Conventional Chest Physical Therapy for Obstructive Lung Disease

Cees P van der Schans PT PhD

Introduction
Conventional Chest Physical Therapy
Directed Cough and Forced Expirations
Postural Drainage
Chest Percussion
Other Airway Clearance Techniques
High-Frequency Chest Wall Compression
Positive Expiratory Pressure Therapy
Autogenic Drainage
Exercise
Vibratory PEP Therapy
Identifying Patients Who Will Benefit From CPT
Selecting and Applying CPT Components
Promoting Patient Adherence to CPT
Risks and Adverse Effects of CPT
Summary

Chest physical therapy (CPT) is a widely used intervention for patients with airway diseases. The main
goal is to facilitate secretion transport and thereby decrease secretion retention in the airways. Histor-
ically, conventional CPT has consisted of a combination of forced expirations (directed cough or huff),
postural drainage, percussion, and/or shaking. CPT improves mucus transport, but it is not entirely
clear which groups of patients benefit from which CPT modalities. In general, the patients who benefit
most from CPT are those with airways disease and objective signs of secretion retention (eg, persistent
rhonchi or decreased breath sounds) or subjective signs of difficulty expectorating sputum, and with
progression of disease that might be due to secretion retention (eg, recurrent exacerbations, infections,
or a fast decline in pulmonary function). The most effective and important part of conventional CPT is
directed cough. The other components of conventional CPT add little if any benefit and should not be
used routinely. Alternative airway clearance modalities (eg, high-frequency chest wall compression,
vibratory positive expiratory pressure, and exercise) are not proven to be more effective than conven-
tional CPT and usually add little benefit to conventional CPT. Only if cough and huff are insufficiently
effective should other CPT modalities be considered. The choice between the CPT alternatives mainly
depends on patient preference and the individual patient’s response to treatment. Key words: chest
physical therapy, pulmonary, mucus transport, sputum, cystic fibrosis, airway secretions, cough, huff, postural
drainage, postural drainage, autogenic drainage. [Respir Care 2007;52(9):1198 –1206. © 2007 Daedalus
Enterprises]

Cees P van der Schans PhD PT CE is affiliated with Hanze University, The author reports no conflicts of interest related to the content of this
University for Applied Sciences, Groningen, The Netherlands. paper.

Dr van der Schans presented a version of this paper at the 39th RESPI-
RATORY CARE Journal Conference, “Airway Clearance: Physiology, Phar- Correspondence: Cees P van der Schans PhD PT CE, Hanze University,
macology, Techniques, and Practice,” held April 21–23, 2007, in Can- University for Applied Sciences, PO Box 3109, 9701 DC Groningen, The
cún, Mexico. Netherlands. E-mail: [email protected].

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 CONVENTIONAL CHEST PHYSICAL THERAPY FOR OBSTRUCTIVE LUNG DISEASE

Introduction secretion-filled bronchi is key to determining which pa-

tient positions to use. The time required in each patient
In health, the production and continuous transport of position depends on the quantity, viscoelasticity, and ad-
airway mucus is an effective defense mechanism. Inhaled hesiveness of the mucus. If tolerated, the patient can sleep
bacteria and dust are cleared and the lower airways are in a postural drainage position. Chest percussion is the
thus kept sterile. In airway diseases that cause mucus hy- manual application of rhythmic clapping to the ventral,
persecretion or impair mucus transport, inadequate mucus lateral, and/or dorsal thorax, at about 3– 6 Hz. Chest per-
clearance increases the risk of infection and related mor- cussion is often delivered in 10 –20-min treatment ses-
bidities, and is associated with faster decline in pulmonary sions, whenever there is ausculatory evidence of airway
function.1–5 In cystic fibrosis (CF) the airway secretions secretion retention. Chest shaking is a coarse movement
contain very little mucin, are largely pus, and are prone to applied to the rib cage during exhalation.7
infection; the paucity of mucus production in the CF air- Conventional CPT has been evaluated in clinical trials
way may predispose to infection. and systematic reviews in subjects with chronic obstruc-
Chest physical therapy (CPT) is a widely used interven- tive pulmonary disease (COPD)8 and CF9 (Table 1).
tion in patients with airway diseases. The main goal is to Newton et al10 evaluated conventional CPT combined
improve mucus clearance, to decrease the risk of pulmo- with intermittent positive-pressure breathing in 79 subjects
nary infection, slow the decline in pulmonary function, with COPD exacerbations. The subjects were assigned to
and improve quality of life. Conventional CPT is used in 3 groups: (1) male subjects with PaO2 ⬎ 60 mm Hg, (2) male
stable patients with obstructive lung disease, to prevent subjects with PaO2 ⬍ 60 mm Hg, and (3) female subjects.
complications in the perioperative period, and in some In each group, subjects were randomly allocated to drug
critically ill patients, such as those receiving mechanical treatment (control) or to drug treatment plus CPT and
ventilation. This paper reviews conventional CPT and al- intermittent positive-pressure breathing. Changes in pul-
ternative CPT modalities in patients with obstructive lung monary function, arterial blood gases, and sputum volume
diseases. between admission and discharge were evaluated, and com-
parisons were made between the CPT and control groups.
Conventional Chest Physical Therapy There were no significant differences in forced expiratory
volume in the first second (FEV1) or vital capacity be-
Historically, CPT has consisted of a combination of tween the CPT and control groups. The change in PaO2 was
forced expirations (directed cough or huff [forced expira- higher in the CPT group in group 1, compared to the
tion with the glottis open from the beginning to the end of control group, and in the control group in group 2, as
the maneuver]), postural drainage, percussion, and/or shak- compared to the CPT group. Mean sputum volume was
ing. I will refer to that combination of modalities as con- only higher in the CPT group in group 1, compared to the
ventional CPT. control group, during the last 3 admission days. In general,
Mucociliary clearance is the primary defense mecha- CPT did not benefit subjects with COPD exacerbation.
nism of the smaller airways, and cough is the primary May et al11 used a heat lamp as a placebo, compared to
defense mechanism for clearance of secretions from the CPT, and found no significant effects on pulmonary func-
larger airways. Cough is also an important mucus-clear- tion or PaO2 with CPT, but found favorable effects on
ance mechanism in the smaller airways when mucociliary sputum expectoration during CPT. However, in subjects
clearance is not functioning optimally (ie, when disease with COPD, Bateman et al13 found a 4 –5-fold increase in
puts secretion production and clearance out of balance mucus clearance, compared to a control period and in a
and/or causes abnormal mucus rheology). During a cough, mixed group of subjects, Sutton et al15 found a higher
the peak intrapulmonary pressure is normally about clearance rate and a higher weight of expectorated sputum.
200 cm H2O before the glottis opens. When the glottis Oldenburg et al12 found that both cough and exercise were
opens, the explosive decompression into the upper airways effective, but that postural drainage had no significant ef-
normally generates a flow of 6 –20 L/s. During huff the fect on clearance of a radioactive tracer.
flow and intrapulmonary pressure are much lower than In a Cochrane systematic review, Jones and Rowe8 as-
during cough.6 Cough and huff can be started at low, me- sessed the effects of conventional CPT in subjects with
dium, or high lung volume. COPD or bronchiectasis. The 7 studies included 6 com-
Postural drainage is the use of various patient positions parisons and 126 subjects. The studies were small and not
to orient secretion-filled bronchi with the expectation that of high quality. CPT produced no significant effects on
gravity can assist secretion drainage. Postural drainage is pulmonary function, apart from clearing sputum in COPD
probably most effective when there is a large quantity of and bronchiectasis. The authors concluded that there is
mucus that has low adhesiveness. Nine postural positions insufficient evidence to support or refute the effectiveness
have been described.7 Determining the locations of the of CPT in subjects with COPD or bronchiectasis.

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Table 1. Studies of Chest Physical Therapy Effects on Pulmonary Function and Mucus Clearance

Patients Variable(s)
First Author, Year Condition CPT Components Duration† Effect‡
(no.) Measured

Newton,10 1978 COPD exacerbation 79 CPT ⫹ IPPB Short-term FEV1 0

VC 0
Sputum volume 0

May,11 1979 COPD 35 Percussion, postural drainage, Immediate PEF 0

vibration, directed cough FVC 0
FEV1 0
FEF50% 0
FEF75% 0
Sputum volume ⫹

Oldenburg,12 1979 COPD 8 Directed coughing Immediate Mucus clearance§ ⫹

Exercise Immediate Mucus clearance§ ⫹
Postural drainage Immediate Mucus clearance§ 0

Bateman,13 1979 COPD 10 Postural drainage, vibration, Immediate Mucus clearance§ ⫹

percussion, shaking, directed
cough

Rossman,14 1982 CF 6 Postural drainage Immediate Mucus clearance§ ⫹

CF 6 Postural drainage, percussion Immediate Mucus clearance§ ⫹
CF 6 Postural drainage, percussion, Immediate Mucus clearance§ ⫹
vibration
CF 6 Directed cough Immediate Mucus clearance§ ⫹

Sutton,15 1983 Mixed group 10 FET, postural drainage, directed Immediate Mucus clearance§ ⫹
cough Sputum weight ⫹

Mortensen,16 1991 CF 10 Postural drainage, FET Immediate Mucus clearance§ ⫹

CF 10 PEP, FET Immediate Mucus clearance§ ⫹

van der Schans,17 1991 CF 8 PEP at 5 cm H2O Immediate Mucus clearance§ 0

PEP at 15 cm H2O Immediate Mucus clearance§ 0

Pfleger,18 1992 CF 15 High-pressure PEP, FET Immediate Mucus clearance ⫹

CF 15 Autogenic drainage Immediate Mucus clearance ⫹
CF 15 High-pressure PEP, FET, then Immediate Mucus clearance ⫹
autogenic drainage
CF 15 Autogenic drainage then PEP, FET Immediate Mucus clearance ⫹

†Short term ⫽ 1–7 days

‡⫹ ⫽ favored CPT, 0 ⫽ no difference
§Mucus clearance measured via clearance of radioactive tracer
CPT ⫽ chest physical therapy
COPD ⫽ chronic obstructive pulmonary disease
IPPB ⫽ intermittent positive-pressure breathing
FEV1 ⫽ forced expiratory volume in the first second
VC ⫽ vital capacity
PEF ⫽ peak expiratory flow
FVC ⫽ forced vital capacity
FEF50% ⫽ forced expiratory flow at 50% of the forced vital capacity
FEF75% ⫽ forced expiratory flow at 75% of the forced vital capacity
CF ⫽ cystic fibrosis
FET ⫽ forced expiration technique
PEP ⫽ positive expiratory pressure.

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In a crossover-design study of 6 subjects with CF, Ross- van der Schans et al9 concluded that there is no robust
man et al14 compared the immediate effect of 4 forms of scientific evidence that CPT is effective in clearing airway
airway clearance: directed vigorous cough, postural drain- secretions in patients with CF.
age, postural drainage with mechanical percussion, and Both the van der Schans9 and Jones and Rowe8 Co-
conventional CPT. The control period included directed chrane reviews concluded that CPT increases sputum ex-
coughs. In this short-term study, each treatment was un- pectoration and mucus transport, but has no effect on pul-
dertaken once, on separate days. All the interventions in- monary function. These studies are summarized in Table 1.
creased mucus transport, as measured by clearance of a Thomas et al20 conducted a meta-analysis of airway
radioactive tracer. clearance modalities in subjects with CF: specifically, PEP,
In a 3-day crossover trial, Mortensen et al16 compared 2 FET, exercise, autogenic drainage, and conventional CPT.
treatments: postural drainage combined with forced expi- They concluded that conventional CPT resulted in signif-
ration technique (FET) versus positive expiratory pressure icantly greater sputum expectoration than no treatment. It
(PEP) therapy combined with FET (PEP plus FET). The is important to note, however, that they based this finding
control period included spontaneous coughing. The char- on p value analysis, and not on the quantity of sputum
acteristic component of FET is that it uses huff (rather than produced. They also found that the combination of con-
cough) and can be combined with breathing exercises and ventional CPT and exercise was associated with a moder-
percussion or shaking. Both postural drainage plus FET ate increase in FEV1, compared to CPT alone. No other
and PEP plus FET increased mucus transport. differences between airway clearance modalities were
In a crossover-design study of 8 subjects with CF, van found.
der Schans et al17 compared the immediate effect of 2
forms of airway clearance: PEP therapy at 5 cm H2O, and Directed Cough and Forced Expirations
PEP therapy at 15 cm H2O. PEP therapy without coughing
had no effect on mucus transport. There was also no dif- Forced expirations and coughing are the most effective
ference between directed cough alone and PEP followed and important parts of CPT.14,21–23 As previously noted,
by directed cough, as measured by clearance of a radio- Rossman et al14 found that there was no significant dif-
active tracer. ference between regimented cough alone and therapist-
In 14 subjects with CF, Pfleger et al18 compared 4 forms administered combined maneuvers, and concluded that in
of airway clearance: PEP therapy plus FET, autogenic CF, vigorous, regimented cough sessions may be as effec-
drainage, PEP therapy plus FET followed by autogenic tive as therapist-administered CPT in removing pulmonary
drainage, and autogenic drainage followed by PEP therapy secretions. Cough may even be effective in patients who
plus FET. The control period included directed coughing. do not expectorate sputum.24 Forced expirations are as
Each treatment was undertaken once, on separate days. effective as cough in patients with COPD or bronchiecta-
The mean weight of expectorated sputum in the control sis, even though patient effort is less with forced expira-
period was approximately 17 g, and in the 3 forms of CPT tions.25 However, a long-term study of subjects with CF
it was 34 – 45 g, although the value of measuring sputum showed less annual decline in expiratory flow during the
weight as a primary outcome is questionable. Similarly, middle half of the forced expiratory volume (FEF25–75%)
Braggion et al19 compared the immediate effect of 3 forms in a group that received chest percussion, postural drain-
of airway clearance: high-frequency chest wall compres- age, and FET than in a group that applied self-adminis-
sion (HFCWC) combined with FET and cough, PEP com- tered FET. There were no statistically significant differ-
bined with FET and cough, and postural drainage com- ences between the 2 groups in decline in forced vital
bined with vibrations, deep breathing, percussion or FET capacity, FEV1, or number of hospitalizations.26 Forced
and cough. The control period involved spontaneous cough- expirations can be manually supported, which may benefit
ing. Each regimen was used twice a day for 2 consecutive patients with respiratory muscle weakness, but not patients
days. Mean wet weight of expectorated sputum during the without muscle weakness.27
control day was 6 g, and during the airway clearance ther-
apy sessions it was 23–30 g. Postural Drainage
In a Cochrane systematic review, van der Schans et al9
analyzed studies of subjects with CF to assess the effec- In an animal model, Chopra et al28 found an increase in
tiveness and acceptability of CPT compared to no treat- tracheal mucus transport velocity during postural drainage.
ment or spontaneous cough alone. There were no random- Other studies have found improved mucus transport in
ized controlled trials or crossover trials eligible for inclusion subjects with CF,29,30 but a study of subjects with chronic
in the review. The short-term crossover trials, which had bronchitis found no improvement.12 Postural drainage may
to be excluded from the review, suggest that airway clear- be useful when forced expirations, assisted cough, and
ance regimens could benefit patients with CF, but exercise are not possible or are inadequate. Disadvantages

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Table 2. Optimal Frequency for Improving Mucus Transport With a day. HFCWC was applied 3 times a day, with frequen-
High-Frequency Chest Wall Percussion cies of 6 –25 Hz, and was also combined with albuterol
inhalation. There was no difference in change in pulmo-
Optimal
First Author, nary function between HFCWC and CPT during the study
Subjects Frequency
Year
(Hz) period.
Flower,32 1979 Patients with CF 15
Radford,33 1982 Dogs 15–35 Positive Expiratory Pressure Therapy
King,34 1983 Dogs 11–15
King,35 1984 Dogs 13 A Cochrane review41 included 7 studies, with 95 total
Chang,36 1988 Experimental-theoretical study 13 subjects with CF, that measured FEV1 after a single treat-
Rubin,37 1989 Dogs 13 ment. There was no difference in FEV1 after PEP com-
pared to FET, postural drainage and percussion, noninva-
sive ventilation, or vibratory PEP therapy at 5 cm H2O or
are that postural drainage is relatively time-consuming and ⬎ 20 cm H2O. One study found that FEV1 was signifi-
may require a special bed or table to be performed effec- cantly lower after autogenic drainage followed by high-
tively. pressure PEP than after autogenic drainage alone.18 Bel-
lone et al42 compared PEP to directed cough in 27 subjects
Chest Percussion with COPD exacerbations that required noninvasive ven-
tilation. Sputum weight was higher and weaning time was
Mechanical vibration and chest compression methods less in the PEP group.
may induce small coughs or resonance with ciliary action.
Chopra et al28 found in an animal study that manual per- Autogenic Drainage
cussion increased tracheal mucus transport. In patients with
COPD it was also found that chest percussion provided a In 2 studies, which included 36 subjects with CF, no
small increase in bronchial mucus transport, but that it had difference in pulmonary function was found between CPT
no more benefit than cough and postural drainage.31 The and autogenic drainage.43 Miller et al44 compared auto-
effect of percussion seems to be frequency-dependent, and genic drainage to CPT (active cycle of breathing and pos-
several studies have found that the optimal frequency is tural drainage) and found no overall differences in pulmo-
well above the 6 Hz possible in manual percussion (Table nary function or sputum weight. In subjects with COPD,
2). Bauer et al38 compared manual chest percussion with Savci et al45 found that peak expiratory flow and oxygen
mechanical percussion in subjects with CF during exacer- saturation increased more after 20 days of treatment with
bations with hospitalization and found pulmonary function autogenic drainage than with CPT (active cycle of breath-
improvement similar in the groups. Other studies have ing). No differences were found in other lung function
similarly failed to detect a difference between manual and variables.
mechanical chest percussion. In a meta-analysis of airway
clearance modalities in subjects with CF, Thomas et al20 Exercise
reported no significant difference for sputum production
(p ⫽ 0.31) or FEV1 (p ⫽ 0.44) in 4 studies, which in- Many patients with chronic hypersecretion and impaired
cluded 68 subjects and compared manual and mechanical mucus transport can increase sputum expectoration with
percussion and vibration. A systematic review of airway physical exercise such as running or bicycling. The in-
clearance therapy concluded that there is insufficient evi- creased expiratory flow, minute volume, and sympathetic
dence to support a benefit for the use of percussion as a activity during exercise increase ciliary beat and may
technique to improve secretion clearance.39 thereby increase mucus transport.46 However, exercise can
theoretically increase secretion viscosity and adhesivity by
Other Airway Clearance Techniques decreasing the humidification of inspired air. Assuming
Compared With CPT that expiratory flow is the most important factor, the ex-
ercise must be of sufficient intensity and duration to in-
High-Frequency Chest Wall Compression crease ventilatory demand. Exercise may improve bron-
chial mucus transport in healthy subjects46 and in patients
Laboratory studies suggest that the optimal HFCWC with COPD12 or CF.47 The addition of exercise to CPT
frequency for improving mucus transport is about 13–15 Hz significantly increases the amount of expectorated mu-
(see Table 2). Arens et al40 compared HFCWC to CPT in cus.48 It has been suggested that exercise may be a sub-
subjects with exacerbations of CF. CPT consisted of per- stitute for conventional CPT, but this was not supported in
cussion, postural drainage, and albuterol inhalation 3 times studies of subjects with CF.49,50

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Vibratory PEP Therapy

In subjects with CF, Konstan et al51 found significantly

more expectorated sputum with vibratory PEP therapy than
with voluntary cough or chest percussion. However, they
found no improvement in pulmonary function or patient
well-being after vibratory PEP therapy. Bellone et al52
compared the short-term effects of postural drainage, vi-
bratory PEP therapy, and forced expiration in lateral pos-
ture on oxygen saturation, pulmonary function, and spu-
tum production in patients with chronic bronchitis
exacerbations. Sputum weight was higher with vibratory
PEP therapy and forced expirations than with postural drain-
age, but there were no differences in pulmonary function
or oxygen saturation.

Identifying Patients Who Will Benefit From CPT

There is sufficient evidence that CPT improves mucus

transport, but it is not entirely clear which groups of pa-
tients benefit from which CPT modalities. It has been
suggested that the amount of expectorated sputum might
predict which patients are likely to benefit from CPT, and
that CPT should be applied in patients who expectorate
more than 25–30 mL/d.53 However, the important problem
is not the amount of secretions expectorated, but the amount
of secretions not expectorated (ie, retained in the airways).
The amount expectorated may not be a reliable outcome
measure, because pulmonary secretions may be swallowed,
and those that are expectorated also include saliva. The
patients most likely to benefit from secretion-clearance
techniques are those with objective signs of secretion re-
tention (eg, persistent rhonchi or decreased breath sounds)
or subjective signs of difficulty expectorating secretions, Fig. 1. Algorithm for choosing secretion-clearance interventions.
and with progression of the disease that might be due to
secretion retention (eg, recurrent exacerbations or infec- and/or huff. Figure 1 shows a proposed algorithm for choos-
tions or a fast decline in pulmonary function). ing secretion-clearance interventions.
Dynamic airway compression during exhalation in-
Selecting and Applying CPT Components creases the airflow velocity in the compressed airway,
which increases secretion transport, unless complete col-
The most effective and important part of CPT is di- lapse obstructs the airway, which interrupts mucus trans-
rected cough. The other components of CPT, including port upstream to the obstruction. In the flow-volume curve,
percussion, shaking, and postural drainage, probably add a sharp decrease in flow is usually a sign of airway col-
little or no benefit and should not be used routinely. Un- lapse. During a forced exhalation, wheezing often accom-
derstanding airway physiology and using the equal pres- panies a sudden decrease in flow. If cough and/or huff are
sure point (the point at which the pressure inside the air- not effective, HFCWC (at about 15 Hz), postural drainage,
way equals the surrounding plural pressure) and the and autogenic drainage should be considered. Exercise
collateral ventilation system between airways will make should also be considered, if the patient can tolerate it. The
airway clearance activities most effective. Finding a match choice of airway clearance modality depends mainly on
between an effective airway clearance method and a pa- patient preference and the individual patient’s response to
tient’s preference is the challenge for the clinician.54 Al- treatment. An n of 1 study (ie, the patient tries various
ternative airway clearance modalities have not been proven treatments and acts as his or her own control to determine
more effective, and usually add little or no benefit to cough which treatment works best for him or her) might be worth-

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while. As yet, however, we do not have a valid, sensitive, dalities is probably the best way to determine which, if
reliable, and clinically feasible outcome measure to deter- any, will benefit a given patient. At present, the patient’s
mine which patient groups benefit from which airway clear- subjective preference is the best measure of which modal-
ance modalities. On the group level, radioactive tracer ity to use. The most effective and important part of con-
clearance and amount of expectorated sputum correlate, ventional CPT is directed cough and/or huff.
but on the individual level, the amount of expectorated Many questions about conventional CPT have not been
sputum is not a reliable or valid measure, because some of studied, so much of CPT practice is not evidence-based
the secretions may be swallowed and the expectorated and differs markedly at different institutions. For example,
secretions include saliva. The combination of the patient’s CPT is often started in infants and young children with CF
subjective preference and the amount of expectorated se- who have very small amounts of retained secretions and
cretions is, at present, the best way to measure the clinical thus probably do not benefit from CPT. On the other hand,
effectiveness of an airway clearance modality or combi- introducing the patient to CPT an early age may lead to
nation of modalities. Potential long-term outcomes include better patient adherence to the CPT regimen in the long
frequency of exacerbations and decline in pulmonary func- term. CPT is often increased during exacerbations, on the
tion. reasoning that there are more secretions during exacerba-
tions, but in a patient who is severely ill and weak and
Promoting Patient Adherence to CPT therefore has a low cough flow, CPT might not provide
clinically important benefit. CPT is often withheld if there
In addition to identifying which treatment(s) is/are ef- is hemoptysis, on the reasoning that chest percussion might
fective for the patient, it is also essential that the patient dislodge a clot and/or worsen the bleeding, but bleeding
adhere to the treatment plan sufficiently to obtain benefit. within the airway will produce clots and airway obstruc-
Only about 30% of patients with CF reported undertaking tion, and the inflammation from the bleeding is likely to
prescribed daily CPT.55 The problems include fitting CPT increase secretions, which suggests that CPT might be of
into their lifestyle, a perception that CPT does not help, greater benefit in a patient with hemoptysis. Finally, the
physical consequences of doing CPT, doing exercises in- optimal frequency and duration of any of the CPT inter-
stead, and doing CPT only when the patient perceives it ventions has not been well studied.
necessary.55 Adherence to CPT is reported to be lower
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Discussion mobilized within 1 or 2 days, so these ing decisions based only on physiology.
patients, if they are not smokers, are In your reviews, does chest PT actually
Hess: I actually have several ques- not at risk. I don’t think there’s a need have a meaningful clinical outcome?
tions for you, Cees. Is there any role for it. Does it keep people out of the hospi-
for CPT to prevent postoperative at-
tals? Does it shorten lengths of stay?
electasis and postoperative pulmonary Hess: I’d like to ask another ques-
Does it reduce important things like
complications? tion. What about chest wall squeezing
cough and health care utilization?
as has been described by some groups?
van der Schans: That’s a com-
van der Schans: We define these
pletely different field. I think for pa- van der Schans: Well, it helps to
force expiration. I just see it as a sup- outcomes in our Cochrane reviews.1,2
tients at risk for postoperative com-
port of the forced expiration. And then We didn’t find any studies about it.
plications, the older patients, the
it works the same as forced expira- But I agree that we need studies using
smokers, etc, I think then there is a
tion, so when the patient doesn’t have these kinds of outcomes, because only
role for routine CPT. But not for all
enough force himself for an effective an improvement in mucus transport,
patients.
cough or effective huff, or forced ex- or only a small improvement in FEV1,
Hess: Even a patient who has no piration, you can support that. But I that’s not enough. You want to pre-
prior pulmonary history and doesn’t think it’s not something completely vent exacerbations. You want to pre-
have phlegm, and . . .? different. vent the decline in pulmonary func-
tion. But these studies are very hard to
van der Schans: No. Patients who MacIntyre: I guess the older I get, do, because you have to follow pa-
underwent heart surgery are usually the more suspicious I become of mak- tients for at least 1-2 years.

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1. Main E, Prasad A, Schans C. Conventional numbers of studies in the ’60s and van der Schans: It was a model
chest physiotherapy compared to other air- ’70s that you chose not to include, or study, so it was—I don’t know what
way clearance techniques for cystic fibrosis.
Cochrane Database Syst Rev 2005;
even consider in your list of studies the time difference between the dif-
CD002011. that were not appropriate for the meta- ferent coughs was, but I think it was
2. van der Schans C, Prasad A, Main E. Chest analysis. I’m surprised that they very short. So when you would like to
physiotherapy compared to no chest physio- weren’t even considered—number translate it to a sort of a clinical set-
therapy for cystic fibrosis. Cochrane Data- one. And I’ve talked to Ammani ting, I think it is the repeated cough-
base Syst Rev 2000;CD001401.
Prasad, a co-author of that Cochrane ing during one expiration.
review about that issue. Number two,
MacIntyre: This may be a silly
question, but is there any evidence that it’s tough to get newborn infants who Rubin: If that’s the study I think it
chest PT might actually cause irrita- have lung disease and CF, or even tod- was, it was from Edith Puchelle’s
tion and increase mucus production? dlers, to do autogenic drainage, PEP, group, and Jean-Marie Zahm actually
or any of the other devices. So, the was able to control the force and vol-
van der Schans: I don’t think so. question I have is: What about the new- ume of a cough using the cough ma-
I’m not aware of any formal studies born infant who is developing lung chine.1 So it was measuring transport
looking at that. I know that rumor goes disease? Do we just not treat those of a mucus bolus, within the cough
around, that percussion or coughing kids with anything? What do we do machine, by giving very exact timed
causes hypersecretion. I don’t think with them? coughs, all of exactly the same size.
that there is any evidence for that. Clinical translation, to my knowledge,
van der Schans: Good question. I’m hasn’t been done.
Schechter: For my talk tomorrow, not a clinician anymore, but I would And also, to answer your earlier
which is limited to pediatric studies, I say to improve ventilation, make ven- question, I’m not aware of any studies
was specifically interested in focusing tilation as good as possible, to use that show that physical therapy would
on clinical outcomes, as opposed to tricks, to get some kind of forced ex- increase mucus secretion. But on the
some of the theoretical endpoints. piration maneuvers, these kinds of other hand, I know of no decent ways
Most of the studies that even try to things. to measure increased or decreased mu-
look at outcomes don’t do a really good cus secretion in vivo anyway. And if
job; but there are some studies that do Tecklin: Again, getting rid of the somebody can come up with a way,
look at a variety of clinical outcomes, secretions is really the question for radiographically, to quantify the total
at least in children. There will be some those kids. And that is actually one airway mucus burden, I think it would
discussion of theoretical stuff, but one instance when doing traditional pos- be a wonderful way to advance this
of the issues I specifically address is tural drainage with percussion has field.
the role of airway clearance therapy been shown to be detrimental, because
it is likely to cause a significant amount 1. Zahm JM, King M, Duvivier C, Pierrot D,
on prevention of postoperative atelec- Girod S, Puchelle E. Role of simulated re-
tasis.1 This was evaluated in one older of reflux, so that today’s approach is petitive coughing in mucus clearance. Eur
study, and no benefit was found.2 not tipping the kids, but rather, keep- Respir J 1991;4(3):311-315.
Again, I didn’t review this in adults, ing them flat, or even head-up. And
so I can’t speak to that. But stay tuned doing, in fact, the percussion that many Rogers: It has been done using MRI
tomorrow. of us have always done. And we can [magnetic resonance imaging] in rats.1
thank Brenda Button for that.1 They analyzed the MRI images to get
1. Schechter M. Airway clearance applications
in infants and children. Respir Care 2007; 1. Button BM, Heine RG, Catto-Smith AG, et a quantitative measure of amount of
52(10): in press. al. Chest physiotherapy in infants with cys- mucus in the lung. I do not know if it
2. Reines HD, Sadde RM, Bradford BF, Mar- tic fibrosis: to tip or not? A five-year study. could be translated into visualizing
shall J. Chest physiotherapy fails to prevent Pediatr Pulmonol 2003;35(3):208-213. mucus in a more complicated system
postoperative atelectasis in children after car-
diac surgery. Ann Surg 1982;195(4):451- such as human airways and lungs.
Chatburn: In the study by Zahm1
455. 1. Karmouty-Quintana H, Cannet C, Sugar R,
that you mentioned, where increasing
Fozard JR, Page CP, Beckmann N. Capsa-
Tecklin:* I don’t want to sound like the frequency increased the mucus
icin-induced mucus secretion in rat airways
a broken record, but again, there were clearance, was that multiple occlusions assessed in vivo and non-invasively by mag-
of a single exhalation? netic resonance imaging. Br J Pharmacol
2007;150(8):1022-1030.
1. Zahm JM, King M, Duvivier C, Pierrot D,
* Jan S Tecklin, PS MSc, Department of Phys- Girod S, Puchelle E. Role of simulated re-
ical Therapy, Arcadia University, Glenside, petitive coughing in mucus clearance. Eur Rubin: They’ve done it with cervi-
Pennsylvania, representing Electromed Respir J 1991;4(3):311-315. cal mucus ex vivo, and been able to

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measure, actually, rheology, viscoelas- Fink: For individual positions? Or my head. The seminal descriptions of
ticity by the T1/T2 ratio on MRI. I for the whole treatment? postural drainage described individual
don’t know that the resolution of MRI positions being drained from periods
in that has been good enough to—you van der Schans: Yeah, but some- as short as 10 minutes up to several
can distinguish mucus from airway, times patients with bronchiectasis, hours.2
but I don’t know that you can actually they know that when they are lying in
1. American Association for Respiratory Care.
quantify 3-dimensionally. It would be a certain position and very watery mu- AARC Clinical Practice Guideline: Postural
interesting; I haven’t seen that, unless cus comes out, it comes out almost drainage therapy. Respir Care 1991;36(12):
you’ve got a really, really strong, pow- immediately. So they don’t have to lie 1418-1426.
erful coil. in position for 20 minutes. It’s very 2. Pryor JA. Physiotherapy for airway clear-
fast, but when the mucus is thick and ance in adults. Eur Respir J 1999;14(6):1418-
1424.
Schechter: The rationale for pa- sticking to the airways, it may take
tients to get bronchodilators before much longer. I know that we advised
Hess: I guess I’ll play the devil’s
chest PT is to prevent possible bron- in the past that our patients sleep in a
advocate. If you could get the same
chospasm. In the world of anecdotal certain position. But you ask a lot of
result in a 10-minute Flutter treatment
medicine, there are several review ar- patients to do that, and it costs a lot of
compared to a 30-minute conventional
ticles that I found that described bron- time for the patient. So when you talk
chest PT treatment, why wouldn’t you
chospasm as a complication of CPT. about compliance, the compliance will
take the 10-minute treatment?
But I found no research study that ac- be low, I think.
tually documented that phenomenon. Tecklin: As I recall, the Flutter treat-
Tecklin: I think we’re talking about
ment was longer than the traditional
Tecklin: Again, in one of these early 20-30 minutes for the entire session.
10 minutes. It might have been 20 min-
studies to which you referred, we had And the only thing I can refer to is a
utes. They tried to do equivalent times,
26 subjects with CF, 6 of whom were study on Flutter. One of the original
which they often do. And again, some
wheezing by auscultation. We looked ones done at Cleveland,1 where their
of us might say if you’re doing a 5-10
at 6 out of 26 who were wheezing definition of chest physiotherapy was
minute Flutter treatment as your treat-
10 minutes, 12 different positions. Ten
before and after our interventions, and ment, that in and of itself might not be
minutes total. In that first study, Flut-
really found no difference in regard to an appropriate use of Flutter, because
ter was much more effective in reduc-
whether the wheezing reduced their you’re also talking about the need for
ing and pulling out secretions.
pulmonary function. They had in- FET afterwards, and the active cycle
When that study was replicated a
creases similar to the group who of breathing and huffing, and cough-
couple of years later, with a more ap-
weren’t wheezing. ing.
propriate definition of chest physio-
1. Tecklin JS, Holsclaw DS. Evaluation of bron- therapy, which was more like—I think
chial drainage in patients with cystic fibro- it was either a 20- or 30-minute treat- Rubin: Not to take from later pre-
sis. Phys Ther 1975;55(10):1081-1084.
ment—there was essentially no dif- sentations, but that study, the first one
ference in the sputum produced be- in the States by Mike Konstan and
Fink: A question about postural
tween the 2 techniques. So, chest colleagues,1 was set up to match the
drainage. At least in the United States physiotherapy doesn’t equal chest duration between the two. But even
there is a tendency for clinicians to be physiotherapy. You really have to more interesting is that their primary
somewhat time-limited for procedures. identify your terms when you’re dis- outcome variable in that study was pul-
That means maybe having 15 minutes cussing it. monary function, and there was no pul-
for the total procedure, and in many monary function change. Their sec-
cases trying to do 10 or 11 positions 1. Konstan MW, Stern RC, Doershuk CF: Ef- ondary outcome variable was wet- and
ficacy of the Flutter device for airway mu-
in that period of time. What’s a rea- cus clearance in patients with cystic fibrosis,
dry-weight of sputum, and that’s where
sonable period of time to get an ef- J Pediatr 1994;124(5 Pt 1):689-693. they saw the differences, which was
fective response in terms of position- an interesting thing.
ing the patient for a single position for Fink: I recall when the first AARC You showed—and again, I hope I’m
drainage of secretions? guideline came out on postural drain- not taking from Rob Chatburn’s talk
age,1 there were a couple of references later on chest wall oscillation— but
van der Schans: I don’t know. My that led us to believe that the recom- you showed a study that suggested the
guess is something around 20, 30 min- mendations should be a minimum of resonant frequency of the thorax was
utes. That’s what everybody does, and 3-5 minutes per position, but I don’t about 8-10 hertz, and in the initial stud-
that’s what you see in the studies. remember the references off the top of ies that Arnold Zidulka did in devel-

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oping the Vest with Malcolm King,2 mogeneous. Different parts of the lung methods of airway clearance to CPT,
they showed it was somewhere about have different conditions and may I think you’re on shaky ground.
10-15 hertz. Yet, frequently we’ll have need a different approach, but I’m not
1. van der Schans C, Prasad A, Main E. Chest
people apply the Vest and cycle over aware of any studies. physiotherapy compared to no chest physio-
a period of time different frequencies, therapy for cystic fibrosis. Cochrane Data-
as opposed to turning it on and just Schechter: I can tell you that War- base Syst Rev 2000(2): CD001401.
leaving it at 10-12 hertz. Is there any ren Warwick, in particular, has a very
advantage to cycling the frequency up complicated and elaborate 30 minute Homnick: I think the study that
or down every 10 minutes or 5 min- regimen with 3 different frequency
Bruce is referring to also showed that
utes or so, as opposed to just leaving levels associated with different pres-
it close to the resonant frequency? at the higher frequencies, with the
sure settings. But he has no proof that
Vest, the volume of oscillation went
1. Konstan MW, Stern RC, Doershuk CF: Ef- this is more efficacious than any other,
down as well, and it was dependent
ficacy of the Flutter device for airway mu- simpler regimen.
cus clearance in patients with cystic fibrosis, I also want to point out that the on the frequency, but also on the back-
J Pediatr 1994;124(5 Pt 1):689-693. studies that have demonstrated effi- ground pressure in the Vest at the time
2. King M, Phillips DM, Gross D, Vartian V, cacy of CPT in cystic fibrosis have it was applied. I’m not sure totally
Chang HK, Zidulka A. Enhanced tracheal how to interpret that, but I think a
mucus clearance with high frequency chest
primarily demonstrated an increase in
quantity of sputum production rather larger volume of oscillation is proba-
wall compression. Am Rev Respir Dis 1983;
128:511-515. than any improvement in FEV1. This bly better for mucus clearance, and
was one of the points of the Cochrane therefore, higher frequency may not
van der Schans: I wouldn’t know, analysis done by Cees.1 So if you are be helpful. It seems like it would be
but I could imagine that the lungs, es- going to use FEV1 as your outcome useful to spend more time in that 10-15
pecially in cystic fibrosis, are not ho- measure in comparing alternative range than at other frequencies.

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