There are lots of different methods involved in airway clearance, and our advice is to see a respiratory physiotherapist who will work out which is best for you. Sputum movement will ultimately depend on several factors which will form part of the assessment by your respiratory physiotherapist. These factors include:. Depending on these factors, physios may choose to introduce a breathing technique, they may want to add in a breathing device, or they may need to think about ways to make your phlegm looser — for example a nebuliser.
About the Author: Emily Lockwood. Related Posts. The patient perspective…two Air Physiotherapy patient stories. Since ineffective mucociliary clearance leads to increased morbidity and mortality, ethical considerations deter the use of sham treatment in ACT research.
Conference proceedings review the clinical evidence and scientific basis for diagnosis and treatment of diseases or the use of therapeutic modalities. For respiratory therapists the New Horizons Symposiums and R espiratory C are Journal Conferences provide a venue for clinical experts and scientists to review and present evidence specific to our practice. Conference proceedings are then published in R espiratory C are. The scientific evidence with respect to the physiology of mucus production and cough, pharmacologic management, and non-pharmacologic approaches to airway clearance were presented and discussed, and findings summarized.
The aforementioned narrative reviews also provide recommendations for new directions and opportunities for future research and clinical care. A systematic review is a summary of the literature that uses an organized method to thoroughly search, critically appraise, and statistically combine data from valid studies in the literature.
Systematic ACT reviews are available and include reviews of specific techniques, such as active cycle of breathing, 52 positive expiratory pressure devices, 53 and oscillatory positive expiratory pressure devices, 54 as well as sequencing pharmacologic agents, 55 , 56 and comparing therapeutic modalities for specific diseases such as CF 57 or COPD.
In the last decade, 2 airway clearance clinical practice guidelines have been published. Guided by systematic review of the literature from multiple databases and hand searches, authors constructed recommendations for the non-pharmacologic management of secretion clearance in pulmonary disease 59 and the use of airway clearance for the treatment of CF lung disease.
Recommendations were provided with respect to the general needs for airway clearance, as well as for treatment of individual patients. A summary of the pertinent findings from these guidelines can be found in Table 3.
The literature supports the use of respiratory therapist-driven protocols. Studies demonstrate that protocol use improves appropriate allocation of respiratory services, by reducing over-ordering and under-ordering of respiratory therapies, and the cost of care. An algorithm for guiding ACT was proposed 17 but did not account for an assessment of the patient's ability to perform therapy, determination of cough characteristics, or frequency of re-evaluation.
Evaluation of the need for ACT and use of a particular device or technique must include initial and ongoing assessment of the patient's lung function, muscle strength, and cognitive ability to perform the therapy. Figure 3 integrates expert opinion, 12 , 17 evidence from published systematic reviews, 52 — 54 , 57 , 58 and clinical practice guidelines 59 , 60 to construct an algorithm to guide the use of ACT.
The establishment and evaluation of patient, process, and financial outcomes are crucial elements in protocol implementation. A computerized system provides an efficient and cost-effective method for evaluating outcomes. Respiratory therapist driven algorithm to guide airway clearance use. An electronic medical record provides the potential to create an integrated system to guide practice, store health information, and evaluate patient and process outcomes Fig.
It is important not only to house protocols and clinical pathways, but also to have an electronic health record that can easily perform protocol or pathway audits to determine allocation of services and patient and process outcomes. Collecting outcome variables, such as hospital or ICU stay, re-visitation rates, delays in care, missed therapy, and order variances, can waste human capital if the data collection process is cumbersome and time-consuming.
An example of an integrated system for storing health information, guiding and evaluating clinical care. ACT has for decades been considered one of the cornerstones of therapy for the prevention and treatment of pulmonary disease and neurorespiratory dysfunction. Although there are methodological challenges that make it difficult to evaluate the clinical efficacy of ACTs clinically, literature does exist to guide our practice.
An integral knowledge of ACTs limitations of use derived from the literature, recommendations from narrative and systematic reviews, and evidence-based clinical practice guidelines , device performance, and patient characteristics disease state, lung and muscle function, cognitive ability, preferences is needed to construct evidence-based approaches to guide care.
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Skip to main content. Teresa A Volsko. Abstract Disease processes can impair ciliary function, alter secretion production and mucus rheology, and interfere with the cough reflex. Introduction The mucociliary escalator and cough reflex maintain optimal function of the respiratory system by removing secretions and preventing airways obstruction. View this table: View inline View popup Download powerpoint. Table 1. Impairment of Secretion Clearance and Pulmonary Disease Rare genetic disorders such as primary ciliary dyskinesia and Kartagener syndrome impair cilia structure and function.
Neurorespiratory Dysfunction and Secretion Clearance Problems Cough is a defense mechanism, initiated either voluntarily or by the stimulation of cough receptors located primarily in the central airways, which aids in the evacuation of secretions, and foreign substances from the respiratory tract. Table 2. Where to Look for Current Evidence There is a lack of empirical evidence to support the superiority of any particular airway-clearance device or technique.
Studies Evidence available in the literature can be categorized into pre-appraised levels 40 Fig. Synthesis Conference proceedings review the clinical evidence and scientific basis for diagnosis and treatment of diseases or the use of therapeutic modalities. Systematic Reviews A systematic review is a summary of the literature that uses an organized method to thoroughly search, critically appraise, and statistically combine data from valid studies in the literature.
Evidenced-Based Clinical Practice Guidelines In the last decade, 2 airway clearance clinical practice guidelines have been published. Table 3. Summary ACT has for decades been considered one of the cornerstones of therapy for the prevention and treatment of pulmonary disease and neurorespiratory dysfunction. The author has disclosed no conflicts of interest. References 1. Physiology of airway mucus clearance. Respir Care ; 47 7 : — OpenUrl PubMed.
Warwick WJ. Mechanisms of mucous transport. Eur J Respir Dis Suppl ; : — Foster WM. Mucociliary transport and cough in humans. Pulm Pharmacol Ther ; 15 3 : — Zaugg M , Lucchinetti E.
Respiratory function in the elderly. Anesthesiol Clin North America ; 18 1 : 47 — Comparative airway inflammatory response of normal volunteers to ozone and lipopolysaccharide challenge. Inhal Toxicol ; 22 8 : — Does passive smoking have an effect on nasal mucociliary clearance? Otolaryngol Head Neck Surg ; 1 : — Relationship between supermaximal flow during cough and mortality in motor neurone disease.
Eur Respir J ; 19 3 : — Hadjikoutis S , Wiles CM. Early diagnosis and implementation of ACT, coupled with management of infections and airways inflammation, can help break the vicious cycle associated with chronic pulmonary and neuromuscular respiratory diseases.
Various airway clearance techniques are utilized to help loosen thick, sticky mucus from the airways and mobilizing them so that it can be cleared from the lungs. Airway clearance therapy can utilize physical or mechanical means to aid the in the mobilization of bronchial drainage and facilitate coughing up the mucus.
Breathing maneuvers, gravity assisted drainage, manual chest physiotherapy or mechanical devices can be used to mobilize mucus and produce a cough. Chest physiotherapy consists of clapping or percussion of the chest wall with a cupped hand, or mechanical device in a rhythmic fashion to loosen mucus from the bronchial walls.
High frequency chest wall oscillation HFCWO is performed with a mechanical vest worn by patients that deliver vibratory forces that oscillate through the chest wall into the lungs to loosen and mobilize secretions. Huff coughing is one of the easiest airway clearance techniques and helps to release mucus from the lungs and passed into airways for clearing. It involves taking a breath in, holding it, and actively exhaling. The PEP device consists of a face mask or mouthpiece and a one-way valve attached to an expiratory resistor to hold airways open for patients to breath in and out against the resistance.
OPEP therapy devices use a mechanical means to interrupt flow, and an expiratory resistor to create air flow oscillations during active exhalation of breath through the device. Autogenic drainage uses low breathing to loosen mucus, normal breath volume to collect mucus, and a large breath to maximize expiratory flow and move mucus from the central airways where they can be cleared by a cough.
Postural drainage includes the use of patient positioning to assist gravity in facilitating the movement of lung mucus from peripheral airways to the larger bronchi where they can be cleared out by coughing.
ACBT uses alternating cycles of breathing control or relaxed breathing, and chest expansion exercises to mobilize lung mucus, and the forced expiration technique to facilitate secretion removal. Sputum rheology changes in cystic fibrosis lung disease following two different types of physiotherapy: flutter vs autogenic drainage. Long-term comparative trial of conventional postural drainage and percussion versus positive expiratory pressure physiotherapy in the treatment of cystic fibrosis.
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Positive expiratory pressure therapy versus other airway clearance techniques for bronchiectasis. Cochr Libr. Physiologic benefits of mechanical insufflation-exsufflation in children with neuromuscular diseases. Mechanical insufflation-exsufflation for people with neuromuscular disorders. Homnick DN. Mechanical insufflation-exsufflation for airway mucus clearance.
Acute effects of mechanical insufflation-exsufflation on the breathing pattern in stable subjects with duchenne muscular dystrophy. Bach JR. A commentary. Eur J Res. Cough augmentation in amyotrophic lateral sclerosis. Efficacy of mechanical insufflation-exsufflation in medically stable patients with amyotrophic lateral sclerosis.
Mechanical insufflation—exsufflation improves outcomes for neuromuscular disease patients with respiratory tract infections. Am J Phys Med Rehabil. Chatwin M, Simonds AK. Airway clearance techniques in neuromuscular disorders: a state of the art review. Effect of manually assisted cough and mechanical insufflation on cough flow of normal subjects, patients with chronic obstructive pulmonary disease COPD , and patients with respiratory muscle weakness. High-frequency oscillation of the airway and chest wall.
Controlled trial of intrapulmonary percussion in adults and children with stable severe neuromuscular disease. Am J Crit Care Med. Physiological response to intrapulmonary percussive ventilation in stable COPD patients. Effect of intrapulmonary percussive ventilation on mucus clearance in duchenne muscular dystrophy patients: a preliminary report. Intrapulmonary percussive ventilation in tracheostomized patients: a randomized controlled trial.
Intens Care Med. The intrapulmonary percussive ventilator and flutter device compared to standard chest physiotherapy in patients wit cystic fibrosis. Clin Pediatr. Safety and efficacy of short-term intrapulmonary percussive ventilation in patients with bronchiectasis.
Intrapulmonary percussive ventilation as an airway clearance technique in subjects with chronic obstructive airway diseases. Enhanced tracheal mucus clearance with high frequency chest wall compression. Mucus transport by high-frequency nonsymmetrical oscillatory airflow. J Appl Physiol. Short-term effects of three chest physiotherapy regimens in patients hospitalized for pulmonary exacerbations of cystic fibrosis: a cross-over randomized study.
The utility of high-frequency chest wall oscillation therapy in the post-operative management of thoracic surgical patient. Short-term comparative study of high frequency chest wall oscillation and European airway clearance techniques in patients with cystic fibrosis. Effectiveness of treatment with high-frequency chest wall oscillation in patients with bronchiectasis. BMC Pulmon Med. Comparing airways clearance techniques in chronic obstructive pulmonary disease and bronchiectasis: positive expiratory pressure or temporary positive expiratory pressure?
A retrospective study. Braz J Phys Ther. Comparison of intermittent positive pressure breathing and temporary positive expiratory pressure in patients with severe chronic obstructive pulmonary disease. Arch Bronconeumol. Comparison of effectiveness of temporary positive expiratory pressure versus oscillatory positive expiratory pressure in severe COPD patients. Clin Respir J. Effectiveness of temporary positive expiratory pressure T-PEP at home and at hospital in patients with severe chronic obstructive pulmonary disease.
J Thorac Dis. Efficacy of temporary positive expiratory pressure TPEP in patients with lung diseases and chronic mucus hypersecretion. Clin Rehabil. Free-Aspire: a new device for the management of airways clearance in patient with ineffective cough. Pediatr Rep. Management of bronchial secretions with Free Aspire in children with cerebral palsy: impact on clinical outcomes and healthcare resources. Ital J Pediatr. A pilot study on the non-invasive management of tracheobronchial secretions in tracheostomised patients.
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Non-invasive ventilation assists chest physiotherapy in adults with acute exacerbations of cystic fibrosis. Non-invasive ventilation for cystic fibrosis. CrossRef Full Text. Randomised placebo controlled trial of non-invasive ventilation for hypercapnia in cystic fibrosis.
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