Airway clearance techniques for chronic obstructive pulmonary disease

Effectiveness of a new "focused pulse" high-frequency chest wall oscillation in patients with moderate to severe COPD

BACKGROUND

Chest physiotherapy plays a crucial role in the treatment of COPD, although the optimal techniques for airway clearance have not been definitively established. Among the different techniques, high-frequency chest wall oscillation (HFCWO) has gained attention for its potential to create a widespread lung percussion, facilitating the removal of secretions and potentially clearing the peripheral bronchial tree. This study aims to assess the effectiveness of a novel "focused pulse" HFCWO in patients with moderate to severe COPD.

METHODS

Sixty patients were randomized to three groups: a group treated with the PEP technique, a group with "focused pulse "HFCWO" and a group with pharmacological therapy alone (control group). The primary outcomes were changes in respiratory function parameters, changes in dyspnea and quality of life scores as well as daily life activity and health status assessment. The secondary outcomes were the number of exacerbations and the number of practitioner or emergency department (ED) visits after 1, 3, and 6 months.

RESULTS

Sixty patients concluded the study with 20 patients allocated to each group. The two devices improved respiratory function tests, quality of life and health scores and dyspnea compared to the control group. Maximal expiratory pressure and diffusing lung carbon oxide were significantly improved in the focused pulse HFCWO group compared to the PEP group. Only pulse-focused HFCWO showed a statistically significant lower number of exacerbations and visits to ED or practitioner compared to the control group.

CONCLUSIONS

The focused pulse HFCWO technique improves daily life activities and lung function in patients with stable COPD. The device demonstrated significantly greater effectiveness in lowering COPD exacerbations as well as visits to ED or practitioner.

Perception and clinical practice regarding mucus clearance devices with chronic obstructive pulmonary disease: a cross-sectional study of healthcare providers in Saudi Arabia

OBJECTIVES

Clearing secretions from the airway can be difficult for people with chronic obstructive pulmonary disease (COPD). Mucus clearance devices (MCDs) are an option in disease management to help with this, but healthcare provider awareness and knowledge about them as well as current clinical practice in Saudi Arabia are not known.

DESIGN

A cross-sectional online survey consisting of four themes; demographics, awareness, recommendations and clinical practice, for MCDs with COPD patients.

SETTING

Saudi Arabia.

PARTICIPANTS

1188 healthcare providers including general practitioners, family physicians, pulmonologists, nursing staff, respiratory therapists and physiotherapists.

PRIMARY OUTCOME MEASURES

Healthcare providers' level of awareness about MCDs, and the identification of current clinical practices of COPD care in Saudi Arabia.

RESULTS

1188 healthcare providers (44.4% female) completed the survey. Regarding devices, 54.2% were aware of the Flutter, 23.8% the Acapella and 5.4% the positive expiratory pressure mask. 40.7% of the respondents identified the Acapella, and 22.3% the Flutter as first choice for COPD management. 75% would usually or always consider their use in COPD patients reporting daily difficulty clearing mucus, whereas 55.9% would sometimes or usually consider the use of MCDs with COPD patients who produced and were able to clear mucus with cough. In clinical practice, 380 (32%) of the respondents would prescribe MCDs, 378 (31.8%) would give MCDs without prescriptions, 314 (26.4%) would not provide them at all and 116 (9.8%) would only advise patients about them.

CONCLUSION

Healthcare providers are aware of the existence of MCDs and their benefits for sputum clearance and believe that MCDs are beneficial for sputum clearance in some COPD patients.

TRIAL REGISTRATION NUMBER

ISRCTN44651852.

An overview of Cochrane systematic reviews for pulmonary rehabilitation interventions in people with chronic obstructive pulmonary disease: a mapping synthesis

INTRODUCTION

There is a global unmet need for rehabilitation to meet which the World Health Organization, in collaboration with Cochrane Rehabilitation, is developing the Package of Interventions for Rehabilitation with the aim of identifying rehabilitation interventions relevant to a range of key health conditions, including chronic obstructive pulmonary disease (COPD). The purpose of this paper is to describe the best available evidence on pulmonary rehabilitation interventions for people with COPD.

EVIDENCE ACQUISITION

An Overview of Cochrane Systematic Reviews (CSRs). Through the search strategy, COPD-related systematic reviews published from January 2009 to November 2021 were identified. Data were extracted on each reported outcome related to an intervention and judgements about the quality of evidence were made, using the GRADE approach.

EVIDENCE SYNTHESIS

Seventeen reviews were analyzed, for a total of 314 primary studies that included 22,206 participants. CSRs provided information on the effectiveness of rehabilitation on functioning, activity, quality of life, anxiety, depression, mortality, and health care resource utilization.

CONCLUSIONS

Our findings report that comprehensive pulmonary rehabilitation programs and water exercises improve the exercise capacity and quality of life (QoL) in people with COPD. Different exercise modalities, intensities, and settings for different muscle groups, breathing exercises, and counseling can improve exercise capacity, QoL, dyspnea, hospitalizations, and physical activity. It is uncertain whether breathing exercise, low-intensity exercise, neuromuscular electrical stimulation, and psychological intervention have an effect on exercise capacity, dyspnea, QoL, and physical activity. The protocol was registered on OSF (registration DOI: 10.17605/OSF.IO/8A26Q).

Non-pharmacological Management in Palliative Care for Patients With Advanced COPD

Chronic obstructive pulmonary disease (COPD) is a disabling condition associated with progressive airflow limitation and lung tissue damage; its main symptoms are breathlessness, fatigue, cough, and sputum production. In the advanced stage of the disease, these symptoms may severely impact on a person's physical and psychological functioning, with some also developing chronic respiratory failure, associated with blood gas abnormalities. Non-pharmacological interventions can improve quality of life and functioning in the management of people living with advanced COPD. This article will provide an overview of common non-pharmacological methods used in the symptomatic management of severe COPD, including: breathlessness and fatigue management strategies, anxiety management, pulmonary rehabilitation (PR) and physical activity (PA), neuromuscular electrical stimulation (NMES), airway clearance techniques (ACTs), nutrition and non-invasive ventilation (NIV). The importance of a holistic and multi-disciplinary approach to people living with COPD will be discussed.

Effect of PEP flute self-care versus usual care in early covid-19: non-drug, open label, randomised controlled trial in a Danish community setting

OBJECTIVE

To determine whether positive expiratory pressure (PEP) by PEP flute self-care is effective in reducing respiratory symptoms among community dwelling adults with SARS-CoV-2 infection and early stage covid-19.

DESIGN

Non-drug, open label, randomised controlled trial.

SETTING

Capital Region and Region Zealand in Denmark from 6 October 2020 to 26 February 2021.

PARTICIPANTS

Community dwelling adults, able to perform self-care, with a new SARS-CoV-2 infection (verified by reverse transcription polymerase chain reaction tests) and symptoms of covid-19.

INTERVENTION

Participants were randomised to use PEP flute self-care in addition to usual care or have usual care only. Randomisation was based on permuted random blocks in a 1:1 ratio, stratified for sex and age (<60 or ≥60 years). The PEP self-care group was instructed to use a PEP flute three times per day during the 30 day intervention.

MAIN OUTCOME MEASURES

Primary outcome was a change in symptom severity from baseline to day 30, as assessed by the self-reported COPD (chronic obstructive pulmonary disease) assessment test (CAT), which was adjusted for baseline values and stratification factors. Participants completed the CAT test questionnaire every day online. Secondary outcomes were self-reported urgent care visits due to covid-19, number of covid-19 related symptoms, and change in self-rated health, all within 30-days' follow-up.

RESULTS

378 participants were assigned to the PEP flute self-care intervention (n=190) or usual care only (n=188). In the PEP self-care group, the median number of days with PEP flute use was 21 days (interquartile range 13-25). For the intention-to-treat population, a group difference was observed in changes from baseline in CAT scores of -1.2 points (95% confidence interval -2.1 to -0.2; P=0.017) in favour of the PEP flute self-care group. At day 30, the PEP flute self-care group also reported less chest tightness, less dyspnoea, more vigour, and higher level of daily activities, but these differences were small, and no consistent effects were seen on the secondary outcomes. No serious adverse events were reported.

CONCLUSIONS

In community dwelling adults with early covid-19, PEP flute self-care had a significant, yet marginal and uncertain clinical effect on respiratory symptom severity, as measured by CAT scores.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04530435.

Methods Used to Evaluate the Immediate Effects of Airway Clearance Techniques in Adults with Cystic Fibrosis: A Systematic Review and Meta-Analysis

This review reports on methods used to evaluate airway clearance techniques (ACT) in adults with CF and examined data for evidence of any effect. Sixty-eight studies described ACT in adequate detail and were included in this review. Frequently reported outcomes were sputum expectoration (72%) and spirometric lung function (60%). Compared with cough alone, following any ACT, there was a trend for greater sputum wet weight, however FEV₁ was not different. The mean (95% CI) within-group effect for sputum wet weight following any ACT was 12.43 g (9.28 to 15.58) (n = 30 studies) and for FEV₁ was 0.03 L (−0.17 to 0.24) (n = 14 studies). Meta-regression demonstrated that, when compared with cough alone, greater sputum wet weight was reported in groups that received additional ACT by between 2.45 and 3.94 g (F_3,66 = 2.97, p = 0.04). These data suggest the addition of ACT to cough alone may optimise sputum clearance; however, FEV₁ lacked sensitivity to detect this change. Importantly, this review highlights the lack of appropriate measures to assess ACT efficacy.

Mucus targeting as a plausible approach to improve lung function in COVID-19 patients

COVID-19 (SARS-CoV-2) has emerged as one of the worst pandemics that have tormented the globe due to its highly contagious nature. Even if the disease manifests fever-like symptoms mostly, the disease may progress to the pulmonary-hyper inflammatory phase, with severe pneumonia, hypoxia and subsequent multiple organ infection. This subsequently creates a huge burden to the health care systems across the globe for an immediate arrangement of ventilator facilities, oxygen supply and advanced health care. We evaluated the pathological similarity of COVID-19 with other airway obstructive disorders such as COPD and asthma and found typical mucus hypersecretion and mucus plugging in COVID-19 subjects. From several bronchoscopy and clinical autopsy carried out in COVID-19 patients, the overexpression of mucin gene was evident which play a significant role in mucus hypersecretion and accumulation, leading to airway obstruction and further to respiratory distress. In the present work, we highlight the need for intense research inputs to elucidate the exact role the mucus plays in worsening COVID-19 symptoms. This will further help to find a proper approach to quantify the airway mucus plugging in each patient and to develop an appropriate therapy either to inhibit mucus secretion or to improve mucus clearance through well-designed clinical trials.

An initial evaluation of the safety of a disposable oscillating positive expiratory pressure device in patients with chronic obstructive pulmonary disease: a sort-term pilot study

Background

Handheld oscillating positive expiratory pressure (OPEP) devices have been a mainstay of treatment for patients with hypersecretory conditions such as cystic fibrosis (CF) and chronic obstructive pulmonary disease (COPD) since the 1970s. Current devices are reusable and require regular cleaning and disinfection to prevent harbouring potentially pathogenic organisms. Adherence to cleaning regimens for respiratory devices is often poor and in response to this, a prototype disposable OPEP device—the ‘UL-OPEP’ (University of Limerick—Oscillating Positive Expiratory Pressure device)—was developed to mitigate the risk of contamination by pathogens. The device was previously evaluated successfully in a group of paediatric CF patients. The aim of the current study was to initially evaluate the safety of the prototype in patients with COPD over a period of 1 month to ensure no adverse events, negative impacts on lung function, exercise tolerance, or quality of life. Data on user experience of the device were also collected during post-study follow-up.

Methods

A sample of 50 volunteer participants were recruited from pulmonary rehabilitation clinics within the local hospital network. The patients were clinically stable, productive, and not current or previous users of OPEP devices. Participants were invited to use a prototype disposable OPEP device daily for a period of 1 month. Pre- and post-study lung function was assessed with standard spirometry, and exercise tolerance with the 6-min-walk-test (6MWT). Quality of life was assessed using the St. George’s Respiratory Questionnaire (SGRQ), and user experience of the prototype device evaluated using a post-study questionnaire.

Results

24 Participants completed the study: 9 were female. Overall median age was 67.5 years, range 53–85 years. Lung function, 6-min walk test, and SGRQ scores showed no significant change post-study. User feedback was positive overall.

Conclusions

The results indicate that the UL-OPEP is safe to use in patients with COPD. No adverse events were recorded during the study or in the follow-up period of 2 weeks. The device did not negatively impact patients’ lung function, exercise tolerance, or quality of life during short term use (1 month), and usability feedback received was generally positive. Larger, longer duration studies will be required to evaluate efficacy.

Registration The study was approved as a Clinical Investigation by the Irish Health Products Regulatory Authority (CRN-2209025-CI0085).

PEP-CoV protocol: a PEP flute-self-care randomised controlled trial to prevent respiratory deterioration and hospitalisation in early COVID-19

INTRODUCTION

Infection with SARS-CoV-2 may progress to severe pulmonary disease, COVID-19. Currently, patients admitted to hospital because of COVID-19 have better prognosis than during the first period of the pandemic due to improved treatment. However, the overall societal susceptibility of being infected makes it pivotal to prevent severe courses of disease to avoid high mortality rates and collapse of the healthcare systems. Positive expiratory pressure (PEP) self-care is used in chronic pulmonary disease and has been shown to prevent pneumonia in a high-risk cohort of patients with leukaemia. PEP flute self-care to prevent respiratory deterioration and hospitalisation in early COVID-19: a randomised trial (The PEP-CoV trial) examines the effectiveness on respiratory symptoms and need of hospital admission by regular PEP flute use among non-hospitalised individuals with confirmed SARS-CoV-2 infection and COVID-19 symptoms.

METHODS AND ANALYSIS

In this randomised controlled trial, we hypothesise that daily PEP flute usage as add-on to usual care is superior to usual care as regards symptom severity measured by the COPD Assessment Test (CAT) at 30-day follow-up (primary outcome) and hospital admission through register data (secondary outcome). We expect to recruit 400 individuals for the trial. Participants in the intervention group receive a kit of 2 PEP flutes and adequate resistances and access to instruction videos. A telephone hotline offers possible contact to a nurse. The eight-item CAT score measures cough, phlegm, chest tightness, dyspnoea, activities of daily living at home, feeling safe at home despite symptoms, sleep quality and vigour. The CAT score is measured daily in both intervention and control arms by surveys prompted through text messages.

ETHICS AND DISSEMINATION

The study was registered prospectively at www.clinicaltrials.gov on 27 August 2020 (NCT04530435). Ethical approval was granted by the local health research ethics committee (Journal number: H-20035929) on 23 July 2020. Enrolment of participants began on 6 October 2020. Results will be published in scientific journals.

TRIAL REGISTRATION NUMBER

NCT04530435; Pre-results.

Inhaled high molecular weight hyaluronan ameliorates respiratory failure in acute COPD exacerbation: a pilot study

Background

Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) carry significant morbidity and mortality. AECOPD treatment remains limited. High molecular weight hyaluronan (HMW-HA) is a glycosaminoglycan sugar, which is a physiological constituent of the lung extracellular matrix and has notable anti-inflammatory and hydrating properties.

Research question

We hypothesized that inhaled HMW-HA will improve outcomes in AECOPD.

Methods

We conducted a single center, randomized, placebo-controlled, double-blind study to investigate the effect of inhaled HMW-HA in patients with severe AECOPD necessitating non-invasive positive-pressure ventilation (NIPPV). Primary endpoint was time until liberation from NIPPV.

Results

Out of 44 screened patients, 41 were included in the study (21 for placebo and 20 for HMW-HA). Patients treated with HMW-HA had significantly shorter duration of NIPPV. HMW-HA treated patients also had lower measured peak airway pressures on the ventilator and lower systemic inflammation markers after liberation from NIPPV. In vitro testing showed that HMW-HA significantly improved mucociliary transport in air–liquid interface cultures of primary bronchial cells from COPD patients and healthy primary cells exposed to cigarette smoke extract.

Interpretation

Inhaled HMW-HA shortens the duration of respiratory failure and need for non-invasive ventilation in patients with AECOPD. Beneficial effects of HMW-HA on mucociliary clearance and inflammation may account for some of the effects (NCT02674880, www.clinicaltrials.gov).

The effect of vibrating positive expiratory pressure therapy on refractory Mycoplasma pneumoniae pneumonia prognosis in children

BACKGROUND

It is well documented that vibration techniques and positive expiratory pressure (PEP) can improve airway clearance, however, few clinical trials have studied the efficacy of vibrating PEP therapy on refractory Mycoplasma pneumoniae (M. pneumoniae) pneumonia (RMPP) in children. This study aimed to explore using vibrating PEP therapy in children with RMPP.

METHODS

Sixty participants in the remission stage of RMPP were recruited into this randomized study and divided into two groups. The Acapella group (n=30) used the Acapella^® Choice twice daily for 2 months to clear their airways. The control group (n=30) used traditional chest percussion or postural drainage to mediate sputum expectoration. The groups administered their respective treatments at home and were followed up weekly. Participants kept a record of their treatment and condition in a daily log. The primary outcome of this study was the resolution of chest images, and the secondary outcome was the sputum period.

RESULTS

There was no significant difference in sex or age distribution between the two groups. There were no significant differences at baseline between the groups in the location of their lesions (P=0.11). After 2 months of treatment, there was a better resolution of chest images in the Acapella group (P=0.00) compared with the control group. Additionally, the mean sputum period was significantly shorter for the Acapella group than for the control group (Acapella: 7.97±1.54 days; control: 11.90±1.64 days; P=0.00).

CONCLUSIONS

Vibrating PEP therapy is an effective therapy for children with RMPP, both in airway clearance and the resolution of lung abnormalities.

ERS International Congress 2020 Virtual: highlights from the Allied Respiratory Professionals Assembly

This article provides an overview of outstanding sessions that were (co)organised by the Allied Respiratory Professionals Assembly during the European Respiratory Society International Congress 2020, which this year assumed a virtual format. The content of the sessions was mainly targeted at allied respiratory professionals, including respiratory function technologists and scientists, physiotherapists, and nurses. Short take-home messages related to spirometry and exercise testing are provided, highlighting the importance of quality control. The need for quality improvement in sleep interventions is underlined as it may enhance patient outcomes and the working capacity of healthcare services. The promising role of digital health in chronic disease management is discussed, with emphasis on the value of end-user participation in the development of these technologies. Evidence on the effectiveness of airway clearance techniques in chronic respiratory conditions is provided along with the rationale for its use and challenges to be addressed in future research. The importance of assessing, preventing and reversing frailty in respiratory patients is discussed, with a clear focus on exercise-based interventions. Research on the impact of disease-specific fear and anxiety on patient outcomes draws attention to the need for early assessment and intervention. Finally, advances in nursing care related to treatment adherence, self-management and patients' perspectives in asthma and chronic obstructive pulmonary disease are provided, highlighting the need for patient engagement and shared decision making. This highlights article provides readers with valuable insight into the latest scientific data and emerging areas affecting clinical practice of allied respiratory professionals.

Impact of Oscillating Positive Expiratory Pressure Device Use on Post-Discharge Hospitalizations: A Retrospective Cohort Study Comparing Patients with COPD or Chronic Bronchitis Using the Aerobika® and Acapella® Devices

Purpose

Managing and preventing disease exacerbations are key goals of COPD care. Oscillating positive expiratory pressure (OPEP) devices have been shown to improve clinical outcomes when added to COPD standard of care. This retrospective database study compared real-world resource use and disease exacerbation among patients with COPD or chronic bronchitis prescribed either of two commonly used OPEP devices.

Patients and methods

Patients using the Aerobika^® (Trudell Medical International, London, ON, Canada) or Acapella^® (Smiths Medical, Wampsville, New York, USA) OPEP device for COPD or chronic bronchitis were identified from hospital claims linked to medical and prescription claims between September 2013 and April 2018; the index date was the first hospital visit with an OPEP device. Severe disease exacerbation, defined as an inpatient visit with a COPD or chronic bronchitis diagnosis, and all-cause healthcare resource utilization over 30 days and 12 months post-discharge were compared in propensity score (PS)-matched Aerobika device and Acapella device users.

Results

In total, 619 Aerobika device and 1857 Acapella device users remained after PS matching. After discharge from the index visit, Aerobika device users were less likely to have ≥1 severe exacerbation within 30 days (12.0% vs 17.4%, p=0.01) and/or 12 months (39.6% vs 45.3%, p=0.01) and had fewer 12-month severe exacerbations (mean, 0.7 vs 0.9 per patient per year, p=0.01), with significantly longer time to first severe exacerbation than Acapella users (log-rank p=0.01). Aerobika device users were also less likely to have ≥1 all-cause inpatient visit within 30 days (13.9% vs 20.3%, p<0.001) and 12 months (44.9% vs 51.8%, p=0.003) than Acapella users.

Conclusion

Patients receiving the Aerobika OPEP device, compared to the Acapella device, had lower rates of subsequent severe disease exacerbation and all-cause inpatient admission. This suggests that Aerobika OPEP device may be a beneficial add-on to usual care and that OPEP devices may vary in clinical effectiveness.

Airway clearance techniques for patients with acute exacerbations of chronic obstructive pulmonary disease: Physical therapy practice in Sweden

There is considerable global variability in clinical practice regarding the prescription of airway clearance techniques (ACTs) for patients with acute exacerbations of chronic obstructive pulmonary disease (AECOPD). Little is known about the physical therapy practice, and no international guidelines are available. The aim of this survey was to identify current physical therapy practice regarding ACT prescription for patients with AECOPD in Sweden. A cross-sectional, descriptive study was conducted via a Web-based questionnaire, sent to all (n = 70) hospitals that offer physical therapy service for patients with AECOPD in Sweden. Responses were received from 117 physical therapists (76%) across all sites. ACTs were prescribed for more than half of all patients with an AECOPD by 75% of physical therapists. The most frequently used ACTs were positive expiratory pressure (PEP) devices (90%), directed huffing (88%) and cough (71%). Most physical therapists (89%) perceived sputum clearance to be an important aspect of the overall management of patients with AECOPD. The main factors influencing choice of ACT were the ‘degree of dyspnoea or work of breathing’ and ‘access to resources/equipment’. Physical therapists prescribe predominantly PEP-based ACTs for patients with AECOPD in Sweden. Several factors come into consideration that influences the choice of treatment technique.

Airway clearance services (ACSs) in Australia for adults with chronic lung conditions: scoping review of publicly available web-based information

BACKGROUND

Consumers frequently access the internet looking for health information. With the growing burden of chronic disease internationally, strategies are focussing on self-management interventions in community and ambulatory settings. The objective of this scoping review was to describe publicly available information on Australian airway clearance services.

METHODS

Publicly funded health services network webpages and Google were systematically searched between July and November 2018 using relevant keywords. We identified the number, location and currency of contact information of services; and described the services that were in operation and/or identifiable on the internet. Where specific airway clearance services were not identifiable via searching methods, webpages were navigated for associated physiotherapy services. All identified services were contacted via the listed phone or email to confirm web-based findings.

RESULTS

Searching 131 publicly funded health service pages and 191 keyword hits identified four publicly funded airway clearance services (two of which were in operation when confirmed by direct contact) and six private services, all in metropolitan areas of capital cities. Webpages described who their services were for (9/10 services), how to gain referral (4/10) and types of airway clearance techniques available (5/10). A further 286 public physiotherapy services were identified, of which 24 (8%) included descriptors of service provision for respiratory patients on their webpage. In contrast, on direct telephone enquiry airway clearance intervention of some kind was confirmed as being available at 174/286 (61%) sites and unavailable at 69/286 (24%) sites.

CONCLUSIONS

This scoping review demonstrated inconsistencies between airway clearance service information available on the internet and the reported provision of services confirmed by direct phone contact. Services that are available need to make information visible to consumers on the internet and include details such as referral pathways, interventions and current contact details, to support people with airway clearance problems to access appropriate care in the community.

European Respiratory Society guidelines on long-term home non-invasive ventilation for management of COPD

Background

While the role of acute non-invasive ventilation (NIV) has been shown to improve outcome in acute life-threatening hypercapnic respiratory failure in COPD, the evidence of clinical efficacy of long-term home NIV (LTH-NIV) for management of COPD is less. This document provides evidence-based recommendations for the clinical application of LTH-NIV in chronic hypercapnic COPD patients.

Materials and methods

The European Respiratory Society task force committee was composed of clinicians, methodologists and experts in the field of LTH-NIV. The committee developed recommendations based on the GRADE (Grading, Recommendation, Assessment, Development and Evaluation) methodology. The GRADE Evidence to Decision framework was used to formulate recommendations. A number of topics were addressed under a narrative format which provides a useful context for clinicians and patients.

Results

The task force committee delivered conditional recommendations for four actionable PICO (target population-intervention-comparator-outcome) questions, 1) suggesting for the use of LTH-NIV in stable hypercapnic COPD; 2) suggesting for the use of LTH-NIV in COPD patients following a COPD exacerbation requiring acute NIV 3) suggesting for the use of NIV settings targeting a reduction in carbon dioxide and 4) suggesting for using fixed pressure support as first choice ventilator mode.

Conclusions

Managing hypercapnia may be an important intervention for improving the health outcome of COPD patients with chronic respiratory failure. The task force conditionally supports the application of LTH-NIV to improve health outcome by targeting a reduction in carbon dioxide in COPD patients with persistent hypercapnic respiratory failure. These recommendations should be applied in clinical practice by practitioners that routinely care for chronic hypercapnic COPD patients.

Airway Clearance with Expiratory Flow Accelerator Technology: Effectiveness of the "Free Aspire" Device in Patients with Severe COPD

OBJECTIVES

Chronic obstructive pulmonary disease (COPD) is associated with a higher risk of pulmonary infections. This risk not only negatively affects patients' quality of life but also increases social and health costs. Hence, there is a need for an effective rehabilitative treatment including airway clearance. The aim of this pilot study was to evaluate the efficacy of a new tool for bronchial clearance based on expiratory flow accelerator (EFA) technology compared with positive expiratory pressure (PEP) treatment.

MATERIALS AND METHODS

Twenty stable patients with COPD, Global Initiative for Chronic Obstructive Lung Disease 3-4 stage, were enrolled and allocated to treatment with EFA or Bubble-PEP (BP) for 20 days during a pulmonary rehabilitation program. At baseline and the end of treatment, the following parameters were measured: arterial blood gases (ABG); respiratory function, including peak cough expiratory flow (PCEF), maximal inspiratory pressure (MIP), and maximal expiratory pressure exercise capacity using the 6-minute walk test (6MWT), dyspnea using the Medical Research Council scale, and quality of life using the St. George's Respiratory Questionnaire.

RESULTS

Expiratory flow accelerator showed a significant pre- and post-improvement in ABG and a significantly greater improvement than BP in PCEF, MIP, and 6MWT post-treatment.

CONCLUSION

Expiratory flow accelerator is a valid device compared with BP as an adjunctive therapy for the treatment of patients with severe COPD.

A randomised controlled trial to investigate the use of high-frequency airway oscillations as training to improve dyspnoea in COPD

Introduction

Chronic obstructive pulmonary disease (COPD) is characterised by expiratory flow limitation resulting in symptomatic dyspnoea, sputum retention and ventilation heterogeneity. Changes in breathing mechanics affect the ability of respiratory muscles to respond to the ventilatory demands, increasing the sensation of dyspnoea. A high-frequency airway oscillating device has been developed to combine respiratory muscle training and oscillations to improve dyspnoea and sputum retention within COPD.

Methods and analysis

Patients with symptomatic COPD (Medical Research Council Breathlessness scale grade ≥2) will be recruited to a double-blind, randomised, sham-controlled trial. Both groups will follow an 8-week intervention phase using the device three times per day for 5 min at a time. This will be recorded in a self-reported diary. The device applies a flow resistive load and oscillations for combined training. Those receiving the sham device will follow the same protocol; however, the mechanism of action will be removed from the device. Improvements in the Chronic Respiratory Questionnaire-Dyspnoea domain will be the primary outcome measure. Secondary outcomes will explore respiratory muscle function, health-related quality of life, exercise capacity and physical activity. The Lung Clearance Index will be an exploratory outcome. Outcomes will be explored using the most appropriate statistical test, dependent on the sample distribution. Focus groups will be an exploratory outcome and analysed by thematic analysis.

Ethics and dissemination

Ethical approval has been obtained from the East Midlands-Leicester South Research Ethics Committee and the trial has been registered through the ISRCTN Registry. The study results will be disseminated to the appropriate stakeholders through presentations, conferences and peer-reviewed journals.

A double-blind, placebo-controlled, randomised trial investigating the effects of high-frequency airway oscillations on dyspnoea, sputum, quality of life and exercise capacity in #COPD.http://bit.ly/2F8bQ6s

Airway clearance techniques for cystic fibrosis: an overview of Cochrane systematic reviews

BACKGROUND

Cystic fibrosis is a life-limiting genetic condition in which thick mucus builds up in the lungs, leading to infections, inflammation, and eventually, deterioration in lung function. To clear their lungs of mucus, people with cystic fibrosis perform airway clearance techniques daily. There are various airway clearance techniques, which differ in terms of the need for assistance or equipment, and cost.

OBJECTIVES

To summarise the evidence from Cochrane Reviews on the effectiveness and safety of various airway clearance techniques in people with cystic fibrosis.

METHODS

For this overview, we included Cochrane Reviews of randomised or quasi-randomised controlled trials (including cross-over trials) that evaluated an airway clearance technique (conventional chest physiotherapy, positive expiratory pressure (PEP) therapy, high-pressure PEP therapy, active cycle of breathing techniques, autogenic drainage, airway oscillating devices, external high frequency chest compression devices and exercise) in people with cystic fibrosis.We searched the Cochrane Database of Systematic Reviews on 29 November 2018.Two review authors independently evaluated reviews for eligibility. One review author extracted data from included reviews and a second author checked the data for accuracy. Two review authors independently graded the quality of reviews using the ROBIS tool. We used the GRADE approach for assessing the overall strength of the evidence for each primary outcome (forced expiratory volume in one second (FEV1), individual preference and quality of life).

MAIN RESULTS

We included six Cochrane Reviews, one of which compared any type of chest physiotherapy with no chest physiotherapy or coughing alone and the remaining five reviews included head-to-head comparisons of different airway clearance techniques. All the reviews were considered to have a low risk of bias. However, the individual trials included in the reviews often did not report sufficient information to adequately assess risk of bias. Many trials did not sufficiently report on outcome measures and had a high risk of reporting bias.We are unable to draw definitive conclusions for comparisons of airway clearance techniques in terms of FEV1, except for reporting no difference between PEP therapy and oscillating devices after six months of treatment, mean difference -1.43% predicted (95% confidence interval -5.72 to 2.87); the quality of the body of evidence was graded as moderate. The quality of the body of evidence comparing different airway clearance techniques for other outcomes was either low or very low.

AUTHORS' CONCLUSIONS

There is little evidence to support the use of one airway clearance technique over another. People with cystic fibrosis should choose the airway clearance technique that best meets their needs, after considering comfort, convenience, flexibility, practicality, cost, or some other factor. More long-term, high-quality randomised controlled trials comparing airway clearance techniques among people with cystic fibrosis are needed.

Safety and effectiveness of the high-frequency chest wall oscillation vs intrapulmonary percussive ventilation in patients with severe COPD

Purpose

Chest physiotherapy is an important tool in the treatment of COPD. Intrapulmonary percussive ventilation (IPV) and high-frequency chest wall oscillation (HFCWO) are techniques designed to create a global percussion of the lung which removes secretions and probably clears the peripheral bronchial tree. We tested the hypothesis that adding IPV or HFCWO to the best pharmacological therapy (PT) may provide additional clinical benefit over chest physiotherapy in patients with severe COPD.

Methods

Sixty patients were randomized into three groups (20 patients in each group): IPV group (treated with PT and IPV), PT group with (treated with PT and HFCWO), and control group (treated with PT alone). Primary outcome measures included results on the dyspnea scale (modified Medical Research Council) and Breathlessness, Cough, and Sputum scale (BCSS), as well as an evaluation of daily life activity (COPD Assessment Test [CAT]). Secondary outcome measures were pulmonary function testing, arterial blood gas analysis, and hematological examinations. Moreover, sputum cell counts were performed at the beginning and at the end of the study.

Results

Patients in both the IPV group and the HFCWO group showed a significant improvement in the tests of dyspnea and daily life activity evaluations (modified Medical Research Council scale, BCSS, and CAT) compared to the control group, as well as in pulmonary function tests (forced vital capacity, forced expiratory volume in 1 second, forced expiratory volume in 1 second/forced vital capacity%, total lung capacity, residual volume, diffusing lung capacity monoxide, maximal inspiratory pressure, maximal expiratory pressure) and arterial blood gas values. However, in the group comparison analysis for the same variables between IPV group and HFCWO group, we observed a significant improvement in the IPV group maximal inspiratory pressure, maximal expiratory pressure, BCSS, and CAT. Similar results were observed in changes of sputum cytology with reduction of inflammatory cells (neutrophils and macrophages).

Conclusion

The two techniques improved daily life activities and lung function in patients with severe COPD. IPV demonstrated a significantly greater effectiveness in improving some pulmonary function tests linked to the small bronchial airways obstruction and respiratory muscle strength and scores on health status assessment scales (BCSS and CAT) as well as a reduction of sputum inflammatory cells compared with HFCWO.

Pharmacological Management of People Living with End-Stage Chronic Obstructive Pulmonary Disease

Supportive care and pharmacological treatment can improve the quality of life of people with end-stage chronic obstructive pulmonary disease (COPD) who cope on a daily basis with substantial physical, psychological, social and spiritual morbidity. Smoking cessation is the only intervention that reduces the rate of progression of COPD, but evidence-based drug treatments and non-pharmacological strategies can relieve symptoms and reduce the impact of exacerbations. People with severe COPD live with increasingly troublesome breathlessness and other symptoms such as fatigue, pain, sputum production and weight loss. As breathlessness increases, treatment is stepped up from short-acting to long-acting bronchodilators supplemented by non-pharmacological interventions such as pulmonary rehabilitation. Opiates relieve breathlessness, and referral to a multidisciplinary breathlessness service is an option for those with intractable symptoms. Other smoking-related conditions, such as coronary heart disease and lung cancer as well as depression and anxiety are common and should be treated with conventional pharmacotherapy. Acute exacerbations become more frequent and more severe as the disease reaches end-stage. Inhaled corticosteroids in combination with long-acting bronchodilators can reduce the frequency of exacerbations, and supported self-management aims to facilitate timely treatment of deterioration. Palliative care services have traditionally been predicated on identifying people with end-stage disease-a model that does not resonate with the unpredictable, relapsing trajectory of COPD. Approaches to care that promote a flexible approach to palliation alongside curative care could do much to improve the burden of living with severe COPD.

Adjuncts for sputum clearance in COPD: clinical consensus versus actual use

Introduction

Oscillatory positive pressure devices (OPEP) can be used as adjuncts to improve sputum clearance in chronic obstructive pulmonary disease (COPD), though the evidence base is incomplete. The attitudes of physiotherapists towards these devices in the care of patients with COPD is unknown. In addition, actual use compared with the prescription of medications has not been studied.

Methods

We analysed English prescribing data, obtained from OpenPrescribing.net, for a 3-year period from 2013. In addition, we conducted an online survey of members of the Association of Chartered Physiotherapists in Respiratory Care regarding awareness of devices, thresholds for treatment and device preference.

Results

Out of a potential 3.2 million COPD patient-years of treatment between 2013 and 2015, 422 744 patient-years of treatment with carbocisteine, at a cost of £73 million, were prescribed, as well as 1.1 million years treatment with tiotropium. In the same period, only 4989 OPEP devices were prescribed. There were 116 responses to the survey (12% response rate), 72% in hospital practice, 28% based in the community. There were variations in respondents’ threshold for treatment with sputum adjuncts in COPD, and when asked to select either the Acapella, Flutter or positive expiratory pressure mask, preferences were 69%, 24% or 6%, respectively.

Conclusions

There is a 100-fold difference between use of carbocisteine and OPEP devices in COPD, with far fewer devices prescribed than are included in the phenotypes clinicians believe them to be effective in. Variation in physiotherapist attitudes to treatment thresholds highlights the need for research into the effectiveness of OPEP devices in specific patient phenotypes.

Results of Physiotherapy Treatments in Exacerbations of Chronic Obstructive Pulmonary Disease: A Systematic Review

Purpose: The objective of this study was to review clinical trials of the effectiveness of physiotherapy compared with standard care, focused mainly on the functional status of patients hospitalized for acute exacerbation of chronic obstructive pulmonary disease (AECOPD). Methods: Search strategies were developed for each of the databases (PubMed, Scopus, and Web of Science). The study eligibility criteria were as follows: (1) The objective was to assess the effect and efficacy of physiotherapy compared with standard care (which included only medical and pharmacological treatment); (2) adults subjects had AECOPD; (3) one of the outcome measures was functional status, defined as an individual's ability to perform the normal daily activities required to meet basic needs, fulfill usual roles, and maintain health and well-being; (4) it was a clinical trial; (5) it was written in English; (6) it was published between January 2009 and February 2016; and (7) the full-text article was available. Results: The review revealed that for patients hospitalized for AECOPD, exercise, neuromuscular electrical stimulation, breathing exercises, and chest therapy significantly improved their functional status compared with standard care. Conclusions: A variety of physiotherapy modalities have been shown to improve functional status compared with standard care among patients hospitalized for AECOPD; other outcome measures also showed improvements.

Australian critical care nursing professionals' attitudes towards the use of traditional "chest physiotherapy" techniques

Background:

Chest physiotherapy techniques, such as percussion, postural drainage, and expiratory vibrations, may be employed in a critical care setting. Physiotherapists are primarily responsible for their provision; however, nurses have also traditionally implemented these treatments. It is unclear whether nurses consider chest physiotherapy to be a part of their role, or how they perceive their knowledge and confidence pertaining to these techniques.

Objective:

To investigate the attitudes of nurses towards traditional chest physiotherapy techniques.

Method:

A total of 1222 members of the Australian College of Critical Care Nurses were invited to participate in an anonymous online survey.

Results:

There were 142 respondents (12%) with the majority (n = 132, 93%) having performed chest physiotherapy techniques in clinical practice. Most of them considered that the provision of chest physiotherapy was a part of nurse's role. Commonly cited factors influencing nurses' use of chest physiotherapy techniques were the availability of physiotherapy services, adequacy of nursing staff training and skill, and perceptions of professional roles.

Conclusions:

Nurses working in critical care commonly utilised traditional chest physiotherapy techniques. Further research is required to investigate the reasons why nursing professionals might assume responsibility for the provision of chest physiotherapy techniques, and if their application of these techniques is consistent with evidence-based recommendations.

Comparing airways clearance techniques in chronic obstructive pulmonary disease and bronchiectasis: positive expiratory pressure or temporary positive expiratory pressure? A retrospective study

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Patients with chronic hypersecretion (CH) of tracheobronchial mucus are a clinical challenge. They have an impaired quality of life, frequent exacerbations, and hospitalizations with need of antibiotics and other type of expensive treatments.

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Chest physical therapy evolved along the last decades and new techniques are currently used to help patients clear the airways efficiently. Among these airway clearance techniques (ACTs), the use of positive expiratory pressure (PEP) is considered one of the most effective.

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We report the retrospective evaluation of 162 patients with CH due to chronic obstructive pulmonary disease or bronchiectasis undergoing ACT in our Pulmonary Rehabilitation Department. They were treated either with PEP or with a new PEP device called UNIKO^®, which applies PEP in a temporary manner (TPEP).

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Comparing the two groups of patients, both treatments (i.e., PEP and TPEP) were followed by great improvements in physiological parameters of spirometry and gas exchange. However, subdividing patients, it was evident that TPEP had better effects than PEP in patients with emphysema and in patients on long-term oxygen treatment, while PEP was superior at least in some parameters in patients on mechanical ventilation.

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This study, albeit retrospective and calling for controlled clinical trials, suggests that different ACTs can be applied in different populations of patients.

Background

Airway clearance techniques include positive expiratory pressure, commonly used in our clinical practice, and a recently introduced temporary positive expiratory pressure device called UNIKO^®. It is unclear which one provides the best benefit to patients.

Objectives

The aim of this observational 4-year study was to retrospectively compare the efficacy of and specific indications for temporary positive expiratory pressure compared to positive expiratory pressure in a standard rehabilitation program.

Method

We retrospectively collected data from 162 subjects (107 males, mean age 70 ± 9 years, 97 with primary diagnosis of chronic obstructive pulmonary disease, 65 with bronchiectasis), 51 treated with temporary positive expiratory pressure and 111 with positive expiratory pressure.

Results

Subjects showed significant improvement in ratio of partial pressure arterial oxygen and fraction of inspired oxygen (p < 0.001), forced vital capacity, forced expiratory volume in one second, peak expiratory flow, arterial oxygen saturation, and partial pressure arterial oxygen with no significant difference between positive expiratory pressure and temporary positive expiratory pressure groups apart from forced expiratory flow, which increased only in the positive expiratory pressure group. Evaluating specific subgroups, temporary positive expiratory pressure was more effective than positive expiratory pressure in improving gas transfer in subjects with emphysema and in those on oxygen therapy, as the effective supplement oxygen flow decreased significantly (p = 0.034 and 0.046 respectively for temporary positive expiratory pressure vs. positive expiratory pressure). In subjects on mechanical ventilation, positive expiratory pressure was superior to temporary positive expiratory pressure in increasing forced expiratory flow (p = 0.018).

Conclusion

The physiological parameters of both groups improved significantly and similarly. Subgroup analysis suggests that temporary positive expiratory pressure could provide some advantage to subjects with emphysema and those on oxygen therapy, while positive expiratory pressure would benefit patients on mechanical ventilation. Randomized clinical trials are necessary to confirm our preliminary results indicating that different subgroups/phenotypes can benefit more from one type of treatment.

Benefits of interventions for respiratory secretion management in adult palliative care patients-a systematic review

BACKGROUND

Respiratory secretions impact negatively on palliative patients. Unfortunately, a gold standard therapy is not yet available. The purpose of this study was to identify which interventions are in use to control respiratory secretions in patients with chronic disease with a poor prognosis and verify their effects on outcomes relevant for palliative care patients.

METHODS

A systematic review of the literature with narrative summary was conducted. We searched eight electronic databases in April (6th), 2016. Citation-tracking and reference list searches were conducted. We included randomized controlled trials, crossover trials, observational and qualitative studies regarding interventions for respiratory secretion management in adult patients with chronic diseases that met inclusion criteria indicating short prognosis.

RESULTS

Six randomized controlled trials, 11 observational studies, ten crossover trials and one qualitative study were found. Interventions included mechanical insufflation-exsufflation (MIE), expiratory muscle training, manually-assisted cough, tracheotomy, chest physiotherapy, suctioning, air stacking, electrical stimulation of abdominal muscles, nebulized saline, positive expiratory pressure masks, percussive ventilation, high frequency chest wall oscillations. The interventions with most promising benefits to patients in palliative care were manually-assisted cough and mechanical insufflation-exsufflation to promote expectoration and percussive ventilation to improve mucous clearance.

CONCLUSION

Therapies, such as manually assisted cough, mechanical insufflation-exsufflation and percussive ventilation, which aim to deal with respiratory secretion, were the most promising treatment for use in palliative care for specific diseases. Nevertheless, the evidence still needs to improve in order to identify which treatment is the best.

Chest physiotherapy compared to no chest physiotherapy for cystic fibrosis

BACKGROUND

Chest physiotherapy is widely used in people with cystic fibrosis in order to clear mucus from the airways. This is an updated version of previously published reviews.

OBJECTIVES

To determine the effectiveness and acceptability of chest physiotherapy compared to no treatment or spontaneous cough alone to improve mucus clearance in cystic fibrosis.

SEARCH METHODS

We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register which comprises references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings.Date of the most recent search of the Group's Cystic Fibrosis Trials Register: 02 June 2015.

SELECTION CRITERIA

Randomised or quasi-randomised clinical studies in which a form of chest physiotherapy (airway clearance technique) were taken for consideration in people with cystic fibrosis compared with either no physiotherapy treatment or spontaneous cough alone.

DATA COLLECTION AND ANALYSIS

Both authors independently assessed study eligibility, extracted data and assessed the risk of bias in the included studies. There was heterogeneity in the published outcomes, with variable reporting which meant pooling of the data for meta-analysis was not possible.

MAIN RESULTS

The searches identified 157 studies, of which eight cross-over studies (data from 96 participants) met the inclusion criteria. There were differences between studies in the way that interventions were delivered, with several of the intervention groups combining more than one treatment modality. One included study looked at autogenic drainage, six considered conventional chest physiotherapy, three considered oscillating positive expiratory pressure, seven considered positive expiratory pressure and one considered high pressure positive expiratory pressure. Of the eight studies, six were single-treatment studies and in two, the treatment intervention was performed over two consecutive days (once daily in one, twice daily in the other). This enormous heterogeneity in the treatment interventions prevented any meta-analyses from being performed. Blinding of participants, caregivers or clinicians in airway clearance studies is impossible; therefore this was not considered as a high risk of bias in the included studies. Lack of protocol data made assessment of risk of bias unclear for the majority of other criteria.Four studies, involving 28 participants, reported a higher amount of expectorated secretions during chest physiotherapy as compared to a control. One study, involving 18 participants, reported no significant differences in sputum weight. In five studies radioactive tracer clearance was used as an outcome variable. In three of these (28 participants) it was reported that chest physiotherapy, including coughing, increased radioactive tracer clearance as compared to the control period. One study (12 participants) reported increased radioactive tracer clearance associated with all interventions compared to control, although this was only reported to have reached significance for postural drainage with percussion and vibrations; and the remaining study (eight participants) reported no significant difference in radioactive tracer clearance between chest physiotherapy, without coughing, compared to the control period. Three studies, involving 42 participants reported no significant effect on pulmonary function variables following intervention; but one further study did report significant improvement in pulmonary function following the intervention in some of the treatment groups.

AUTHORS' CONCLUSIONS

The results of this review show that airway clearance techniques have short-term effects in the terms of increasing mucus transport. No evidence was found on which to draw conclusions concerning the long-term effects.

Oscillatory Positive Expiratory Pressure in Chronic Obstructive Pulmonary Disease

Evidence-based guidance for the use of airway clearance techniques (ACT) in chronic obstructive pulmonary disease (COPD) is lacking in-part because well-established measurements of pulmonary function such as the forced expiratory volume in 1s (FEV1) are relatively insensitive to ACT. The objective of this crossover study was to evaluate daily use of an oscillatory positive expiratory pressure (oPEP) device for 21-28 days in COPD patients who were self-identified as sputum-producers or non-sputum-producers. COPD volunteers provided written informed consent to daily oPEP use in a randomized crossover fashion. Participants completed baseline, crossover and study-end pulmonary function tests, St. George's Respiratory Questionnaire (SGRQ), Patient Evaluation Questionnaire (PEQ), Six-Minute Walk Test and (3)He magnetic resonance imaging (MRI) for the measurement of ventilation abnormalities using the ventilation defect percent (VDP). Fourteen COPD patients, self-identified as sputum-producers and 13 COPD-non-sputum-producers completed the study. Post-oPEP, the PEQ-ease-bringing-up-sputum was improved for sputum-producers (p = 0.005) and non-sputum-producers (p = 0.04), the magnitude of which was greater for sputum-producers (p = 0.03). There were significant post-oPEP improvements for sputum-producers only for FVC (p = 0.01), 6MWD (p = 0.04), SGRQ total score (p = 0.01) as well as PEQ-patient-global-assessment (p = 0.02). Clinically relevant post-oPEP improvements for PEQ-ease-bringing-up-sputum/PEQ-patient-global-assessment/SGRQ/VDP were observed in 8/7/9/6 of 14 sputum-producers and 2/0/3/3 of 13 non-sputum-producers. The post-oPEP change in (3)He MRI VDP was related to the change in PEQ-ease-bringing-up-sputum (r = 0.65, p = 0.0004) and FEV1 (r = -0.50, p = 0.009). In COPD patients with chronic sputum production, PEQ and SGRQ scores, FVC and 6MWD improved post-oPEP. FEV1 and PEQ-ease-bringing-up-sputum improvements were related to improved ventilation providing mechanistic evidence to support oPEP use in COPD. Clinical Trials # NCT02282189 and NCT02282202.

Positive expiratory pressure - Common clinical applications and physiological effects

Breathing out against resistance, in order to achieve positive expiratory pressure (PEP), is applied by many patient groups. Pursed lips breathing and a variety of devices can be used to create the resistance giving the increased expiratory pressure. Effects on pulmonary outcomes have been discussed in several publications, but the expected underlying physiology of the effect is seldom discussed. The aim of this article is to describe the purpose, performance, clinical application and underlying physiology of PEP when it is used to increase lung volumes, decrease hyperinflation or improve airway clearance. In clinical practice, the instruction how to use an expiratory resistance is of major importance since it varies. Different breathing patterns during PEP increase or reduce expiratory flow, result in movement of EPP centrally or peripherally and can increase or decrease lung volume. It is therefore necessary to give the right instructions to obtain the desired effects. As the different PEP techniques are being used by diverse patient groups it is not possible to give standard instructions. Based on the information given in this article the instructions have to be adjusted to give the optimal effect. There is no consensus regarding optimal treatment frequency and number of cycles included in each treatment session and must also be individualized. In future research, more precise descriptions are needed about physiological aims and specific instructions of how the treatments have been performed to assure as good treatment quality as possible and to be able to evaluate and compare treatment effects.

Chest physiotherapy compared to no chest physiotherapy for cystic fibrosis

BACKGROUND

Chest physiotherapy is widely used in people with cystic fibrosis in order to clear mucus from the airways.

OBJECTIVES

To determine the effectiveness and acceptability of chest physiotherapy compared to no treatment or spontaneous cough alone to improve mucus clearance in cystic fibrosis.

SEARCH METHODS

We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register which comprises references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings.Date of the most recent search of the Group's Cystic Fibrosis Trials Register: 04 February 2013.

SELECTION CRITERIA

Randomised or quasi-randomised clinical studies in which a form of chest physiotherapy (airway clearance technique) were taken for consideration in people with cystic fibrosis compared with either no physiotherapy treatment or spontaneous cough alone.

DATA COLLECTION AND ANALYSIS

Both authors independently assessed study eligibility, extracted data and assessed study quality. There was heterogeneity in the published outcomes, with variable reporting which meant pooling of the data for meta-analysis was not possible.

MAIN RESULTS

The searches identified 144 studies, of which eight cross-over studies (data from 96 participants) met the inclusion criteria. There were differences between studies in the way that interventions were delivered, with several of the intervention groups combining more than one treatment modality. One included study looked at autogenic drainage, six considered conventional chest physiotherapy, three considered oscillating positive expiratory pressure, seven considered positive expiratory pressure and one considered high pressure positive expiratory pressure. Of the eight studies, six were single-treatment studies and in two, the treatment intervention was performed over two consecutive days (once daily in one, twice daily in the other). This enormous heterogeneity in the treatment interventions prevented any meta-analyses from being performed.Four studies, involving 28 participants, reported a higher amount of expectorated secretions during chest physiotherapy as compared to a control. One study, involving 18 participants, reported no significant differences in sputum weight. In five studies radioactive tracer clearance was used as an outcome variable. In three of these (28 participants) it was reported that chest physiotherapy, including coughing, increased radioactive tracer clearance as compared to the control period. One study (12 participants) reported increased radioactive tracer clearance associated with all interventions compared to control, although this was only reported to have reached significance for postural drainage with percussion and vibrations; and the remaining study (eight participants) reported no significant difference in radioactive tracer clearance between chest physiotherapy, without coughing, compared to the control period. Three studies, involving 42 participants reported no significant effect on pulmonary function variables following intervention; but one further study did report significant improvement in pulmonary function following the intervention in some of the treatment groups.

AUTHORS' CONCLUSIONS

The results of this review show that airway clearance techniques have short-term effects in the terms of increasing mucus transport. No evidence was found on which to draw conclusions concerning the long-term effects.

Positive expiratory pressure via mask does not improve ventilation inhomogeneity more than huffing and coughing in individuals with stable chronic obstructive pulmonary disease and chronic sputum expectoration

BACKGROUND

Positive expiratory pressure (PEP) has been used to promote airway clearance in individuals with chronic obstructive pulmonary disease (COPD) for many years; however, its mechanism of action and benefits are unclear. Previous authors have suggested that PEP improves collateral ventilation via changes in lung volumes.

OBJECTIVES

It was the aim of this study to determine whether PEP improves ventilation inhomogeneity more than controlled huffing and coughing in individuals with stable COPD.

METHODS

Twelve participants with COPD (mean forced expiratory volume in 1 s 45% predicted) and chronic sputum expectoration performed PEP therapy (10-20 cm H2O) or controlled huffing and coughing in random order on alternate study days with a 48-hour washout. Measures of acinar and conductive airway ventilation (S(acin), S(cond)), lung volumes, spirometry and sputum wet weight were recorded before, immediately after and 90 min following treatment. Ease of expectoration [visual analogue scale (VAS)] and oxyhaemoglobin saturation were assessed immediately following treatment.

RESULTS

There were no significant differences between the effect of either test condition at any time point for any test parameter. Mean Sacin immediately following PEP and control conditions was 0.465 and 0.438 litre(-1), respectively (p = 0.45 for comparison between conditions) and mean S(cond) was 0.042 and 0.039 litre(-1) (p = 0.55). PEP therapy did not significantly enhance total mean sputum expectoration compared to controlled huffing and coughing (7.06 vs. 6.15 g; p = 0.51) and did not improve ease of expectoration (VAS PEP 4.8 cm vs. control 4.1 cm; p = 0.53).

CONCLUSION

Any therapeutic benefits of PEP in individuals with COPD and chronic sputum expectoration are unlikely to be mediated by improvements in ventilation or lung volumes.