Chest physiotherapy and cystic fibrosis. Why is the most effective form of treatment still unclear?

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.

The correlation between 6-min walk test and respiratory parameters in children with cystic fibrosis

BACKGROUND

The 6-min walk test (6MWT) is a sub-maximal exercise test and has been widely used for evaluating of exercise capacity of patients with cystic fibrosis (CF) in recent years. Few studies have examined the relationship between 6MWT and parameters used to assess the severity of the disease in children with CF. In this study, we have examined this relationship to find out if 6MWT can be a marker of the severity of cystic fibrosis.

METHODS

A cross-sectional study was done to analyze the correlations among spirometry parameters, body mass index (BMI), chest tomography (CT), and 6MWT. CF patients, aged 7-14 years, were involved.

RESULTS

Seventy-six patients, 32F/44M, mean age 10.49 ± 3.18 years, were studied. The mean distance in 6MWT was 447 ± 84.1. The following correlations versus distance were found: FEV1 (r = 0.255, p = 0.026), FVC(r = 0.285, p = 0.013), FEF25-75% (r = 0.546, p < 0.001), BMI (r = 0.163, p = 0.160), and CT (r = 0.075, p = 0.520).The following correlations versus O₂ saturation (SpO₂) decline were found: FEV1 (r = -0.393, p < 0.001), FVC (r = -0.431, p < 0.001), FEF25-75% (r = -0.296, p = 0.010), BMI (r = 0.042, p = 0.721), and CT (r = -0.196, p = 0.090). There was a significant correlation between 6MWT (distance and SpO₂ decline) and pulmonary function test. There was no significant correlation between BMI, chest CT, and 6MWT.

CONCLUSIONS

6MWT can be applied beside spirometry and chest CT for CF patients follow up.

Positive expiratory pressure physiotherapy for airway clearance in people with cystic fibrosis

BACKGROUND

Chest physiotherapy is widely prescribed to assist the clearance of airway secretions in people with cystic fibrosis (CF). Positive expiratory pressure (PEP) devices provide back pressure to the airways during expiration. This may improve clearance by building up gas behind mucus via collateral ventilation and by temporarily increasing functional residual capacity. The developers of the PEP technique recommend using PEP with a mask in order to avoid air leaks via the upper airways and mouth. In addition, increasing forced residual capacity (FRC) has not been demonstrated using mouthpiece PEP. Given the widespread use of PEP devices, there is a need to determine the evidence for their effect. This is an update of a previously published review.

OBJECTIVES

To determine the effectiveness and acceptability of PEP devices compared to other forms of physiotherapy as a means of improving mucus clearance and other outcomes in people with CF.

SEARCH METHODS

We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register comprising of references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings. The electronic database CINAHL was also searched from 1982 to 2017. Most recent search of the Group's CF Trials Register: 20 February 2019.

SELECTION CRITERIA

Randomised controlled studies in which PEP was compared with any other form of physiotherapy in people with CF. This included, postural drainage and percussion (PDPV), active cycle of breathing techniques (ACBT), oscillating PEP devices, thoracic oscillating devices, bilevel positive airway pressure (BiPaP) and exercise.

DATA COLLECTION AND ANALYSIS

Three authors independently applied the inclusion and exclusion criteria to publications, assessed the risk of bias of the included studies and assessed the quality of the evidence using the GRADE recommendations.

MAIN RESULTS

A total of 28 studies (involving 788 children and adults) were included in the review; 18 studies involving 296 participants were cross-over in design. Data were not published in sufficient detail in most of these studies to perform any meta-analysis. In 22 of the 28 studies the PEP technique was performed using a mask, in three of the studies a mouthpiece was used with nose clips and in three studies it was unclear whether a mask or mouthpiece was used. These studies compared PEP to ACBT, autogenic drainage (AD), oral oscillating PEP devices, high-frequency chest wall oscillation (HFCWO) and BiPaP and exercise. Forced expiratory volume in one second was the review's primary outcome and the most frequently reported outcome in the studies (24 studies, 716 participants). Single interventions or series of treatments that continued for up to three months demonstrated little or no difference in effect between PEP and other methods of airway clearance on this outcome (low- to moderate-quality evidence). However, long-term studies had equivocal or conflicting results regarding the effect on this outcome (low- to moderate-quality evidence). A second primary outcome was the number of respiratory exacerbations. There was a lower exacerbation rate in participants using PEP compared to other techniques when used with a mask for at least one year (five studies, 232 participants; moderate- to high-quality evidence). In one of the included studies which used PEP with a mouthpiece, it was reported (personal communication) that there was no difference in the number of respiratory exacerbations (66 participants, low-quality evidence). Participant preference was reported in 10 studies; and in all studies with an intervention period of at least one month, this was in favour of PEP. The results for the remaining outcome measures (including our third primary outcome of mucus clearance) were not examined or reported in sufficient detail to provide any high-quality evidence; only very low- to moderate-quality evidence was available for other outcomes. There was limited evidence reported on adverse events; these were measured in five studies, two of which found no events. In a study where infants performing either PEP or PDPV experienced some gastro-oesophageal reflux , this was more severe in the PDPV group (26 infants, low-quality evidence). In PEP versus oscillating PEP, adverse events were only reported in the flutter group (five participants complained of dizziness, which improved after further instructions on device use was provided) (22 participants, low-quality evidence). In PEP versus HFCWO, from one long-term high-quality study (107 participants) there was little or no difference in terms of number of adverse events; however, those in the PEP group had fewer adverse events related to the lower airways when compared to HFCWO (high-certainty evidence). Many studies had a risk of bias as they did not report how the randomisation sequence was either generated or concealed. Most studies reported the number of dropouts and also reported on all planned outcome measures.

AUTHORS' CONCLUSIONS

The evidence provided by this review is of variable quality, but suggests that all techniques and devices described may have a place in the clinical treatment of people with CF. Following meta-analyses of the effects of PEP versus other airway clearance techniques on lung function and patient preference, this Cochrane Review demonstrated that there was high-quality evidence that showed a significant reduction in pulmonary exacerbations when PEP using a mask was compared with HFCWO. It is important to note that airway clearance techniques should be individualised throughout life according to developmental stages, patient preferences, pulmonary symptoms and lung function. This also applies as conditions vary between baseline function and pulmonary exacerbations.

Six-minute walk test as a determinant of the functional capacity of children and adolescents with cystic fibrosis: A systematic review

Cystic Fibrosis (CF) is a multisystem disorder. The involvement of the respiratory system is frequent and culminates in dyspnea and exercise intolerance. Functional capacity is an important diagnostic tool, because it reflects the cardiorespiratory status, quality of life and prognosis. This systematic review aims to assess the reproducibility and validity of the six minute walk test (6MWT) to reflect the functional capacity of children and adolescents with cystic fibrosis, and also the correlation between 6MWT and lung function. Searches for articles were performed in eight databases using MeSH/DeCS keywords. A total of 695 articles were found and, after verifying all eligibility criteria, six articles were included for analysis and scoring regarding the methodological quality according to the QUADAS scale (Quality Assessment of Diagnostic Accuracy Studies). All articles had good methodology (QUADAS between 9 and 11 points). The 6MWT is not correlated with lung function. There is a strong indication that the 6MWT is a reproducible test to assess the functional capacity of children and adolescents with CF. The validity assessment could not be reached because the studies included in this systematic review did not use adequate statistical tools to carry out such an evaluation.

Positive expiratory pressure therapy versus other airway clearance techniques for bronchiectasis

BACKGROUND

People with bronchiectasis experience chronic cough and sputum production and require the prescription of airway clearance techniques (ACTs). A common type of ACT prescribed is positive expiratory pressure (PEP) therapy. A previous review has suggested that ACTs including PEP therapy are beneficial compared to no treatment in people with bronchiectasis. However, the efficacy of PEP therapy in a stable clinical state or during an acute exacerbation compared to other ACTs in bronchiectasis is unknown.

OBJECTIVES

The primary aim of this review was to determine the effects of PEP therapy compared with other ACTs on health-related quality of life (HRQOL), rate of acute exacerbations, and incidence of hospitalisation in individuals with stable or an acute exacerbation of bronchiectasis.Secondary aims included determining the effects of PEP therapy upon physiological outcomes and clinical signs and symptoms compared with other ACTs in individuals with stable or an acute exacerbation of bronchiectasis.

SEARCH METHODS

We searched the Cochrane Airways Group Specialised Register of Trials, PEDro and clinical trials registries from inception to February 2017 and we handsearched relevant journals.

SELECTION CRITERIA

Randomised controlled parallel and cross-over trials that compared PEP therapy versus other ACTs in participants with bronchiectasis.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures as outlined by Cochrane.

MAIN RESULTS

Nine studies involving 213 participants met the inclusion criteria, of which seven were cross-over in design. All studies included adults with bronchiectasis, with eight including participants in a stable clinical state and one including participants experiencing an acute exacerbation. Eight studies used oscillatory PEP therapy, using either a Flutter or Acapella device and one study used Minimal PEP therapy. The comparison intervention differed between studies. The methodological quality of studies was poor, with cross-over studies including suboptimal or no washout period, and a lack of blinding of participants, therapists or personnel for outcome measure assessment in most studies. Clinical heterogeneity between studies limited meta-analysis.Daily use of oscillatory PEP therapy for four weeks was associated with improved general health according to the Short-Form 36 questionnaire compared to the active cycle of breathing technique (ACBT). When applied for three sessions over one week, minimal PEP therapy resulted in similar improvement in cough-related quality of life as autogenic drainage (AD) and L'expiration Lente Totale Glotte Ouverte en Decubitus Lateral (ELTGOL). Oscillatory PEP therapy twice daily for four weeks had similar effects on disease-specific HRQOL (MD -0.09, 95% CI -0.37 to 0.19; low-quality evidence). Data were not available to determine the incidence of hospitalisation or rate of exacerbation in clinically stable participants.Two studies of a single session comparison of oscillatory PEP therapy and gravity-assisted drainage (GAD) with ACBT had contrasting findings. One study found a similar sputum weight produced with both techniques (SMD 0.54g (-0.38 to 1.46; 20 participants); the other found greater sputum expectoration with GAD and ACBT (SMD 5.6 g (95% CI 2.91 to 8.29: 36 participants). There was no difference in sputum weight yielded between oscillatory PEP therapy and ACBT with GAD when applied daily for four weeks or during an acute exacerbation. Although a single session of oscillatory PEP therapy was associated with less sputum compared to AD (median difference 3.1 g (95% CI 1.5 to 4.8 g; one study, 31 participants), no difference between oscillatory PEP therapy and seated ACBT was evident. PEP therapy had a similar effect on dynamic and static measures of lung volumes and gas exchange as all other ACTs. A single session of oscillatory PEP therapy (Flutter) generated a similar level of fatigue as ACBT with GAD, but greater fatigue was noted with oscillatory PEP therapy compared to ACBT alone. The degree of breathlessness experienced with PEP therapy did not differ from other techniques. Among studies exploring adverse events, only one study reported nausea with use of oscillatory PEP therapy.

AUTHORS' CONCLUSIONS

PEP therapy appears to have similar effects on HRQOL, symptoms of breathlessness, sputum expectoration, and lung volumes compared to other ACTs when prescribed within a stable clinical state or during an acute exacerbation. The number of studies and the overall quality of the evidence were both low. In view of the chronic nature of bronchiectasis, additional information is needed to establish the long-term clinical effects of PEP therapy over other ACTs for outcomes that are important to people with bronchiectasis and on clinical parameters which impact on disease progression and patient morbidity in individuals with stable bronchiectasis. In addition, the role of PEP therapy during an acute exacerbation requires further exploration. This information is necessary to provide further guidance for prescription of PEP therapy for people with bronchiectasis.

Is there a role for airway clearance techniques in chronic obstructive pulmonary disease?

Chronic cough and sputum production are common featuresof chronic obstructive pulmonary disease (COPD) and havea significant impact on exacerbation frequency and qualityof life. Despite this, techniques to assist with removal of sputum from the airway do not have a well-defined role in COPD management. Clinical trials of airway clearance techniques (ACTs) in COPD have shown mixed results with little evidence of long-term benefit. However many studies havefailed to account for the heterogeneity of COPD lung disease, particularly with regard to the presence of bronchiectasis. Analysis of short-term studies suggests that there may be a cohort of patients who will benefit from prescription of a sputum clearance regimen. This review proposes a physiological rationale for the use of ACTs in COPD, taking into consideration the presence of bronchiectasis, the amount of sputum produced, the degree of airflow obstruction and the presence of decreased lung elastic recoil. The selection of an optimal ACT for individuals with COPD should take into account its effects on lung vloumes, expiratory flow and dynamic airway compression. Care should be taken to avoid airway collapse during forced expirations in patients with reduced lung recoil pressure; positive expiratory pressure therapy or autogenic drainage may prove effective in this patient group. The acceptability of ACTs to patients should also be considered, especially where long-term adherence is required. Future research should focus on more appropriate matching of the physiological effects of individual ACTs to the pathophysiology of lung disease in COPD.

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.

Airway clearance techniques for bronchiectasis

BACKGROUND

People with non-cystic fibrosis bronchiectasis commonly experience chronic cough and sputum production, features that may be associated with progressive decline in clinical and functional status. Airway clearance techniques (ACTs) are often prescribed to facilitate expectoration of sputum from the lungs, but the efficacy of these techniques in a stable clinical state or during an acute exacerbation of bronchiectasis is unclear.

OBJECTIVES

Primary: to determine effects of ACTs on rates of acute exacerbation, incidence of hospitalisation and health-related quality of life (HRQoL) in individuals with acute and stable bronchiectasis. Secondary: to determine whether:• ACTs are safe for individuals with acute and stable bronchiectasis; and• ACTs have beneficial effects on physiology and symptoms in individuals with acute and stable bronchiectasis.

SEARCH METHODS

We searched the Cochrane Airways Group Specialised Register of trials from inception to November 2015 and PEDro in March 2015, and we handsearched relevant journals.

SELECTION CRITERIA

Randomised controlled parallel and cross-over trials that compared an ACT versus no treatment, sham ACT or directed coughing in participants with bronchiectasis.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures as expected by The Cochrane Collaboration.

MAIN RESULTS

Seven studies involving 105 participants met the inclusion criteria of this review, six of which were cross-over in design. Six studies included adults with stable bronchiectasis; the other study examined clinically stable children with bronchiectasis. Three studies provided single treatment sessions, two lasted 15 to 21 days and two were longer-term studies. Interventions varied; some control groups received a sham intervention and others were inactive. The methodological quality of these studies was variable, with most studies failing to use concealed allocation for group assignment and with absence of blinding of participants and personnel for outcome measure assessment. Heterogeneity between studies precluded inclusion of these data in the meta-analysis; the review is therefore narrative.One study including 20 adults that compared an airway oscillatory device versus no treatment found no significant difference in the number of exacerbations at 12 weeks (low-quality evidence). Data were not available for assessment of the impact of ACTs on time to exacerbation, duration or incidence of hospitalisation or total number of hospitalised days. The same study reported clinically significant improvements in HRQoL on both disease-specific and cough-related measures. The median difference in the change in total St George's Respiratory Questionnaire (SGRQ) score over three months in this study was 7.5 units (P value = 0.005 (Wilcoxon)). Treatment consisting of high-frequency chest wall oscillation (HFCWO) or a mix of ACTs prescribed for 15 days significantly improved HRQoL when compared with no treatment (low-quality evidence). Two studies reported mean increases in sputum expectoration with airway oscillatory devices in the short term of 8.4 mL (95% confidence interval (CI) 3.4 to 13.4 mL) and in the long term of 3 mL (P value = 0.02). HFCWO improved forced expiratory volume in one second (FEV1) by 156 mL and forced vital capacity (FVC) by 229.1 mL when applied for 15 days, but other types of ACTs showed no effect on dynamic lung volumes. Two studies reported a reduction in pulmonary hyperinflation among adults with non-positive expiratory pressure (PEP) ACTs (difference in functional residual capacity (FRC) of 19%, P value < 0.05; difference in total lung capacity (TLC) of 703 mL, P value = 0.02) and with airway oscillatory devices (difference in FRC of 30%, P value < 0.05) compared with no ACTs. Low-quality evidence suggests that ACTs (HFCWO, airway oscillatory devices or a mix of ACTs) reduce symptoms of breathlessness and cough and improve ease of sputum expectoration compared with no treatment (P value < 0.05). ACTs had no effect on gas exchange, and no studies reported effects of antibiotic usage. Among studies exploring airway oscillating devices, investigators reported no adverse events.

AUTHORS' CONCLUSIONS

ACTs appear to be safe for individuals (adults and children) with stable bronchiectasis and may account for improvements in sputum expectoration, selected measures of lung function, symptoms and HRQoL. The role of these techniques in acute exacerbation of bronchiectasis is unknown. In view of the chronic nature of bronchiectasis, additional data are needed to establish the short-term and long-term clinical value of ACTs for patient-important outcomes and for long-term clinical parameters that impact disease progression in individuals with stable bronchiectasis, allowing further guidance on prescription of specific ACTs for people with bronchiectasis.

Positive expiratory pressure physiotherapy for airway clearance in people with cystic fibrosis

BACKGROUND

Chest physiotherapy is widely prescribed to assist the clearance of airway secretions in people with cystic fibrosis. Positive expiratory pressure (PEP) devices provide back pressure to the airways during expiration. This may improve clearance by building up gas behind mucus via collateral ventilation and by temporarily increasing functional residual capacity. Given the widespread use of PEP devices, there is a need to determine the evidence for their effect. This is an update of a previously published review.

OBJECTIVES

To determine the effectiveness and acceptability of PEP devices compared to other forms of physiotherapy as a means of improving mucus clearance and other outcomes in people with cystic fibrosis.

SEARCH METHODS

We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register comprising of references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings. The electronic database CINAHL was also searched from 1982 to 2013.Most recent search of the Group's Cystic Fibrosis Trial Register: 02 December 2014.

SELECTION CRITERIA

Randomised controlled studies in which PEP was compared with any other form of physiotherapy in people with cystic fibrosis. This included, postural drainage and percussion, active cycle of breathing techniques, oscillating PEP devices, thoracic oscillating devices, bilevel positive airway pressure (BiPaP) and exercise. Studies also had to include one or more of the following outcomes: change in forced expiratory volume in one second; number of respiratory exacerbations; a direct measure of mucus clearance; weight of expectorated secretions; other pulmonary function parameters; a measure of exercise tolerance; ventilation scans; cost of intervention; and adherence to treatment.

DATA COLLECTION AND ANALYSIS

Three authors independently applied the inclusion and exclusion criteria to publications and assessed the risk of bias of the included studies.

MAIN RESULTS

A total of 26 studies (involving 733 participants) were included in the review. Eighteen studies involving 296 participants were cross-over in design. Data were not published in sufficient detail in most of these studies to perform any meta-analysis. These studies compared PEP to active cycle of breathing techniques (ACBT), autogenic drainage (AD), oral oscillating PEP devices, high frequency chest wall oscillation (HFCWO) and Bi level PEP devices (BiPaP) and exercise.Forced expiratory volume in one second was the review's primary outcome and the most frequently reported outcome in the studies. Single interventions or series of treatments that continued for up to three months demonstrated no significant difference in effect between PEP and other methods of airway clearance on this outcome. However, long-term studies had equivocal or conflicting results regarding the effect on this outcome. A second primary outcome was the number of respiratory exacerbations. There was a lower exacerbation rate in participants using PEP compared to other techniques when used with a mask for at least one year. Participant preference was reported in 10 studies; and in all studies with an intervention period of at least one month, this was in favour of PEP. The results for the remaining outcome measures were not examined or reported in sufficient detail to provide any high-level evidence. The only reported adverse event was in a study where infants performing either PEP or postural drainage with percussion experienced some gastro-oesophageal reflux. This was more severe in the postural drainage with percussion group. Many studies had a risk of bias as they did not report how the randomisation sequence was either generated or concealed. Most studies reported the number of dropouts and also reported on all planned outcome measures.

AUTHORS' CONCLUSIONS

Following meta-analyses of the effects of PEP versus other airway clearance techniques on lung function and patient preference, this Cochrane review demonstrated that there was a significant reduction in pulmonary exacerbations in people using PEP compared to those using HFCWO in the study where exacerbation rate was a primary outcome measure. It is important to note, however, that there may be individual preferences with respect to airway clearance techniques and that each patient needs to be considered individually for the selection of their optimal treatment regimen in the short and long term, throughout life, as circumstances including developmental stages, pulmonary symptoms and lung function change over time. This also applies as conditions vary between baseline function and pulmonary exacerbations.However, meta-analysis in this Cochrane review has shown a significant reduction in pulmonary exacerbations in people using PEP in the few studies where exacerbation rate was a primary outcome measure.

Effects of noninvasive ventilation on treadmill 6-min walk distance and regional chest wall volumes in cystic fibrosis: randomized controlled trial

BACKGROUND

Dyspnea and exercise intolerance are the symptoms that most affect the quality of life of children and adolescents with respiratory disorders resulting from cystic fibrosis (CF).

OBJECTIVE

To evaluate the effect of noninvasive ventilation (NIV) on treadmill 6-min walk distance and regional chest wall volumes in cystic fibrosis patients.

METHOD

Crossover clinical trial, randomized, controlled and open with 13 children and adolescents with CF, aged 7-16 years, with pulmonary impairment (NTC01987271). The patients performed a treadmill walking test (TWT) during 6 min, with and without NIV on a BiLEVEL mode, an interval of 24-48 h between tests. Before and after each test, patients were assessed by spirometry and optoelectronic plethysmography.

RESULTS

Walking distance in TWT with NIV was significantly higher that without ventilatory support (mean ± sd: 0.41 ± 0.08 vs. 0.39 ± 0.85 km, p = 0.039). TWT with NIV increase forced expiratory volume on 1 s (FEV1; p = 0.036), tidal volume (Vt; p = 0.005), minute ventilation (MV; p = 0.013), pulmonary rib cage volume (Vrcp; p = 0.011), and decrease the abdominal volume (Vab; p = 0.013) after test. There was a significant reduction in oxygen saturation (p = 0.018) and permanent increase in respiratory rate after 5 min (p = 0.021) after the end test without NIV.

CONCLUSION

During the walking test on the treadmill, the NIV change thoracoabdominal kinematics and lung function in order to optimized ventilation and tissue oxygenation, with improvement of walk distance. Consequently, NIV is an effective tool to increase functional capacity in children and adolescents with cystic fibrosis.

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.

Airway clearance techniques for bronchiectasis

BACKGROUND

People with non-cystic fibrosis bronchiectasis commonly experience chronic cough and sputum production and these features may be associated with progressive decline in clinical status. Airway clearance techniques (ACTs) are often prescribed to facilitate expectoration of sputum from the lungs, but the efficacy of these techniques in a stable clinical state or during an acute exacerbation of bronchiectasis is unclear.

OBJECTIVES

Primary: to determine the effects of ACTs on the rate of acute exacerbations, incidence of hospitalisation and health-related quality of life in individuals with acute and stable bronchiectasis.Secondary: to determine whether a) ACTs are safe for individuals with acute and stable bronchiectasis and b) ACTs have beneficial effects on physiology and symptoms in individuals with acute and stable bronchiectasis.

SEARCH METHODS

We searched the Cochrane Airways Group Specialised Register of trials from inception to October 2012, PEDro in October 2012 and handsearched relevant journals.

SELECTION CRITERIA

Randomised controlled parallel and cross-over trials that compared an ACT to no treatment, sham ACT or directed coughing in participants with bronchiectasis.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by The Cochrane Collaboration.

MAIN RESULTS

Five studies involving 51 participants met the inclusion criteria of the review, all of which were cross-over design. Four studies were on adults with stable bronchiectasis, and the other study was on clinically stable children with bronchiectasis. Three studies were single treatment sessions, two were longer-term studies. The interventions varied and some control groups received a sham intervention while others were inactive. The methodological quality of the studies was variable and the studies were not able to blind participants and personal. Heterogeneity between studies precluded these data from meta-analysis and the review was therefore narrative.One study on 20 adults comparing an airway oscillatory device with no treatment found no significant difference in the number of exacerbations at 12 weeks (low-quality evidence). No data were available to assess the impact of ACTs on the time to exacerbation, duration of, incidence of hospitalisation or total number of hospitalised days. The same study reported clinically significant improvements in health-related quality of life in both disease-specific and cough-related measures. While based on a small number of participants and the data were skewed, the median difference in the change in total St George's Respiratory Questionnaire (SGRQ) score over three months in this study was 8.5 units (P value = 0.005 (Wilcoxon), low-quality evidence). Two studies reported mean increases in volume of sputum expectorated with airway oscillatory devices in the short term of 8.4 mL (95% CI 3.4 to 13.4 mL) and in the long term of 3 mL (P value = 0.02), with no significant effect on lung function. One study reported an immediate reduction in pulmonary hyperinflation in adults with non-positive expiratory pressure (PEP) ACTs (difference in functional residual capacity (FRC) of 19%, P value < 0.05) and with airway oscillatory devices (difference in FRC of 30%, P value < 0.05) compared to no ACTs. A similar decrease in pulmonary hyperinflation (difference in FRC of 6%) was found in children using an airway oscillatory device for 3 months compared to sham therapy. No studies reported on the effects of gas exchange, people's symptoms or antibiotic usage.

AUTHORS' CONCLUSIONS

ACTs appear to be safe for individuals (adults and children) with stable bronchiectasis, where there may be improvements in sputum expectoration, selected measures of lung function and health-related quality of life. The role of these techniques in people with an acute exacerbation of bronchiectasis is unknown. In view of the chronic nature of bronchiectasis, more data are needed to establish the clinical value of ACTs over the short and long term on patient-important outcomes, including symptoms, on physiological outcomes which may clarify the rationale for each technique and on long-term parameters that impact on disease progression in individuals with stable bronchiectasis. This is necessary in order to provide further guidance of specific ACT prescription for people with bronchiectasis. It may also be important to establish the comparative effect of different types of ACTs in people with bronchiectasis.

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.

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.

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.

Positive expiratory pressure physiotherapy for airway clearance in people with cystic fibrosis

BACKGROUND

Chest physiotherapy is widely prescribed to assist the clearance of airway secretions in people with cystic fibrosis (CF). Positive expiratory pressure (PEP) devices provide constant back pressure to the airways during expiration. This may improve clearance by building up gas behind mucus via collateral ventilation. Given the widespread use of PEP devices, there is a need to determine the evidence for their effect.

OBJECTIVES

To determine the effectiveness and acceptability of PEP devices compared to other forms of physiotherapy as a means of improving mucus clearance and other outcomes in people with CF.

SEARCH STRATEGY

We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register comprising of references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings. The electronic database CINAHL was also searched from 1982 to 2001. Most recent search of the Group's register: February 2006.

SELECTION CRITERIA

Randomised controlled studies in which PEP was compared with any other form of physiotherapy in people with CF.

DATA COLLECTION AND ANALYSIS

Two authors independently applied the inclusion and exclusion criteria to publications and assessed the quality of the included studies.

MAIN RESULTS

Forty studies were identified and twenty-five studies involving 507 participants met the review inclusion criteria. Most included studies had low scores on a scale of study quality. Twenty of these studies involving 300 participants were cross-over in design. Data were not published in sufficient detail in most of these studies to perform meta-analysis.Forced expiratory volume in one second (FEV1) was the most frequently measured outcome. Single interventions or series of treatments continued for up to three months demonstrated no significant difference in effect between PEP and other methods of airway clearance on FEV1. Long-term studies had equivocal or conflicting results regarding the effect on FEV1. Participant preference was reported in nine studies. In all studies with an intervention period of at least one month, measures of participant preference were in favour of PEP. The results for the remaining outcome measures were not examined or reported in sufficient detail to provide any high level evidence.

AUTHORS' CONCLUSIONS

There was no clear evidence that PEP was a more or less effective intervention overall than other forms of physiotherapy. There was limited evidence that PEP was preferred by participants compared to other techniques, but this finding is from studies of low quality.

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.

The use of human deoxyribonuclease (rhDNase) in the management of cystic fibrosis

In patients with cystic fibrosis (CF), the poor clearance of airway secretions promotes recurrent cycles of pulmonary infection and inflammation. In recent years, novel drugs have been developed to alter the properties of the secretions in an attempt to aid chest physiotherapy in improving airway clearance. Once-daily nebulised recombinant human deoxyribonuclease (rhDNase; dornase alfa; Pulmozyme) is the most widely used mucoactive therapy in patients with CF. It has been shown to reduce the viscoelasticity of sputum from patients with CF and enhance the clearance of secretions. Clinical trials have shown rhDNase to be a well tolerated treatment that improves pulmonary function and reduces respiratory exacerbations. However, the response to treatment is heterogeneous and only a proportion of patients with CF actually benefit from the treatment. At present, we are unable to predict which patients will benefit from rhDNase. Many CF centers have developed formal n-of-1 trials of treatment to find out who benefits and to justify prescribing the agent. rhDNase is an expensive therapy and is mainly used in patients over the age of 5 years with moderate to severe lung disease. However, studies have shown that rhDNase may be useful in patients with milder lung disease. Comparisons with another mucoactive drug, hypertonic saline, have shown rhDNase to be more effective. Recently, it has been shown that giving rhDNase on an alternate-day basis, rather than daily, is equally effective, potentially reducing costs and treatment time.

Positive expiratory pressure (PEP) treatment in children with multiple severe disabilities

BACKGROUND

Children with multiple severe disabilities cannot be spontaneously physically active and therefore lack the ventilatory stimulation of physical activity. They often produce large quantities of airway mucus, which they have difficulty to evacuate on their own. The accumulation of mucus may lead to respiratory insufficiency.

AIM

To investigate whether chest physiotherapy with positive expiratory pressure (PEP) could improve the blood oxygen tension (PO(2)) and/or decrease carbon dioxide tension (PCO(2)) in severely disabled children with airway mucus accumulation.

METHODS

Eighteen disabled children (mean age 7.5 y, SD 4.3, range 1.7-17.8 y) participated in the study. Transcutaneous (tc) PO(2), tcPCO(2) and respiratory rate (RR) were recorded before and after PEP treatment. The reproducibility of the effect of the treatment was tested by repeating the recordings.

RESULTS

The mean tcPO(2) increased 1.0 kPa (range -0.2 to 3.4 kPa) immediately after PEP treatment (p=0.0001). No significant changes in tcPCO(2) or RR were noted. The reproducibility of the effect of PEP treatment was good, with a significant increase in tcPO(2) at all retests. All children accepted the treatment well.

CONCLUSION

PEP increases blood oxygen tension immediately after treatment in severely disabled children with airway mucus accumulation. Long-term effects remain to be proven.

Positive expiratory pressure physiotherapy for airway clearance in people with cystic fibrosis

BACKGROUND

Chest physiotherapy is widely prescribed to assist the clearance of airway secretions in people with cystic fibrosis (CF). Positive expiratory pressure (PEP) devices provide constant back pressure to the airways during expiration. This may improve clearance by building up gas behind mucus via collateral ventilation. Given the widespread use of PEP devices, there is a need to determine the evidence for their effect.

OBJECTIVES

To determine the effectiveness and acceptability of PEP devices compared to other forms of physiotherapy as a means of improving mucus clearance and other outcomes in people with CF.

SEARCH STRATEGY

We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group trials register comprising of references identified from comprehensive electronic database searches and handsearching of relevant journals and abstract books of conference proceedings. The electronic database CINAHL was also searched from 1982 to 2001. Most recent search of the Group's register: November 2003.

SELECTION CRITERIA

Randomised controlled trials in which PEP was compared with any other form of physiotherapy in people with CF.

DATA COLLECTION AND ANALYSIS

Two reviewers independently applied the inclusion and exclusion criteria to publications and assessed the quality of the included studies.

MAIN RESULTS

Thirty-three studies were identified and twenty studies involving 429 participants met review inclusion criteria. Most included studies had low scores on a scale of study quality. Sixteen of these studies involving 257 participants were cross-over in design. Data were not published in sufficient detail in these studies to perform meta-analysis.Forced expiratory volume in one second (FEV1) was the most frequently measured outcome. Single interventions or series of treatments continued for up to one month demonstrated no significant difference in effect between PEP and other methods of airway clearance on FEV1. Long-term studies had equivocal or conflicting results regarding the effect on FEV1. Patient preference was reported in nine studies. In all studies with an intervention period of at least one month, measures of patient preference were in favour of PEP. The results for the remaining outcome measures were not examined or reported in sufficient detail to provide any high level evidence.

REVIEWER'S CONCLUSIONS

There was no clear evidence that PEP was a more or less effective intervention overall than other forms of physiotherapy. There was limited evidence that PEP was preferred by participants compared to other techniques but this finding is from studies of low quality.

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.

Applications of hyperpolarized helium-3 gas magnetic resonance imaging in pediatric lung disease

Hyperpolarized gas magnetic resonance imaging (MRI) of the lung provides high temporal and spatial resolution images of the air spaces of the lung and can be used to elucidate both lung ventilation and morphology. Because no ionizing radiation is involved, hyperpolarized gas MRI is ideal for the evaluation of pediatric lung diseases. In the article, we describe briefly the basic principles of hyperpolarized gas MRI, review the literature of hyperpolarized gas MRI in two pediatric lung diseases (asthma and cystic fibrosis), and discuss possible future clinical applications of hyperpolarized gas imaging in pediatric lung disease.

Hyperpolarized noble gas MR imaging of the lung: potential clinical applications

Hyperpolarized noble gases are a new class of MR contrast agent. Since the first hyperpolarized gas MR images of the lung were reported, there has been considerable interest in using hyperpolarized gas to obtain high spatial and temporal resolution images of the air spaces of the lung. In addition to static images of lung ventilation, new techniques are being developed using hyperpolarized gas to obtain dynamic, diffusion and oxygen concentration images of the lung. In this article, we review the potential clinical applications of pulmonary hyperpolarized gas MRI and discuss the preliminary findings in a variety of lung diseases. Hyperpolarized gas MRI has the potential to provide a comprehensive morphologic and functional assessment of the lung.

Validation of an instrument measuring patient satisfaction with chest physiotherapy techniques in cystic fibrosis

OBJECTIVES

Chest physiotherapy (CPT) has been an important part of cystic fibrosis (CF) treatment regimens for > 40 years. Techniques with different perceived costs, benefits, and patient satisfaction exist. An instrument measuring patient satisfaction with CPT has not been reported. Our goal was to develop and validate such an instrument.

DESIGN

A cross-sectional survey sent to 349 patients seen at a large, urban, academic CF care center. The two-page survey asked 17 questions related to CPT satisfaction (efficacy, convenience, comfort, overall satisfaction), followed by 4 general CF-care questions (disease severity, importance of therapies, prescribed vs missed therapies). A 5-point Likert-type scale was used for responses. Psychometric analysis included itemetric performance, confirmatory factor analysis, test-retest reliability, and evaluation of subject's responses to the general CF-care questions.

RESULTS

One hundred twenty-nine individuals returned completed surveys (39%; 66 males and 63 females; age range, 2 months to 47 years). FEV(1)values were 21 to 155% predicted (mean, 76%; n = 82). Disease severity was as follows: 60 mild, 47 moderate, and 14 severe. Seventy-nine subjects used postural drainage, percussion, and vibration (PDPV), 21 used a flutter device, and 14 used high-frequency chest wall oscillation (HFCWO). Five subjects used more than one technique. Internal consistency analysis found an overall coefficient alpha of 0.87 (range, 0.74 to 0.89 for four domains). Factor analysis demonstrated domains for efficacy, convenience, comfort, and overall satisfaction. Mean total satisfaction scores differed significantly among therapies (R(2) = 0. 118; F[ 2,111] = 7.56; p = 0.0008): PDPV, 3.8 (SD = 0.6); Flutter, 4. 3 (SD = 0.5); and HFCWO, 4.1 (SD = 0.5). Therapies also differed significantly on all subscores. Perceived importance of CPT and compliance with CPT increased linearly with disease severity. Overall satisfaction was positively correlated with CPT compliance.

CONCLUSIONS

The CPT satisfaction survey has good reliability and content validity. Significant differences in patient satisfaction exist among therapies. Sicker patients recognize the importance of, and demonstrate better compliance with prescribed CPT. Increased satisfaction is associated with better compliance with therapy.

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

Alternatives to percussion and postural drainage. A review of mucus clearance therapies: percussion and postural drainage, autogenic drainage, positive expiratory pressure, flutter valve, intrapulmonary percussive ventilation, and high-frequency chest compression with the ThAIRapy Vest

The purpose of this article is to review published studies on the efficacy of old and new mucus clearance techniques and to develop recommendations for different groups of patients. Mucus clearance is a problem in cystic fibrosis, bronchiectasis, and many other pulmonary conditions. Percussion and postural drainage (P & PD) was the traditional method of facilitating mucus clearance, but the many hazards and contraindications along with the onerous nature and resultant poor patient compliance of this procedure have led to the development of alternative therapies. Research studies with cystic fibrosis patients support the efficacy of P & PD in patients who can tolerate it. However, equivalent sputum production can be accomplished with autogenic drainage, positive expiratory pressure, and Flutter valve therapy without the assistance of another caregiver, as long as the patient has the motivation, breath control, and neuromuscular function to perform these modalities. The Intrapulmonary Percussive Ventilation device and high-frequency chest compression with the ThAIRapy vest involve more elaborate and expensive equipment, yet these devices provide mucus clearance assistance to patients who lack the ability to perform the simpler techniques. Both mechanized modalities promote independence and self-care in the patient, and the effectiveness of both has been supported by the limited research published to date. Which alternative to recommend depends on the ability, motivation, preference, needs, and resources of each patient.

Finding evidence to support airway clearance techniques in cystic fibrosis

Chest physiotherapy, aiming to clear bronchopulmonary secretions, has become a mainstay in the respiratory management of cystic fibrosis (CF). Early diagnosis and new therapeutic interventions have dramatically improved the outlook for patients with this disorder and it is no longer a disease of childhood. Along with these changes chest physiotherapy has also progressed, with the development of several treatment modalities that are more effective and can be performed by the patient without assistance. This allows older children and adults with CF to lead more normal and independent lifestyles. Despite this progress questions remain regarding the efficacy and consequences of airway clearance techniques, the scientific evidence available to support the selection of the most appropriate treatment modality and, not least, the problems associated with the treatment-related burden that is placed on patients and their families.