Airway clearance devices in cystic fibrosis

doi:10.1016/j.prrv.2007.02.003

Paediatric Respiratory Reviews

Volume 8, Issue 1, March 2007, Pages 17-23

https://doi.org/10.1016/j.prrv.2007.02.003 Get rights and content

Summary

Clearance of infected airway secretions is essential to preserve lung function in patients with cystic fibrosis (CF). Although the value of regular airway clearance treatments has been shown in many studies, adherence to the prescribed treatments is not very good (see Making airway clearance successful, pp. 000–000). In the past the only method available was conventional chest physiotherapy (CCPT; also known as manual percussion and postural drainage). CCPT remains the ‘gold standard’ of airway clearance methods and may be the best choice for some patients, such as infants and young children. However, the many newer methods of airway clearance available now allow CF patients and their families to choose the techniques and devices that best suits them. Most of the newer airway clearance devices have been studied in comparison to standard chest physiotherapy and most studies show no advantage of one method over another. This review will describe newer airway clearance devices available for CF patients and discuss evidence for the effectiveness of these devices compared to standard chest physiotherapy.

Section snippets

Positive expiratory pressure

The PEP device is the simplest and least expensive of the airway clearance devices. The PEP mask was developed in Denmark in the late 1970s as an alternative to CCPT. The mask has a one-way inhalation valve and an expiratory resistor. Exhalation through the resistor generates positive pressure in the airways which can be measured with a manometer or pressure indicator. Resistance orifices of different diameters can be chosen so that individual patients can generate pressures of 10–20 cm H₂O. The

Flutter^®

The Flutter^® (Axcan Scandipharm, Birmingham, Alabama, USA) is a small, handheld, mucus clearance device that provides PEP therapy with oral airway oscillations. It is shaped like a pipe with a hardened plastic mouthpiece at one end, a plastic, protective, perforated cover at the other end, and a high-density stainless steel ball resting in a plastic circular cone on the inside (Fig. 2). The patient sits comfortably and inhales to about 75% of inspiratory capacity, then exhales through the

Conclusion

Several devices have been developed to enhance airway clearance in CF patients. With the exception of the PEP valve, these devices all involve airway oscillation, either orally or via chest wall vibration. The advantage of these devices is that they can be used by patients independently without the need for an assistant or caregiver. Most of these devices have been studied in either short- or long-term comparisons with CCPT. The studies are generally underpowered and it is not clear which

Practice points

•
Airway clearance devices as alternatives to CCPT allow CF patients to choose the therapy that best fits their lifestyle and allows greatest independence
•
Airway clearance devices are preferred by many patients compared to CCPT and may result in better adherence.
•
PEP may be more effective for airway clearance than CCPT.
•
Oscillating positive expiratory pressure devices and HFCWO appear to be at least as effective as CCPT.

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Cited by (28)

Respiratory physical therapy techniques recommended for patients with cystic fibrosis treated in specialized centers
2020, Brazilian Journal of Physical Therapy
Citation Excerpt :
Respiratory physical therapy devices and techniques provide an increase in the transport of mucus in the airways, contributing to an improvement in mucociliary clearance.9 Thus, there is a consensus that airway clearance is essential for patients with CF to slow-down damage and progression of lung disease.10 In the past, few resources were available for airway clearance and conventional respiratory physical therapy was basically composed of chest percussion, vibration, and postural drainage.11
Respiratory therapy is a part of the treatment of patients with cystic fibrosis (CF). However, there is no information about the main factors influencing the recommendation of the use of different techniques or devices by physical therapists from different specialized centers.
To determine the respiratory therapy techniques recommended for the treatment of patients with CF seen in specialized treatment centers in Brazil.
This is a descriptive study including a sample of Brazilian CF specialized treatment centers. Data on demographics, spirometric variables, and recommended respiratory therapy treatment techniques were collected.
Twelve specialized treatment centers with a total of 974 patients were included (13.5 ± 11.3 years old and FEV₁ (%) 75.7 ± 27.9). The most recommended techniques were huffing (61.1% of patients), high frequency oral oscillation (HFOO) (52.0%), and positive expiratory pressure (PEP) (45.3%). Most often, recommendation was to perform treatment once (54.8% of patients) or twice (34%) a day. There was great variability in the recommendation among the different states. When data were separated by age, there was a predominance of performing conventional and manual techniques in infants and preschool children. There were no significant variations according to pulmonary function. Based on the literature, techniques based on volume, huffing, and PEP were most prevalently performed in international centers.
The most recommended treatment techniques for patients with CF in Brazil are huffing, HFOO, and PEP, followed by volume-based techniques. There were geographical variations in the preferred treatment techniques, as well as based on patient age, but not based on the level of pulmonary function.
Physical Therapies in Pediatric Respiratory Disease
2019, Kendig's Disorders of the Respiratory Tract in Children
Pediatric physical therapy (physiotherapy) is an essential component in the management of many cardio respiratory presentations in infants and children of all ages. The input will vary considerably depending on assessment findings and underlying pathology; however, the general principles remain the same across the spectrum. This chapter covers the key areas of physical therapy for specific conditions such as cystic fibrosis and bronchiectasis regarding airway clearance techniques, exercise, inhalation therapies, ventilator support, and secondary complications. It also identifies the role of cough augmentation and noninvasive ventilation in the management of children with neuromuscular conditions and spinal cord injuries. The role of the physical therapist in the critical care environment is discussed, with strategies modified for the intubated child to assist in secretion clearance and promote early rehabilitation. The importance of postoperative input through mobilization for children that require intervention and adjuncts to support therapy is outlined. Conditions that cause airway or structural abnormalities and may respond effectively to physiotherapy management are discussed. The interventions, as always, are tailored to the individual and monitored for safety and efficacy. Conditions and clinical presentations usually not amenable to physiotherapy are also reviewed. The main focus of the chapter is to highlight the essential elements of pediatric physical therapy for respiratory disease, reviewing the growing evidence base behind the many interventions available in the therapist's “toolbox.” Physiotherapy is not only a science but also an art. It requires the therapist to constantly review, modify, and adapt to a potentially changing presentation as well as the ability to communicate with the child and family for engagement and best outcomes.
Complementary Home Mechanical Ventilation Techniques: SEPAR Year 2014
2014, Archivos de Bronconeumologia
Citation Excerpt :
Thus, positive pressure proportional to the degree of resistance of the device is generated, preventing premature closure of the airways during expiration. Moreover, they act mechanically on the rheological properties of mucus.7,8 Other systems, such as intrapulmonary percussive ventilation9,10 or external high-frequency chest-wall oscillation/compression devices, have been used in airway clearance, helping to mobilize secretions and acting on mucus viscoelasticity.11
This is a review of the different complementary techniques that are useful for optimizing home mechanical ventilation (HMV).
Airway clearance is very important in patients with HMV and many patients, particularly those with reduced peak cough flow, require airway clearance (manual or assisted) or assisted cough techniques (manual or mechanical) and suctioning procedures, in addition to ventilation.
In the case of invasive HMV, good tracheostomy cannula management is essential for success.
HMV patients may have sleep disturbances that must be taken into account. Sleep studies including complete polysomnography or respiratory polygraphy are helpful for identifying patient-ventilator asynchrony.
Other techniques, such as bronchoscopy or nutritional support, may be required in patients on HMV, particularly if percutaneous gastrostomy is required.
Information on treatment efficacy can be obtained from HMV monitoring, using methods such as pulse oximetry, capnography or the internal programs of the ventilators themselves.
Finally, the importance of the patient's subjective perception is reviewed, as this may potentially affect the success of the HMV.
La ventilación mecánica domiciliaria (VMD) precisa técnicas complementarias para optimizar el tratamiento, que son revisadas en el presente trabajo.
El manejo de las secreciones respiratorias es muy importante, ya que muchos pacientes, particularmente cuando descienden los flujos de tos, precisan la aplicación de técnicas manuales o asistidas para el manejo de secreciones, técnicas de tos asistida (manual o mecánica) y aspiración mecánica de secreciones.
Si se aplica la VMD de forma invasiva, el buen manejo de la cánula de traqueostomía es esencial para su éxito.
Las alteraciones durante el sueño pueden estar presentes en estos pacientes, siendo un aspecto a valorar, estudiadas mediante polisomnografía o poligrafía respiratoria, que además ayudan a identificar las asincronías entre el paciente y el ventilador.
Otras técnicas que pueden ser requeridas en pacientes con VMD son la fibrobroncoscopia o el soporte nutricional (especialmente si se requiere la colocación de una sonda de gastrostomía).
La monitorización de la VMD aporta información sobre la efectividad del tratamiento aplicado. Existen varios métodos para ello, como pueden ser la pulsioximetría, la capnografía o los programas internos de los ventiladores.
Finalmente, se revisa la importancia de la percepción subjetiva del paciente, ya que puede tener potencial influencia en el éxito de la VMD.
Pulmonary Disease in Cystic Fibrosis
2012, Kendig and Chernick's Disorders of the Respiratory Tract in Children
Physical Therapies in Pediatric Respiratory Disease
2012, Kendig and Chernick's Disorders of the Respiratory Tract in Children
Pulmonary Care of Children and Adolescents with Developmental Disabilities
2008, Pediatric Clinics of North America
Citation Excerpt :
The head down position should not be used in patients with GER. Several independently administered airway clearance devices have been shown to be effective in aiding airway clearance in cystic fibrosis patients, including positive expiratory pressure, the intrapulmonary percussive ventilation device, the high-frequency chest wall oscillation devices, and various other devices.53 These devices have not been well studied in children with developmental disabilities, but children capable of mastering the use of an airway clearance device may benefit.
Caring for children and adolescents with developmental disabilities is challenging because of their susceptibility to varying degrees of respiratory morbidity and mortality. This article discusses the common pulmonary problems affecting children with developmental disabilities. Topics to be discussed include gastroesophageal reflux, drooling, and dysphagia and their relation to aspiration and aspiration pneumonia, upper airway obstruction and obstructive sleep apnea, and the role of airway clearance. Case studies are used to introduce a discussion of the underlying etiology, currently accepted methods to evaluate the conditions, and evidence-based treatment options. The goal of managing these problems is to use anticipatory guidance when possible and choose therapies that improve the child's quality of life with minimal side effects.

View all citing articles on Scopus

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Mini-symposium: Airway clearance in cystic fibrosisAirway clearance devices in cystic fibrosis

Summary

Section snippets

Positive expiratory pressure

Flutter®

Conclusion

Practice points

J Pediatr

Respir Med

Chest

Chest

J Pediatr

Chest

J Pediatr

Chest

Chest

Chest

Role of conventional physiotherapy in cystic fibrosis

J Pediatr

Forced expirations against a variable resistance: a new chest physiotherapy method in cystic fibrosis

Pediatr Pulmonol

Recruiting collapsed lung through collateral channels with positive end-expiratory pressure

Scand J Respir Dis

Physiologic evidence for the efficacy of positive expiratory pressure as an airway clearance technique in patients with cystic fibrosis

Phys Ther

Face mask therapy in cystic fibrosis

Arch Dis Child

Mini-symposium: Airway clearance in cystic fibrosis
Airway clearance devices in cystic fibrosis

Flutter^®