ALERT: How to perform lung volume recruitment (LVR) therapy in home and community?
Connected Care Quick Hits are up to date and evidence based recommendations for the care of children with medical complexity & technology dependence, from hospital to home.
ALERT: How to perform lung volume recruitment (LVR) therapy in home and community?
SITUATION:
This QuickHit was informed by a recent announcement by Philips Respironics of the global discontinuation of the model E70 CoughAssist (mechanical in-exsufflation device) effective Sept 12, 2023. In the absence of, or pending a new technology, lung volume recruitment (LVR) therapy is encouraged as an alternative secretion clearance strategy
BACKGROUND:
Children with medical complexity may be prescribed pulmonary clearance therapies such as mechanical in-exsufflation at home. Pulmonary clearance is important to keep the airways and lungs clear of excess mucus and to reduce risk of infection and airway inflammation. Children that may benefit from pulmonary clearance include those who have a tracheostomy +/- ventilation or a condition that causes muscle weakness.
The Philips Respironics E70 CoughAssist is a mechanical in-exsufflation device that is commonly used for children that require pulmonary clearance at home. With the discontinuation of this device, alternative therapies such as LVR are increasingly being prescribed. The Ventilator Equipment Pool (VEP) is also working to secure alternative products to replace the Philips Respironics E70 CoughAssist device.
ASSESSMENT:
LVR can be very effective as a pulmonary clearance therapy. It uses a manual resuscitation bag attached to a one-way valve to increase the amount of air in a child’s lungs which promotes a cough and allows the child to clear secretions effectively. This therapy is prescribed the same frequency as CoughAssist (i.e., BID or TID). LVR is most effective when conducted prior to meals and bedtime. Additionally, the child should be awake, alert, and willing to participate in the therapy for optimal results.
LVR can be performed using a mask, mouthpiece (for older children) or tracheostomy adaptor. A nose plug can be used when using a mouthpiece option. The LVR bag is a small portable setup that can be used while the child is on the go. The equipment required for LVR is outlined in the diagram below.
To perform LVR, the manual resuscitation bag is squeezed during inhalation (breathing in) for a series of a few breaths to increase the total amount of air in the lungs. After the lungs are filled with air, the child breathes or spontaneously coughs out. Filling the lungs with more air allows the child to clear secretions more effectively. After several cycles of LVR, the child will find that breathing becomes easier.
LVR can also be used alongside manually assisted cough (MAC), if prescribed, to increase the force of air out of the lungs. This will assist the child’s cough and help them clear secretions. MAC involves pushing inwards and upwards underneath the child’s rib cage.
RECOMMENDATION:
Connected Care recommends the following when performing LVR for a child in home and community:
Confirm that you have the child's most up-to-date orders for LVR, including settings, type of interface (e.g. mask or trach adaptor) and when to provide therapy. Partner with family caregivers to discuss any changes to the plan of care.
Ensure the child is awake, alert and cooperating when performing therapy. It is better if the child is in a sitting position to promote lung expansion.
If the child experiences dizziness, chest discomfort or pain, stop the LVR and have them rest.
Ensure LVR bag (with one-way valve) is separate from the manual resuscitation bag (without one-way valve). Consider clearly labelling both the LVR bag and manual resuscitation bag to ensure that the correct one is used.
Ensure you are familiar with LVR therapy prior to performing this on a child. Register for additional Connected Care education if there are knowledge/skills gaps identified.
Review the AboutKidsHealth article that reviews LVR therapy including equipment and supplies required, step-by-step procedure, and safety precautions.
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