Device for guiding breathing gas

Abstract

Device for guiding respiratory gas, characterized in that means for ventilation and means for coughing support are integrated simultaneously and, in addition to a ventilation pressure intended for ventilation, an increased airway pressure is generated at least temporarily, wherein air is stacked in the lungs over several breaths and wherein the coughing aid (10) is a controlled negative pressure generator.

Description

[0001] The invention relates to a device for guiding respiratory gas to improve lung condition.

[0002] In patients with severely mucus-filled airways (frequently in cystic fibrosis or underlying neuromuscular diseases), facilitating expectoration while avoiding invasive methods can be very helpful in addition to ventilation. Secretion management represents an important adjunctive therapy to the commonly used ventilation.

[0003] Furthermore, there are patients affected by conditions such as pulmonary fibrosis or scoliosis, in whom restrictive forces reduce compliance and thus lead to lung stiffening. This has adverse effects on respiratory function.

[0004] Therefore, it is important for these patients to maintain their lung elasticity for as long as possible, or that poorly ventilated lung areas are at least temporarily subject to good ventilation.

[0005] Numerous patients with respiratory insufficiency and accompanying mucus retention die from infections today because they no longer have sufficient muscle strength to cough up secretions from their airways. To help patients survive these critical phases, a technique called air stacking can be performed, in which air is stacked in the lungs over several breaths. This can then be followed by a forced expiration, which, through increased airflow velocities and the resulting increased shear stresses in the airways, supports or even enables the loosening of secretions. Such forced expiration can be supplemented with physiotherapy if necessary.

[0006] Studies have shown that 85-90% of total lung capacity (TLC) and cough peak flows (CPF) of at least 160 L / m³ are beneficial for effective expectoration. These studies have shown that the higher the CPF, the more effective the expectoration and the less frequently secretions accumulate in the lungs, leading to respiratory distress. Furthermore, generating airway pressures of up to 70 cmH₂O during inspiration or insufflation is helpful.

[0007] Furthermore, maintaining elevated airway pressure or deep insufflation leads to ventilation of even the most remote lung areas, which, due to their high resistance, can be filled later (lung recruitment).

[0008] Such insufflation maneuvers can be carried out today in the following ways: • Using a resuscitation bag, which the doctor, the patient himself or a relative compresses for the stacking maneuver. • With a separate ventilator that must be switched to volume-controlled ventilation for the maneuver. The patient independently suspends expiration and builds up the required pressure through several breaths. • With a special device (Cough Assist by JH Emerson, Cambridge, MA USA) that switches abruptly from high overpressure to high suction pressure without stepwise stacking. Further prior art is known from: DE 195 16 536 C2, DE 10 2004 006 396 A1, US 4 316 458 A, DE 10 2005 007 284 B3 and DE 195 05 409 A1.

[0009] All the forms shown have their own disadvantages: • A maneuver using a bag valve mask is completely uncontrolled with regard to the applied pressures. At the same time, it is cumbersome for the patient and may even be completely impossible for a neuromuscular patient to perform the maneuver themselves, so that there is always a dependency, for example on family members. • This maneuver cannot be effectively performed with most ventilators unless the patient is already being ventilated in a suitable ventilation mode for therapeutic reasons. Only a few ventilators allow the patient to manually switch the ventilator to the required (volume-controlled) mode for the maneuver. • The cough assist device is another device that must be used in addition to the ventilator. Such a device is not always available in situations where, for example, cough assistance is needed due to an infection.

[0010] It is advantageous if an air stacking or insufflation maneuver, or cough support, can be performed with the ventilator itself, so that a second device is not required or a device change is not necessary.

[0011] The object of the present invention is to design a device of the type mentioned in the introduction in such a way as to improve lung quality.

[0012] This problem is solved according to the invention by performing deep insufflations. Furthermore, the problem is solved or optimized by integrating a cough aid or cough support.

[0013] This problem is solved according to the invention by generating an increased airway pressure at least temporarily in addition to the ventilation pressure intended for ventilation.

[0014] Furthermore, an object of the present invention is to improve the operability of a ventilator.

[0015] This problem is solved according to the invention by the fact that the ventilator has a remote control element.

[0016] The methods, constructive embodiments, and design variants explained in detail below can be used alternatively or complementarily. In particular, each individual inventive concept can be implemented independently of every other inventive concept; however, a combined implementation offers additional advantages.

[0017] A special maneuver for deep insufflation can be implemented as an add-on on a ventilator. The maneuver can be initiated by the patient, the physician, or a family member during or in conjunction with ventilation.

[0018] The procedure can be carried out, for example, in the following way: The physician first determines a maximum maneuver pressure and the (maximum) maneuver volume. The maneuver can, for example, be performed in several stages, with a pause between each stage instead of an expiration (air stacking). Alternatively, deep insufflation can be performed in a single stroke, which is typically longer and / or deeper than a normal inspiration. In addition to setting maneuver times and parameters (pressure or volume), a pressure rise rate can be specified, which may differ from the rate of rise during ventilation.

[0019] The ventilated patient can initiate the maneuver at any time. According to the settings made by the physician, the pressure from the ventilator is increased during deep insufflation. At the end of the insufflation, the patient can perform a deep and forced exhalation (cough), preferably through the mouth.

[0020] The expiratory time is adjusted according to the previous total insufflation time or depending on the total inspired volume (possibly based on the I:E ratio during ventilation). This ensures that the entire volume can escape from the lungs and that lung hyperinflation does not occur.

[0021] The patient (or a relative or doctor) can, if necessary or desired, abort the ongoing maneuver at any time by pressing a button. The maneuver can be repeated as often as needed, depending on the therapeutic requirements or the patient's wishes. Operation is possible via a remote control or PC remote control, which can be of great importance, for example, for patients with advanced neuromuscular disease.

[0022] After each maneuver, the patient is given a pause or the opportunity to return to their original breathing pattern with renewed ventilation until a new maneuver begins, if necessary. This time could be, for example, 20-30 seconds and reduces the risk of potential hyperventilation.

[0023] In another embodiment, the device can facilitate the patient's familiarization with this procedure; the pressure / CPF and the frequency can be adjusted to the target pressure and the desired frequency over several hours or days.

[0024] In another embodiment, where the patient initiates the maneuver independently by pressing a button on the device, using a remote control, or via another means of communication with the device, the patient can be assisted in adhering to the desired number of maneuvers per day. After entering the desired maneuvers per day or a detailed daily maneuver schedule, the device emits a signal—audible, visual, or via a pressure / volume pattern—at the calculated time. This is repeated until the patient performs the maneuver, postpones the reminder by a certain time, or declines the maneuver.

[0025] To enable the maneuver to be performed from the bed, one embodiment envisions equipping the device with a control unit that can communicate with it via the integrated interface, either wired or wirelessly (Bluetooth, infrared, etc.). For example, this control unit could include a button that, when pressed, increases the pressure up to an adjustable level.

[0026] In another embodiment, it is also possible to determine the optimal final pressure by previously determining the TLK and other parameters (compliance, resistance, etc.) and to apply it to the patient in order to achieve the highest possible CPF.

[0027] Furthermore, pulsations can loosen the mucus formed in the lungs, thus facilitating its removal during coughing. To prevent the descending migration of loosened mucus into finer lung areas and the resulting deterioration of these areas, the pulsations are preferably triggered at the end of inspiration or the beginning of expiration. The pulsations can be generated, for example, by using an additional high-frequency unit (similar to an ODS pump), a diaphragm, a loudspeaker, or a piston pump.

[0028] Advantages of integrating an insufflation maneuver as a programmable maneuver include: • Easy handling, as only one device is required • Flexibility in settings and good adaptability to the patient's needs • The expiratory time can be adjusted to the maneuver digesters so that the switch to ventilation, i.e., the subsequent inspiration, is not made too early. • Can be combined with ventilation; ventilation and air-stacking maneuvers can be alternated with one device. • The maneuver can be performed under pressure control. • During a pressure-controlled maneuver, pressure rise rates can be preset to increase comfort, similar to ventilation.

[0029] The maneuver can be performed on the ventilator with both pressure and volume control.

[0030] It can be performed, for example, on a non-invasive ventilator using a single-tube expiratory system or on a ventilator with separate inspiratory and expiratory tubes. The maneuver can be applied, for example, via a mask, a tracheostomy, or an endotracheal tube.

[0031] When using a single-tube system with an exhalation system, a second tube system without an exhalation system can be used for the "air stacking" maneuver. This offers the following advantages: • Higher maneuver pressures can be applied with the ventilator than with ventilation, as no flushing flow is required to wash out the CO2-enriched air. • The device allows for the determination of the applied volume and the maximum expiratory flow. This information can also be displayed on the device for motivational purposes. • Recording of individual maneuvers and evaluation options for patient and doctor via transmission to a computer.

[0032] In order to apply increased pressure in a ventilation method that was originally based on a leakage system, one embodiment offers the possibility of replacing the mask or the leakage system with a special mouthpiece.

[0033] To facilitate the use of the mouthpiece, it can alternatively be inserted into the mask. In this case, the mouthpiece is designed to seal any existing leakage openings, e.g., in the mask.

[0034] To return to the original ventilation mode after coughing has ceased, the leak detection system must be reactivated. If this requirement is not met, the device will detect that no leak detection system is in use because the leakage required to flush the CO2 from the tubing is zero or too low, and will sound an alarm.

[0035] As described above, coughing is assumed to be active, driven solely by the previously applied pressure and the recoil forces of the lungs. The effectiveness of coughing can be further enhanced by applying negative pressure and / or negative flow at the moment of coughing.

[0036] In the device according to the invention, this can be achieved by at least one valve which reverses / diverts the airflow by switching the air routing to the blower suction side. The original pressure side is switched to atmospheric pressure at the same time.

[0037] Alternatively, the necessary negative pressure can also be created by an additional negative pressure generator, e.g., a separate fan. The fan runs before coughing to generate the necessary dynamics and enable a sudden switchover.

[0038] In another embodiment, the necessary negative pressure can also be achieved by pre-tensioning a spring, which generates the negative pressure via volume displacement.

[0039] The spring-loaded mechanism can alternatively be provided by a linear drive using a rotary drive and spindle.

[0040] To prevent sputum, secretions, or other particles from entering the devices mentioned herein, elements can be positioned in the airflow upstream of these devices to capture these components. A preferred form of such a sputum trap is easily cleaned, disinfected, and sterilized, thus ensuring reusable use.

[0041] The devices mentioned above can be optionally connected to the existing ventilator by means of an extra unit similar to a humidifier, placed between the device and the hose.

[0042] In a particularly preferred form, a combination of the respiratory humidifier and the cough aid is provided in one module.

[0043] In another embodiment, the arrangement is provided below the device in order not to increase the required floor space for the overall system.

[0044] In another embodiment, the idea is to determine the volume of air inhaled during the maneuvers and then not to exceed this volume during assisted exhalation; this can prevent a possible negative pressure trauma.

[0045] Alternatively or additionally, protection against negative pressure trauma can also be achieved by integrating a pressure sensor within the cough aid. Character description: Fig. 1: Illustration of the possible coupling of a cough module to a ventilator Fig. 2: Illustration of the possible coupling of a cough module to a ventilator similar to a humidifier. Fig. 3: Illustration of the module with the integration of the existing fan Fig. 4: Illustration of the module with a spring element Fig. 5: Illustration of the module with a motor spindle as drive Fig. 6: Illustration of the different curve progressions for air stacking, stacking of air in the lungs Fig. 7-18 schematic diagrams illustrating the optional supply of positive or negative pressure or directed flows. Fig. 19 A compilation of the pneumatic circuit symbols used.

[0046] Fig. 1 and Fig. Figure 2 shows the basic structure of a ventilation device. A breathing gas pump is located inside a device housing (1) with a control panel (2) and display (3). A connecting hose (5) is attached via a coupling (4). An additional pressure measuring hose (6) can run along the connecting hose (5) and can be connected to the device housing (1) via a pressure inlet port (7). The device housing (1) has an interface (8) to enable data transmission.

[0047] In Fig. 1 A coughing aid (10) is arranged under the device. In Fig. 2. The cough aid (10), similar to a humidifier, is inserted between the device and the breathing tube. This design is particularly advantageous because connection to the device outlet is simple, and data and control information can be easily exchanged with the ventilator, e.g., via the interface (9) originally intended for a heating element or a separate interface. An arrangement of the cough aid to the side of the device is also provided (not shown).

[0048] Communication via the heating element interface can be achieved through a modulated power supply.

[0049] Fig. Figure 3 shows a gas flow diagram in which, in the basic position, the patient is ventilated normally, and when the valve (11) is switched, the patient is connected to the blower suction side, thus supporting the coughing process. This can be combined by module (13). A possible integration of a sputum trap (12) is also shown.

[0050] Fig. Figure 4 shows another module (16) in which a spring element (14) is arranged next to the main flow direction through the fan (15). When a coughing maneuver is performed, the spring element (14) is pre-tensioned. After air stacking has occurred, the module (16) switches to the spring element and assists the patient during coughing by a sudden or controlled retraction of the spring; the spring (14) can be an element in a piston-cylinder system. Alternatively, a sputum trap (12) can also be used here.

[0051] Fig. Figure 5 shows a different module that generates the vacuum using a motor-driven spindle (17) and a cylinder-piston system. Retraction can be achieved via a characteristic curve (18).

[0052] Fig. Figure 6(ad) shows different pressure profiles of the stacking of air. Fig. 6 a) The built-up pressure is maintained for a longer period of time in order to reach all lung areas.

[0053] In Fig. 6 b) shows that a significantly longer expiratory time is also necessary for adequate ventilation of the lungs; here, three times the normal expiratory time Te is shown as an example. Fig. Figures 6 c) and d) show different curve shapes of a maneuver.

[0054] The embodiments shown and described below differ mainly in the number of pressure / or flow sources (hereinafter referred to as blowers), in the valve variant (number of connections, number of switching positions) or in whether the ventilation mask, first mask, (52) and the cough mask, second mask, (53) are either installed in parallel on the device or must be changed manually for the respective application.

[0055] As in Fig. As can be seen in Figure 7, only one blower (51) is used, and the ventilation and cough masks (52 + 53) are connected to the device in parallel. The valve is a 5 / 3-way valve, with two ports connected to the blower (51), two to the masks (52 + 53), and one to the atmosphere (59).

[0056] A sputum trap (55) is located in the airflow path of the cough mask (53), and an exhalation system (54) and a silencer (57) are located in the airflow path of the ventilation mask (52). A silencer (57) and a filter (56) are also located between the valve (58) and the atmosphere (59).

[0057] In the first switching position of the valve (58), the ventilation process takes place. Consequently, the positive pressure side of the blower (51) is connected to the ventilation mask (52) and the negative pressure side to the atmosphere (59) with upstream filter (56) and silencer (57). The cough mask (53) is not connected during the ventilation process.

[0058] The cough maneuver is performed in the second and third switch positions. The patient must change the mask for this. Once the cough mask (53) is correctly in place, the patient can begin the cough maneuver by entering a signal. The valve (58) moves to the second switch position, and instead of the ventilation mask (52), the cough mask (53) is now connected to the positive pressure side of the blower (51), and the negative pressure side of the blower (51) is connected to the atmosphere (59). The patient is thus insufflated.

[0059] Once a sufficiently high pressure has built up in the patient's lungs, the valve (58) instantly switches to the third position. In this position, the negative pressure side is applied instead of the positive pressure side. A strong negative pressure is thus suddenly applied to the airways of the lungs, and the patient is exsufflated. This process can be repeated several times.

[0060] Once the process is complete, the valve (58) returns to its first switching position, in which the cough mask (53) is disconnected from the blower (51) and the ventilation mask (52) is connected. The patient must now switch masks again.

[0061] As described above, according to Fig. 7 a silencer (57) and a filter (56), which introduce a noticeable flow resistance. However, to generate the highest possible flow, it is desirable to keep the flow resistance as low as possible. In Fig. 8 In the exsufflation phase, an additional flow path at the valve (58) connects the overpressure side of the blower (51) directly to the atmosphere (59), thus bypassing the flow resistance caused by the filter (56) and silencer (57).

[0062] One variant of the arrangement, as in Fig. 7 and Fig. As shown in section 8, the valve is divided into two valves, each with fewer connections and switching positions (see Fig. 9a + b). However, this does not change the switching processes.

[0063] The concepts described above can also be implemented with only one mask connection, as shown in Fig. 10 shown. The resulting elimination of the mask connection requires one less flow path at the valve (58), thus simplifying the valve (58). What else in Fig. 7 can be implemented with a 5 / 3-way valve, according to Fig. 10 can be accomplished with a 4 / 2-way valve (58).

[0064] As in the previous embodiments, the positive pressure and negative pressure sides of the blower (51) are connected to two ports of the valve (58). The atmosphere (59) with upstream filter (56) and silencer (57), as well as either the breathing mask or the cough mask (53), are connected to the other ports of the valve (58).

[0065] During ventilation, the valve (58) is in the first position and the ventilation mask (52) is connected to the positive pressure side of the blower (51). If the patient wishes to perform a cough maneuver, they must first remove the ventilation mask (52) from the mask port and connect the cough mask (53). Unlike the previous concepts, when the cough maneuver is initiated, the valve (58) remains in the first position, and the patient is insufflated through the cough mask (53). Once sufficient pressure has built up in the patient's lungs, the valve (58) switches to the second position, connecting the negative pressure side of the blower (51) to the cough mask (53) and exsufflating the patient.

[0066] As in Fig. As can be seen in Figure 11, in this embodiment, the filter (56) and the silencers (57) can also be bypassed by means of additional connections on the valve (58). However, no additional switching positions are required here, and instead of a 4 / 2-way valve, a 6 / 2-way valve (58) is required in this embodiment.

[0067] Another variant presents the arrangement in Fig. Figure 12. In this embodiment, a separate blower (51) (hereinafter referred to as the positive pressure and negative pressure blower) is used for generating the positive and negative pressure, and the breathing and coughing masks (53) are connected to the device in parallel, as in the previous arrangements. A 4 / 3-way valve (58) is used.

[0068] The positive pressure blower (51) is completely enclosed by the silencers (57) and the filter (56) and is responsible only for the ventilation and insufflation phase. The negative pressure blower (51), on the other hand, is used exclusively for the exsufflation phase and, due to the desired reduction of flow resistance, is arranged without silencers (57) and filters (56). In a particularly preferred embodiment, the negative pressure blower can be a flow source.

[0069] In the first switching position of the valve (58), the ventilation process takes place. The patient wears the ventilation mask (52), which is connected to the positive pressure blower (51). The cough mask (53) and the negative pressure blower (51) are not connected during the ventilation process.

[0070] If the patient wishes to perform a coughing maneuver, they must first change the mask and then start the procedure. The valve (58) then switches to the second position, in which the cough mask (53) is now connected to the positive pressure blower (51). The patient is then insufflated. Once sufficient pressure has built up in the patient's lungs, the valve (58) immediately switches to the third position, in which the negative pressure blower (51) is now connected to the cough mask (53). The resulting sudden negative pressure in the lungs initiates the exsufflation phase.

[0071] The valve (58) then returns to its first switching position, in which the cough mask (53) is disconnected from the negative pressure blower (51) and the ventilation mask (52) is reconnected to the positive pressure blower (51). The patient must now switch masks again.

[0072] In Fig. 13 is the 4 / 3-way valve made of Fig. 12 are divided into two 3 / 2-way valves (58). This reduces the number of connections and switching positions of the respective valves (58). However, the switching operations remain the same.

[0073] In Fig. 14 A separate blower (51) is used for the ventilation process as well as for the coughing maneuver. The blower (51) used for ventilation, unlike the blower (51) used exclusively for the coughing maneuver, is surrounded by silencers (57) and a filter (56).

[0074] A valve (58) is only required during coughing maneuvers. This 4 / 2-way valve (58) connects, depending on whether insufflation or exsufflation is taking place, the positive pressure or negative pressure side of the blower (51) to the cough mask (53) and the corresponding negative pressure side to the atmosphere (59).

[0075] Compared to the embodiment in Fig. 12 can be found in Fig. The arrangement shown in Figure 15 can also be implemented with only one mask connection. The elimination of the mask connection simplifies the 4 / 3-way valve to a 3 / 2-way valve (58).

[0076] During ventilation, the valve (58) is in the first position, in which the positive pressure blower (51) is connected to the ventilation mask (52). If the patient wishes to perform a coughing maneuver, they exchange the cough mask (53) for the ventilation mask (52) at the mask port, put it on, and begin coughing. The same blower (51) then insufflates the patient. Once sufficient pressure has built up in the lungs, the valve (58) switches to the second position, and the negative pressure side of the second blower (51) is immediately connected to the mask, exsufflating the patient. The patient then switches the masks again, and the valve (58) returns to its initial position.

[0077] As in Fig. 16 can be seen, analogous to Fig. 13 the first blower (51) is only needed for the ventilation process and the second for the coughing process.

[0078] However, in contrast to Fig. 13 uses only one mask connection. This requires an additional 3 / 2-way valve (58) to the 4 / 3-way valve (58). The 3 / 2-way valve (58) is used to switch between ventilation and coughing, and the 4 / 3-way valve (58) is responsible for switching between insufflation and exsufflation. The coughing maneuver itself is identical to the other embodiments shown previously.

[0079] As in Fig. As shown in Figures 17 a + b, three blowers (51) are used in each case. One blower (51) is responsible for the entire ventilation process, another for insufflation, and the third for exsufflation. If the masks are connected to the system in parallel, a 3 / 2-way valve is only required for the coughing maneuver, which connects the second or third blower (51) to the corresponding mask.

[0080] With only one connection, a second 3 / 2-way valve (58) is required, which can be used to switch between the ventilation process and the coughing maneuver.

[0081] Fig. Figure 18 illustrates an arrangement for selectively applying either positive or negative pressure to a patient. For this purpose, fan blowers can be connected to the patient via connecting hoses, once in the direction of airflow and once against the direction of airflow. The switching is preferably automatic.

[0082] To provide pressure-controlled deep insufflation with increased airway pressure, the focus is on performing additional maneuvers to support deep insufflation and / or exsufflation, in addition to the normal control sequences of the ventilator. This delivers an additional volume of air to the lungs above the normal tidal volume, either to perform lung training or to support the removal of mucus through subsequent forced exspiration.

[0083] The aforementioned remote control can be used both in connection with pressure-controlled deep insufflation and generally for operating a ventilator.

[0084] The maneuver for performing deep insufflation and / or exsufflation can be carried out in a manner adjustable by the physician. For example, a maximum pressure, a rate of increase, a stepwise increase in tidal volume or ventilation pressure, or a rise in maximum pressure over a predetermined period can be defined. A stepwise change can, for example, be performed in one, two, or three stages.

[0085] The remote control concept discussed above in connection with improving lung function can also be applied to general ventilators. Remote control can be achieved via a dedicated remote or using the controls of a PC. This facilitates operation, particularly for patients with disabilities who have difficulty using standard devices. These patients can typically operate a separate remote control or a PC. The remote control can also be attached to a wheelchair.

[0086] For example, the following functions can be activated or set using a remote control: • Activation of an insufflation maneuver or switching between PCV and VCV • Adjusting maneuver parameters (such as insufflation) to increase comfort within limits specified by the physician. • Retrieving data stored in the ventilator (for example, monitoring the progress of maneuvers performed), conceivable, for example, as a means of monitoring success and motivating the patient to continue the corresponding training maneuvers. • Soft start activation • Switching the humidifier on / off or changing the humidifier heating level • Trigger adjustment or pressure increase, if approved by the doctor • Device on / off, e.g. for speaking

[0087] Other functional options include, for example, the patient acknowledging alarms or triggering an alarm via the ventilator.

[0088] Furthermore, remote control using a PC offers the possibility of freely configuring functions that may have been authorized by a physician. For example, it is possible to parameterize the method of insufflation. Using the remote control, the patient can control the procedure and, in particular, activate or abort it.

Claims

[1] Device for guiding breathing gas, characterized by , that means for ventilation and means for cough support are integrated simultaneously and that, in addition to a ventilation pressure intended for ventilation, an increased airway pressure is generated at least temporarily, whereby air is stacked in the lungs over several breaths and wherein the cough aid (10) is a controlled negative pressure generator. [2] Device for guiding breathing gas according to claim 1, characterized by that means for ventilation and means for lung training are integrated simultaneously [3] Device for guiding breathing gas according to claim 1, characterized by that the means for ventilation and means for cough support are modularly coupled. [4] Device according to any one of the preceding claims, characterized by , that the cough module (10) is coupled to a ventilation module similar to a respiratory humidifier. [5] Device according to any one of the preceding claims, characterized by , that the coupling to the ventilation module can take place in any position; in particular laterally, one above the other, next to each other, partially integrated, attached or via connecting lines. [6] Device according to any one of the preceding claims, characterized by that the means for ventilation and the means for lung training are identical. [7] Device according to any one of the preceding claims, characterized by that the means for ventilation or lung training or cough support are preferably blowers (51). [8] Device according to any one of the preceding claims, characterized by that the means for ventilation or lung training or cough support flow sources are preferably displacement systems. [9] Device according to any one of the preceding claims, characterized by , that a vacuum is applied by means of a linear drive and piston (17). [10] Device according to any one of the preceding claims, characterized by , that a vacuum is applied by means of a spring element (14). [11] Device according to any one of the preceding claims, characterized by , that a change between overpressure and underpressure is generated by switching a valve (11). [12] Device according to any one of the preceding claims, characterized by , that a remote control element communicates with the device-side interface (8). [13] Device according to claim 12, characterized by that the remote control element is designed to communicate with a PC. [14] Device according to any one of claims 1 to 13, comprising at least one flow and / or pressure source (51) and at least one valve (11) which has at least two switching positions, characterized by, that in a first switching position the patient is connected to the positive pressure side of a pressure or flow source (51) and in a further switching position the patient is connected to the negative pressure side of a pressure or flow source (51). [15] Device according to any one of the preceding claims, characterized by , that at least one patient interface (52, 53), for example tube, mask or tracheostomy and connecting elements, are part of the device and establish the connection between the patient and the rest of the device. [16] Device according to any one of the preceding claims, characterized by , that the device has a connection for coupling a patient interface (52, 53), which serves for ventilation (52) and cough support (53) and is switched between the functions by means of switching at least one valve (11). [17] Device according to any one of the preceding claims, characterized by, that the device has two ports for coupling patient interfaces (52, 53), wherein a first port is for ventilation (52) and a second port is for cough support (53). [18] Device according to any one of the preceding claims, characterized by , that at least one first patient interface (52) is provided for ventilation and a second patient interface (53) for performing a maneuver. [19] Device according to any one of the preceding claims, characterized by , that an exhalation element, which is an exhalation system or exhalation valve, is arranged in the area of ​​a patient interface (52, 53). [20] Device according to any one of the preceding claims, characterized by , that a sputum trap (55) is arranged in the area of ​​a patient interface (52, 53). [21] Device according to any one of the preceding claims, characterized by, that a filter (56) and / or a silencer (57) is arranged in the area of ​​the overpressure and / or underpressure side of the pressure or flow source (51) and / or the patient interface (52, 53). [22] Device according to any one of the preceding claims, characterized by , that, away from the patient, several openings to the atmosphere (59) are possible behind the pressure or flow source (51), depending on the switching position of the valve(s) (58). [23] Device according to any one of the preceding claims, characterized by , that another pressure or flow source (51) is integrated, such that the first pressure or flow source (51) is used for operation with the first patient interface (52) and the second pressure or flow source (51) is used for operation with the second patient interface (53). [24] Device according to any one of the preceding claims, characterized by, that at least one gas source (51) is connected to at least one patient interface (52, 53) via at least one valve arrangement (58) and that the valve arrangement (58) has at least one connection for at least one connecting line leading to the patient interface (52, 53). [25] Device according to claim , characterized by , that both a ventilation mask (52) and a cough mask (53) can be connected to the valve arrangement (58). [26] Device according to claim , characterized by , that the ventilation mask (52) and the cough mask (53) can be connected to the valve assembly (58) simultaneously. [27] Device according to claim , characterized by , that the ventilation mask (52) and the cough mask (53) can be connected one after the other to a common connection with the valve assembly (58). [28] Device according to any one of the preceding claims, characterized by , that the valve arrangement (58) consists of a valve. [29] Device according to any one of the preceding claims, characterized by , that the valve arrangement (58) consists of two valves. [30] Device according to claim , characterized by , that the valve has two ports for the simultaneous connection of a ventilation mask (52) and a cough mask (53). [31] Device according to claim , characterized by , that the valve has a connection for optional connection to different patient interfaces (52, 53). [32] Device according to any one of the preceding claims, characterized by , that the valve arrangement (58) is connected to exactly one gas source (51). [33] Device according to any one of the preceding claims, characterized by , that the valve arrangement (58) is connected to exactly two gas sources (51). [34] Device according to any one of the preceding claims, characterized by that the valve arrangement (58) is connected to exactly three gas sources (51). [35] Device according to any one of the preceding claims, characterized by , that the valve arrangement (58) for the exsufflation phase is bridged by an additional flow path to connect the patient interface (52, 53) with an environment.

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