Chest physiotherapy in cystic fibrosis: a comparative study of autogenic drainage and the active cycle of breathing techniques with postural drainage

Airway clearance techniques compared to no airway clearance techniques for cystic fibrosis

BACKGROUND

Cystic fibrosis (CF) is an inherited progressive life-limiting disease characterised by the build-up of abnormally thick, sticky mucus affecting mostly the lungs, pancreas, and digestive system. Airway clearance techniques (ACTs), traditionally referred to as chest physiotherapy, are recommended as part of a complex treatment programme for people with CF. The aim of an ACTs is to enhance mucociliary clearance and remove viscous secretions from the airways within the lung to prevent distal airway obstruction. This reduces the infective burden and associated inflammatory effects on the airway epithelia.  There are a number of recognised ACTs, none of which have shown superiority in improving short-term outcomes related to mucus transport. This systematic review, which has been updated regularly since it was first published in 2000, considers the efficacy of ACTs compared to not performing any ACT in adults and children with CF. It is important to continue to review this evidence, particularly the long-term outcomes, given the recent introduction of highly effective modulator therapies and the improved health outcomes and potential changes to CF management associated with these drugs.

OBJECTIVES

To determine the effectiveness and acceptability of airway clearance techniques compared to no airway clearance techniques or cough alone in people with 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, to 17 October 2022. We searched ongoing trials registers (Clinicaltrials.gov and the WHO International Clinical Trials Registry Platform) to 7 November 2022.

SELECTION CRITERIA

We included randomised or quasi-randomised studies that compared airway clearance techniques (chest physiotherapy) with no airway clearance techniques or spontaneous cough alone in people with CF.

DATA COLLECTION AND ANALYSIS

Both review authors independently assessed study eligibility, extracted data, and assessed the risk of bias of the included studies. We used GRADE methodology to assess the certainty of the evidence.

MAIN RESULTS

We included 11 cross-over studies (153 participants) and one parallel study (41 participants). There were differences between studies in how the interventions were delivered, with several intervention groups combining more than one ACT. One study used autogenic drainage; five used conventional chest physiotherapy; nine used positive expiratory pressure (PEP), with one study varying the water pressure between arms; three studies used oscillating PEP; two used exercise; and two used high-frequency chest wall oscillation (HFCWO). Of the 12 included studies, 10 were single-treatment studies, and two delivered the intervention over two consecutive days (once daily in one study, twice daily in the second). This substantial heterogeneity in the treatment interventions precluded pooling of data for meta-analysis. Blinding of participants, caregivers, and clinicians is impossible in airway clearance studies; we therefore judged all studies at unclear risk of performance bias. Lack of information in eight studies made assessment of risk of bias unclear for most other domains.  We rated the certainty of evidence as low or very low due to the short-term cross-over trial design, small numbers of participants, and uncertain risk of bias across most or all domains. Six studies (84 participants) reported no effect on pulmonary function variables following intervention; but one study (14 participants) reported an improvement in pulmonary function following the intervention in some of the treatment groups. Two studies reported lung clearance index: one (41 participants) found a variable response to treatment with HFCWO, whilst another (15 participants) found no effect on lung clearance index with PEP therapy (low-certainty evidence). Five studies (55 participants) reported that ACTs, including coughing, increased radioactive tracer clearance compared to control, while a further study (eight participants) reported no improvement in radioactive tracer clearance when comparing PEP to control, although coughing was discouraged during the PEP intervention. We rated the certainty of evidence on the effect of ACTs on radioactive tracer clearance as very low. Four studies (46 participants) investigated the weight of mucus cleared from the lungs and reported greater secretions during chest physiotherapy compared to a control. One study (18 participants) reported no differences in sputum weight (very low-certainty evidence).

AUTHORS' CONCLUSIONS

The evidence from this review shows that ACTs may have short-term effects on increasing mucus transport in people with CF. All included studies had short-term follow-up; consequently, we were unable to draw any conclusions on the long-term effects of ACTs compared to no ACTs in people with CF. The evidence in this review represents the use of airway clearance techniques in a CF population before widespread use of cystic fibrosis transmembrane conductance regulator (CFTR) modulators. Further research is needed to determine the effectiveness and acceptability of airway clearance in those treated with highly effective CFTR modulators.

Effectiveness of Autogenic Drainage in Improving Pulmonary Function in Patients with Cystic Fibrosis

The use of autogenic drainage (AD) in patients with cystic fibrosis (CF) has been officially approved; therefore, the purpose of this study was to compare the efficiency of the leading therapeutic techniques based on AD in patients with CF; Among patients with CF assessments were made of spirometric parameters, percent blood oxygen saturation, and the general feeling of the patients (Borg, VAS, and mMRC dyspnea scale) before and after therapy using AD, using AD in connection with a belt or a Simeox device and AD in combination with both a belt and Simeox device simultaneously. The best therapeutic effects were generated by the combination of AD with the belt and with the Simeox device. The greatest improvements were observed for FEV1, FVC, PEF, FET, saturation, and patient comfort. In patients <10.5 years of age, the increase in the level of FEV3 and FEV6 was significant in comparison to older patients. Due to their efficacy, therapies connected with AD should be applied not only in hospital departments but also during daily patient care. Given the particular benefits observed in patients <10.5 years of age, it is important to guarantee real accessibility to this form of physiotherapy, especially in this age group.

Active cycle of breathing technique for cystic fibrosis

BACKGROUND

People with cystic fibrosis (CF) experience chronic airway infections as a result of mucus buildup within the lungs. Repeated infections often cause lung damage and disease. Airway clearance therapies aim to improve mucus clearance, increase sputum production, and improve airway function. The active cycle of breathing technique (ACBT) is an airway clearance method that uses a cycle of techniques to loosen airway secretions including breathing control, thoracic expansion exercises, and the forced expiration technique. This is an update of a previously published review.

OBJECTIVES

To compare the clinical effectiveness of ACBT with other airway clearance therapies in CF.

SEARCH METHODS

We searched the Cochrane Cystic Fibrosis Trials Register, compiled from electronic database searches and handsearching of journals and conference abstract books. We also searched clinical trials registries and the reference lists of relevant articles and reviews. Date of last search: 29 March 2021.

SELECTION CRITERIA

We included randomised or quasi-randomised controlled clinical studies, including cross-over studies, comparing ACBT with other airway clearance therapies in CF.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened each article, abstracted data and assessed the risk of bias of each study. We used GRADE to assess our confidence in the evidence assessing quality of life, participant preference, adverse events, forced expiratory volume in one second (FEV1) % predicted, forced vital capacity (FVC) % predicted, sputum weight, and number of pulmonary exacerbations.

MAIN RESULTS

Our search identified 99 studies, of which 22 (559 participants) met the inclusion criteria. Eight randomised controlled studies (259 participants) were included in the analysis; five were of cross-over design. The 14 remaining studies were cross-over studies with inadequate reports for complete assessment. The study size ranged from seven to 65 participants. The age of the participants ranged from six to 63 years (mean age 18.7 years). In 13 studies follow up lasted a single day. However, there were two long-term randomised controlled studies with follow up of one to three years. Most of the studies did not report on key quality items, and therefore, have an unclear risk of bias in terms of random sequence generation, allocation concealment, and outcome assessor blinding. Due to the nature of the intervention, none of the studies blinded participants or the personnel applying the interventions. However, most of the studies reported on all planned outcomes, had adequate follow up, assessed compliance, and used an intention-to-treat analysis. Included studies compared ACBT with autogenic drainage, airway oscillating devices (AOD), high-frequency chest compression devices, conventional chest physiotherapy (CCPT), positive expiratory pressure (PEP), and exercise. We found no difference in quality of life between ACBT and PEP mask therapy, AOD, other breathing techniques, or exercise (very low-certainty evidence). There was no difference in individual preference between ACBT and other breathing techniques (very low-certainty evidence). One study comparing ACBT with ACBT plus postural exercise reported no deaths and no adverse events (very low-certainty evidence). We found no differences in lung function (forced expiratory volume in one second (FEV1) % predicted and forced vital capacity (FVC) % predicted), oxygen saturation or expectorated sputum between ACBT and any other technique (very low-certainty evidence). There were no differences in the number of pulmonary exacerbations between people using ACBT and people using CCPT (low-certainty evidence) or ACBT with exercise (very low-certainty evidence), the only comparisons to report this outcome.

AUTHORS' CONCLUSIONS

There is little evidence to support or reject the use of the ACBT over any other airway clearance therapy and ACBT is comparable with other therapies in outcomes such as participant preference, quality of life, exercise tolerance, lung function, sputum weight, oxygen saturation, and number of pulmonary exacerbations. Longer-term studies are needed to more adequately assess the effects of ACBT on outcomes important for people with cystic fibrosis such as quality of life and preference.

Efficacy of the Simeox® Airway Clearance Technology in the Homecare Treatment of Children with Clinically Stable Cystic Fibrosis: A Randomized Controlled Trial

BACKGROUND

Cystic fibrosis (CF) patients require regular airway clearance therapy (ACT). The aim of this study was to evaluate homecare therapeutic effects of a new ACT (Simeox®) added to the optimal standard of care, including home chest physiotherapy, in the treatment of clinically stable children.

METHODS

Forty pediatric CF patients (8-17 years old) with stable disease were randomized 1:1 in a single-center, prospective, open-label, cross-over trial into two groups: with or without Simeox®. Lung function (impulse oscillometry, spirometry, body plethysmography, multi-breath nitrogen washout) results, health-related quality of life, and safety were assessed during the study after 1 month of therapy at home.

RESULTS

A significant decrease in proximal airway obstruction (as supported by improvement in airway resistance at 20 Hz (R20Hz) and maximum expiratory flow at 75% of FVC (MEF75)) compared to the control group was observed after 1 month of therapy with the device. Lung-clearance index was stable in the study group, while it worsened in the control group. In addition, the device group demonstrated a significant increase in the Cystic Fibrosis Questionnaire-Revised (CFQ-R) physical score. No side effects were identified during the study.

CONCLUSIONS

Simeox® may improve drainage of the airways in children with clinically stable CF and could be an option in chronic treatment of the disease.

Autogenic drainage for airway clearance in cystic fibrosis

BACKGROUND

Autogenic drainage is an airway clearance technique that was developed by Jean Chevaillier in 1967. The technique is characterised by breathing control using expiratory airflow to mobilise secretions from smaller to larger airways. Secretions are cleared independently by adjusting the depth and speed of respiration in a sequence of controlled breathing techniques during exhalation. The technique requires training, concentration and effort from the individual but it has previously been shown to be an effective treatment option for those who are seeking techniques to support and promote independence.  However, at a time where the trajectory and demographics of the disease are changing, it is important to systematically review the evidence demonstrating that autogenic drainage is an effective intervention for people with cystic fibrosis.

OBJECTIVES

To compare the clinical effectiveness of autogenic drainage in people with cystic fibrosis with other physiotherapy airway clearance techniques.

SEARCH METHODS

We searched the Cochrane Cystic Fibrosis Trials Register, compiled from electronic database searches and handsearching of journals and conference abstract books. We also searched the reference lists of relevant articles and reviews, as well as two ongoing trials registers (02 February 2021). Date of most recent search of the Cochrane Cystic Fibrosis Trials Register: 06 July 2021.

SELECTION CRITERIA

We identified randomised and quasi-randomised controlled studies comparing autogenic drainage to another airway clearance technique or no therapy in people with cystic fibrosis for at least two treatment sessions.

DATA COLLECTION AND ANALYSIS

Data extraction and assessments of risk of bias were independently performed by three authors. The authors assessed the quality of the evidence using the GRADE system. The authors contacted seven teams of investigators for further information pertinent to their published studies.

MAIN RESULTS

Searches retrieved 64 references to 37 individual studies, of which eight (n = 212) were eligible for inclusion. One study was of parallel design with the remaining seven being cross-over in design; participant numbers ranged from 4 to 75. The total study duration varied between four days and two years. The age of participants ranged between seven and 63 years with a wide range of disease severity reported. Six studies enrolled participants who were clinically stable, whilst participants in two studies received treatment whilst hospitalised with an infective exacerbation. All studies compared autogenic drainage to one (or more) other recognised airway clearance technique. Exercise is commonly used as an alternative therapy by people with cystic fibrosis; however, there were no studies identified comparing exercise with autogenic drainage. The certainty of the evidence was generally low or very low. The main reasons for downgrading the level of evidence were the frequent use of a cross-over design, outcome reporting bias and the inability to blind participants. The review's primary outcome, forced expiratory volume in one second, was the most common outcome measured and was reported by all eight studies; only three studies reported on quality of life (also a primary outcome of the review). One study reported on adverse events and described a decrease in oxygen saturation levels whilst performing active cycle of breathing techniques, but not with autogenic drainage. Seven of the eight included studies measured forced vital capacity and three of the studies used mid peak expiratory flow (per cent predicted) as an outcome. Six studies reported sputum weight. Less commonly used outcomes included oxygen saturation levels, personal preference, hospital admissions, intravenous antibiotics and pseudomonas gene expression. There were no statistically significant differences found between any of the techniques used with respect to the outcomes measured except when autogenic drainage was described as being the preferred technique of the participants in one study over postural drainage and percussion.

AUTHORS' CONCLUSIONS

Autogenic drainage is a challenging technique that requires commitment from the individual. As such, this intervention merits systematic review to ensure its effectiveness for people with cystic fibrosis, particularly in an era where treatment options are changing rapidly. From the studies assessed, autogenic drainage was not found to be superior to any other form of airway clearance technique. Larger studies are required to better evaluate autogenic drainage in comparison to other airway clearance techniques in view of the relatively small number of participants in this review and the complex study designs. The studies recruited a range of participants and were not powered to assess non-inferiority. The varied length and design of the studies made the analysis of pooled data challenging.

Effect of the Active Cycle of Breathing Technique on Perioperative Outcome in Individuals With Esophagectomy: A Quasi-Experimental Study

Background: The effect of active cycle of breathing technique (ACBT) on EC patients has not been well elucidated. In this research, we aim to explore the effect of ACBT on the perioperative outcomes in patients with esophageal carcinoma who underwent esophagectomy. Methods: Patients who underwent esophagectomy in an academic institution from December 2017 to July 2019 were included in this study. In a quasi-experimental study, participants were randomly divided into an experimental group (active cycle of breathing technique, n = 107) and an observational group (n = 106) by drawing lots. The chi-squared test, Cochran-Mantel-Haenszel test, Logistic regression analysis, and Kruskal-Wallis test were used to analyze data. A two-sided P value <0.05 was considered statistically significant. The primary observational endpoint was the mean weight of the sputum. Other outcomes included the six-min-walk test (6MWT), Borg scale, anastomotic leakage, and the length of hospital stay. Results: 95 patients underwent minimally invasive surgery, and 118 patients received open surgery. There were 16 patients with anastomotic leakage in the present study, and we found that patients in the observational group had higher odds of anastomotic leakage. The results showed that the mean weight of the sputum in the observation group was lighter than that of the experimental group. After esophagectomy, the experimental group had better outcomes than the observation group (Borg scale: 2.448 vs. 1.547; 6-MWT: 372.811 vs. 425.355m, all P < 0.05). The mean length of hospital stay was longer in the observation group (17.953 days) than that in the experimental group (12.037 days, P = 0.01). We also found that the observational group had a higher discharge ratio over 2 weeks in all cohort (adjusted OR 2.487, 95% confidence intervals 1.147-5.392, P = 0.021). Conclusion: Active cycle of breathing technique may improve the perioperative outcomes and decrease the length of hospital stay after surgery in patients with esophageal cancer. However, we need more researches to validate these findings.

Secretion management in patients with ineffective airway clearance with non-invasive mechanical ventilation use: Expert guidance for clinical practice

Non-invasive ventilation (NIV) is a mainstay of management of chronic respiratory failure in many disorders which are known to cause abnormal airway secretion clearance. Currently, there is no guidance regarding either the secretion handling during NIV use or the role of NIV in secretion management in these patients. The aim of this document was to provide an overview of the various techniques available in the management of respiratory secretions and their use in conjunction with NIV. Literature search was performed using the keywords, "(secretion OR secretions) AND (noninvasive ventilation OR NIV)" on PubMed and EMBASE. The search yielded 1681 and 509 titles from PubMed and EMBASE, respectively. After screening, 19 articles were included in this review. Suggestions of the expert panel were formulated by mutual consensus after reviewing the relevant literature. The draft of the expert panel's suggestions was circulated among all authors via electronic mail for comments. Any conflicts were resolved by mutual discussion to achieve agreement. The final document was approved by all. This document by the International Network for Airway Secretions Management in NIV describes various airway secretion clearance techniques. It provides the expert panel's suggestions for the use of these techniques in conjunction with NIV for patients with muco-obstructive and neuromuscular disorders.

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.

New insights into the mechanisms controlling the bronchial mucus balance

In this work, we aim to analyze and compare the mechanisms controlling the volume of mucus in the bronchial region of the lungs of a healthy human adult, at rest and in usual atmospheric conditions. This analysis is based on a balance equation for the mucus in an airway, completed by a computational tool aiming at characterizing the evaporation, during respiration, of the water contained in the bronchial mucus. An idealized representation of the lungs, based on Weibel’s morphometric model, is used. The results indicate that the mechanisms controlling the volume of mucus in an airway depend on the localization of the airway in the bronchial region of the lungs. In the proximal generations, the volume of mucus in an airway is mainly controlled by the evaporation of the water it contains and the replenishment, with water, of the mucus layer by epithelial cells or the submucosal glands. Nevertheless, cilia beating in this part of the bronchial region remains of fundamental importance to transport the mucus and hence to eliminate dust and pathogens trapped in it. On the other hand, in the distal generations of the bronchial region, the volume of mucus in an airway is mainly controlled by the mucociliary transport and by the absorption of liquid by the epithelium. This absorption is a consequence of the mucus displacement by the cilia along generations with an interface between the epithelium and the airway surface layer of decreasing area. The numerical results obtained are in good agreement with previously published experimental data, thus validating our approach. We also briefly discuss how our results can improve the understanding and, possibly, the treatment of pulmonary diseases.

Mechanical insufflation-exsufflation for airway clearance in adults with cystic fibrosis

In cystic fibrosis (CF), acute exacerbations can decrease the effectiveness of patients' usual airway clearance techniques (ACT). In order to maintain effective airway clearance and preserve lung function, these ACT must be adapted to prevent further dyspnoea and fatigue and improve ease of expectoration. Mechanical insufflation-exsufflation (MI-E) is widely used in neuromuscular disorders to facilitate airway clearance and augment cough but has rarely been used in CF despite potential indications. The NIPPY Clearway, an airway clearance device with multiple modes including MI-E, can be set to deliver multiple insufflations prior to a single exsufflation. We present two cases where this modified version of MI-E was used as an adjunct to traditional ACT in adults during an acute exacerbation of CF.

Airway Clearance Techniques for Primary Ciliary Dyskinesia; is the Cystic Fibrosis literature portable?

Primary Ciliary Dyskinesia (PCD) is a rare inherited disease with impaired mucociliary clearance. Airway clearance techniques (ACTs) are commonly recommended for patients with PCD to facilitate mucus clearance, despite a lack of evidence in this group. Current physiotherapy practice in PCD is based on evidence extrapolated from the field of Cystic Fibrosis (CF). This paper focuses on the available evidence and outlines challenges in extrapolating evidence between the conditions for best clinical practice.

Autogenic drainage for airway clearance in cystic fibrosis

BACKGROUND

Autogenic drainage is an airway clearance technique that was developed by Jean Chevaillier in 1967. The technique is characterised by breathing control using expiratory airflow to mobilise secretions from smaller to larger airways. Secretions are cleared independently by adjusting the depth and speed of respiration in a sequence of controlled breathing techniques during exhalation. The technique requires training, concentration and effort from the individual. It is important to systematically review the evidence demonstrating that autogenic drainage is an effective intervention for people with cystic fibrosis.

OBJECTIVES

To compare the clinical effectiveness of autogenic drainage in people with cystic fibrosis with other physiotherapy airway clearance techniques.

SEARCH METHODS

We searched the Cochrane Cystic Fibrosis Trials Register, compiled from electronic database searches and handsearching of journals and conference abstract books. We also searched the reference lists of relevant articles and reviews, as well as two trials registers (31 August 2017).Dtae of most recent search of the Cochrane Cystic Fibrosis Trials Register: 25 September 2017.

SELECTION CRITERIA

We identified randomised and quasi-randomised controlled studies comparing autogenic drainage to another airway clearance technique or no therapy in people with cystic fibrosis for at least two treatment sessions.

DATA COLLECTION AND ANALYSIS

Data extraction and assessments of risk of bias were independently performed by two authors. The authors assessed the quality of the evidence using the GRADE system. The authors contacted two investigators for further information pertinent to their published studies.

MAIN RESULTS

Searches retrieved 35 references to 21 individual studies, of which seven (n = 208) were eligible for inclusion. One study was of parallel design with the remaining six being cross-over in design; participant numbers ranged from 17 to 75. The total study duration varied between four days and two years. The age of participants ranged between seven and 63 years with a wide range of disease severity reported. Six studies enrolled participants who were clinically stable, whilst participants in one study had been hospitalised with an infective exacerbation. All studies compared autogenic drainage to one (or more) other recognised airway clearance technique. Exercise is commonly used as an alternative therapy by people with cystic fibrosis; however, there were no studies identified comparing exercise with autogenic drainage.The quality of the evidence was generally low or very low. The main reasons for downgrading the level of evidence were the frequent use of a cross-over design, outcome reporting bias and the inability to blind participants.The review's primary outcome, forced expiratory volume in one second, was the most common outcome measured and was reported by all seven studies; only three studies reported on quality of life (also a primary outcome of the review). One study reported on adverse events and described a decrease in oxygen saturation levels whilst performing active cycle of breathing techniques, but not with autogenic drainage. Six of the seven included studies measured forced vital capacity and three of the studies used mid peak expiratory flow (per cent predicted) as an outcome. Six studies reported sputum weight. Less commonly used outcomes included oxygen saturation levels, personal preference, hospital admissions or intravenous antibiotics. There were no statistically significant differences found between any of the techniques used with respect to the outcomes measured except when autogenic drainage was described as being the preferred technique of the participants in one study over postural drainage and percussion.

AUTHORS' CONCLUSIONS

Autogenic drainage is a challenging technique that requires commitment from the individual. As such, this intervention merits systematic review to ensure its effectiveness for people with cystic fibrosis. From the studies assessed, autogenic drainage was not found to be superior to any other form of airway clearance technique. Larger studies are required to better evaluate autogenic drainage in comparison to other airway clearance techniques in view of the relatively small number of participants in this review and the complex study designs. The studies recruited a range of participants and were not powered to assess non-inferiority. The varied length and design of the studies made the analysis of pooled data challenging.

Autogenic Drainage in Children With Cystic Fibrosis

PURPOSE

Airway clearance is an essential part of the management of cystic fibrosis (CF) as it facilitates clearance of viscous pulmonary secretions. This review aimed to determine the effect of autogenic drainage (AD) and assisted autogenic drainage (AAD) compared with no, sham, or other types of airway clearance in children with CF.

SUMMARY OF KEY POINTS

Two pediatric randomized cross-over trials were identified on the use of AD in children with CF; no studies were available on the use of AAD. In one study AD had a positive influence on the Huang score, and is preferred over postural drainage in this population.

CONCLUSIONS AND RECOMMENDATIONS

We could not determine the efficacy of AD and AAD in children with CF. We recommend the implementation of pediatric-specific randomized controlled trials with adequate sample sizes, appropriate clinical outcome measures, and analysis of adverse effects.

Effects of Autogenic Drainage on Sputum Recovery and Pulmonary Function in People with Cystic Fibrosis: A Systematic Review

PURPOSE

To determine the effects of short- and long-term use of autogenic drainage (AD) on pulmonary function and sputum recovery in people with cystic fibrosis (CF).

METHODS

The authors conducted a systematic review of randomized and quasi-randomized clinical trials in which participants were people with CF who use AD as their sole airway clearance technique.

RESULTS

Searches in 4 databases and secondary sources using 5 key terms yielded 735 articles, of which 58 contained the terms autogenic drainage and cystic fibrosis. Ultimately, 4 studies, 2 of which were long term, were included. All measured forced expiratory volume in 1 second (FEV1) and found no change. The long-term studies were underpowered to detect change in FEV1; however, the short-term studies found a clinically significant sputum yield (≥4 g).

CONCLUSION

AD has been shown to produce clinically significant sputum yields in a limited number of investigations. The effect of AD on the function of the pulmonary system remains uncertain, and questions have emerged regarding the appropriateness of FEV1 as a valid measure of airway clearance from peripheral lung regions. Further consideration should be given to the use of FEV1 as a primary measure of the effect of AD.

Active cycle of breathing technique for cystic fibrosis

BACKGROUND

People with cystic fibrosis experience chronic airway infections as a result of mucus build up within the lungs. Repeated infections often cause lung damage and disease. Airway clearance therapies aim to improve mucus clearance, increase sputum production, and improve airway function. The active cycle of breathing technique (also known as ACBT) is an airway clearance method that uses a cycle of techniques to loosen airway secretions including breathing control, thoracic expansion exercises, and the forced expiration technique. This is an update of a previously published review.

OBJECTIVES

To compare the clinical effectiveness of the active cycle of breathing technique with other airway clearance therapies in cystic fibrosis.

SEARCH METHODS

We searched the Cochrane Cystic Fibrosis Trials Register, compiled from electronic database searches and handsearching of journals and conference abstract books. We also searched the reference lists of relevant articles and reviews.Date of last search: 25 April 2016.

SELECTION CRITERIA

Randomised or quasi-randomised controlled clinical studies, including cross-over studies, comparing the active cycle of breathing technique with other airway clearance therapies in cystic fibrosis.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened each article, abstracted data and assessed the risk of bias of each study.

MAIN RESULTS

Our search identified 62 studies, of which 19 (440 participants) met the inclusion criteria. Five randomised controlled studies (192 participants) were included in the meta-analysis; three were of cross-over design. The 14 remaining studies were cross-over studies with inadequate reports for complete assessment. The study size ranged from seven to 65 participants. The age of the participants ranged from six to 63 years (mean age 22.33 years). In 13 studies, follow up lasted a single day. However, there were two long-term randomised controlled studies with follow up of one to three years. Most of the studies did not report on key quality items, and therefore, have an unclear risk of bias in terms of random sequence generation, allocation concealment, and outcome assessor blinding. Due to the nature of the intervention, none of the studies blinded participants or the personnel applying the interventions. However, most of the studies reported on all planned outcomes, had adequate follow up, assessed compliance, and used an intention-to-treat analysis.Included studies compared the active cycle of breathing technique with autogenic drainage, airway oscillating devices, high frequency chest compression devices, conventional chest physiotherapy, and positive expiratory pressure. Preference of technique varied: more participants preferred autogenic drainage over the active cycle of breathing technique; more preferred the active cycle of breathing technique over airway oscillating devices; and more were comfortable with the active cycle of breathing technique versus high frequency chest compression. No significant difference was seen in quality of life, sputum weight, exercise tolerance, lung function, or oxygen saturation between the active cycle of breathing technique and autogenic drainage or between the active cycle of breathing technique and airway oscillating devices. There was no significant difference in lung function and the number of pulmonary exacerbations between the active cycle of breathing technique alone or in conjunction with conventional chest physiotherapy. All other outcomes were either not measured or had insufficient data for analysis.

AUTHORS' CONCLUSIONS

There is insufficient evidence to support or reject the use of the active cycle of breathing technique over any other airway clearance therapy. Five studies, with data from eight different comparators, found that the active cycle of breathing technique was comparable with other therapies in outcomes such as participant preference, quality of life, exercise tolerance, lung function, sputum weight, oxygen saturation, and number of pulmonary exacerbations. Longer-term studies are needed to more adequately assess the effects of the active cycle of breathing technique on outcomes important for people with cystic fibrosis such as quality of life and preference.

Physiotherapy for cystic fibrosis in Australia and New Zealand: A clinical practice guideline

Physiotherapy management is a key element of care for people with cystic fibrosis (CF) throughout the lifespan. Although considerable evidence exists to support physiotherapy management of CF, there is documented variation in practice. The aim of this guideline is to optimize the physiotherapy management of people with CF in Australia and New Zealand. A systematic review of the literature in key areas of physiotherapy practice for CF was undertaken. Recommendations were formulated based on National Health and Medical Research Council (Australia) guidelines and considered the quality, quantity and level of the evidence; the consistency of the body of evidence; the likely clinical impact; and applicability to physiotherapy practice in Australia and New Zealand. A total of 30 recommendations were made for airway clearance therapy, inhalation therapy, exercise assessment and training, musculoskeletal management, management of urinary incontinence, managing the newly diagnosed patient with CF, delivery of non-invasive ventilation, and physiotherapy management before and after lung transplantation. These recommendations can be used to underpin the provision of evidence-based physiotherapy care to people with CF in Australia and New Zealand.

[Manual airway clearance techniques in adults and adolescents: What level of evidence?]

BACKGROUND

The aim of this systematic literature review was to grade the levels of evidence of the most widely used manual airway clearance techniques.

METHODS

A literature search was conducted over the period 1995-2014 from the Medline, PEDro, ScienceDirect, Cochrane Library, REEDOC and kinedoc databases, with the following keywords: "postural drainage", "manual vibrations", "manual chest percussion", "directed cough", "increased expiratory flow", "ELTGOL", "autogenic drainage" and "active cycle of breathing technique".

RESULTS

Two-hundred and fifty-six articles were identified. After removing duplicates and reading the titles and abstracts, 63 articles were selected, including 9 systematic reviews. This work highlights the lack of useful scientific data and the difficulty of determining levels of evidence for manual airway clearance techniques. Techniques were assessed principally with patients with sputum production (cystic fibrosis, DDB, COPD, etc.). It also shows the limited pertinence of outcome measures to quantify congestion and hence the efficacy of airway clearance techniques.

CONCLUSION

The 1994 consensus conference summary table classifying airway clearance techniques according to physical mechanism provides an interesting tool for assessment, grouping together techniques having identical mechanisms of action. From the findings of the present systematic review, it appears that only ELTGOL, autogenic drainage and ACBT present levels of evidence "B". All other techniques have lower levels of evidence.

LEVEL OF EVIDENCE

II.

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.

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.

Structure and function of the mucus clearance system of the lung

In cystic fibrosis (CF), a defect in ion transport results in thick and dehydrated airway mucus, which is difficult to clear, making such patients prone to chronic inflammation and bacterial infections. Physiotherapy using a variety of airway clearance techniques (ACTs) represents a key treatment regime by helping clear the airways of thickened, adhered, mucus and, thus, reducing the impact of lung infections and improving lung function. This article aims to bridge the gap between our understanding of the physiological effects of mechanical stresses elicited by ACTs on airway epithelia and the reported effectiveness of ACTs in CF patients. In the first part of this review, the effects of mechanical stress on airway epithelia are discussed in relation to changes in ion transport and stimulation in airway surface layer hydration. The second half is devoted to detailing the most commonly used ACTs to stimulate the removal of mucus from the airways of patients with CF.

Active cycle of breathing technique for cystic fibrosis

BACKGROUND

People with cystic fibrosis experience chronic airway infections as a result of mucus build up within the lungs. Repeated infections often cause lung damage and disease. Airway clearance therapies aim to improve mucus clearance, increase sputum production, and improve airway function. The active cycle of breathing technique (ACBT) is an airway clearance method that uses a cycle of techniques to loosen airway secretions including breathing control, thoracic expansion exercises, and the forced expiration technique.

OBJECTIVES

To compare the clinical effectiveness of ACBT with other airway clearance therapies in cystic fibrosis.

SEARCH METHODS

We searched the Cochrane Cystic Fibrosis Trials Register, compiled from electronic database searches and handsearching of journals and conference abstract books. We also searched the reference lists of relevant articles and reviews.Date of last search: 02 August 2012.

SELECTION CRITERIA

Randomised or quasi-randomised controlled clinical studies, including cross-over studies, comparing ACBT with other airway clearance therapies in cystic fibrosis.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened each article, abstracted data and assessed the risk of bias of each study.

MAIN RESULTS

Sixty studies were identified of which 18 (375 participants) met the inclusion criteria. Five randomised controlled studies (127 participants) were included in the meta-analysis; four were of cross-over design. The 13 remaining studies were cross-over studies with inadequate reports for complete assessment.Included studies compared ACBT to autogenic drainage, airway oscillating devices, high frequency chest compression devices, conventional chest physiotherapy, and positive expiratory pressure. Patient preference varied: more patients preferred autogenic drainage over ACBT; more preferred ACBT over airway oscillating devices; and more were comfortable with ACBT versus high frequency chest compression. No significant difference was seen in sputum weight, lung function, or oxygen saturation between ACBT and autogenic drainage or between ACBT and airway oscillating devices. There was no significant difference in lung function and the number of pulmonary exacerbations between ACBT and ACBT plus conventional chest physiotherapy. All other outcomes were either not measured or had insufficient data for analysis.

AUTHORS' CONCLUSIONS

There is insufficient evidence to support or reject the use of ACBT over any other airway clearance therapy. Five studies, with five different comparators, found that ACBT was comparable to other therapies in outcomes such as patient preference, lung function, sputum weight, oxygen saturation, and number of pulmonary exacerbations. Longer-term studies are needed to more adequately assess the effects of ACBT on outcomes important for patients such as quality of life and patient preference.

The active cycle of breathing technique: a systematic review and meta-analysis

QUESTION

What is the best available research evidence (volume, quality, consistency, generalisability) for the active cycle of breathing technique (ACBT)?

DESIGN

Systematic review with meta-analysis.

PARTICIPANTS

Participants with respiratory conditions characterised by chronic sputum production.

INTERVENTION

The active cycle of breathing or forced expiratory technique. COMPARATOR: All comparators including control conditions.

OUTCOME MEASURES

All outcomes providing continuous data.

RESULTS

Twenty-four studies were included. Ten comparators were identified with the most common being conventional chest physiotherapy, positive expiratory pressure and a control. The outcomes most frequently assessed were sputum wet weight (n = 17), forced vital capacity (n = 12) and forced expiratory volume in 1 s (n = 12). Meta-analysis was completed on the primary outcome of sputum wet weight. The standardised mean difference (SMD, random effects) showed an increase in sputum wet weight during and up to 1 h post ACBT compared to conventional physiotherapy (SMD 0.32, 95%CI 0.05-0.59), external oscillatory devices (0.75, 0.48-1.02), and control (0.24, 0.02-0.46).

CONCLUSION

The overall body of evidence was classified as good (good volume, quality and consistency, excellent generalisability). High level, variable risk of bias research evidence favours ACBT over most alternatives for short-term improvements in secretion clearance.

Health-related quality of life in cystic fibrosis

PURPOSE OF REVIEW

To review the contribution of various therapeutic interventions on both longevity and quality of life in cystic fibrosis patients.

RECENT FINDINGS

Long-term survival in cystic fibrosis has increased markedly in the past 25 years, largely due to a robust clinical trials program carried out at Cystic Fibrosis Foundation accredited clinical centers in the United States and similar organizations worldwide. Cystic fibrosis patients are recommended complex, time-intensive daily therapies that are often difficult for families and patients to sustain long-term. Recently, attention to the perceived value of a particular therapy on a patient's well being is recognized as important for individualizing therapeutic regimens that provide maximal clinical benefit and are more likely to be adhered to long-term by the patient. Cystic fibrosis care is in a new era in which patient-related outcomes (PROs) for the assessment of health-related quality of life (HRQOL) are regarded with equal importance to medically beneficial therapies.

SUMMARY

Numerous advances in the clinical care of cystic fibrosis have led to improved survival, although definitive correction of the abnormal cystic fibrosis transmembrane regulator protein function remains elusive. Patients struggle to maintain rigorous, time-intensive therapeutic regimens, whereas clinicians strive to identify which interventions preserve quality of life. Cystic fibrosis patients depend on their caregiver's ability to assess both the medical benefit and the contribution to quality of life that therapeutic regimes bring to their disease. Caregivers, in turn, need measures of HRQOL in order to prioritize the various therapeutic interventions that are at their disposal in order to provide not just longevity, but meaningful quality of life.

Evaluation of a novel sputum clearance technique--hydro-acoustic therapy (HAT) in adult patients with cystic fibrosis: a feasibility study

This study was designed to investigate the efficacy, safety and patients' acceptance of a novel system for sputum clearance--Hydro Acoustic Therapy (HAT) in patients with cystic fibrosis (CF). This is a prospective crossover study where 18 patients received 6 sessions of physiotherapy over 6 separate days. These consisted of 2 sessions of either HAT, flutter valve or and sitting in the bath with sounds without vibration (placebo) for 30 minutes each. The efficacy was investigated by measuring the weight of wet and dry sputum after each session and by change in spirometry values. The preference was assessed by a questionnaire completed by patients at the end of the study about their preference of which type of physiotherapy received. The weight of both dry and wet sputum produced was similar in the 3 arms of the study. Spirometry values but not oxygen saturation were reduced after HAT and flutter therapy sessions. HAT therapy was preferred to flutter and placebo in terms of breathlessness, ease of sputum production and relaxation. Of the patients, 70% stated that they would choose HAT as their preferred physiotherapy method compared to 0% for flutter (χ(2) = 20.3, p < 0.0001). There were no procedure-related complications in any of the 3 arms of the study. HAT was found to be safe, well tolerated and favoured by the majority of CF patients. The effect of HAT, however, on sputum production was not superior to flutter or placebo.

Physiotherapeutic management strategies for the treatment of cystic fibrosis in adults

Physiotherapy has long been considered a cornerstone of condition management for people with cystic fibrosis (CF). The presentation of CF has changed over time with an increased life expectancy and increased expectations of people with CF to have a complete lifestyle. In turn, the scope of strategies used in physiotherapy for CF have also changed dramatically over the years, moving away from routine postural drainage and manual techniques toward an individualized regimen including the choice of many different forms of airway clearance, such as both independent and assisted, exercise, treatments to promote continence and good posture, inhalation therapy, oxygen, and noninvasive ventilation. This article describes the techniques and overall strategies used by physiotherapists in helping people with CF to manage the symptoms and progression of their condition.

Active cycle of breathing technique for cystic fibrosis

BACKGROUND

People with cystic fibrosis (CF) experience chronic airway infections as a result of mucus build up within the lungs. Repeated infections often cause lung damage and disease. Airway clearance therapies aim to improve mucus clearance, increase sputum production, and improve airway function. The active cycle of breathing technique (ACBT) is an airway clearance method that uses a cycle of techniques to loosen airway secretions including breathing control, thoracic expansion exercises, and the forced expiration technique.

OBJECTIVES

To compare the clinical effectiveness of ACBT with other airway clearance therapies in CF.

SEARCH STRATEGY

We searched the Cochrane CF Trials Register, compiled from electronic database searches and handsearching of journals and conference abstract books. We also searched the reference lists of relevant articles and reviews.Last search: 05 August 2010.

SELECTION CRITERIA

Randomised or quasi-randomised controlled clinical studies, including crossover studies, comparing ACBT with other airway clearance therapies in CF.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened each article, abstracted data and assessed the risk of bias of each study.

MAIN RESULTS

Fifty-eight studies were identified of which 17 (346 participants) met the inclusion criteria. Four randomised controlled studies (98 participants) were included in the meta-analysis; three were of crossover design. The 13 remaining studies were crossover studies with inadequate reports for complete assessment.Included studies compared ACBT to autogenic drainage, airway oscillating devices, high frequency chest compression devices, and conventional chest physiotherapy. Patient preference varied: more patients preferred autogenic drainage over ACBT, more preferred ACBT over airway oscillating devices, and more were comfortable with ACBT versus high frequency chest compression. No significant difference was seen in sputum weight between ACBT and autogenic drainage or between ACBT and airway oscillating devices. There was no significant difference in lung function and the number of pulmonary exacerbations between ACBT and ACBT plus conventional chest physiotherapy. All other outcomes were either not measured or had insufficient data for analysis.

AUTHORS' CONCLUSIONS

There is insufficient evidence to support or reject the use of ACBT over any other airway clearance therapy. Four studies, with four different comparators, found that ACBT was comparable to other therapies in outcomes such as patient preference, lung function, sputum weight, oxygen saturation, and number of pulmonary exacerbations. Longer-term studies are needed to more adequately assess the effects of ACBT on outcomes important for patients such as quality of life and patient preference.

Long-term comparative trial of two different physiotherapy techniques; postural drainage with percussion and autogenic drainage, in the treatment of cystic fibrosis

In N. America, over the past decade, various airway clearance techniques (ACT) have been introduced for the treatment of cystic fibrosis (CF). We hypothesized that autogenic drainage (AD), an ACT developed in Belgium would be as effective as postural drainage with percussion (PD) in treating patients with CF.

METHODS

Thirty-six CF patients, aged 12-18 years, with Shwachman score 65-98, were enrolled in a 2-year cross-over trial. Patients were matched as pairs and members of each pair were randomly assigned to two groups. For the first study year, Group A performed PD while Group B performed AD. At the end of 1 year Groups A and B crossed over physiotherapy techniques. Clinical status and pulmonary function (FVC, FEV(1), FEF(25-75)) were measured at 3 monthly intervals. Only results from the first year of the study are reported, as 10 out of 17 patients who had completed performing AD for the first year refused to change back to PD for the second year.

RESULTS

During the first year of the study, both the AD and PD groups demonstrated improved pulmonary function with no significant difference between the two groups. Change in FVC and FEV(1) percent predicted for Groups A and B was 0.47 ± 1.65(se) versus 2.35 ± 1.51(se) and 2.09 ± 2.2(se) versus 0.92 ± 2.25(se). However, CF patients exhibited a marked preference for the AD technique. Results suggest that both AD and PD are effective methods of performing physiotherapy for CF patients and that the benefits of either technique are enhanced by measures which encourage adherence.

Chest physiotherapy in cystic fibrosis: short-term effects of autogenic drainage preceded by wet inhalation of saline versus autogenic drainage preceded by intrapulmonary percussive ventilation with saline

BACKGROUND

Chest physiotherapy has been used for many years to assist in the removal of abnormal viscid bronchial secretions in cystic fibrosis (CF) patients.

OBJECTIVES

This study compared the short-term effects of two physiotherapy regimens in patients with CF: autogenic drainage (AD) preceded by either saline inhalation ('saline(NEB) + AD') or by intrapulmonary percussive ventilation (IPV) with saline ('saline(IPV) + AD').

METHODS

In a randomized crossover design, 20 clinically stable CF patients with similar pulmonary function at baseline received either 'saline(NEB) + AD' or 'saline(IPV) + AD' on 2 consecutive days. Transcutaneous oxygen saturation, heart rate, Borg dyspnea score and mucus wet weight were evaluated after 15 min of either saline(NEB) or saline(IPV), and after a subsequent 30 min of AD.

RESULTS

There were no significant changes in oxygen saturation, heart rate or Borg score at any point of either physiotherapy intervention. There was no significant difference in sputum wet weight recovered with either saline(NEB) (2.2 +/- 1.8 g, mean +/- SD) or saline(IPV) (1.7 +/- 1.9 g) alone. Subsequent AD did produce significantly greater amounts of sputum wet weight (p < 0.0001 for both) than in the initial saline delivery period, yet the amount of wet weight was similar irrespective of whether AD was preceded by saline(NEB) (9.7 +/- 6.5 g) or saline(IPV) (11.6 +/- 7.3 g).

CONCLUSIONS

Recovered sputum weight is similar whether AD is preceded by saline(NEB) or saline(IPV). The much greater amount of mucus obtained during the AD period than during the saline delivery period warrants further investigation.

Chest physical therapy, breathing techniques and exercise in children with CF

Chest physiotherapy in the form of airway clearance techniques and exercise has played an important role in the treatment of cystic fibrosis. Until the 1990s the primary airway clearance technique used was postural drainage combined with percussion and vibration (PD&P). It was introduced into the treatment of CF with little evidence to support its efficacy and once established, it has been difficult ethically to perform a study comparing PD&P to no treatment. A common question, yet unanswered is when should it be commenced, especially for the newly diagnosed asymptomatic CF patient? Recently, the technique of PD&P has been modified to include only non-dependant head-down positioning due to the detrimental effects of placing a person in a Trendelenburg position. In the 1990s other airway clearance techniques gained popularity, in that they could be performed independently, in a sitting position and avoided many of the detrimental effects of PD&P. These techniques include the Active cycle of breathing technique, formally called the Forced expiration technique and Autogenic drainage. Both these breathing techniques aim at using expiratory airflow to mobilize secretions up the airways and incorporate breathing strategies to assist in the homogeneity of ventilation. Studies suggest that both these techniques are as effective if not more effective than as PD&P and offer many advantages over PD&P. It has been suggested that exercise can be used as an airway clearance technique; however the literature does not support this. Rather, when exercise is used in addition to an airway clearance technique there is enhanced secretion removal and an overall benefit to the patient. Further research needs to be directed at assessing the effects of an airway clearance technique on the individual patient using appropriate outcome measures.

Nonpharmacologic airway clearance therapies: ACCP evidence-based clinical practice guidelines

BACKGROUND

Airway clearance may be impaired in disorders associated with abnormal cough mechanics, altered mucus rheology, altered mucociliary clearance, or structural airway defects. A variety of interventions are used to enhance airway clearance with the goal of improving lung mechanics and gas exchange, and preventing atelectasis and infection.

METHOD

A formal systematic review of nonpharmacologic protussive therapies was performed and constitutes the basis for this section of the guideline. In addition, the articles reviewed were found using the same methodology but were not limited to those that focused only on cough as a symptom. The MEDLINE database was searched for this review and consisted of studies published in the English language between 1960 and April 2004. The search terms used were "chest physiotherapy," "forced expiratory technique," "positive expiratory pressure," "high frequency chest compression," "insufflation," and "exsufflation."

RESULTS

In general, studies of nonpharmacologic methods of improving cough clearance are limited by methodological constraints, and most were conducted only in patients with cystic fibrosis. Chest physiotherapy, including postural drainage, chest wall percussion and vibration, and a forced expiration technique (called huffing), increase airway clearance as assessed by sputum characteristics (ie, volume, weight, and viscosity) and clearance of the radioaerosol from the lung, but the long-term efficacy of these techniques compared with unassisted cough alone is unknown. Other devices that allow patients to achieve the same benefits derived from chest physiotherapy without the assistance of a caregiver appear to be as effective as chest physiotherapy in increasing sputum production.

CONCLUSIONS

Some nonpharmacologic therapies are effective in increasing sputum production, but their long-term efficacy in improving outcomes compared with unassisted cough alone is unknown.

Change in physiotherapy management of children with cystic fibrosis in a large urban hospital

A retrospective audit was conducted in 1998 and 2000 to review the physiotherapy management of hospitalized children with cystic fibrosis (CF) at the Brisbane Royal Children's Hospital (RCH). The objective was to detect and explore possible changes in patient management in this time period and investigate whether these changes reflected changes in the current theory of CF management. All children over two years of age with CF admitted during 1998 and 2000 with pulmonary manifestation and who satisfied set criteria were included (n = 249). Relative frequency of each of six treatment modalities used were examined on two occasions, revealing some degree of change in practice reflecting the changes in current theory. There was a significant decrease in the frequency of usage of postural drainage with head-down tilt (p < 0.001), and autogenic drainage (p < 0.001) between 1998 and 2000. Modified postural drainage without head-down tilt (p < 0.001), and positive expiratory pressure devices (p < 0.001) were used more frequently in 2000 (p < 0.001). No significant changes were identified in the use of Flutter VRP1 (p = 0.145) and exercise (p = 0.763). No significant differences were found in population demographics or occurrence of concomitant factors that may influence patient management.

Non-invasive ventilation assists chest physiotherapy in adults with acute exacerbations of cystic fibrosis

BACKGROUND

Chest physiotherapy is essential to the management of cystic fibrosis (CF). However, respiratory muscle fatigue and oxygen desaturation during treatment have been reported. The aim of this study was to determine whether non-invasive ventilation (NIV) during chest physiotherapy could prevent these adverse effects in adults with exacerbations of CF.

METHODS

Twenty six patients of mean (SD) age 27 (6) years and forced expiratory volume in 1 second (FEV1) 34 (12)% predicted completed a randomised crossover trial comparing standard treatment (active cycle of breathing technique, ACBT) with ACBT + NIV. Respiratory muscle strength (PImax, PEmax), spirometric parameters, and dyspnoea were measured before and after treatment. Pulse oximetry (SpO2) was recorded during treatment. Sputum production during treatment and 4 and 24 hours after treatment was evaluated.

RESULTS

There was a significant reduction in PImax following standard treatment that was correlated with baseline PImax (r=0.73, p<0.001). PImax was maintained following NIV (mean difference from standard treatment 9.04 cm H2O, 95% confidence interval (CI) 4.25 to 13.83 cm H2O, p=0.006). A significant increase in PEmax was observed following the NIV session (8.04 cm H2O, 95% CI 0.61 to 15.46 cm H2O, p=0.02). The proportion of treatment time with SpO2 < or =90% was correlated with FEV1 (r=-0.65, p<0.001). NIV improved mean SpO2 (p<0.001) and reduced dyspnoea (p=0.02). There were no differences in FEV1, forced vital capacity (FVC) or sputum weight, but FEF(25-75) increased following NIV (p=0.006).

CONCLUSION

Reduced inspiratory muscle strength and oxygen desaturation during chest physiotherapy are associated with inspiratory muscle weakness and severity of lung disease in adults with exacerbations of CF. Addition of NIV improves inspiratory muscle function, oxygen saturation and small airway function and reduces dyspnoea.

Prevalence of urinary incontinence in women with cystic fibrosis

OBJECTIVE

To determine the prevalence of urinary incontinence (UI) in female patients (aged > or = 15 years) attending a cystic fibrosis (CF) centre, in whom stress UI could be common, as chronic coughing and sputum production are frequent symptoms associated with progressive lung disease in these patients.

PATIENTS AND METHODS

An anonymous questionnaire was completed by 176 women with CF (mean age 24.6 years, SD 5.8) during routine assessments as outpatients.

RESULTS

In all, 72 patients (41%) were classified as never incontinent; occasional UI was reported in 61 women (35%). Regular UI, occurring twice or more a month for at least two consecutive months in the last year, was reported in 43 patients (24%). Regular UI was associated with increasing age and a lower mean (SD) forced expiratory volume/s (of that predicted) than in women with no urinary symptoms, at 26.9 (6.5) years and 53.5 (23.5)%, and 23.1 (5.4) years and 65.5 (23.2)%, respectively (P < 0.01 and P < 0.05, respectively). All incontinent women recorded stress UI; coughing, laughing and physical activity were associated with UI in 92%, 33% and 21% of the patients, respectively.

CONCLUSION

Stress UI is a common symptom in women with CF. As urine loss can be under-reported to the healthcare providers, women should be asked about incontinence as part of their routine follow-up. Pelvic floor muscle exercises are effective in treating stress UI and should be considered for those with CF and regular UI.

Regional mucociliary clearance in patients with cystic fibrosis

This paper reports on a large retrospective analysis of mucociliary clearance (MCC) studies in a group of 59 patients with cystic fibrosis (CF) and 17 age-matched healthy subjects. As many of the CF patients were studied on multiple occasions, a total of 184 patient studies are presented. MCC was measured using a radioaerosol and gamma camera technique. In addition to whole lung clearance, MCC was measured from the central, intermediate, peripheral, basal, mid and apical regions of the lung. MCC was markedly decreased in the CF patient group. Not only was whole lung clearance (14.2 +/- 1.4% vs. 28.0 +/- 3.7%) impaired, but also clearance from the central (19.1 +/- 1.9% vs. 35.6 +/- 4.3%), intermediate (10.7 +/- 1.6% vs. 25.5 +/- 3.7%), apical (12.4 +/- 2.6% vs. 31.6 +/- 4.6%) and mid (14.0 +/- 1.9% vs. 30.4 +/- 4.0%) regions. Attempts were made to identify factors that may have influenced MCC in both the normal subjects and CF patients. Age, gender, body mass index, patient genotype, penetration index, spontaneous cough, and various lung function parameters were entered into a stepwise multiple regression model, but none of the factors proved to be statistically important in determining MCC. Both intrasubject repeatability and intersubject variability estimates are presented for the patients and normal subjects that had multiple studies. The values were found to be remarkably similar for both CF patients and normal subjects and for both intra- and intersubject repeatability. With marked deviation from normal ranges and good repeatability, the measurement of MCC in CF patients would seem to be a valuable outcome measure for clinical trials involving new pharmaceuticals and physical therapy designed to improve removal of secretions from the airways.

Chest physiotherapy compared to no chest physiotherapy for cystic fibrosis

BACKGROUND

Chest physiotherapy is widely used in patients 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 STRATEGY

Relevant trials are identified in the Cochrane Cystic Fibrosis and Genetic Disorders Group Specialised Register of Controlled Trials. This register was compiled by conducting computerised searches of Medline from 1966 to present and from Embase from 1974 to 1995. The register of randomised controlled trials is updated every three months. Unpublished work has been identified by searching through the abstract books of the three major cystic fibrosis conferences; the International Cystic Fibrosis Conference: the European Cystic Fibrosis Conference and the North American Cystic Fibrosis Conference. Date of the most recent search of the Group's specialised register: November 1999.

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

There were no randomised controlled trials or cross over trials eligible for inclusion in the review.

MAIN RESULTS

There were no randomised controlled trials or cross over trials eligible for inclusion in the review.

REVIEWER'S CONCLUSIONS

Short-term crossover trials, which had to be excluded from this review, suggest that airway clearance regimens could have beneficial effects in patients with cystic fibrosis. However based on this review there is currently no robust scientific evidence to support the hypothesis that chest physiotherapy for the purpose of clearing airway secretions has a beneficial effect in patients with cystic fibrosis.

A comparison of autogenic drainage and the active cycle of breathing techniques in patients with chronic obstructive pulmonary diseases

PURPOSE

The effects of a long-term treatment of autogenic drainage (AD) and the active cycle of breathing techniques (ACBT) were evaluated in patients with chronic obstructive pulmonary disease (COPD).

METHODS

Thirty clinically stable male COPD patients were randomly assigned to AD or the ACBT treatment for a 20-day treatment period. Patients were assessed through pulmonary function tests, arterial blood gases, a 6-minute walking test, and a modified Borg Scale before, and immediately after the walking test.

RESULTS

Autogenic drainage improved forced vital capacity, forced expiratory volume in 1 second, peak expiratory flow rate, forced expiratory volume from 25 to 75%, chronic hypercapnia, arterial oxygenation, exercise performance, and dyspnea perception during exercise. The ACBT increased forced vital capacity, peak expiratory flow rate, arterial oxygenation and exercise performance. Peak expiratory flow rate increased in AD more than in ACBT. In AD treatment, the increase in oxygen saturation was significantly higher than in ACBT treatment. Chronic hypercapnia improved significantly in AD treatment than in ACBT. No differences were found in other lung function parameters.

CONCLUSIONS

Autogenic drainage is as effective as the ACBT in cleaning secretions and improving lung functions. These techniques can be used in stable COPD patients according to the patients' and the physiotherapists' preferences.

Chest physiotherapy in cystic fibrosis: improved tolerance with nasal pressure support ventilation

OBJECTIVE

Chest physiotherapy (CPT) is an integral part of the treatment of patients with cystic fibrosis (CF). CPT imposes additional respiratory work that may carry a risk of respiratory muscle fatigue. Inspiratory pressure support ventilation (PSV) is a new mode of ventilatory assistance designed to maintain a constant preset positive airway pressure during spontaneous inspiration with the goal of decreasing the patient's inspiratory work. The aim of our study was 1) to evaluate respiratory muscle fatigue and oxygen desaturation during CPT and 2) to determine whether noninvasive PSV can relieve these potential adverse effects of CPT.

METHODS

Sixteen CF patients in stable condition with a mean age of 13 +/- 4 years participated to the study. For CPT, we used the forced expiratory technique (FET), which consisted of one or more slow active expirations starting near the total lung capacity (TLC) and ending near the residual volume. After each expiration, the child was asked to perform a slow, nonmaximal, diaphragmatic inspiration. After one to four forced breathing cycles, the child was asked to cough and to expectorate. A typical 20-minute CPT session consisted of 10 to 15 FET maneuvers separated by rest periods of 10 to 20 breathing cycles each. During the study, each patient received two CPT sessions in random order on two different days, at the same time of day, with the same physiotherapist. During one of these two sessions, PSV was provided throughout the session (PSV session) via a nasal mask using the pressure support generator ARM25 designed for acute patients (TAEMA, Antony, France). The control session was performed with no nasal mask or PSV. Both CPT sessions were performed without supplemental oxygen. Lung function and maximal inspiratory pressures (PImax) and expiratory pressures (PEmax) were recorded before and after each CPT session.

RESULTS

Mean lung function parameters were comparable before the PSV and the control sessions. Baseline pulse oximetry (SpO2) was significantly correlated with the baseline vital capacity (% predicted) and forced expiratory volume in 1 second (FEV1) (% predicted). PSV was associated with an increase in tidal volume (Vt) from 0.42 +/- 0.01 liters to 1.0 +/- 0.02 liters. Respiratory rate was significantly lower during PSV. SpO2 between the FET maneuvers was significantly higher during PSV as compared with the control session. SpO2 decreases after FET were significantly larger during the control session (nadir: 91.8 +/- 0. 7%) than during the PSV session (93.8 +/- 0.6%). Maximal pressures decreased during the control session (from 71.9 +/- 6.1 to 60.9 +/- 5.3 cmH2O, and from 85.3 +/- 7.9 to 77.5 +/- 4.8 cmH2O, for PImax and PEmax, respectively) and increased during the PSV session (from 71.6 +/- 8.6 to 83.9 +/- 8.7 cmH2O, and from 80.4 +/- 7.8 to 88.0 +/- 7.4 cmH2O, for PImax and PEmax, respectively). The decrease in PEmax was significantly correlated with the severity of bronchial obstruction as evaluated based on baseline FEV1 (% predicted). Forced expiratory flows did not change after either CPT session. The amount of sputum expectorated was similar for the two CPT sessions (5.3 +/- 5.3 g vs 4.6 +/- 4.8 g after the control and PSV session, respectively; NS). Fifteen patients felt less tired after the PSV session. Ten patients reported that expectoration was easier with PSV, whereas 4 did not note any difference; 2 patients did not expectorate. Nine patients expressed a marked and 5 a small preference for PSV, and 2 patients had no preference. The physiotherapists found it easier to perform CPT with PSV in 14 patients and did not perceive any difference in 2 patients.

DISCUSSION

Our study in CF children shows that respiratory muscle performance, as evaluated based on various parameters, decreased after CPT and that significant falls in oxygen saturation occurred after the FET maneuvers despite the quiet breathing periods between each FET cycle. These unwanted effects of CPT were