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.
Bibliographical noteFunding Information:
This project was supported by the National Institute for Health Research (NIHR), via Cochrane Infrastructure funding to Cochrane Neuromuscular. The views and opinions expressed herein are those of the review authors and do not necessarily reflect those of the Systematic Reviews Programme, NIHR, National Health Service, or the Department of Health. Cochrane Neuromuscular is also supported by the MRC Centre for Neuromuscular Disease.
Sponsorship source: partly sponsored by the Jennifer Trust for Spinal Muscular Atrophy, UK
Funding source: Jennifer Trust for Spinal Muscular Atrophy,UK (M Chatwin); Brompton Breathers Trust Fund, UK (patient expenses support); Cystic Fibrosis Trust, UK (E Ross); British Lung Foundation, UK (AH Nickol); Association Française Contre Les Myopathies, France (N Hart)
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.
Funding source: financial support was provided by the Associação Fundo de Incentivo à Psicofarma-cologia (AFIP, Association for the Incentive Funding of Psychopharmacology).
The Information Specialist of Cochrane Neuromuscular, Angela Gunn, developed the search strategy in consultation with the review authors. The Methods section of this protocol was based on a template developed by the Cochrane Neuromuscular Disease Group from an original created by the Cochrane Airways Group. This project was supported by the National Institute for Health Research (NIHR), via Cochrane Infrastructure funding to Cochrane Neuromuscular. The views and opinions expressed herein are those of the review authors and do not necessarily reflect those of the Systematic Reviews Programme, NIHR, National Health Service, or the Department of Health. Cochrane Neuromuscular is also supported by the MRC Centre for Neuromuscular Disease.
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