Create a formative OSCE station describing how to demonstrate and educate a 68‑year‑old male with amyotrophic lateral sclerosis on the use of a cough assist device to augment cough and clear secretions.

FICM OSCE Station: Cough Assist Device Education in ALS

Station Overview

Time: 10 minutes
Candidate Role: ICU physician/physiotherapist
Patient: 68-year-old male with ALS and impaired cough effectiveness
Task: Demonstrate and educate on mechanical insufflation-exsufflation (MI-E) device use

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Candidate Instructions

You are seeing Mr. Thompson, a 68-year-old man with amyotrophic lateral sclerosis diagnosed 18 months ago. He has progressive limb weakness and is now experiencing difficulty clearing secretions. His peak cough expiratory flow is 180 L/min, and maximal expiratory pressure is 42 cm H₂O. He has mild bulbar symptoms (Norris bulbar score 32/39). He lives at home with his wife who will be his primary caregiver.

Your tasks:

1. Assess his understanding of why he needs this device
2. Demonstrate proper use of the MI-E device
3. Educate him and his caregiver on technique, settings, and troubleshooting
4. Address safety concerns and when to seek help

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Examiner Instructions

Setting: Simulated home care environment with MI-E device (cough assist), face mask, and mouthpiece interfaces available.

Standardized Patient Brief:

• You are concerned about choking on secretions
• You've heard the device is uncomfortable
• You want to know how often to use it
• Your wife is anxious about using medical equipment

Assessment Domains:

1. Clinical Assessment (25%)

   • Identifies indications: PCF <270 L/min, MEP <60 cm H₂O 1
   • Recognizes bulbar involvement implications 2, 3
   • Assesses baseline oxygen saturation

2. Technical Demonstration (35%)

   • Device setup and interface selection:

     • Explains mask vs. mouthpiece options
     • Checks device connections and power

   • Parameter setting based on patient factors:

     • Initial settings: Start ±20 cm H₂O due to bulbar symptoms 2, 3
     • Explains rationale: bulbar dysfunction causes laryngeal adduction during insufflation 4, 2
     • Plans gradual titration to ±30-40 cm H₂O if tolerated
     • Avoids starting at ±50 cm H₂O which can worsen upper airway obstruction 3

   • Proper technique sequence:

     • Position patient semi-recumbent (30-45 degrees)
     • Apply interface ensuring good seal
     • Coordinate with patient's breathing
     • Insufflation phase: 1-2 seconds, watch for chest rise
     • Brief pause (0.5-1 second) for glottic closure
     • Exsufflation phase: 2-3 seconds, observe secretion mobilization
     • 5-6 cycles per treatment session 1, 5

3. Patient Education (25%)

   • Frequency and timing:

     • Minimum twice daily for maintenance 1
     • Increase to 4-6 times daily during respiratory infections 1
     • Use before meals to clear secretions

   • Recognizing effectiveness:

     • Audible secretion movement
     • Improved oxygen saturation (maintain SpO₂ ≥95%) 6
     • Reduced work of breathing

   • Troubleshooting bulbar-related issues:

     • If ineffective at current settings, check for laryngeal obstruction patterns 4
     • May need to reduce insufflation pressure if paradoxically worsening 2, 3
     • Consider adding manual abdominal thrust during exsufflation 1
     • Coordinate with air stacking techniques for volume recruitment 7

4. Safety and Complications (15%)

   • Expected side effects:

     • Transient nausea, abdominal distention 1
     • Mild bradycardia or tachycardia 1

   • Warning signs requiring medical attention:

     • SpO₂ drops below 90% despite treatment 6
     • Persistent respiratory distress
     • Hemoptysis
     • Severe chest pain

   • Contraindications to mention:

     • Active pneumothorax
     • Recent barotrauma
     • Severe cardiovascular instability

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Key Evidence-Based Points

Indications for MI-E in ALS:

• Peak cough flow <270 L/min indicates need for assisted cough techniques 1
• MEP <60 cm H₂O correlates with ineffective cough 1
• MI-E superior to manual techniques and breath stacking for generating peak flows 1

Critical ALS-Specific Considerations:

• Bulbar dysfunction causes laryngeal adduction during insufflation, especially at high pressures 4, 2, 3
• Upper motor neuron bulbar signs predict obstruction during insufflation 4
• Lower motor neuron bulbar signs predict airway collapse during exsufflation 4
• Individually customized pressure settings prevent laryngeal obstruction 2
• Adverse laryngeal responses can occur before clinical bulbar symptoms in spinal-onset ALS 3

Outcomes:

• Prevents hospitalization and reduces need for tracheostomy when PCF around 160 L/min 1
• On-demand access programs with MI-E avoid 30+ hospitalizations per cohort 6
• 98.55% of ALS patients achieve effective MI-E after parameter adjustment 4

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Marking Scheme

Pass Standard: Candidate must demonstrate safe device use with appropriate pressure settings for bulbar involvement, explain frequency of use, and identify key warning signs.

Critical Failures (Automatic Fail):

• Starting with high pressures (≥40 cm H₂O) without assessing bulbar function
• Failing to recognize need for lower pressures with bulbar symptoms
• Not explaining when to seek emergency help
• Unsafe technique risking barotrauma

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Model Answer Key Points

"Mr. Thompson needs this device because his cough muscles are too weak to clear secretions effectively—your peak cough flow of 180 L/min is below the 270 L/min threshold where secretion clearance becomes problematic." 1

"Because you have some bulbar symptoms, we'll start with gentler pressures of ±20 cm H₂O rather than the higher settings, as your larynx may close reflexively during the insufflation phase, making the treatment less effective or uncomfortable." 4, 2, 3

"Use this at least twice daily, and increase to 4-6 times when you have a cold or respiratory infection. Your wife should monitor your oxygen levels—if they drop below 95% and don't improve with treatment, call us immediately." 1, 6

"The device prevents pneumonia and hospitalization by clearing secretions from deep in your lungs, which regular coughing or suctioning cannot reach." 1