testing.
Am J Respir Crit Care Med, 166 (2002), pp. 518-624
[20.]
J.R. Bach, S.W. Kang.
Disorders of ventilation.
Chest, 117 (2000), pp. 301-303
[21.]
A. Vianello, A. Corrado, G. Arcaro, F. Gallan, C. Ori, M. Minuzzo, et al.
Mechanical insufflation-exsufflation improves outcomes for neuromuscular disease patients with respiratory tract infections.
Am J Phys Med Rehabil, 84 (2005), pp. 83-88
[22.]
J.C. Winck, M.R. Gonçalves, C. Lourenço, P. Viana, J. Almeida, J.R. Bach.
Effects of Mechanical Insufflation-Exsufflation on Respiratory Parameters for patients with chronic airway secretion encumbrance.
Chest, 126 (2004), pp. 774-780
[23.]
J.R. Bach, C. Bianchi, E. Aufiero.
Oximetry and indications for tracheotomy for amyotrophic lateral sclerosis.
Chest, 126 (2004), pp. 1502-1507
[24.]
M.R. Gonçalves, J.R. Bach.
Mechanical insufflation-exsufflation improves outcomes for neuromuscular disease patients with respiratory tract infections. A step in the right direction.
Am J Phys Med Rehabil, 84 (2005), pp. 89-91
[25.]
J. Sancho, E. Servera, J. Díaz, J. Marín.
Efficacy of Mechanical Insufflation-Exsufflation in Medically Stable Patients with Amyotrophic Lateral Sclerosis.
Chest, 125 (2004), pp. 1400-1405
[26.]
A.K. Simonds.
Recent advances in respiratory care for neuromuscular disease.
Chest, 130 (2006), pp. 1879-1886
[27.]
T. Magnus, M. Beck, R. Giess.
Disease progression in amyotrophic lateral sclerosis: predictors of survival.
Muscle Nerve, 25 (2002), pp. 709-714
[28.]
J.R. Bach.
A comparison of long-term ventilatory support alternatives from the perspective of the patient and the care giver.
Chest, 104 (1993), pp. 1702-1706
[29.]
J.R. Bach.
Noninvasive respiratory muscle aids: intervention goals and mechanism of action. In Management of patients with neuromuscular disease.
Hanley & Belfus, (2004),
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