Chest
Volume 129, Issue 1, Supplement, January 2006, Pages 250S-259S
Journal home page for Chest

Supplement
Diagnosis and Management of Cough: ACCP Evidence-Based Clinical Practice Guidelines
Nonpharmacologic Airway Clearance Therapies: ACCP Evidence-Based Clinical Practice Guidelines

https://doi.org/10.1378/chest.129.1_suppl.250SGet rights and content

Background:

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

Method:

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

Results:

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

Conclusions:

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

Section snippets

Chest Physiotherapy (Percussion, Postural Drainage, and Vibration)

Physical therapy techniques have been employed alone and in combination to facilitate airways clearance and to render cough more effective. The systematic review of randomized controlled trials assessing the effects of these techniques on cough are summarized in Table 1; they include postural drainage1, 2, 3, 4, 5, 6, 7 as well as percussion, vibration,8, 9, 10, 11 and shaking of the chest wall. Taken together, these maneuvers can be grouped under the term chest physiotherapy and are long

RECOMMENDATION

1. In patients with CF, chest physiotherapy is recommended as an effective technique to increase mucus clearance, but the effects of each treatment are relatively modest and the long-term benefits unproven. Level of evidence, fair; benefit, small; grade of recommendation, C

RECOMMENDATIONS

2. In patients with expiratory muscle weakness, manually assisted cough should be considered to reduce the incidence of respiratory complications. Level of evidence, low; benefit, small; grade of recommendation, C

3. In persons with airflow obstruction caused by disorders like COPD, manually assisted cough may be detrimental and should not be used. Level of evidence, low; benefit, negative; grade of recommendation, D

UNASSISTED TECHNIQUES

The questionable efficacy of chest physiotherapy, together with the undesirable qualities of needing an assistant, inconvenience, discomfort, and the likelihood that long-term compliance is less than optimal led to the study of techniques that were designed to either enhance the results of standard chest physiotherapy or produce comparable results with less rigorous demands on patient time and effort.

RECOMMENDATION

4. In patients with COPD and CF, huffing should be taught as an adjunct to other methods of sputum clearance. Level of evidence, low; benefit, small; grade of recommendation, C

RECOMMENDATION

5. In patients with CF, autogenic drainage should be taught as an adjunct to postural drainage as a method to clear sputum because it has the advantage of being performed without assistance and in one position. Level of evidence, low; benefit, small; grade of recommendation, C

RECOMMENDATION

6. In patients with neuromuscular weakness and impaired cough, expiratory muscle training is recommended to improve peak expiratory pressure, which may have a beneficial effect on cough. Level of evidence, expert opinion; benefit, small; grade of recommendation, E/C

DEVICES

Many devices have been investigated in an attempt to augment the beneficial effects of conventional chest physiotherapy or to allow the patient to achieve these benefits without assistance. Most of these studies were performed in patients with CF, and most compared the effects of treatment with the device with conventional physiotherapy, or the effects of the device in addition to physiotherapy. These studies have not directly addressed the efficacy of self-administered therapy, as study

RECOMMENDATION

7. In patients with CF, PEP is recommended over conventional chest physiotherapy because it is approximately as effective as chest physiotherapy, and is inexpensive, safe, and can be self-administered. Level of evidence, fair; benefit, intermediate; grade of recommendation, B

In the only outcome study to evaluate the impact of PEP therapy in patients with chronic bronchitis, Christensen and colleagues53 investigated whether PEP therapy was a useful adjunct to “self-administered diaphragmatic

RECOMMENDATION

8. In patients with CF, devices designed to oscillate gas in the airway, either directly or by compressing the chest wall, can be considered as an alternative to chest physiotherapy. Level of evidence, low; benefit, conflicting; grade of recommendation, I

RECOMMENDATION

9. In patients with neuromuscular disease with impaired cough, mechanical cough assist devices are recommended to prevent respiratory complications. Level of evidence, low; benefit, intermediate; grade of recommendation, C

CONCLUSION

The limited data available indicate that in patients with copious secretions (and especially those with CF), the clearance of secretions as assessed by either sputum volume or radioaerosol clearance can be enhanced with a variety of physical therapy procedures and devices. Postural drainage may augment forced exhalation, but the additional value of percussion and vibration are questionable. PEP therapy provides benefits that are comparable to those of forced expiration and postural drainage in

RECOMMENDATION

10. The effect of nonpharmacologic airway clearance techniques on long-term outcomes such as health-related quality of life and rates of exacerbations, hospitalizations, and mortality is not known at this time. The committee recommends that future investigations measure these outcomes in patients with CF, and in other populations with bronchiectasis, COPD, and neuromuscular diseases. Level of evidence, expert opinion; benefit, substantial; grade of recommendation, E/A

SUMMARY OF

REFERENCES (69)

  • EM App et al.

    Sputum rheology changes in cystic fibrosis lung disease following two different types of physiotherapy: flutter vs autogenic drainage

    Chest

    (1998)
  • JE Natale et al.

    Comparison of intrapulmonary percussive ventilation and chest physiotherapy: a pilot study in patients with cystic fibrosis

    Chest

    (1994)
  • TA Scherer et al.

    Effect of high-frequency oral airway and chest wall oscillation and conventional chest physical therapy on expectoration in patients with stable cystic fibrosis

    Chest

    (1998)
  • AC Tzeng et al.

    Prevention of pulmonary morbidity for patients with neuromuscular disease

    Chest

    (2000)
  • LJ Miske et al.

    Use of the mechanical in-exsufflator in pediatric patients with neuromuscular disease and impaired cough

    Chest

    (2004)
  • RJ Jaeger et al.

    Cough in spinal cord injured patients: comparison of three methods to produce cough

    Arch Phys Med Rehabil

    (1993)
  • SH Linder

    Functional electrical stimulation to enhance cough in quadriplegia

    Chest

    (1993)
  • CM Rossman et al.

    Effect of chest physiotherapy on the removal of mucus in patients with cystic fibrosis

    Am Rev Respir Dis

    (1982)
  • SM Varekojis et al.

    A comparison of the therapeutic effectiveness of and preference for postural drainage and percussion, intrapulmonary percussive ventilation, and high-frequency chest wall compression in hospitalized cystic fibrosis patients

    Respir Care

    (2003)
  • MI Lorin et al.

    Evaluation of postural drainage by measurement of sputum volume and consistency

    Am J Phys Med

    (1971)
  • L Lannefors et al.

    Mucus clearance with three chest physiotherapy regimes in cystic fibrosis: a comparison between postural drainage, PEP and physical exercise

    Eur Respir J

    (1992)
  • PP Sutton et al.

    Chest physiotherapy: a review

    Eur J Respir Dis

    (1982)
  • M Maxwell et al.

    Comparative trial of manual and mechanical percussion technique with gravity-assisted bronchial drainage in patients with cystic fibrosis

    Arch Dis Child

    (1979)
  • PH Weller et al.

    Short-term effects of chest physiotherapy on pulmonary function in children with cystic fibrosis

    Respiration

    (1980)
  • JRM Bateman et al.

    Is cough as effective as chest physiotherapy in removal of excessive tracheobronchial secretions?

    Thorax

    (1981)
  • C DeBoeck et al.

    Cough versus chest physiotherapy: a comparison of the acute effects on pulmonary function in patients with cystic fibrosis

    Am Rev Respir Dis

    (1984)
  • P Anthonisen et al.

    The value of lung physiotherapy in the treatment of acute exacerbations in chronic bronchitis

    Acta Med Scand

    (1964)
  • LH Kirilloff et al.

    Does chest physical therapy work?

    Chest

    (1988)
  • D Pavia

    The role of chest physiotherapy in mucus hypersecretion

    Lung

    (1990)
  • J Thomas et al.

    Chest physical therapy management of patients with cystic fibrosis

    Am J Respir Crit Care Med

    (1995)
  • A Pfleger et al.

    Self-administered chest physiotherapy in cystic fibrosis: a comparative study of high-pressure PEP and autogenic drainage

    Lung

    (1992)
  • M Falk et al.

    Improving the ketchup bottle method with positive expiratory pressure PEP, in cystic fibrosis

    Eur J Respir Dis

    (1984)
  • CP van Der Schans et al.

    Effect of manual percussion on tracheobronchial clearance in patients with chronic airflow obstruction and excessive tracheobronchial secretion

    Thorax

    (1986)
  • C Braggion et al.

    Short-term effects of three chest physiotherapy regimens in patients hospitalized for pulmonary exacerbations of cystic fibrosis: a cross-over randomized study

    Pediatr Pulmonol

    (1995)
  • Cited by (182)

    • Pulmonological issues

      2022, Current Problems in Pediatric and Adolescent Health Care
    • Acute Lobar Atelectasis

      2019, Chest
      Citation Excerpt :

      Vest vibration can be applied during spontaneous breathing or superimposed on conventional ventilation but is not well tolerated by many hospitalized patients or effectively applied in most patients with major chest deformation, burns, or rib fractures. Chest pummeling during postural drainage (“stir-up” regimens), entrenched components of physiotherapy, and prophylaxis127,128 lack convincing documentation of effectiveness.95,97,109,129,130 ALA is a predictable, readily diagnosed, and pathogenic companion to acute illness, postoperative care, and chronic debility.

    View all citing articles on Scopus

    Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/misc/reprints.shtml).

    View full text