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Fig. 1. Factors which, associated with the inherent weakness of the underlying disease, contribute to making coughing and alveolar ventilation more difficult in some patients with neuromuscular diseases.
Fig. 3. Patient with amyotrophic lateral sclerosis without significant bulbar dysfunction carrying out insufflation maneuvers to obtain maximum insufflation capacity.
Fig. 4. Peak flow curves during cough recorded on a flow/volume axis by a conventional pneumotachometer and oronasal mask in a patient with amyotrophic lateral sclerosis. The smallest curve corresponds to a spontaneous cough, the next to a maximum insufflation capacity cough with manual assistance, and the largest to a mechanical insufflation-exsufflation maneuver. Manually assisted and, above all, mechanical insufflation-exsufflation coughs achieve a better peak flow during cough and greater mobilized air volumes.
Fig. 5. Right-sided atelectasia in a patient with very advanced Alzheimer's disease who was unable to achieve an effective cough. After 6 hours of mechanical insufflation-exsufflation therapy and oronasal mask (every 15-30 minutes), and without any self-assistance, the atelectasia disappeared.
Fig. 6. Computerized axial tomography scans showing the difference in permeability of the upper airways during an insufflation maneuver with the Emerson Coflator and during exsufflation in a patient with amyotrophic lateral sclerosis and bulbar dysfunction.
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