Autogenic Drainage Research Articles

Techniques manuelles de drainage bronchique des adultes et adolescents : quel niveau de preuve ?

The aim of this systematic literature review was to grade the levels of evidence of the most widely used manual airway clearancetechniques. A literature search was conducted over the period 1995-2014from the Medline, PEDro, ScienceDirect, Cochrane Library, REEDOC and kinedoc databases, with the following keywords: "postural drainage", "manual vibrations", "manual chest percussion", "directed cough", "increased expiratory flow", "ELTGOL", "autogenic drainage" and "active cycle of breathing technique". Two-hundred and fifty-six articles were identified. After removing duplicates and reading the titles and abstracts, 63articles were selected, including 9systematic reviews. This work highlights the lack of useful scientific data and the difficulty of determining levels of evidence for manual airway clearance techniques. Techniques were assessed principally with patients with sputum production (cystic fibrosis, DDB, COPD, etc.). It also shows the limited pertinence of outcome measures to quantify congestion and hence the efficacy of airway clearance techniques. The 1994consensus conference summary table classifying airway clearance techniques according to physical mechanism provides an interesting tool for assessment, grouping together techniques having identical mechanisms of action. From the findings of the present systematic review, it appears that only ELTGOL, autogenic drainage and ACBT present levels of evidence "B". All other techniques have lower levels of evidence. II.

Chest physiotherapy compared to no chest physiotherapy for cystic fibrosis.

Chest physiotherapy is widely used in people with cystic fibrosis in order to clear mucus from the airways. This is an updated version of previously published reviews. To determine the effectiveness and acceptability of chest physiotherapy compared to no treatment or spontaneous cough alone to improve mucus clearance in cystic fibrosis. We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register which comprises references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings.Date of the most recent search of the Group's Cystic Fibrosis Trials Register: 02 June 2015. Randomised or quasi-randomised clinical studies in which a form of chest physiotherapy (airway clearance technique) were taken for consideration in people with cystic fibrosis compared with either no physiotherapy treatment or spontaneous cough alone. Both authors independently assessed study eligibility, extracted data and assessed the risk of bias in the included studies. There was heterogeneity in the published outcomes, with variable reporting which meant pooling of the data for meta-analysis was not possible. The searches identified 157 studies, of which eight cross-over studies (data from 96 participants) met the inclusion criteria. There were differences between studies in the way that interventions were delivered, with several of the intervention groups combining more than one treatment modality. One included study looked at autogenic drainage, six considered conventional chest physiotherapy, three considered oscillating positive expiratory pressure, seven considered positive expiratory pressure and one considered high pressure positive expiratory pressure. Of the eight studies, six were single-treatment studies and in two, the treatment intervention was performed over two consecutive days (once daily in one, twice daily in the other). This enormous heterogeneity in the treatment interventions prevented any meta-analyses from being performed. Blinding of participants, caregivers or clinicians in airway clearance studies is impossible; therefore this was not considered as a high risk of bias in the included studies. Lack of protocol data made assessment of risk of bias unclear for the majority of other criteria.Four studies, involving 28 participants, reported a higher amount of expectorated secretions during chest physiotherapy as compared to a control. One study, involving 18 participants, reported no significant differences in sputum weight. In five studies radioactive tracer clearance was used as an outcome variable. In three of these (28 participants) it was reported that chest physiotherapy, including coughing, increased radioactive tracer clearance as compared to the control period. One study (12 participants) reported increased radioactive tracer clearance associated with all interventions compared to control, although this was only reported to have reached significance for postural drainage with percussion and vibrations; and the remaining study (eight participants) reported no significant difference in radioactive tracer clearance between chest physiotherapy, without coughing, compared to the control period. Three studies, involving 42 participants reported no significant effect on pulmonary function variables following intervention; but one further study did report significant improvement in pulmonary function following the intervention in some of the treatment groups. The results of this review show that airway clearance techniques have short-term effects in the terms of increasing mucus transport. No evidence was found on which to draw conclusions concerning the long-term effects.

Improvement of upper limb’s condition of women with post mastectomy syndrome with the help of problem-oriented program of physical rehabilitation

Purpose: to determine effectiveness of problem-oriented program of women’s physical rehabilitation with post mastectomy syndrome in improvement of upper limb’s functional state. Material: 50 women with early symptoms of post mastectomy syndrome at stationary rehabilitation stage, who underwent radical mastectomy by Madden were involved in the research. Testing of movement amplitude in shoulder joint, swelling of upper limb and muscular strength of hand’s flexors was conducted on 2 nd day after surgery and at the end of stationary rehabilitation period (12-14 th day). Results: Main means of the authors’ program were: general and special physical exercises; static and dynamic breathing exercises; breathing through preloaded lips, controlled coughing, autogenic drainage, manual pressing, manual vibration; post-isometric relaxation; elements of labor therapy; lymphatic drainage massage and self massage; topical talks; consultations; auto training. The trainings were conducted individually 2-3 times a day; 20-30 minutes every session. The patients’ independent trainings included: fulfillment of therapeutic positions, self-massage, relaxation exercises and auto-training. Conclusions: application of problem-oriented physical rehabilitation program facilitates improvement of upper limb’s functional potentials of women with post mastectomy syndrome.

Effects of Autogenic Drainage on Sputum Recovery and Pulmonary Function in People with Cystic Fibrosis: A Systematic Review

To determine the effects of short- and long-term use of autogenic drainage (AD) on pulmonary function and sputum recovery in people with cystic fibrosis (CF). The authors conducted a systematic review of randomized and quasi-randomized clinical trials in which participants were people with CF who use AD as their sole airway clearance technique. Searches in 4 databases and secondary sources using 5 key terms yielded 735 articles, of which 58 contained the terms autogenic drainage and cystic fibrosis. Ultimately, 4 studies, 2 of which were long term, were included. All measured forced expiratory volume in 1 second (FEV1) and found no change. The long-term studies were underpowered to detect change in FEV1; however, the short-term studies found a clinically significant sputum yield (≥4g). AD has been shown to produce clinically significant sputum yields in a limited number of investigations. The effect of AD on the function of the pulmonary system remains uncertain, and questions have emerged regarding the appropriateness of FEV1 as a valid measure of airway clearance from peripheral lung regions. Further consideration should be given to the use of FEV1 as a primary measure of the effect of AD.

Comparison of Effects of Flutter Device versus Autogenic Drainage on Peak Expiratory Flow Rate, Oxygen Saturation, Respiratory Rate and Pulse Rate in COPD Patients

Purpose: To evaluate the effects of short term treatment of Flutter device and Autogenic Drainage (AD) in patients with chronic obstructive pulmonary disease (COPD).

Delivering intrapulmonary percussive ventilation physiotherapy with assisted autogenic drainage is associated with a lower incidence of ventilator-associated gram-negative infection

Chest physiotherapy is frequently provided to ICU patients but its role remains questionable. Intrapulmonary percussive ventilation physiotherapy with assisted autogenic drainage (IPV-AAD) is an emerging form of chest physiotherapy designed to enhance clearance of endobronchial secretions whilst enhancing alveolar recruitment.

Positive expiratory pressure physiotherapy for airway clearance in people with cystic fibrosis.

Chest physiotherapy is widely prescribed to assist the clearance of airway secretions in people with cystic fibrosis. Positive expiratory pressure (PEP) devices provide back pressure to the airways during expiration. This may improve clearance by building up gas behind mucus via collateral ventilation and by temporarily increasing functional residual capacity. Given the widespread use of PEP devices, there is a need to determine the evidence for their effect. This is an update of a previously published review. To determine the effectiveness and acceptability of PEP devices compared to other forms of physiotherapy as a means of improving mucus clearance and other outcomes in people with cystic fibrosis. We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register comprising of references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings. The electronic database CINAHL was also searched from 1982 to 2013.Most recent search of the Group's Cystic Fibrosis Trial Register: 02 December 2014. Randomised controlled studies in which PEP was compared with any other form of physiotherapy in people with cystic fibrosis. This included, postural drainage and percussion, active cycle of breathing techniques, oscillating PEP devices, thoracic oscillating devices, bilevel positive airway pressure (BiPaP) and exercise. Studies also had to include one or more of the following outcomes: change in forced expiratory volume in one second; number of respiratory exacerbations; a direct measure of mucus clearance; weight of expectorated secretions; other pulmonary function parameters; a measure of exercise tolerance; ventilation scans; cost of intervention; and adherence to treatment. Three authors independently applied the inclusion and exclusion criteria to publications and assessed the risk of bias of the included studies. A total of 26 studies (involving 733 participants) were included in the review. Eighteen studies involving 296 participants were cross-over in design. Data were not published in sufficient detail in most of these studies to perform any meta-analysis. These studies compared PEP to active cycle of breathing techniques (ACBT), autogenic drainage (AD), oral oscillating PEP devices, high frequency chest wall oscillation (HFCWO) and Bi level PEP devices (BiPaP) and exercise.Forced expiratory volume in one second was the review's primary outcome and the most frequently reported outcome in the studies. Single interventions or series of treatments that continued for up to three months demonstrated no significant difference in effect between PEP and other methods of airway clearance on this outcome. However, long-term studies had equivocal or conflicting results regarding the effect on this outcome. A second primary outcome was the number of respiratory exacerbations. There was a lower exacerbation rate in participants using PEP compared to other techniques when used with a mask for at least one year. Participant preference was reported in 10 studies; and in all studies with an intervention period of at least one month, this was in favour of PEP. The results for the remaining outcome measures were not examined or reported in sufficient detail to provide any high-level evidence. The only reported adverse event was in a study where infants performing either PEP or postural drainage with percussion experienced some gastro-oesophageal reflux. This was more severe in the postural drainage with percussion group. Many studies had a risk of bias as they did not report how the randomisation sequence was either generated or concealed. Most studies reported the number of dropouts and also reported on all planned outcome measures. Following meta-analyses of the effects of PEP versus other airway clearance techniques on lung function and patient preference, this Cochrane review demonstrated that there was a significant reduction in pulmonary exacerbations in people using PEP compared to those using HFCWO in the study where exacerbation rate was a primary outcome measure. It is important to note, however, that there may be individual preferences with respect to airway clearance techniques and that each patient needs to be considered individually for the selection of their optimal treatment regimen in the short and long term, throughout life, as circumstances including developmental stages, pulmonary symptoms and lung function change over time. This also applies as conditions vary between baseline function and pulmonary exacerbations.However, meta-analysis in this Cochrane review has shown a significant reduction in pulmonary exacerbations in people using PEP in the few studies where exacerbation rate was a primary outcome measure.

164 Autogenic drainage and assisted autogenic drainage in children with cystic fibrosis: A systematic review

Chest physiotherapy is considered an essential part of symptomatic, multidisciplinary management in cystic fibrosis (CF), as it facilitates clearance of viscous pulmonary secretions. Objectives To determine the effect of autogenic drainage (AD) and assisted autogenic drainage (AAD) compared to no; sham; or other types of chest physiotherapy in children with CF. Methods Six databases, clinicaltrials.gov and pactr.org were searched. We included randomized controlled trials, quasi-randomized controlled trials and randomized cross-over trials on AD and AAD in children younger than 18 years, diagnosed with CF. One author conducted the database search. Titles, abstracts and data were evaluated by two independent reviewers with agreement by discussion and consensus. Results A total of 126 titles were screened, of which seven were eligible. However, only two studies made a clear distinction between pediatric (ntotal = 47; n1 = 36 & n2 = 9) and adult data, and were therefore analyzed. We were unable to perform a meta-analysis, as only one study clearly indicated separate results for the different periods of the cross-over. Based on the pediatric data of this one study, participants who received AD had a significant improvement in Huang scores; a tendency to have fewer hospital admissions during one year when compared to postural drainage; and a clear preference for AD by participants. One other study reported pediatric data, however no significance levels were provided. Conclusion Due to the lack of pediatric-specific randomized controlled trials, small sample sizes and unclear risk of bias of most studies, we were unable to determine the efficacy and/or safety of AD and AAD in children with CF.

WS21.1 Evaluation of the use of IPV for the treatment of atelectasis in cystic fibrosis

While the majority of CF patients respond to any of the recognized airway clearance techniques (ACT), there are occasions where a specific ACT may prove more beneficial than others. Objectives We hypothesised that Intra Pulmonary Pressure Ventilation (IPV) would be an effective ACT in CF patients who have significant areas of atelectasis. Methods We report here a series of 3 CF patients with significant segmental atelectasis despite good adherence. Patients A, B and C were initially treated with an intensive airway clearance regimen of both positive expiratory pressure and autogenic drainage with no improvement. Patients A and B had bronchoscopies with no improvement. IPV was initiated as an out-patient in patient A, and as an in-patient in patients B and C. Patient C had previously been admitted to hospital for IV antibiotics with no resolution of atelectasis. Pulmonary function and chest radiographs (CXR) were performed prior to and post treatment. CXRs were objectively measured using the Brasfield score. Results All 3 patients had significant improvement in both their CXR and FEV1 (Table 1). Each patient tolerated IPV well with no adverse effects. Table 1 . Change in CXR and FEV1 pre and post treatment Patient Age (yrs) Area of atelectasis Brasfield score pre Brasfield score post FEV1 pre FEV1 post A 17 RLL 19/25 22/25 99% 105% B 15 RML 13/25 18/25 59% 79% C 14 L Lingula and RLL 15/25 20/25 76% 83% Conclusion This series of case studies demonstrates that IPV is an effective airway clearance tool in a select group of CF patients and it shows the need to individualise the ACT to the underlying pathology. There have only been a few short-term studies using IPV with mixed results, further studies are needed.

161 The effect of a short-stay revalidation program on lung function parameters and weight

Introduction Lung function and weight evolution are important parameters in the follow-up of health condition in CF patients. Objectives Aim of this study was to investigate the influence of a 4-week multicomponent rehabilitation program on lung function (FEV1, FVC, LCI and Sraw) and weight in adolescent and adult cystic fibrosis patients. Methods 49 CF-patients (22.4±8.7 y, 34/15 m/f) admitted in 2013 to a CF-rehabilitation centre received a 4-week treatment program consisting of individually adapted intensive physiotherapy (Autogenic Drainage, sports), simultaneously increasing caloric food-intake, medication adherence, social contacts with adapted psycho-educational interventions for each component. Parameters for lung function (FEV1, FVC, Sraw and LCI) were retrospectively analysed. Weight was measured on a calibrated balance. Results Residential short-time treatment significantly improved FEV1 (N = 49) (mean 60.5±23.5 vs 65.3±22, p Conclusion A short-treatment regimen consisting of supervised exercise training and AD was effective in improving lung function and weight.

English

English

Effectiveness of Autogenic Drainage Versus Postural Drainage on Oxygen Saturation in Patients with Chronic Bronchitis with 15 Minutes Post Therapy

Background : Patients with COPD will have more amount of secretions. To clear the secretions by using of different bronchial hygiene techniques like postural drainage and autogenic drainage technique, manual hyperventilation technique ,active cycle breathing technique .Hence in this study to compare the short-term effects of postural drainage with clapping (PD) and autogenic drainage (AD) on level of oxygen saturation in blood, and amount of sputum recovery. Methodology : The study was done on 60 patients with COPD. Dividing Patients into two group and patients were treated with PD or AD in separate Groups. The effectiveness of the treatment was measured up to 6 days. Pulse oximetry was monitored and sputum was collected immediately after treatment and 15 minutes following each treatment. Results : The results of the study shown that there was significant difference in the amount of sputum recovered with AD (14.0±3.5 g) vs PD (24.4±3.0 g) and significant differences in Oxygen saturation; during PD fell from 93.3±0.7% to 91.2±0.8% (p<0.01) and required 15 min following treatment to return to baseline. Oxygen saturation did not fall during AD and increased to gradually following complete treatment days (baseline, 93.3±0.8%; p<0.01). Conclusion : Hence this study concludes that Autogenic drainage is more effective in improving spo2 in COPD & does not cause a sudden fall in spo2 as occurs in Postural drainage immediately after therapy. And it can be better tolerated by patients with COPD while producing fewer benefits in sputum clearance. In concern to mean amount of secretion removal Postural is found to be more effective

Physiotherapy and cystic fibrosis: what is the evidence base?

To provide a comprehensive overview and evidence to support the role of physiotherapy in the management of individuals with cystic fibrosis (CF) including airway clearance, exercise, and musculoskeletal concerns which can affect activities of daily living and respiratory health. Several long-term studies have looked at the efficacy of airway clearance techniques, including active cycle of breathing techniques, autogenic drainage, high frequency chest wall oscillation, postural drainage, positive expiratory pressure (PEP), and oscillating PEP. Each of these studies reported some efficacy of airway clearance in maintaining health with no one technique being superior to another. However, one study suggested that high frequency chest wall oscillation was not as effective as PEP in maintaining health in CF patients. Individual preference needs to be considered when selecting a technique. Recent studies have found exercise to increase mucociliary clearance peripherally. Musculoskeletal issues, including posture, bone density, urinary incontinence, and pain should be assessed and managed in individuals to improve the mechanics of breathing and overall well-being. The role of physiotherapy in CF is complex and includes airway clearance, exercise, and management of the long-term sequelae of musculoskeletal issues. More rigorous physiotherapy studies are required to assist with evidence based practice.

Prática fisioterapêutica no tratamento da fibrose cística

A fibrose cística (FC), denominada também de mucoviscidose, é uma doença genética do tipo autossômica recessiva que acomete principalmente crianças e indivíduos de raça branca. O objetivo deste estudo foi propiciar uma visão sobre a FC, assim como as possíveis formas de tratamento fisioterapêutico. A pesquisa da literatura foi realizada nas bases de dados SciELO e PubMed, no período de abril de 2002 a março de 2013, através da seleção de artigos científicos referentes à FC, utilizando como palavras-chave: “fibrose cística”, “fisioterapia em fibrose cística” e “fisioterapia respiratória”. Por meio desta revisão, pôde-se observar que, apesar da complexidade da doença, a prática fisioterapêutica, com o uso das técnicas: tapotagem, vibração, drenagem postural (DP), huffing, oscilação oral de alta frequência (OOAF), drenagem autógena (DA) e o ciclo ativo da respiração (CAR), apresenta eficácia tanto no tratamento como na manutenção da qualidade de vida dos pacientes com FC.

WS14.4 Analysis of expiratory flow rates used in autogenic drainage. Are they sufficiently high to mobilize secretions?

WS14.4 Analysis of expiratory flow rates used in autogenic drainage. Are they sufficiently high to mobilize secretions?

Chest physiotherapy techniques in neurological intensive care units of India: A survey.

Context:Neurological intensive care units (ICUs) are a rapidly developing sub-specialty of neurosciences. Chest physiotherapy techniques are of great value in neurological ICUs in preventing, halting, or reversing the impairments caused due to neurological disorder and ICU stay. However, chest physiotherapy techniques should be modified to a greater extent in the neurological ICU as compared with general ICUs.Aim:The aim of this study is to obtain data on current chest physiotherapy practices in neurological ICUs of India.Settings and Design:A tertiary care hospital in Karnataka, India, and cross-sectional survey.Subjects and Methods:A questionnaire was formulated and content validated to assess the current chest physiotherapy practices in neurological ICUs of India. The questionnaire was constructed online and a link was distributed via E-mail to 185 physiotherapists working in neurological ICUs across India.Statistical Analysis Used:Descriptive statistics.Results:The response rate was 44.3% (n = 82); 31% of the physiotherapists were specialized in cardiorespiratory physiotherapy and 30% were specialized in neurological physiotherapy. Clapping, vibration, postural drainage, aerosol therapy, humidification, and suctioning were used commonly used airway clearance (AC) techniques by the majority of physiotherapists. However, devices for AC techniques such as Flutter, Acapella, and standard positive expiratory pressure devices were used less frequently for AC. Techniques such as autogenic drainage and active cycle of breathing technique are also frequently used when appropriate for the patients. Lung expansion therapy techniques such as breathing exercises, incentive spirometry exercises, and positioning, proprioceptive neuromuscular facilitation of breathing are used by majority of physiotherapists.Conclusions:Physiotherapists in this study were using conventional chest physiotherapy techniques more frequently in comparison to the devices available for AC.

Adherence to Airway Clearance Therapies by Adult Cystic Fibrosis Patients

Airway clearance therapy (ACT) is critical in cystic fibrosis (CF). To determine rates of self-reported adherence to ACT by patients treated in an adult CF program, to identify patient characteristics associated with poor adherence, to typify adherence according to ACT technique, and to indicate reasons for poor adherence. Our cross-sectional study included CF subjects age 16 years and older. Enrollees were evaluated via general structured questionnaire, adherence questionnaire, clinical assessment, spirometry, and S(pO(2)) values. Each was stratified by self-reporting protocol as high, moderate, or poor adherence to ACT. Concordance between physiotherapist recommended ACT technique and self-reported subject adherence was subjected to agreement analysis. Of the 63 subjects studied, 38 (60%) qualified as high adherence, 12 (19%) as moderate adherence, and 13 (21%) as poor adherence. Logistic regression identified education level (less than high school) as an independent factor associated with poor adherence (odds ratio 10.2, 95% CI 1.23-84.7, P = .03). Positive expiratory pressure (κ = 0.87) and flutter device (κ = 0.63) usage both corresponded with a high level of agreement, while active cycle of breathing technique (κ = 0.40) and autogenic drainage (κ = 0.39) each showed moderate agreement. Agreement was low for percussion and postural drainage (κ = 0.23). Reasons given most frequently for poor adherence to ACT were "not enough time to do ACT" (28%), "cannot be bothered" (16%), and "do not enjoy ACT technique" (8%). Many (32%) provided no reason. Study outcomes showed a high rate of ACT adherence in adult CF subjects. Lower level of education was the most important factor in poor adherence to ACT. Self-reported adherence and treatment recommendations were in best agreement with positive expiratory pressure and flutter device techniques.

245 Audit of accepted hypertonic saline concentration in children with cystic fibrosis

Background: Inhalation of hypertonic saline 6% (HS) improves mucociliary transport on short time basis in CF patients and is also proven to be a safe and low cost intervention. Autogenic Drainage (AD) is an effective airway clearance technique, experienced as very comfortable by CF patients. The aim of this study is to evaluate the efficacy of an AD treatment combined with inhalation of HS. It will also be examined if it is more efficient to inhale the HS before or during the AD session, and if the interventions are safe and comfortable. Methods: In this randomized, clinical cross-over study, 12 hospitalised CF patients >14yrs of age, received 3 therapy regimens in 3 consecutive days: inhalation of HS (4ml of NaCl 6%) during AD (30min), inhalation of HS (4ml of NaCl 6%) before AD (HS pre AD), and AD only (30min). Before and after each session, oxygen saturation (SaO2), heart frequency (HF) and dyspnoea were measured and wet sputum was collected and weighed. Results: Patients significantly coughed up more sputum during treatments where AD was combined with HS (“AD+HS” and “HS pre AD”) compared to the AD treatment without HS (respectively 20.4±9.6 and 20.6± vs. 15.2±9.3 g; respectively p = 0.01 and p = 0.028). There was no significant difference in wet sputum weight between “HS+AD” and “HS pre AD” (p = 0.942). For SaO2, HF and dyspnoea, no significant differences were found before and after treatments. Conclusion: By inhaling HS during AD, the duration of treatment can be shortened and the compliance improved without a loss of efficiency in sputum clearance. This intervention has proven to be safe and comfortable.

244* Influence of inhaled hypertonic saline (NaCI 6%) before or during autogenic drainage on sputum weight, oxygen saturation, heart frequency and dyspnoea in cystic fibrosis patients

244* Influence of inhaled hypertonic saline (NaCI 6%) before or during autogenic drainage on sputum weight, oxygen saturation, heart frequency and dyspnoea in cystic fibrosis patients

Airway Clearance in COPD: Need for a Breath of Fresh Air? A Systematic Review

Background: Airway clearance is a key component of respiratory physiotherapy management for patients with excess secretions, including patients with chronic obstructive pulmonary disease (COPD). The aim of this review is to give an overview of the available evidence for the use of different airway clearance techniques (ACT) and their effects in patients with COPD. Methods: A systematic literature search was performed on CEBAM, PUBMED, Cochrane CT, Science Direct and Biomed central data bases. After screening, a total of 26 articles were included. Results: Studies that provide solid evidence of the effectiveness of different airway clearance techniques in patients with COPD are rather scarce. The available evidence indicates that active breathing techniques, such as active cycle of breathing techniques, autogenic drainage and forced expiration, can be effective in the treatment of COPD. The evidence for passive techniques such as postural drainage and percussion is low. Supporting techniques such as intrapulmonary percussive ventilation, positive expiratory pressure and non-invasive ventilation have little evidence because of the small number of studies. Little evidence is found for the combined use of active techniques and supporting techniques such as (oscillating) positive expiratory pressure, postural drainage and vibration in COPD patients. There is clearly a need for well-powered controlled clinical trials on the long-term effects of (combined) airway clearance techniques in COPD.