Use of Mechanical Insufflation-Exsufflation Devices for Airway Clearance in Subjects With Neuromuscular Disease

The aim of this systematic review is to examine the benefit/risk ratio of the use of mechanical insufflation-exsufflation (MI-E) devices for airway clearance in patients with neuromuscular diseases. A search was conducted for relevant studies in MEDLINE, the Cochrane Library, and the Health Technology Assessment Database using the main key words: cough, airway clearance, in-exsufflation. The search limits were studies published in English and French between 1970 and 2014 (literature watch until December 2015). The methodological quality of the studies was assessed using (1) the Cochrane Collaboration's risk of bias tool for randomized controlled trials and (2) the Institute of Health Economics' 20-item checklist for comparative and observational studies. Data were extracted into an evidence table according to (1) study design, (2) population characteristics (including age and type of diseases) and intervention (MI-E associated or not with other interventions), (3) outcome measures, and (4) key findings. Twelve studies met the inclusion criteria (4 randomized controlled trials, 3 comparative studies, and 5 observational studies). The quality of the selected studies was poor. None of the studies reported survival outcome. All studies evaluated change of pulmonary function parameters, such as peak expiratory flow. This review underlines the lack of robust data on mechanical medical devices used for airway clearance. The current scientific evidence does not support the use of MI-E for cough augmentation in patients with neuromuscular diseases, but health-care professionals are faced with the reality of medical practice and the absence of alternatives. Most European and American guidelines recommend the use of MI-E despite low-level evidence. However, even if performing comparative trials in a specific population is difficult, the medical device industry should provide reliable data to assist health-care professionals, providers, and payers in the decision-making process. This is the only way to ensure the best treatment for patients.