SUMMARY OF
Chest
SupplementDiagnosis and Management of Cough: ACCP Evidence-Based Clinical Practice GuidelinesNonpharmacologic Airway Clearance Therapies: ACCP Evidence-Based Clinical Practice Guidelines
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
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