Clearance Of Airway Secretions Research Articles

Upper Airway and Translaryngeal Resistance During Mechanical Insufflation-Exsufflation

Mechanical insufflation-exsufflation (MI-E) uses positive and negative pressures to assist weak cough and help clear airway secretions. Laryngeal visualization during MI-E has revealed that inappropriate upper airway responses can impede its efficacy. However, the dynamics of pressure transmission in the upper airways during MI-E is unclear, as are the relationships between anatomical structure, pressure and airflow. Can airflow resistance through the upper airway and the larynx feasibly be calculated during MI-E, and if so, how are the pressures transmitted to the trachea? Cross-sectional study of ten healthy adults, where MI-E was provided with and without active cough, employing pressure settings +20/-40 and ±40 cmH2O. Airflow and pressure at the level of the facemask were measured using a pneumotachograph, while pressure transducers (positioned via transnasal fiberoptic laryngoscopy) recorded pressures above the larynx and within the trachea. Upper airway resistance (Ruaw) and translaryngeal resistance (Rtl) were calculated (cmH2O/L/sec) and compared to direct observations via laryngoscopy. Positive pressures reached the trachea effectively, while negative tracheal pressures during exsufflation were approximately half of the intended settings. Insufflation pressure increased slightly when passing through the larynx. Participant effort influenced tracheal pressures and the resistances, with findings consistent with laryngoscopic observations. During MI-E, resistance appears dynamic, with Ruaw exceeding Rtl. Inappropriate laryngeal closure increased Rtl during both positive and negative pressures. Upper airway and translaryngeal resistance can feasibly be calculated during MI-E. The findings indicate different transmission dynamics for positive and negative pressures, and that resistances are influenced by participant effort. The findings support using lower insufflation pressures and higher negative pressures in clinical practice.

Expert consensus on clinical application of mechanical airway clearance techniques

Mechanical airway clearance techniques refer to the therapeutic method of using mechanical means to clear airway secretions and maintain airway patency. Currently, mechanical airway clearance techniques are widely used in clinical practice and have significant effects in clearing respiratory secretions, improving symptoms of respiratory distress, and preventing and reducing respiratory tract infections. However, up to now, there is no consensus, guidance, or standardized procedures for the clinical application of mechanical airway clearance techniques. Therefore, the Respiratory Care Group of Chinese Thoracic Society organized relevant experts to write the consensus on the clinical application of mechanical airway clearance techniques, and systematically describe the definition, historical development, working principles and mechanisms, and clinical applications of mechanical airway clearance techniques. The aim is to increase awareness of mechanical airway clearance techniques, to provide clinical practitioners with standardized procedures for the application of mechanical airway clearance techniques, and to guide the standardized clinical practice.

Effect of different endotracheal suctioning methods on clearance of airway secretions in patients with craniocerebral injury and tracheotomy

Effect of different endotracheal suctioning methods on clearance of airway secretions in patients with craniocerebral injury and tracheotomy

Effectiveness of video assisted teaching on knowledge and practice regarding suctioning of children on mechanical ventilator among nurses working in paediatric department

Background: Airway secretion clearance is a normal process that is essential for preventing respiratory infections, atelectasis, pulmonary haemorrhage and maintaining airway patency. In order to ensure this, effective and safe suction is necessary. Thus, endotracheal suctioning removes secretions which gets accumulated in the endotracheal tube through using negative suction pressure. The study aimed to assess the effectiveness of video assisted teaching on knowledge and practice regarding suctioning of children on mechanical ventilator among nurses working in pediatric department. Methods: Data were collected with the help of demographic-profile, Self-Structured knowledge questionnaire and Rating scale tool from 38 samples using Purposive sampling technique who met the inclusion criteria. The pretest data collected before intervention and post-test data collected after one week of video assisted teaching. Results: The result revealed that post intervention knowledge score was found to be more (20.44±2.68) than pre intervention knowledge score (14.31±2.77), t=9.19. Post intervention attitude score was found to be more (26.86±3.30) than pre intervention attitude score (18.52±3.68), t=8.17 at 0.05 level of significance. Conclusions: These findings revealed that the video assisted teaching programme on knowledge and practice was effective.

High-frequency chest wall oscillation multiple times daily can better reduce the loss of pulmonary surfactant and improve lung compliance in mechanically ventilated patients

BackgroundHigh-frequency chest wall oscillation (HFCWO) has been widely recognized for its airway secretion clearance effectiveness in critically ill ICU patients. ObjectivesThe purpose of this randomized controlled trial is to validate and compare the effects of different frequencies of HFCWO on oxygenation, lung compliance, and pulmonary surfactant proteins (SPs) in critically ill patients admitted to the intensive care unit (ICU). MethodsSixty patients with severe craniocerebral injury treated with a tracheostomy and mechanical ventilation were randomized into three groups (20 patients in each group): a single group (treated with 30 minutes of HFCWO once daily) and a double group (treated with 30 minutes of HFCWO twice daily), and a blank group (treated without HFCWO). Primary outcome measures included results on several specific proteins (SP-A, SP-B, SP-C, and SP-D) in serum and alveolar lavage fluid. Secondary outcome measures were lung static compliance test and oxygenation. ResultsPatients in both the single and double groups exhibited significant oxygenation and static compliance improvement. Similar results were observed in changes in SPs concentrations in the alveolar lavage fluid. However, a significant reduction of SPs levels was observed in the serum. In the group comparison analysis for the same variables between the single and double group, twice daily HFCWO treatments showed a significantly better result. ConclusionCompared with HFCWO once daily, HFCWO twice daily is advantageous in patients with tracheostomy and prolonged ventilation, which demonstrated significantly greater effectiveness in improving oxygenation and lung static compliance linked to the increase of and SPs contents in the airways as well as a reduction of SPs shift from airways to the blood.

Pulmonological issues

Pediatric leukodystrophies are rare neurodegenerative diseases involving multiple systems. Each form has unique neurologic features but are characterized by encephalopathy with accompanying impairments evidenced in reflexes, muscle tone and movement control. Weakness of expiratory, inspiratory, and upper airway muscles may lead to impaired airway secretion clearance resulting in recurrent respiratory infections, dysphagia, sleep-disordered breathing, restrictive lung disease, and ultimately chronic respiratory insufficiency.

Mechanical insufflation–exsufflation to facilitate ventilator weaning and possible decannulation for patients with encephalopathic conditions

BackgroundClinicians are often faced with apparently tracheostomy mechanical ventilation dependent (TMV), patients who are ventilator unweanable due to encephalopathic/upper motor neuron conditions, that hamper return to the community. ObjectivesA protocol is suggested to wean these patients from mechanical ventilation and criteria offered for possible decannulation. MethodsAfter excluding patients with severe muscle weakness due to neuromuscular diseases and high level spinal cord disorders, consecutive, apparently unweanable and unresponsive encephalopathic patients were to be weaned by a protocol that first normalized CO2 levels at full ventilatory support settings. Then, supplemental oxygen was discontinued so that ambient air baseline oxyhemoglobin saturation (O2 Sat) could be determined and subsequently be normalized by using mechanical insufflation–exsufflation (MIE), at 60–70 cmH2O pressures, via the tubes every 2 hours, with the tube cuffs inflated. Once ambient air O2 Sat levels remained normal, ambient air spontaneous, unassisted autonomous breathing “sprints” were initiated and continued until O2 Sat decreased below 95% with respiratory distress. Patients spontaneously moving over 300 mL of air into their lungs without pressure support had very good prognoses for rapid ventilator weaning. Patients were not returned to TMV irrespective of tachypnea. After the “sprint”, they were rested by using 1–3 hours of full ventilatory support before the next sprint. Sprints lengthened until being fully weaned. After weaning, potential decannulation was evaluated using MIE expiratory flows (MIE-EF) and O2 Sat. ResultsO2 Sat normalized from the initial use of MIE via the tube for 7 of 13 patients then 4 weaned from the initial ambient air sprint. Weaning occurred in 4 days or less for 11 of 13. Despite continuous TMV dependence for 31 days to 15 months before the intervention, 7 weaned patients were successfully decannulated, 6 of the 7 with MIE-EF ≥ 190 L/m. All but 2 remained unresponsive, but 6 were discharged home to their families once decannulated. ConclusionOnce primary ventilatory pump failure is excluded and lung disease improved to the extent that the ambient air O2 Sat can be normalized by using MIE via invasive airway tubes to clear airway secretions, encephalopathic patients can have sufficient muscle strength to wean from ventilatory support and possibly be decannulated if mechanically augmented cough flows exceed 190 L/m.

Psychological Stress Induced by Prone Positioning among Adults with Severe Cerebral Palsy.

The purpose of this study was to investigate the psychological impact of various positionings in subjects with cerebral palsy (CP). The participants were 17 individuals with severe motor and intellectual disability due to CP. They began in a sitting position in their wheelchair, and were placed consecutively in prone or supine positions, with no intervals between placements. Physiological observations were made in each position, and included salivary α-amylase activity, pulse, percutaneous oxygen saturation, respiratory rate, learance or not of airway secretions, and occurrence or not of adverse events. Salivary α-amylase activity values were higher in the prone position than in the baseline and supine positions (p<0.05). Clearance of airway secretions was significantly more prevalent in the prone position than in the baseline and supine positions (p <0.05). The participants' pulse was significantly lower in the supine and prone positions than in the baseline position (p<0.05). Greater prevalence of airway secretion clearance and significantly higher stress levels as indicated by saliva amylase were observed in the prone position than in the other two positions. Therefore, when such patients are placed in a prone position, close attention to airway management and the potential for psychological stress may be necessary.

Design of In Vivo Deposition and Clearance Experiments.

Experiments designed to image in vivo deposition of radiolabel-drug mixtures are useful for estimating inhaled drug delivery and for assessing bioequivalence of delivery devices. Validation of the radiolabel-drug mixture is vital to ensure that subsequent imaging is reflective of drug deposition. Application of gamma attenuation corrections allows both total and regional lung deposition of drug to be estimated by two-dimensional (2D) imaging. Imaging methods are also useful for measuring in vivo mucociliary clearance (MC) function. Such measures allow assessment of the efficacy of drugs designed to improve clearance of airway secretions in airway disease. MC rates can be measured by controlled inhalation and gamma camera monitoring of radiolabeled aerosols containing non-permeating tracers. While in vivo MC rates reflect the function of the mucociliary apparatus, they are also dependent on regional deposition patterns of the inhaled aerosol.

Inhaled Dry Powder Mannitol Treatment in Pediatric Patients with Cystic Fibrosis: Evaluation of Clinical Data in a Real-World Setting.

Background: Cystic fibrosis (CF) is a genetic disorder, in which defective clearance of airway secretions leads to progressive lung function loss. Inhaled mannitol is used to increase sputum and mucociliary clearance. There are little data from real-world studies on the effectiveness of mannitol in children. Our objective was to evaluate the spirometry and clinical results of mannitol in pediatric patients. Methods: We retrospectively reviewed the records of 30 children and adolescents with CF receiving inhaled mannitol who were already on recombinant human deoxyribonuclease (rhDNase) treatment. The change in forced expiratory volume in 1 second (FEV1) from baseline at 2-4 months was the primary outcome. Secondary measures were other spirometry results, body mass index (BMI), hospital admissions, sputum characteristics, and positive bacterial colonization. Results: Compared to baseline, we found significant improvement in percent predicted FEV1 at 2-4 months of treatment; 84.50 (58.00-99.00) vs. 96.00 (66.00-106.00) (P = 0.0007). The absolute change in FEV1 was +11.5% at 2-4 months, +6.5% at 5-7 months, and +4% at 8-12 months. Also, significant improvements in other spirometry results were observed. Adolescents had significantly lower FEV1 results, but the improvement in their lung function was sustained for a more extended period than children. Mannitol provided easier sputum removal, increased sputum volume, significant decline in hospitalizations, and significantly fewer patients with positive sputum cultures. A significant increase in BMI at 8-12 months was observed. Cough was the most frequent adverse effect. Conclusion: In a real-world setting, our results demonstrated that adding mannitol to rhDNase therapy is tolerable in pediatric patients with CF and may provide improved spirometry and clinical outcomes. In addition, our results showed that mannitol provided recovery in overall lung function at 2-4 months, which was sustained up to 12 months together with improved BMI, easier sputum removal, and a decline in bacterial colonization and hospital admissions. However, cough was the most frequent side effect.

Atypical Causes of Dyspnea: A Review of Neuromuscular and Chest Wall Disorders that Compromise Ventilation.

Dyspnea is a common presenting symptom among patients with cardiopulmonary diseases. However, several neuromuscular and chest wall conditions are often overlooked and under-recognized causes of dyspnea. These disorders frequently adversely affect the structure and function of the ventilatory pump (diaphragm, accessory muscles of ventilation) and can precipitate respiratory failure despite normal lung parenchyma. Weakened musculature impairs clearance of airway secretions leading to aspiration and pneumonia, further compromising respiratory function. Radiologists should be aware of the pathophysiology and imaging manifestations of these conditions and might suggest them to be causes of dyspnea which otherwise may not have been considered by referring clinicians.

Physiotherapy Practice Pattern in the Adult Intensive Care Units of Singapore – A Multi-Centre Survey

Background The roles of physiotherapy in Intensive Care Unit (ICU) have significantly developed from the traditional management of respiratory conditions to early rehabilitation and mobilisation of patients on mechanical ventilation. Surveys of United Kingdom, Australia and regional ICU physiotherapy practice have been published but there are no local data sets. This study aims to report the physiotherapy practices across the adult ICUs of Singapore. Methods Twenty-nine item questionnaire was mailed to 90 physiotherapists working in 15 adult ICUs across restructured and private hospitals in Singapore. Data sets were summarised from the returned questionnaires. This includes identifying common physiotherapy techniques and exercise prescription protocols for both mechanically and non-mechanically ventilated patients in the ICU. Results A total of 63 (70%) questionnaires were returned. The most used physiotherapy interventions were airway secretion clearance, techniques to improve lung ventilation and mobilisation out of bed. Positioning was most used respiratory technique (60/61, 98%). Sitting on the edge of bed is the most preferred physical activity for ICU patients (43/44, 98%). Exercise was routinely prescribed (50/61, 83%) although only a minority (8/50, 16%) have established exercise prescription protocols. For mechanically ventilated patients, active/active assisted exercises were most used (40/44, 91%). 12% of ICU use either Chelsea Critical Care Physical Assessment Tool or the Functional Status Score for the Intensive Care Unit as routine outcome measures. Conclusion Airway clearance was stated as the most used physiotherapy technique. Exercise is routinely prescribed in ICU. Validated outcome measures are only used by few.

Secretion management in patients with ineffective airway clearance with non-invasive mechanical ventilation use: Expert guidance for clinical practice.

Non-invasive ventilation (NIV) is a mainstay of management of chronic respiratory failure in many disorders which are known to cause abnormal airway secretion clearance. Currently, there is no guidance regarding either the secretion handling during NIV use or the role of NIV in secretion management in these patients. The aim of this document was to provide an overview of the various techniques available in the management of respiratory secretions and their use in conjunction with NIV. Literature search was performed using the keywords, "(secretion OR secretions) AND (noninvasive ventilation OR NIV)" on PubMed and EMBASE. The search yielded 1681 and 509 titles from PubMed and EMBASE, respectively. After screening, 19 articles were included in this review. Suggestions of the expert panel were formulated by mutual consensus after reviewing the relevant literature. The draft of the expert panel's suggestions was circulated among all authors via electronic mail for comments. Any conflicts were resolved by mutual discussion to achieve agreement. The final document was approved by all. This document by the International Network for Airway Secretions Management in NIV describes various airway secretion clearance techniques. It provides the expert panel's suggestions for the use of these techniques in conjunction with NIV for patients with muco-obstructive and neuromuscular disorders.

Analysis of the effect of sequential high-flow nasal canula oxygen therapy in post-extubation mechanically ventilated patients in intensive care unit

To observe the application effect of high-flow nasal canula oxygen therapy (HFNC) after extubation in patients with mechanical ventilation (MV) in the intensive care unit (ICU). A prospective study was conducted. From January 2018 to June 2020, 163 MV patients admitted to Yijishan Hospital of Wannan Medical College were enrolled, and they were divided into HFNC group (82 cases) and traditional oxygen therapy group (81 cases) according to the oxygen therapy model. The patients included in the study were given conventional treatment according to their condition. In the HFNC group, oxygen was inhaled by a nasal high-flow humidification therapy instrument. The gas flow was gradually increased from 35 L/min to 60 L/min according to the patient's tolerance, and the temperature was set at 34-37 centigrade. The fraction of inspiration oxygen (FiO2) was set according to the patient's pulse oxygen saturation (SpO2) and SpO2 was maintained at 0.95-0.98. A disposable oxygen mask or nasal cannula was used to inhale oxygen in the traditional oxygen therapy group, and the oxygen flow was 5-8 L/min, maintaining the patient's SpO2 at 0.95-0.98. The differences in MV duration before extubation, total MV duration, intubation time, reintubation time, extubation failure rate, ICU mortality, ICU stay, and in-hospital stay were compared between the two groups, and weaning failure were analyzed. There was no significant differences in MV duration before extubation (days: 4.33±3.83 vs. 4.15±3.03), tracheal intubation duration (days: 4.34±1.87 vs. 4.20±3.35), ICU mortality [4.9% (4/82) vs. 3.7% (3/81)] and in-hospital stay [days: 28.93 (15.00, 32.00) vs. 27.69 (15.00, 38.00)] between HFNC group and traditional oxygen therapy group (all P > 0.05). The total MV duration in the HFNC group (days: 4.48±2.43 vs. 5.67±3.84) and ICU stay [days: 6.57 (4.00, 7.00) vs. 7.74 (5.00, 9.00)] were significantly shorter than those in the traditional oxygen therapy group, the reintubation duration of the HFNC group was significantly longer than that of the traditional oxygen therapy group (hours: 35.75±10.15 vs. 19.92±13.12), and the weaning failure rate was significantly lower than that of the traditional oxygen therapy group [4.9% (4/82) vs. 16.0% (13/81), all P < 0.05]. Among the reasons for weaning failure traditional oxygen therapy group had lower ability of airway secretion clearance than that of the HFNC group [8.64% (7/81) vs. 0% (0/82), P < 0.05], there was no statistically differences in the morbidity of heart failure, respiratory muscle weakness, hypoxemia, and change of consciousness between the two groups. For MV patients in the ICU, the sequential application of HFNC after extubation can reduce the rate of weaning failure and the incidence of adverse events, shorten the length of ICU stay.

Novel assisted cough system based on simulating cough airflow dynamics.

Cough is a defensive behavior that protects the respiratory system from infection and clears airway secretions. Cough airflow dynamics have been analyzed by a variety of mathematical and experimental tools. In this paper, the cough airflow dynamics of 42 subjects were obtained and analyzed. An identification model based on piecewise Gauss function for cough airflow dynamics is proposed through the dimensionless method, which could achieve over 90% identification accuracy. Meanwhile, an assisted cough system based on pneumatic flow servo system is presented. The vacuum situation and feedback control are used to increase the simulated peak cough flow rate, which are important for airway secretion clearance and to avoid airway collapse, respectively. The simulated cough peak flow could reach 5 L/s without the external assistance such as manual pressing, patient cooperation and other means. Finally, the backstepping control is developed to generate a simulated cough airflow that closely mimics the natural cough airflow of humans. The assisted cough system opens up wide opportunities of practical application in airway secretion clearance for critically ill patients with COVID 2019 and other pulmonary diseases.Graphic abstract

Respiratory care in myotubular myopathy.

X-linked myotubular myopathy is a neuromuscular condition caused by pathogenic variants in the MTM1 gene, which encodes for myotubularin, a phosphatidylinositol 3-phosphate phosphatase. Affected individuals typically require intensive medical intervention to survive, though there are some milder phenotypes. To date, respiratory management has been primarily supportive, optimising clearance of airway secretions, providing ventilatory support and prevention/early intervention of respiratory infections. Encouragingly, there has been significant progress in the development of novel therapeutic strategies such as gene therapy, enzyme replacement therapy and drugs that modulate downstream pathways. In this review, we discuss the common respiratory issues using four illustrative real-life cases, and summarise recent translational research, which offers hope to many patients and their families.

Noninvasive Ventilation and Mechanical Insufflator-Exsufflator for Acute Respiratory Failure in Children With Neuromuscular Disorders.

Children with neuromuscular disorder (NMD) usually have pulmonary involvement characterized by weakened respiratory muscles, insufficient coughing, and inability to clear airway secretions. When suffering from community-acquired pneumonia, these patients are more likely to develop acute respiratory failure (ARF). Therefore, recurrent pneumonias leading to acute on chronic respiratory failure accounts for a common cause of mortality in children with NMD. For many years, noninvasive ventilation (NIV) has been regarded as a life-prolonging tool and has been used as the preferred intervention for treating chronic hypoventilation in patients with advanced NMD. However, an increasing number of studies have proposed the utility of NIV as first-line management for acute on chronic respiratory failure in NMD patients. The benefits of NIV support in acute settings include avoiding invasive mechanical ventilation, shorter intensive care unit or hospital stays, facilitation of extubation, and improved overall survival. As the difficulty in clearing respiratory secretions is considered a significant risk factor attributing to NIV failure, combined coughing assistance of mechanical insufflator-exsufflator (MI-E) with NIV has been recommended the treatment of acute neuromuscular respiratory failure. Several recent studies have demonstrated the feasibility and effectiveness of combined NIV and MI-E in treating ARF of children with NMD in acute care settings. However, to date, only one randomized controlled study has investigated the efficacy of NIV in childhood ARF, but subjects with underlying NMD were excluded. It reflects the need for more studies to elaborate evidence-based practice, especially the combined NIV and MI-E use in children with acute neuromuscular respiratory failure. In this article, we will review the feasibility, effectiveness, predictors of outcome, and perspectives of novel applications of combined NIV and MI-E in the treatment of ARF in NMD children.

Oscillating devices 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. Oscillating devices generate intra- or extra-thoracic oscillations orally or external to the chest wall. Internally they create variable resistances within the airways, generating controlled oscillating positive pressure which mobilises mucus. Extra-thoracic oscillations are generated by forces outside the respiratory system, e.g. high frequency chest wall oscillation. This is an update of a previously published review. To identify whether oscillatory devices, oral or chest wall, are effective for mucociliary clearance and whether they are equivalent or superior to other forms of airway clearance in the successful management of secretions in people with cystic fibrosis. We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register comprising references identified from comprehensive electronic database searches and hand searches of relevant journals and abstract books of conference proceedings. Latest search of the Cystic Fibrosis Trials Register: 29 July 2019. In addition we searched the trials databases ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform. Latest search of trials databases: 15 August 2019. Randomised controlled studies and controlled clinical studies of oscillating devices compared with any other form of physiotherapy in people with cystic fibrosis. Single-treatment interventions (therapy technique used only once in the comparison) were excluded. Two authors independently applied the inclusion criteria to publications, assessed the quality of the included studies and assessed the evidence using GRADE. The searches identified 82 studies (330 references); 39 studies (total of 1114 participants) met the inclusion criteria. Studies varied in duration from up to one week to one year; 20 of the studies were cross-over in design. The studies also varied in type of intervention and the outcomes measured, data were not published in sufficient detail in most of these studies, so meta-analysis was limited. Few studies were considered to have a low risk of bias in any domain. It is not possible to blind participants and clinicians to physiotherapy interventions, but 13 studies did blind the outcome assessors. The quality of the evidence across all comparisons ranged from low to very low. Forced expiratory volume in one second was the most frequently measured outcome and while many of the studies reported an improvement in those people using a vibrating device compared to before the study, there were few differences when comparing the different devices to each other or to other airway clearance techniques. One study identified an increase in frequency of exacerbations requiring antibiotics whilst using high frequency chest wall oscillation when compared to positive expiratory pressure (low-quality evidence). There were some small but significant changes in secondary outcome variables such as sputum volume or weight, but not wholly in favour of oscillating devices and due to the low- or very low-quality evidence, it is not clear whether these were due to the particular intervention. Participant satisfaction was reported in 13 studies but again with low- or very low-quality evidence and not consistently in favour of an oscillating device, as some participants preferred breathing techniques or techniques used prior to the study interventions. The results for the remaining outcome measures were not examined or reported in sufficient detail to provide any high-level evidence. There was no clear evidence that oscillation was a more or less effective intervention overall than other forms of physiotherapy; furthermore there was no evidence that one device is superior to another. The findings from one study showing an increase in frequency of exacerbations requiring antibiotics whilst using an oscillating device compared to positive expiratory pressure may have significant resource implications. More adequately-powered long-term randomised controlled trials are necessary and outcomes measured should include frequency of exacerbations, individual preference, adherence to therapy and general satisfaction with treatment. Increased adherence to therapy may then lead to improvements in other parameters, such as exercise tolerance and respiratory function. Additional evidence is needed to evaluate whether oscillating devices combined with other forms of airway clearance is efficacious in people with cystic fibrosis.There may also be a requirement to consider the cost implication of devices over other forms of equally advantageous airway clearance techniques. Using the GRADE method to assess the quality of the evidence, we judged this to be low or very low quality, which suggests that further research is very likely to have an impact on confidence in any estimate of effect generated by future interventions.

Safety and Efficacy of an Innovative Airway Clearance Device Versus Manual Chest Physiotherapy Techniques For Airway Secretion Clearance: a Feasibility Study

Safety and Efficacy of an Innovative Airway Clearance Device Versus Manual Chest Physiotherapy Techniques For Airway Secretion Clearance: a Feasibility Study

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

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