MI-E application
cough
MI-E treatment sessions were administered using the CoughAssist E70 (Phillips Respironics, Murrysville, Pennsylvania), which was set to generate 3 s of insufflation, 2 s of exsufflation, and 2 s of rest for one cough, with a low inhale flow setting and oscillation off to simulate physiological coughing and facilitate better cooperation for higher in-exsufflation pressureAfter determining the optimal MI-E pressure settings, the protocol comprised five consecutive voluntary coughs following 3 s of full inspiration, 2 s of maximal expiration, and rest was initiated. Participants were instructed to cough five times into the facemask while wearing a well-sealed mask (Air Way 96 mm (#4), ACE Medical Co., South Korea) with support from a physiotherapist or caregiver to prevent any air leak. After eliminating the expelled sputum, one set of five MI-E-assisted coughs was provided, followed by another set of five more MI-E-assisted coughs with manual thrusts. The three sets (5 coughs/1 set) of different application maneuvers—voluntary cough, MI-E assist, and MI-E with manual thrust—comprised one session at each position, and these three sets were repeated in the same order at the next assigned position.When performing MI-E combined with manual thrust, the physiotherapist asked the participant to cough at the start of the exsufflation period while delivering manual pressure to the participant’s bilateral costophrenic angle toward the direction of the upper chest simultaneously. An experienced physiotherapist blinded to the analysis of the mean PCF conducted all MI-E treatments and measured the concomitant airflow. A separate researcher blinded to the assigned group and applied position performed all the analyses.