Oscillating Positive Expiratory Pressure on Respiratory Resistance in Chronic Obstructive Pulmonary Disease With a Small Amount of Secretion: A Randomized Clinical Trial

Impact of Aerobika® oscillating positive expiratory pressure in improving small airway resistance, lung function, symptoms and exercise capacity in chronic obstructive pulmonary disease

Background

Aerobika^® oscillating positive expiratory pressure (OPEP) device promotes airway clearance in many respiratory diseases. However, studies have yet to focus on its effectiveness in improving small airway resistance via impulse oscillometry (IOS) measurement in COPD subjects. We aim to evaluate the improvement of small airway resistance (via IOS), lung function (spirometry), exercise capacity [via 6-min walking test (6MWT)], symptoms [COPD assessment test (CAT)] and severe exacerbation events among COPD subjects using Aerobika^® OPEP.

Methods

This was a prospective, single-arm interventional study among COPD subjects with small airway disease. Subjects were instructed to use twice daily Aerobika^® OPEP (10 min each session); for 24 weeks; as an additional to standard therapy. IOS, spirometry, 6MWT, CAT score and severe exacerbation events were evaluated at baseline, 12 weeks and 24 weeks.

Results

Fifty-three subjects completed the study. Aerobika^® usage showed improvement of IOS parameters; e.g. measurement of airway resistance at 5 Hz (R5), cmH20/L/s, (12-week p = 0.008, 24-week p < 0.001), R5% predicted (12-week p = 0.007, 24-week p < 0.001) and small airway resistance (R5-R20), cmH20/L/s, (12-week p = 0.021, 24-week p < 0.001). There were improvement of lung function; e.g. FEV₁, L (12-week p = 0.018, 24-week p = 0.001), FEV₁% predicted (12-week p = 0.025, 24-week p = 0.001), FEF_25-75, L (12-week p = 0.023, 24-week p = 0.002), and FEF_25-75% predicted (12-week p = 0.024, 24-week p < 0.001). CAT score improved at 12 weeks (p < 0.001) and 24 weeks (p < 0.001). Subjects had improved exercise capacity (6MWT, metres) after 24 weeks (p = 0.016). However, there was no significant difference in severe exacerbation events 24 weeks before and after Aerobika^® usage.

Conclusion

Aerobika^® OPEP demonstrated significant improvement in small airway resistance as early as 12 weeks of usage, with sustained improvement at 24 weeks. Aerobika^® OPEP administration had significantly improved lung function, 6MWT, and CAT scores over 24 weeks. There was no difference in severe exacerbation events.

Short-Term Effect of Intermittent Intrapulmonary Deflation on Air Trapping in Patients With COPD

BACKGROUND

Intermittent intrapulmonary deflation is an airway clearance technique that generates negative pressure during expiratory phases. This technology is intended to reduce air trapping by delaying the onset of air-flow limitation during exhalation. The objective of this study was to compare the short-term effect of intermittent intrapulmonary deflation versus positive expiratory pressure (PEP) therapy on trapped gas volume and vital capacity (VC) in patients with COPD.

METHODS

We designed a randomized crossover study in which the participants with COPD received a 20-min session of both intermittent intrapulmonary deflation and PEP therapy on separate days and in random order. Lung volumes were measured via body plethysmography and helium dilution techniques, and spirometric outcomes were reviewed before and after each therapy. The trapped gas volume was estimated via functional residual capacity (FRC), residual volume (RV), and by the difference between FRC obtained through body plethysmography and helium dilution. Each participant also performed 3 VC maneuvers, from total lung capacity to RV with both devices.

RESULTS

Twenty participants with COPD (mean ± SD ages 67 ± 8 y; FEV1 48.1 ± 17.0%) were recruited. There was no difference between the devices in FRC or trapped gas volume. However, the RV decreased more during intermittent intrapulmonary deflation compared with PEP. The intermittent intrapulmonary deflation mobilized a larger expiratory volume than PEP during the VC maneuver (mean difference 389 mL, 95% CI 128-650 mL; P = .003).

CONCLUSIONS

The RV decreased after intermittent intrapulmonary deflation compared with PEP, but this effect was not captured by other estimates of hyperinflation. Although the expiratory volume obtained during the VC maneuver with intermittent intrapulmonary deflation was greater than that obtained with PEP, the clinical importance as well as the long-term effects remain to be determined.(ClinicalTrials.gov registration NCT04157972.).

Oscillatory positive expiratory pressure therapy in COPD (O-COPD): a randomised controlled trial

BACKGROUND

Oscillatory positive expiratory pressure (OPEP) devices are intended to facilitate sputum clearance and reduce cough, but there is limited evidence for their effectiveness in COPD, or to guide patient selection. We aimed to assess the impact of OPEP therapy on quality of life and objective measures of cough and sleep disturbance in patients with COPD with regular sputum production.

METHODS

We enrolled stable patients with COPD, who reported sputum production every day or most days, into an assessor-blind, parallel-group, randomised controlled trial comparing 3 months of using an Acapella device against usual care (including use of the active cycle of breathing technique). The primary outcome was cough-related quality of life measured using the Leicester Cough Questionnaire (LCQ). Secondary outcomes included fatigue (Functional Assessment of Chronic Illness Therapy, FACIT score) and generic quality of life (EuroQol-5 Dimensions, EQ-5D). In a substudy (n=45), objective monitoring of cough and disturbance/movement during sleep were also available.

RESULTS

122 participants (61/61 OPEP/control) were recruited, 40% female, 17% smokers, FEV1 38 (25-56)% predicted, and age 62±10 years. 103 completed the study (55/48 OPEP/control). Use of OPEP was associated with an improvement in LCQ compared with controls; MD (95% CI) 1.03 (0.71 to 2.10); (p=0.03), FACIT score 4.68 (1.34 to 8.02); (p<0.001) and EQ-5D 4.00 (0.49 to 19.75); (p=0.04). There was also an improvement in cough frequency -60 (-43 to -95) coughs/24 hours (p<0.001), but no statistically significant effect on sleep disturbance was identified.

CONCLUSIONS

Regular use of an Acapella device improves symptoms and quality of life in people with COPD who produce sputum daily or most days.

TRIAL REGISTRATION NUMBER

ISRCTN44651852.

Correlation among clinical, functional and morphological indexes of the respiratory system in non-cystic fibrosis bronchiectasis patients

Background

Non-cystic fibrosis bronchiectasis (NCFB) is a heterogeneous disease, which assessment and severity can’t be defined by one particular instrument but using a multidimensional score. Thus, in additional to traditional methods, alternative tools have been developed to assist these patients’ evaluation.

Objective

To correlate functional and morphological indexes with severity and dyspnea in NCFB patients, focusing on the correlation between the impulse oscillometry system (IOS) and the quantitative analysis of computed tomography (CT).

Methods

Clinically stable NCFB patients, between 18 and 80 years old were submitted to clinical, functional and morphological evaluations assessed by Bronchiectasis Severity Index (BSI) and Medical Research Council (MRC) scale; spirometry and IOS; and subjective and quantitative Chest CT scans analysis, respectively.

Results

This study included 38 patients. The best correlations obtained between functional and morphological airway indexes were: resistance at 5 Hz—R5 and the normalized thickness of bronchial walls—Pi10 (r = 0.57), and the mean forced expiratory flow (FEF_25-75%) and CT score (r = -0.39). BSI as well as MRC showed higher correlations with the quantitative automated analysis of CT (BSI and Pi10: r = 0.41; MRC and Pi10: r = 0.35) than with subjective CT score (BSI and CT score: r = 0.41; MRC and CT score: r = 0.15); and moderate and weak correlations were obtained on both functional airway indexes (BSI and peripheral airways resistance - R5-R20: r = 0.53; BSI and forced expiratory volume at the first second—FEV₁: R = -0,64; MRC and R5-R20: r = 0.42; and MRC and VEF₁: r = -0.45).

Conclusion

In NCFB patients, compartmentalized methods for assessing the respiratory system (IOS and the automated quantitative CT analysis) have a good correlation with severity and dyspnea.

The Use of Airway Clearance Devices in the Management of Chronic Obstructive Pulmonary Disease. A Systematic Review and Meta-analysis of Randomized Controlled Trials

Rationale: Sputum retention in chronic obstructive pulmonary disease (COPD) is a troubling symptom and can lead to reduced quality of life and increased exacerbations. Airway clearance devices are commonly used in COPD; however, their efficacy is unclear and is inconsistent among cohorts.Objectives: This study aims to systematically review the evidence to determine the impact of airway clearance devices in patients with COPD.Methods: Databases for systematic reviews and published evidence were searched. Studies were included if they were randomized and compared an airway clearance device to usual care or control. Studies were required to report at least one of the following: exacerbations, sputum volume, hospitalizations, and health-related quality of life. Data were extracted and assessed for risk of bias, and outcomes were synthesized using RevMan.Results: Eighteen studies with available data were eligible for this review, totaling 855 participants. Airway clearance devices demonstrated significant improvements in sputum volume (-1.07 ml; -0.37 to -1.77). There were significant improvements in the rate of exacerbation frequency at 6 months (rate ratio, 0.50; 95% confidence interval, 0.30-0.83; P < 0.01). No significant improvement was noted for the Saint George's Respiratory Questionnaire (0.30; -1.56 to -3.41; P = 0.10) in stable patients. There was an improvement of -5.73 (-7.30 to -4.15) for the COPD Assessment Test and -1.72 (-2.85 to -0.59) for the Breathlessness Cough and Sputum Score (P < 0.01).Conclusions: Airway clearance devices can improve exacerbation frequency, sputum clearance, and symptoms in stable COPD. The evidence included in this review was predominantly low- to moderate-grade evidence.

Comparative evaluation of expiratory airflow limitation between patients with COPD and BE using IOS

Impulse oscillometry (IOS) allows evaluation of the compartmentalized resistance and reactance of the respiratory system, distinguishing central and peripheral obstruction. The IOS measurements are getting attention in the diagnosis and differentiation of chronic respiratory diseases. However, no data are available in the literature to differentiate between COPD and BE using IOS parameters. We aimed to evaluate the feasibility of IOS in the diagnosis of bronchiectasis non-cystic fibrosis (BE) in comparison to COPD. Whole breath, inspiration, expiration, and inspiratory-expiratory difference (Δ) were evaluated based on the IOS parameters: total resistance (R5), central airway resistance (R20), peripheral airway resistance (R5-R20), reactance (X5), reactance area (AX), and resonance frequency (Fres). Fifty-nine subjects (21 Healthy, 19 BE, and 19 COPD) participated in this study. It was observed a significant difference in the comparison of healthy and pulmonary disease groups (BE and COPD) for total breathing (R5-R20, X5, AX, and Fres), inspiratory phase (R5 and R5-R5), and expiratory phase (R5-R20 and X5). The comparison between BE and COPD groups showed significant difference in the expiratory phase for resistance at 5 and 20 Hz and, ΔR5 and ΔR20. The IOS evidenced an increase of R5, R20 and R5-R20 in patients with BE and COPD when compared to healthy subjects. Expiratory measures of IOS revealed increased airway resistance in COPD compared to BE patients who had similar FEV1 measured by spirometry, however, further studies are needed to confirm these differences.

Biofeedback flutter device for managing the symptoms of patients with COPD

BACKGROUND

Flutter is a device used in removing excess lung secretions. The conventional flutter lacks a biofeedback component to facilitate optimal use by the patients.

OBJECTIVE

The current research aims to compare the effects of biofeedback flutter devices with the conventional flutter in managing the symptoms of patients with chronic obstructive pulmonary diseases.

METHODS

One hundred and sixty-eight participants were randomly allocated into four groups: Group A (conventional), Group B (visual biofeedback), Group C (auditory biofeedback) and Group D (visual and auditory biofeedback). All groups were treated five days for 20 minutes. Outcome measures included wet sputum weight [during intervention (T1) and 1 hour after intervention (T2)], oxygen saturation and dyspnea score (before and after intervention) on all days.

RESULTS

The wet sputum expectorated (T2) by Group B was significantly higher than Group A (P< 0.001), Group C (P< 0.001) and Group D (P< 0.05). The dyspnea score for Group B (P< 0.05), Group C (P< 0.05) and Group D (P< 0.05) was significantly lower than Group A. The post-intervention oxygen saturation level was higher in Group D followed by Groups B, C and A.

CONCLUSION

The use of biofeedback flutter is effective in the removal of secretion, reducing dyspnea and improving oxygen saturation when compared to conventional flutter.

Comparing the Effect of Incentive Spirometry with Acapella on Blood Gases in Physiotherapy After Coronary Artery Bypass Graft

Objective

To compare the effect of incentive spirometry with Acapella (Smiths Medical Inc, Carlsbad, California) in physiotherapy after coronary artery bypass surgery.

Methods

A randomized controlled trial comparing incentive spirometry with Acapella was conducted in the intensive care unit of Chaudhary Pervaiz Elahi Institute of Cardiology (CPEIC) Multan. The study began from December 2017 to August 2019 after getting approval from the ethical committee of the hospital. Informed written consent was taken from all 270 patients who were included in the study. Patients who underwent coronary artery bypass graft (CABG) were divided into two groups by the lottery method. The primary end-point of the study was to check the blood gases on Day 3 after the procedure at room air and compare it with the baseline and with blood gases immediately after the procedure. SPSS 23 (IBM Corp., Armonk, NY) was used to analyze the data of this study. For qualitative variables in data such as gender, place of living, patients with any comorbidities, and education status were statistically analyzed in percentage and frequencies. For numerical variables, such as age, body mass index, blood gases values, distance covered in a six-minute walk test, and spirometry values were analyzed and statistically measured as mean and standard deviation. A P-value of less than .05 was considered significant.

Results

The mean partial pressure of oxygen (PaO2) of incentive spirometry was 58.1±2.31 and 67.2±3.24 after extubation and after three days, respectively. While the PaO2 of Acapella was 56.3±3.43 and 66.4±3.54 after extubation and after three days, respectively. The mean PCO2 of incentive spirometry was 41.4±3.26 and 36.1±2.11 after extubation and after three days, respectively. While the partial pressure of carbon dioxide (PCO2) of Acapella was 39.4±2.55 and 37.5±3.58 after extubation and after three days, respectively. The differences were statistically significant at p-value ≤0.05.

Conclusion

It was concluded that both Acapella and incentive spirometry treatment after coronary artery bypass graft improved blood gases.

Exercise and Cystic Fibrosis

Cystic fibrosis (CF) is an autosomal recessive, inherited congenital disease caused by the mutation of the family autosomal CF gene, with cumulative exocrine secretion characterized by inflammation, tracheal remodeling, and mucus accumulation. With the development of modern medical technology, CF patients are living longer lives and receiving more and more treatments, including traditional drugs, physical therapy, and gene therapy. Exercise is widely used to prevent and treat metabolic diseases such as cardiovascular diseases, obesity, diabetes, and metabolic syndrome. Regular exercise is beneficial to aerobic capacity and lung health. Exercise therapy has been of great interest since people realized that CF can be affected by exercise. Exercise alone can be used as an ACT (airway clearance technique), which promotes the removal of mucosal cilia. Exercise therapy is more easily accepted by any society, which helps to normalize the lives of CF patients, rather than placing a psychological burden on them. In this chapter, we will review the latest research progress about exercise in CF.

Effects of exercise on secretion transport, inflammation, and quality of life in patients with noncystic fibrosis bronchiectasis: Protocol for a randomized controlled trial

BACKGROUND

Bronchiectasis is characterized by pathological and irreversible bronchial dilatation caused by the inefficient mucus and microorganism clearance and progression of inflammatory processes. The most frequent characteristic is the increase in bronchial mucus production resulting in slower transport and damage to the mucociliary transport.

AIMS

To evaluate the effects of exercise on mucus transport, inflammation, and resistance of the respiratory and autonomic nervous systems and subsequent effects on quality of life in patients with bronchiectasis who are enrolled in a pulmonary rehabilitation program.

METHODS

Sixty subjects of both sexes between 18 and 60 years (30 volunteers with clinically stable bronchiectasis and 30 healthy volunteers) will be included. Participants with chronic obstructive pulmonary disease, decompensated cardiovascular or metabolic diseases, neuromuscular and musculoskeletal diseases, and active smokers will be excluded. Volunteers will be randomly allocated to the pulmonary rehabilitation or control groups. The primary outcomes will be nasal transport time as evaluated by nasal saccharin transport time, analysis of nasal lavage, enzyme immunoassay of exhaled expiration, and analysis of the mucus properties. The secondary outcomes will include pulmonary function tests, impulse oscillometry, heart rate variability analysis, and quality of life questionnaires.

DISCUSSION

In addition to the benefits for patients already described in the literature, the additional benefit of mucus removal may contribute to optimizing treatments and better control of the disease.

CONCLUSION

This protocol could provide new information about the unclear mechanisms regarding exercise to aid in the removal of secretions.

Effects of combination therapy indacaterol/glycopyrronium versus tiotropium on moderate to severe COPD: evaluation of impulse oscillometry and exacerbation rate

BACKGROUND

Small airways are considered the major site of airflow limitation in COPD. Impulse oscillometry (IOS) is a forced oscillation technique, which provides passive measurement of lung mechanics. It can differentiate small airway from large airway obstruction and is more sensitive than spirometry for peripheral airway disease. In this study the efficacy of the combination of Indacaterol/Glycopirronium (IND/GLY) versus Tiotropium on airway resistance (R5, R20, R5-20), lung reactance (X) and resonant frequency in moderate to severe COPD patients has been evaluated. We also evaluated inspiratory capacity (IC), forced expiratory volume in 1 s (FEV₁), forced vital capacity (FVC), exacerbation rate and quality of life.

METHODS

Forty patients were monitored with forced oscillation technique and spirometry. Patients were randomized in 2 groups: 20 received fixed dose once daily Indacaterol/Glycopyrronium (Group A) and 20 received single Tiotropium (Group B). The oscillometry parameters were the measure of resistance in the airways at 5 Hz (R5), at 20 Hz (R20) and the lung reactance (X).

RESULTS

There was a statistically significant difference between pre-dosing at V₁ and at follow up visits in R₅, R₂₀ and X values in patients receiving dual bronchodilation but not in control group. Pre-dosing IC value at follow up visits in patients receiving dual bronchodilation had a statistical significant variation.

CONCLUSIONS

The "new" bronchodilator combination LABA/LAMA significantly reduces bronchial obstruction in small airways too. The oscillometry demonstrated greater sensitivity compared with spirometry for monitoring outcome measures of airway obstruction and the effect of long-term therapy.

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.