Airway Clearance Techniques

Patrick A. Flume

doi:10.1055/s-2004-815668

Seminars in Respiratory and Critical Care Medicine, Table of Contents

Semin Respir Crit Care Med 2003; 24(6): 727-736
DOI: 10.1055/s-2004-815668

Airway Clearance Techniques

Patrick A. Flume

Pediatrics and Medicine, Medical University of South Carolina, Charleston, South Carolina

Abstract

ABSTRACT

The airways of the patient with cystic fibrosis (CF) are chronically infected. There is excess mucus within the airways and, because of the chronic infection, the mucus also contains bacteria and inflammatory cells. Mucociliary clearance is impaired in patients with CF, and patients become dependent upon cough and other techniques to clear their airways of the thick sputum. This review discusses the various techniques and medications that have been demonstrated to be effective at assisting the clearance of the excess secretions in the CF airways. No single method has been proven to be better than the others, and not all patients will benefit, or use, the same techniques. Therefore, the methods of airway clearance must be tailored for each patient to assure effective therapy.

KEYWORDS

Cystic fibrosis - airway clearance - mucociliary clearance

Full Text

References

REFERENCES

1 King M, Rubin B K. Rheology of airway mucus: relationship with clearance function. In: Takashima T, Shimura S, eds. Airway Secretion: Physiological Bases for the Control of Mucus Hypersecretion New York: Marcel Dekker 1994: 283-314
2 Regnis J A, Robinson M, Bailey D L. et al . Mucociliary clearance in patients with cystic fibrosis and in normal subjects. Am J Respir Crit Care Med . 1994; 150 66-71
3 Pfleger A, Theissl B, Oberwaldner B. et al . Self-administered chest physiotherapy in cystic fibrosis: a comparative study of high-pressure PEP and autogenic drainage. Lung . 1992; 170 323-330
4 Miller S, Hall D O, Clayton C B. et al . Chest physiotherapy in cystic fibrosis: a comparative study of autogenic drainage and the active cycle of breathing techniques with postural drainage. Thorax . 1995; 50 165-169
5 Button B M, Heine R G, Catto-Smith A G. et al . Postural drainage and gastro-oesophageal reflux in infants with cystic fibrosis. Arch Dis Child . 1997; 76 148-150
6 Button B M, Heine R G, Catto-Smith A G. et al . Postural drainage in cystic fibrosis: is there a link with gastro-oesophageal reflux?. J Paediatr Child Health . 1998; 34 330-334
7 Vandenplas Y, Diericx A, Blecker U. et al . Esophageal pH monitoring data during chest physiotherapy. J Pediatr Gastroenterol Nutr . 1991; 13 23-26
8 Orenstein S R. Respiratory complications of reflux disease in infants. In: Stein MR, ed. Gastroesophageal Reflux Disease and Airway Disease New York: Marcel Dekker, 1999: 269-284
8a AARC Clinical Practice Guideline. Use of positive airway pressure adjuncts to bronchial hygiene therapy. American Association for Respiratory Care. Respir Care . 1993; 38 516-521
8b AARC Clinical Practice Guideline. Directed cough. American Association for Respiratory Care. Respir Care . 1993; 38 495-499
8c AARC Clinical Practice Guideline. Postural drainage therapy. American Association for Respiratory Care. Respir Care . 1991; 36 1418-1426
9 Partridge C, Pryor J, Webber B. Characteristics of the forced expiratory technique. Physiotherapy . 1989; 75 193-194
10 Hardy K A. A review of airway clearance: new techniques, indications, and recommendations. Respir Care . 1994; 39 440-455
11 Pryor J A, Webber B A. An evaluation of the forced expiration technique as an adjunct to postural drainage. Physiotherapy . 1979; 65 304-307
12 Pryor J A. The forced expiratory technique. In: Pryor J, ed. International Perspectives in Physical Therapy-7 Respiratory Care. Edinburgh: Churchill Livingstone 1991: 79-100
13 Chevaillier J. Autogenic drainage. In: Lawson D, ed. Cystic Fibrosis: Horizons Chichester: John Wiley 1984: 235
14 Andersen J B, Qvist J, Kann T. Recruiting collapsed lung through collateral channels with positive end-expiratory pressure. Scand J Respir Dis . 1979; 60 260-266
15 Paul W L, Downs J B. Postoperative atelectasis: intermittent positive pressure breathing, incentive spirometry, and face-mask positive end-expiratory pressure. Arch Surg . 1981; 116 861-863
16 Andersen J B, Jespersen W. Demonstration of intersegmental respiratory bronchioles in normal human lungs. Eur J Respir Dis . 1980; 61 337-341
17 McIlwaine P M, Wong L T, Peacock D. et al . Long-term comparative trial of conventional postural drainage and percussion versus positive expiratory pressure physiotherapy in the treatment of cystic fibrosis. J Pediatr . 1997; 131 570-574
18 Flume P A. Pneumothorax in cystic fibrosis. Chest . 2003; 123 217-221
19 Zach M, Oberwaldner B. Effect of positive expiratory pressure breathing in patients with cystic fibrosis [letter to the editor]. Thorax . 1992; 47 66-67
20 Konstan M W, Stern R C, Doershuk C F. Efficacy of the Flutter device for airway mucus clearance in patients with cystic fibrosis. J Pediatr . 1994; 124 689-693
21 Warwick W J, Hansen L G. The long-term effect of high-frequency chest compression therapy on pulmonary complications of cystic fibrosis. Pediatr Pulmonol . 1991; 11 265-271
22 Arens R, Gozal D, Omlin K J. et al . Comparison of high frequency chest compression and conventional chest physiotherapy in hospitalized patients with cystic fibrosis. Am J Respir Crit Care Med . 1994; 150 1154-1157
23 Hansen L G, Warwick W J. High-frequency chest compression system to aid in clearance of mucus from the lung. Biomed Instrum Technol . 1990; 24 289-294
24 Oldenburg Jr A F, Dolovich M B, Montgomery J M. et al . Effects of postural drainage, exercise, and cough on mucus clearance in chronic bronchitis. Am Rev Respir Dis . 1979; 120 739-745
25 Zach M, Oberwaldner B, Hausler F. Cystic fibrosis: physical exercise versus chest physiotherapy. Arch Dis Child . 1982; 57 587-589
26 Edlund L D, French R W, Herbst J J. et al . Effects of a swimming program on children with cystic fibrosis. Am J Dis Child . 1986; 140 80-83
27 Bilton D, Dodd M E, Abbot J V. et al . The benefits of exercise combined with physiotherapy in the treatment of adults with cystic fibrosis. Respir Med . 1992; 86 507-511
28 Baldwin D R, Hill A L, Peckham D G. et al . Effect of addition of exercise to chest physiotherapy on sputum expectoration and lung function in adults with cystic fibrosis. Respir Med . 1994; 88 49-53
29 Salh W, Bilton D, Dodd M. et al . Effect of exercise and physiotherapy in aiding sputum expectoration in adults with cystic fibrosis. Thorax . 1989; 44 1006-1008
30 Thomas J, Cook D J, Brooks D. Chest physical therapy management of patients with cystic fibrosis: a meta-analysis. Am J Respir Crit Care Med . 1995; 151 846-850
31 Prasad S A, Tannenbaum E L, Mikelsons C. Physiotherapy in cystic fibrosis. J R Soc Med . 2000; 93 27-36
32 Desmond K J, Schwenk W F, Thomas E. et al . Immediate and long-term effects of chest physiotherapy in patients with cystic fibrosis. J Pediatr . 1983; 103 538-542
33 Regelmann W E, Elliott G R, Warwick W J. et al . Reduction of sputum Pseudomonas aeruginosa density by antibiotics improves lung function in cystic fibrosis more than do bronchodilators and chest physiotherapy alone. Am Rev Respir Dis . 1990; 141 914-921
34 Coates A L. Chest physiotherapy in cystic fibrosis: spare the hand and spoil the cough?. J Pediatr . 1997; 131 506-508
35 Rubin B K. The pharmacologic approach to airway clearance: mucoactive agents. Respir Care . 2002; 47 818-822
36 Reas H W. The effect of N-acetylcysteine on the viscosity of tracheobronchial secretions. J Pediatr . 1963; 62 31-35
37 Denton R, Kwart H, Litt M. N-acetylcysteine in cystic fibrosis: mechanical and chemical factors in treatment by aerosol. Am Rev Respir Dis . 1967; 95 643-651
38 Duijvestijn Y C, Brand P L. Systematic review of N-acetylcysteine in cystic fibrosis. Acta Paediatr . 1999; 88 38-41
39 Howatt W F, DeMuth G R. A double-blind study of the use of acetylcysteine in patients with cystic fibrosis. Univ Mich Med Cent J . 1966; 32 82-85
40 Tecklin J S, Holsclaw Jr S D. Bronchial drainage with aerosol medications in cystic fibrosis. Phys Ther . 1976; 56 999-1003
41 Dano G. Bronchospasm caused by acetylcysteine in children with bronchial asthma. Acta Allergol . 1971; 26 181-190
42 Picot R, Das I, Reid L. Pus, deoxyribonucleic acid, and sputum viscosity. Thorax . 1978; 33 235-242
43 Smith A L, Redding G, Doershuk C. et al . Sputum changes associated with therapy for endobronchial exacerbation in cystic fibrosis. J Pediatr . 1988; 112 547-554
44 Lethem M I, James S L, Marriott C. et al . The origin of DNA associated with mucus glycoproteins in cystic fibrosis sputum. Eur Respir J . 1990; 3 19-23
45 Shak S. Aerosolized recombinant human DNase 1 for the treatment of cystic fibrosis. Chest . 1995; 107 S65-S70
46 Ramsey B W, Astley S J, Aitken M L. et al . Efficacy and safety of short-term administration of aerosolized recombinant human deoxyribonuclease in patients with cystic fibrosis. Am Rev Respir Dis . 1993; 148 145-151
47 Fuchs H J, Borowitz D S, Christiansen D H. et al . Effect of aerosolized recombinant human DNase on exacerbations of respiratory symptoms and on pulmonary function in patients with cystic fibrosis. The Pulmozyme Study Group. N Engl J Med . 1994; 331 637-642
48 McCoy K, Hamilton S, Johnson C. Effects of 12-week administration of dornase alfa in patients with advanced cystic fibrosis lung disease. Pulmozyme Study Group. Chest . 1996; 110 889-895
49 Robinson M, Regnis J A, Bailey D L. et al . Effect of hypertonic saline, amiloride, and cough on mucociliary clearance in patients with cystic fibrosis. Am J Respir Crit Care Med . 1996; 153 1503-1509
50 Eng P A, Morton J, Douglass J A. et al . Short-term efficacy of ultrasonically nebulized hypertonic saline in cystic fibrosis. Pediatr Pulmonol . 1996; 21 77-83
51 King M, Dasgupta B, Tomkiewicz R P. et al . Rheology of cystic fibrosis sputum after in vitro treatment with hypertonic saline alone and in combination with recombinant human deoxyribonuclease I. Am J Respir Crit Care Med . 1997; 156 173-177
52 Bennett W D. Effect of beta-adrenergic agonists on mucociliary clearance. J Allerg Clin Immunol . 2002; 110 (suppl 6) S291-S297
53 Sanderson M J, Dirksen E R. Mechanosensitive and beta-adrenergic control of the ciliary beat frequency of mammalian respiratory tract cells in culture. Am Rev Respir Dis . 1989; 139 432-440
54 Verdugo P, Johnson N T, Tam P Y. Beta-adrenergic stimulation of respiratory ciliary activity. J Appl Physiol Respir Environ Exerc Physiol . 1980; 48 868-871
55 Wanner A, Salathe M, O'Riordan T G. Mucociliary clearance in the airways. Am J Respir Crit Care Med . 1996; 154 1868-1902
56 Sturgess J, Reid L. An organ culture study of the effect of drugs on the secretory activity of the human bronchial submucosal gland. Clin Sci . 1972; 43 533-543
57 Shelhamer J H, Marom Z, Kaliner M. Immunologic and neuropharmacologic stimulation of mucous glycoprotein release from human airways in vitro. J Clin Invest . 1980; 66 1400-1408
58 Phipps R J, Nadel J A, Davis B. Effect of alpha-adrenergic stimulation on mucus secretion and on ion transport in cat trachea in vitro. Am Rev Respir Dis . 1980; 121 359-365
59 Webber S E, Widdicombe J G. The actions of methacholine, phenylephrine, salbutamol and histamine on mucus secretion from the ferret in-vitro trachea. Agents Actions . 1987; 22 82-85
60 Jones R, Reid L. Beta-agonists and secretory cell number and intracellular glycoproteins in airway epitheliumz: the effect of isoproterenol and salbutamol. Am J Pathol . 1979; 95 407-421
61 Widdicombe J H, Bastacky S J, Wu D X. et al . Regulation of depth and composition of airway surface liquid. Eur Respir J . 1997; 10 2892-2897
62 Davis B, Marin M G, Yee J W. et al . Effect of terbutaline on movement of Cl- and Na+ across the trachea of the dog in vitro. Am Rev Respir Dis . 1979; 120 547-552
63 Yeates D B, Aspin N, Levison H. et al . Mucociliary tracheal transport rates in man. J Appl Physiol . 1975; 39 487-495
64 Houtmeyers E, Gosselink R, Gayan-Ramirez G. et al . Effects of drugs on mucus clearance. Eur Respir J . 1999; 14 452-467
65 Mossberg B, Strandberg K, Philipson K. et al . Tracheobronchial clearance in bronchial asthma: response to beta-adrenoceptor stimulation. Scand J Respir Dis . 1976; 57 119-128
66 Wood R E, Wanner A, Hirsch J. et al . Tracheal mucociliary transport in patients with cystic fibrosis and its stimulation by terbutaline. Am Rev Respir Dis . 1975; 111 733-738
67 Mortensen J, Hansen A, Falk M. et al . Reduced effect of inhaled beta 2-adrenergic agonists on lung mucociliary clearance in patients with cystic fibrosis. Chest . 1993; 103 805-811
68 Avital A, Sanchez I, Chernick V. Efficacy of salbutamol and ipratropium bromide in decreasing bronchial hyperreactivity in children with cystic fibrosis. Pediatr Pulmonol . 1992; 13 34-37