On a March afternoon in 2017, after a particularly tough year (including four months of lying head down almost non-stop), it finally hit me: while the coughing mask is prohibitively difficult to get airtight against my ugly face, I am constantly wearing a BPAP mask so tightly that it has eaten away the skin on my nose and the straps are sawing my ears off! Could the BPAP mask potentially be used with the cough assist device as well?

The BPAP mask connects to the tube via an elbow piece that has a quick-release lock. The elbow piece also fits inside the cough assist device tube, and each mask comes with a new elbow piece so I had plenty of them. One thing though: the elbow piece has a valve with holes to let the exhalation air out. This valve would form a shortcut during the exsufflation phase of the coughing phase, preventing the desired suctioning effect from affecting the lungs. I have read stories where uninformed people have blocked those holes, causing the same air to flow back and forth in the tube, and the patient to die of carbon dioxide poisoning. I figured that the larger pressure difference with the cough assist device would cause the tube to breathe through and expel the CO2 through the device. Nevertheless, we decided to be careful and monitor my condition closely when starting the experimentation.

We blocked the exhalation valves in one elbow piece with duct tape, inserted it in the coughing tube, started the machine for the first time in a year, switched the cough assist device tube in place of the BPAP tube in my mask...

And it worked! No more air leaks between the mask and my face and the machine indicated a cycle volume of about 5 liters, well above the 0.7 l that fits in the tube. No risk of carbon dioxide accumulating in the tube and killing me. What once had been an hour-long ordeal usually ending in an argument, could now be done in five minutes. And boy, did it feel good to get the lungs full of air for a change!

As the cycling seemed to go smoothly, we decided to screw the instructions to do the operation while sitting upright, and try if I would survive doing it while lying down. We started it carefully, but soon enough went full Gordon by gradually increasing the pressures and extending the duration. When the pressures were at ±40 mbar and I had been pumped for ten minutes, sweet, yellow gunk started to appear in the tube.

That was a sign. I indicated my wife to lift my bed into the Trendelenburg position, closed my eyes, and thought of Finland... The gunk kept coming for 45 minutes and when it finally ended, I was exhausted, exhilarated, and even though not a smoker, kind of felt like having a cigar. Who would have known that coughing upside down could feel so good?

What had started six months earlier with a teaching visit by a lung physiotherapist, found its fulfillment in this new way of using the cough assist device. I was able to sit and communicate once again without gunk blocking my airways, and unlike suctioning, every nurse was able to clear my airways with this technique. Staying at the interval facility during my wife's vacations was suddenly a lot less scary. 

Trendelenburg coughing evolved into a daily routine, and I got so comfortable with it that after a while it did not disturb me at all. I could ask for coffee while coughing upside down. Or take a nap. Or maximize the enjoyment in other ways...

During that five-month period between getting the idea and undergoing a tracheotomy, I fell in love with Philips Respironics T70. But better was yet to come...