Nonpharmacologic Airway Clearance Techniques in...

Nonpharmacologic Airway Clearance Techniquesin Hospitalized Patients: A Systematic Review

Jeff Andrews MD, Nila A Sathe MA MLIS, Shanthi Krishnaswami MBBS MPH,and Melissa L McPheeters PhD MPH

IntroductionMethods

Literature Search StrategyInclusion and Exclusion CriteriaStudy SelectionData Extraction and SynthesisQuality (Risk of Bias) Assessment of Individual Studies

ResultsStudies Evaluating CPT in Non-Postoperative SubjectsStudies in Postoperative Subjects

DiscussionSputum Weight or VolumeOxygenation and Gas ExchangePulmonary Function TestsNeed for and Progression to or Duration of Mechanical VentilationSigns and SymptomsExercise TolerancePulmonary ComplicationsStayExacerbations/Hospital ReadmissionsQuality of LifeHarms of Airway Clearance TechniquesMethodologic Considerations and LimitationsFuture Research

Summary

Nonpharmacologic airway clearance techniques are used to reduce the sequelae of obstructivesecretions. We systematically reviewed comparative studies of nonpharmacologic interventions thathealth professionals can employ to achieve mucus clearance in hospitalized or postoperative pa-tients without cystic fibrosis, over the age of 12 months. We searched MEDLINE and other data-bases from 1990 to 2012 to identify relevant literature. Two reviewers independently assessed eachstudy against predetermined inclusion/exclusion criteria. Two reviewers also independently ex-tracted data regarding subject and intervention characteristics and outcomes, and assigned overallquality ratings. The 32 studies meeting the review criteria included 24 randomized controlled trials,7 crossover randomized controlled trials, and one prospective cohort study. Studies were typicallysmall and together included a total of 2,453 subjects (mean 76/study). Studies generally examinedchest physical therapy/physiotherapy modalities in postoperative or critically ill subjects or thosewith COPD. Interventions, comparators, and populations varied considerably across studies, ham-pering our ability to draw firm conclusions. Interventions, including conventional chest physical

2160 RESPIRATORY CARE • DECEMBER 2013 VOL 58 NO 12

therapy/physiotherapy, intrapulmonary percussive ventilation, and positive expiratory pressure,typically provided small benefits in pulmonary function, gas exchange, oxygenation, and needfor/duration of ventilation, among other outcomes, but differences between groups were generallysmall and not significant. Harms of the techniques were not consistently reported, though airwayclearance techniques were generally considered safe in studies that did comment on adverse effects.Further research with clearly characterized populations and interventions is needed to understandthe potential benefits and harms of these techniques. Key words: airway clearance techniques; chestphysical therapy; breathing exercises; airway obstruction/therapy; physical therapy modalities. [RespirCare 2013;58(12):2160–2186. © 2013 Daedalus Enterprises]

Introduction

Airway clearance techniques are intended to reduce thesequelae of obstructive secretions, which can include air-flow obstruction, wheeze, respiratory infection, dyspnea,fatigue, and reduced quality of life.1 Clearance techniquesinclude modalities such as active cycle of breathing tech-nique (ACBT), positive expiratory pressure (PEP) tech-niques such as the Flutter device, and intrapulmonary per-cussive ventilation (IPV). Conventional chest physicaltherapy or physiotherapy (CPT) approaches are frequentlyused as well, and include postural drainage, percussion,and vibration. Techniques may be categorized or groupedin multiple ways, and are often used in concert. Airwayclearance approaches may be used in individuals with im-paired cough or muscle weakness,2 impaired mucociliaryclearance,3-6 structural impairments such as bronchiecta-sis or asthma,7-9 and air-flow limitation, as seen inCOPD.7,10-12

The goal of the current project was to systematicallyreview comparative studies of nonpharmacologic interven-tions that respiratory therapists and other health profes-sionals can employ to achieve mucus clearance in hospi-talized or postoperative subjects over the age of 12 months.The American Association for Respiratory Care (AARC)

commissioned the review, and AARC committee membersparticipated in the review process. As a collaborative ef-fort, the AARC team and the Vanderbilt Evidence-BasedPractice Center developed the key questions and inclusionand exclusion criteria, and engaged in identification andreview of abstracts. The AARC members involved in thework were paired with Vanderbilt Evidence-Based Prac-tice Center staff in order to maintain rigor and protectagainst bias.

Methods

Literature Search Strategy

Detailed methods for this review and our search strate-gies can be found in the supplementary materials at http://www.rcjournal.com. Our primary literature search em-ployed the MEDLINE (via the PubMed interface) andCumulative Index of Nursing and Allied Health Literature(CINAHL) databases. Our search strategies used a com-bination of subject heading terms appropriate for each da-tabase and key words relevant to airway clearance (eg,sputum clearance, CPT). We limited searches to literaturepublished in English since 1990 to ensure that interven-tions used currently would be represented. Our searcheswere conducted in August 2012. We imported all citationsinto an electronic database and into the DistillerSR pro-gram for screening. We also manually searched the refer-ence lists of included studies and of recent narrative andsystematic reviews and meta-analyses addressing airwayclearance in adults to locate citations of potential rele-vance.

Inclusion and Exclusion Criteria

Studies needed to include subjects over 1 year of agewithout cystic fibrosis, who were receiving nonpharmaco-logic airway clearance therapies and who were either hos-pitalized (but not postoperative) or postoperative, had neu-romuscular disease or respiratory muscle weakness, or whohad impaired cough. We note that we excluded studies ofsubjects with cystic fibrosis, as the Cystic Fibrosis Foun-

The authors are affiliated with the Vanderbilt Evidence-Based PracticeCenter, Institute for Medicine and Public Health, Vanderbilt UniversityMedical Center, Nashville, Tennessee. Drs Andrews and McPheeters arealso affiliated with the Department of Obstetrics and Gynecology, Van-derbilt University Medical Center, Nashville, Tennessee.

This review was supported by the American Association for RespiratoryCare. The authors have disclosed no conflicts of interest.

Supplementary material related to this paper is available at http://www.rcjournal.com.

Correspondence: Melissa McPheeters PhD MPH, Vanderbilt Evidence-Based Practice Center, Institute for Medicine and Public Health, Van-derbilt University Medical Center, Suite 600, 2525 West End Avenue,Nashville TN 37203-1738. E-mail: [email protected].

DOI: 10.4187/respcare.02704

NONPHARMACOLOGIC AIRWAY CLEARANCE TECHNIQUES IN HOSPITALIZED PATIENTS

RESPIRATORY CARE • DECEMBER 2013 VOL 58 NO 12 2161

dation recently published guidelines specifically related toairway clearance.13 Studies had to report on interventionsexplicitly used for airway clearance and include a treat-ment group and an appropriate comparison group (Ta-ble 1). Comparators included other nonpharmacologicairway clearance approaches, no airway clearance inter-vention, or placebo. We also required that studies addressone of the outcomes related to the effects of the interven-tion on mucus clearance outlined in Table 1. We includedstudies with any length of follow-up and in the hospitalsetting (ie, not home- or out-patient-clinic-based).

Study Selection

Once we identified potential articles, we examined theabstracts to determine whether studies met our criteria.Two reviewers separately evaluated each abstract for in-clusion or exclusion, using an abstract review form (seethe supplementary materials at http://www.rcjournal.com).If one reviewer concluded that the article could be eligiblefor the review based on the abstract, we retained it for fulltext assessment. Two reviewers independently assessedthe full text of each included study, using a standardized

Table 1. Inclusion and Exclusion Criteria

Category Criteria

Study population Hospitalized or postoperative patients, over 1 year of age, without cystic fibrosis, and receiving nonpharmacologicairway clearance therapies

Patients with neuromuscular disease or respiratory muscle weakness, over 1 year of age, without cystic fibrosis,and receiving nonpharmacologic airway clearance therapies

Patients with impaired cough, over 1 year of age, without cystic fibrosis, and receiving nonpharmacologic airwayclearance therapies

Time period 1990–2012Publication languages English onlyAdmissible study designs Controlled trials, observational studies, including prospective cohort studiesOther criteria

Original research studies that provide sufficient detail regarding methods and results to enable use and adjustmentof the data and results

Patient population must include individuals as noted aboveMust address one or more of the following interventions:

Active cycle of breathingAutogenic drainageBronchoscopyChest physiotherapy (percussion, vibration, positioning, postural drainage)Cough assist (insufflation/exsufflation, forced expiratory technique, device)CuirassHigh-frequency chest compression vestIntrapulmonary percussive ventilationPositive expiratory pressure (PEP, oscillatory PEP, Flutter, Acapella)

Must provide baseline and outcome data for one or more of the following outcomes of interest:Time to exacerbation of disease/conditionNeed for ventilatory assistanceTime to re-admissionQuality of lifePulmonary function (FEV1, FVC, peak flow)Gas exchangeSymptoms and signs (dyspnea, cough, heart rate, breath sounds, retractions)Sputum clearance and expectoration (transport, weight, volume)Exercise toleranceOxygenation

or outcome data forAntibiotic use as affected by airway clearanceHarms (including mortality) related to airway clearance interventionsICU or hospital stayNumber of hospital admissions or hospital days

Must include extractable data on relevant outcomes, including data presented in text or tables (vs solely in figures)Must be hospital-based or in-patient-based



form (see the supplementary materials at http://www.rcjournal.com) that included questions stemming from ourinclusion/exclusion criteria. Disagreements between re-viewers were resolved by a third-party adjudicator. Thegroup of abstract and full text reviewers included expertclinicians and health services researchers, and we requiredthat studies be excluded by at least one clinician and onemethodologist. AARC members involved in screening werepaired with Vanderbilt Evidence-Based Practice Centerstaff in order to maintain rigor and protect against bias.

Data Extraction and Synthesis

We extracted data on study design, population charac-teristics (including age, underlying conditions, and needfor mechanical ventilation), intervention characteristics (in-cluding type and duration of intervention and concomitanttherapies), and key outcomes data into evidence tables (seethe supplementary materials at http://www.rcjournal.com).In addition to outcomes related to airway clearance inter-vention effectiveness, we extracted all data available onharms of airway clearance. Harms encompass the full rangeof specific negative effects, including the narrower defi-nition of adverse events. We determined that the differ-ences among populations, interventions, controls, and out-comemeasures renderedmeta-analysis inappropriate.Thus,our analysis was qualitative.

Quality (Risk of Bias) Assessment of IndividualStudies

We assessed quality using separate tools, as appropriateby study design. Tools included the Cochrane Risk of Biastool for randomized controlled trials (RCTs) and the New-castle-Ottawa scale for cohort studies. We rated the qualityfor key outcomes for which data were provided. If a studynoted, for example, that a given outcome was not signif-icantly different between groups but did not provide therelevant data, we did not rate quality for that outcome.Two reviewers independently assessed the quality of each

study, with final decisions made via discussion to reachconsensus or by third-party adjudication by a senior meth-odologist, as needed. We used the parameters outlined inTable 2 to translate quality ratings into final levels (good,fair, poor). We defined “good” studies as not having anyof the criteria that create a high risk of bias. For studieswith “unclear” ratings, we considered the likelihood that afactor would bias a given outcome and the importance ofthe limitation and down-graded the final level as appro-priate. Quality ratings for each outcome in the studiesreviewed can be found in the supplementary materials athttp://www.rcjournal.com.

Results

We reviewed 2,054 abstracts and 313 full-text papers,and 32 papers (representing 32 separate studies) met theinclusion criteria (Figure). The excluded studies can befound in the supplementary materials at http://www.rcjournal.com. The 32 studies that met the review criteriaincluded 24 RCTs, 7 crossover RCTs, and one prospectivecohort study (Table 3). The studies were mostly small, andtogether included a total of 2,453 subjects (mean 76 sub-jects/study). Studies typically examined CPT modalities inpostoperative or critically ill subjects or those with COPD.Subjects were typically assessed immediately following

Table 2. Quality Rating Algorithm

Low Risk ofBias Criteria

High Risk ofBias Criteria

Unclear Riskof Bias Criteria

Quality Level

7 0 0 Good6 0, 1 0, 1 Good or fair5 0, 1 1, 2 Good or fair5 2 0 Fair or poor4 0–2 0–3 Fair or poor0–3 0–7 0–7 Poor0–7 3–7 0–7 Poor0–7 0–7 4–7 Poor

Figure. Flow chart of study selection.



short-term interventions or upon hospital or ICU discharge.Five studies followed subjects for one to 6 months post-discharge.14-18

The following sections summarize the results of studiesthat met our criteria, and are categorized by interventionand comparison in those studies, including primarily hos-pitalized, non-postoperative subjects (Table 4) and thosefocused on postoperative subjects (Table 5). Several stud-ies of ICU populations included both postoperative sub-jects and subjects hospitalized for medical therapies. Wehave grouped these papers with studies of hospitalizedsubjects because their primary focus is not on the postop-erative period.

Studies Evaluating CPT in Non-PostoperativeSubjects

CPT Compared to Usual Care or Added to AnotherTreatment. Kodric and colleagues compared the “expi-ration with the glottis open in lateral posture” CPT tech-

nique (expiration group, n � 30) with standard medicaltreatment (n � 29) in subjects hospitalized with COPDexacerbation.16 Subjects in the expiration group also re-ceived standard medical therapy and were continued onmedical therapy alone after 7 days of the expiration treat-ment (two 30–40 min sessions/d). Investigators analyzedsubject respiratory data after 7 days of treatment, qualityof life (St George’s Respiratory Questionnaire [SGRQ])1 month post-discharge, and number of exacerbations andhospital admissions at 6 months post-discharge. The pri-mary outcome of sputum volume was not significantlydifferent between the groups after 7 days of treatment(mean 6.8 � 7.6 mL/d in the expiration group, 8.2 � 9.4in the medical treatment only group), though the volumechanges within each group differed significantly from base-line to follow-up (P � .001). Dyspnea (Borg scale) wassignificantly reduced in the expiration group at 7 days(3.0 � 1.8 vs 4.3 � 1.5, P � .004). Stay was similarbetween groups (mean 9.5 � 3.2 d in the expiration groupvs 10.0 � 2.4 d in the medical treatment only group). At1 month post-discharge, quality of life scores were notsignificantly different between the groups. Similarly, at 6months post-discharge, COPD exacerbations and hospital-izations did not differ significantly, though only roughly37% of subjects in each group were available at the 6-monthfollow-up. We rated the quality of all the outcome as-sessed (pulmonary function, oxygenation, dyspnea, qualityof life, sputum volume, stay, exacerbations) as poor.

In an RCT including mechanically ventilated ICU sub-jects, Templeton and Palazzo compared CPT (thoracic andpulmonary expansion; respiratory muscle exercise; and se-cretion removal via manual hyperinflation with vibration,positioning, and suctioning) with standard ICU care.21 Thefrequency and intensity of CPT could be varied at thetherapist’s discretion, and therapists were not blinded tosubjects’ group allocations. Control group subjects receivedsuctioning, mobilization, and decubitus care, though allsubjects could receive rescue CPT as needed (45 CPT and37 control group subjects required rescue CPT at any timewhile ventilated). The mean age of the 87 subjects in theCPT group was 57.7 years (median Acute Physiology andChronic Health Evaluation [APACHE] II score 49), whilethe corresponding values for the control group were58.2 years and median APACHE II score of 41. The groupswere not significantly different at baseline. Reasons forICU admission in both groups varied and included respi-ratory insufficiency (n � 21), intracerebral hemorrhage(n � 35), and gastrointestinal causes including bleedingand perforation (n � 18). The median number of days forhalf of subjects to become ventilator free was significantlylower in the control group than in the CPT group (11 d,range 3–76 d, vs 15 d, range 3–82 d, P � .045). Fourteenpercent (n � 12) of the control subjects and 12.6% (n � 11)of the CPT subjects required re-ventilation after becoming

Table 3. Overview of Included Studies

RCTCrossover

RCTProspective

CohortAll

Studies

Number of studies 24 7 1 32Population

Adult 18 7 1 26Pediatric 4 0 0 4Mixed 2 0 0 2

Underlying condition*Asthma 5 0 0 5Bronchiectasis 1 3 0 4COPD 8 2 1 11Pneumonia or other

pulmonary infection1 3 0 4

Post-surgical/criticalillness/trauma

13 3 1 17

Intervention category*Active cycle of breathing

technique0 1 0 1

Chest physical therapy 19 4 1 24High-frequency chest wall

compression1 0 0 1

Intrapulmonary percussiveventilation

3 1 0 4

Positive expiratory pressure 6 4 0 10Country

Asia 2 3 0 5Australia 4 1 1 6Europe 9 2 0 11South America 2 1 0 3United States or Canada 5 0 0 5Africa 2 0 0 2

* Numbers do not tally because studies may appear in more than one category.RCT � randomized controlled trial



Tab

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onar

yfu

nctio

nte

stva

lues

Sign

ific

ant

diff

eren

cein

FEV

1/F

VC

betw

een

pre

and

post

ther

apy

inbo

thgr

oups

(P�

.03)

Subj

ects

mor

eco

mfo

rtab

lew

ithA

CB

Tth

anC

PT(V

AS

P�

.004

)C

PTco

mpa

red

with

IPV

Pane

roni

26

2011

RC

T,

cros

sove

rA

dults

with

bron

chie

ctas

isad

mitt

edto

resp

irat

ory

depa

rtm

ent

G1:

CPT

:fo

rced

expi

ratio

n,po

stur

aldr

aina

ge,

perc

ussi

on,

and

vibr

atio

nG

2:In

trap

ulm

onar

ype

rcus

sive

vent

ilatio

nG

1/G

2:22

/22

No

sign

ific

ant

betw

een-

grou

pdi

ffer

ence

sin

hear

tra

te,

S pO

2,vo

lum

eor

wet

ordr

yw

eigh

tof

sput

um,

dysp

nea,

sens

atio

nof

phle

gmen

cum

bran

ceSi

gnif

ican

tlygr

eate

rde

crea

sein

brea

thin

gfr

eque

ncy

with

IPV

Hea

rtra

tede

crea

sed

sign

ific

antly

inbo

thgr

oups

Sign

ific

antly

less

post

-tre

atm

ent

disc

omfo

rtin

IPV

grou

p,al

thou

ghth

ere

was

high

vari

abili

tyA

nton

aglia

27

2006

RC

TA

dult

ICU

patie

nts

with

CO

PDex

acer

batio

nG

1:St

anda

rdhe

lmet

NIV

�pe

rcus

sion

,po

stur

aldr

aina

ge,

expi

ratio

nw

ithgl

ottis

open

inla

tera

lpo

stur

e20

/20

G2:

Hel

met

NIV

�no

ninv

asiv

eIP

V20

/20

G3:

Face

mas

kN

IV�

perc

ussi

on,

post

ural

drai

nage

,ex

pira

tion

with

glot

tisop

enin

late

ral

post

ure

(his

tori

cal

cont

rols

)40

/40

At

disc

harg

e,IP

Vgr

oup

had

low

erP a

CO

2,hi

gher

P aO

2/F I

O2,

shor

ter

mec

hani

cal

vent

ilatio

n,an

dsh

orte

rIC

Ust

ayth

anth

eot

her

2gr

oups

Blo

odga

sex

chan

ge,

hear

tra

te,

and

brea

thin

gfr

eque

ncy

impr

oved

afte

rIP

V

Clin

i18

2006

RC

TA

dult

in-p

atie

nts

with

trac

heos

tom

yad

mitt

edfo

rve

ntila

tor

wea

ning

G1:

CPT

(pos

tura

ldr

aina

ge,

man

ual

drai

nage

)pl

usIP

V24

/23

G2:

CPT

22/2

1

Sign

ific

antly

mor

epa

tient

sw

ithno

soco

mia

lpn

eum

onia

inG

2N

osi

gnif

ican

tbe

twee

n-gr

oup

diff

eren

cein

acut

ehe

mor

rhag

e,at

elec

tasi

s,P a

O2,

P aC

O2,

orpH

Sign

ific

ant

impr

ovem

ent

inP a

O2/

F IO

2an

dm

axim

alex

pira

tory

pres

sure

inIP

Vgr

oup

(con

tinue

d)



Tab

le4.

Con

tinue

d

Firs

tA

utho

rY

ear

Stud

yD

esig

nPo

pula

tion

Gro

ups,

nE

nrol

lmen

t/nFi

nal

Key

Find

ings

Stud

ies

eval

uatin

gPE

Pm

odal

ities

Chi

cayb

an28

2011

RC

T,

cros

sove

rM

echa

nica

llyve

ntila

ted

adul

tpa

tient

sw

ithpu

lmon

ary

infe

ctio

n

G1:

Flut

ter

G2:

Nor

mal

pres

sure

-con

trol

led

vent

ilatio

nG

1/G

2:20

/20

Flut

ter

impr

oved

sput

umpr

oduc

tion

(P�

.001

),ex

pira

tory

flow

at75

%of

tidal

volu

me

(P�

.005

),an

dP a

O2/

F IO

2

(P�

.001

)N

osi

gnif

ican

tch

ange

inre

spir

ator

yre

sist

ance

,he

art

rate

,or

mea

nar

teri

alpr

essu

reT

sang

29

2003

RC

TA

dults

with

exac

erba

tion

ofbr

onch

iect

asis

G1:

Post

ural

drai

nage

�br

eath

ing

and

coug

hing

G2:

Flut

ter

�br

eath

ing

and

coug

hing

G3:

Bre

athi

ngan

dco

ughi

ngal

one

G1/

G2/

G3:

26/1

5(5

inea

chgr

oup)

No

sign

ific

ant

diff

eren

ces

insp

utum

prod

uctio

n(w

etw

eigh

t)or

lung

func

tion

para

met

ers

amon

gth

e3

grou

ps

Sam

rans

amru

ajki

t30

2003

RC

TC

hild

ren

with

acut

e,un

com

plic

ated

asth

ma

G1:

Flut

ter

�st

anda

rdth

erap

y20

/20

G2:

Stan

dard

ther

apy

20/2

0G

1ha

dm

ore

seve

reas

thm

aat

base

line

Bot

hgr

oups

had

sign

ific

ant

incr

ease

inFV

Can

dFE

V1

onth

e1s

tan

d2n

dho

spita

lda

ysG

1ha

dhi

gher

FEV

(P�

.08)

No

betw

een-

grou

pdi

ffer

ence

inho

spita

lst

ay(P

�.3

)N

ose

riou

sad

vers

eef

fect

sin

G1

Bel

lone

31

2002

RC

TA

dults

with

CO

PDex

acer

batio

nre

quir

ing

NIV

inre

spir

ator

yIC

U

G1:

PEP

�as

sist

edco

ugh

13/1

3G

2:A

ssis

ted

coug

hon

ly14

/14

Sput

umpr

oduc

tion

atth

een

dof

trea

tmen

tw

ashi

gher

inG

1:9.

6�

3.9

gvs

4.7

�2.

5g

(P�

.01)

Mor

talit

yno

tsi

gnif

ican

tlydi

ffer

ent

betw

een

the

grou

psN

osi

gnif

ican

tch

ange

inox

ygen

satu

ratio

nin

eith

ergr

oup

Sens

atio

nof

disc

omfo

rtre

port

edw

ithPE

Pby

2pa

tient

s(1

5.3%

)A

mbr

osin

o32

1995

RC

T,

cros

sove

rA

dult

in-p

atie

nts

with

high

sput

um(�

25m

L/d

)du

eto

dise

ases

othe

rth

ancy

stic

fibr

osis

G1:

Osc

illat

ory

PEP

G2:

Post

ural

drai

nage

�pe

rcus

sion

G1/

G2:

14/1

4

No

chan

gein

expi

rato

ryfl

owor

oxyg

ensa

tura

tion

Sim

ilar

amou

ntof

sput

umpr

oduc

ed60

min

afte

rtr

eatm

ent

No

adve

rse

effe

cts

duri

ngei

ther

trea

tmen

t

Uno

ki33

2005

RC

T,

cros

sove

rA

dult

mec

hani

cally

vent

ilate

dIC

Upa

tient

sG

1:R

ibca

geco

mpr

essi

on/s

uctio

ning

G2:

Suct

ioni

ng/r

ibca

geco

mpr

essi

onG

1/G

2:14

4/31

No

impr

ovem

ent

inox

ygen

atio

n,ve

ntila

tion,

orse

cret

ion

clea

ranc

ew

ithri

bca

geco

mpr

essi

onN

osi

gnif

ican

tP a

O2/

F IO

2or

P aC

O2

diff

eren

ces

betw

een

the

2po

st-i

nter

vent

ion

peri

ods

No

sign

ific

ant

diff

eren

ces

inw

eigh

tof

colle

cted

sput

umin

the

2pe

riod

sSt

udie

sev

alua

ting

post

ural

drai

nage

Ber

ney3

420

02R

CT

,do

uble

cros

sove

rIn

tuba

ted,

vent

ilate

dan

dca

rdio

vasc

ular

lyst

able

adul

tpa

tient

s

G1:

Post

ural

drai

nage

plus

man

ual

hype

rinf

latio

n,fo

llow

edby

vent

ilato

rhy

peri

nfla

tion

G2:

Post

ural

drai

nage

plus

vent

ilato

rhy

peri

nfla

tion,

follo

wed

bym

anua

lhy

peri

nfla

tion

G1/

G2:

20

No

sign

ific

ant

diff

eren

cein

sput

umw

etw

eigh

tbe

twee

ngr

oups

(P�

.11)

Pulm

onar

yco

mpl

ianc

eim

prov

edw

ithbo

thhy

peri

nfla

tion

tech

niqu

es(P

�.0

01)

No

adve

rse

chan

ges

inhe

art

rate

,m

ean

arte

rial

pres

sure

,or

oxyg

ensa

tura

tion

(con

tinue

d)



Tab

le4.

Con

tinue

d

Firs

tA

utho

rY

ear

Stud

yD

esig

nPo

pula

tion

Gro

ups,

nE

nrol

lmen

t/nFi

nal

Key

Find

ings

Nto

umen

opou

los3

519

98R

CT

Mec

hani

cally

vent

ilate

dad

ult

trau

ma

patie

nts

G1:

Man

ual

hype

rinf

latio

n�

post

ural

drai

nage

22/1

8G

2:St

anda

rdca

re24

/16

No

betw

een-

grou

pdi

ffer

ence

inpu

lmon

ary

dysf

unct

ion

(wor

stda

ilyP a

O2/

F IO

2)N

oIC

Ude

aths

No

betw

een-

grou

pdi

ffer

ence

inIC

Ust

ay:

G1

7.4

�5.

7d,

G2

6.8

�4.

6d

Mor

eno

soco

mia

lpn

eum

onia

inG

2(P

�.0

2)K

raus

e36

2000

RC

TIn

tuba

ted

teen

/adu

ltIC

Upa

tient

sw

ithat

elec

tasi

s(a

cute

loba

r)

G1:

Post

ural

drai

nage

�pe

rcus

sion

�su

ctio

ning

9/9

G2:

Mod

ifie

dpo

stur

aldr

aina

ge�

perc

ussi

on�

suct

ioni

ng8/

8

Oxy

gena

tion

impr

oved

mor

ein

G1

than

G2

G1

requ

ired

3tr

eatm

ents

whi

leG

2re

quir

ed4.

5tr

eatm

ents

tore

solv

elu

ngco

llaps

eB

ette

rlu

ngga

sex

chan

gein

G1,

and

min

imal

chan

ges

inG

2N

osi

gnif

ican

tdi

ffer

ence

sB

arke

r37

2002

RC

TM

echa

nica

llyve

ntila

ted

adul

tIC

Upa

tient

sw

ithac

ute

lung

inju

ry

G1:

Suct

ioni

ng5/

5G

2:Su

ctio

ning

�po

sitio

ning

5/5

G3:

Suct

ioni

ng�

posi

tioni

ng�

man

ual

hype

rinf

latio

n7/

7

Sign

ific

ant

P aC

O2

chan

ge(P

�.0

3)ov

ertim

ein

all

3gr

oups

,bu

tno

diff

eren

cebe

twee

ngr

oups

(P�

.56)

P aO

2/F I

O2

did

not

alte

rin

any

grou

pSi

gnif

ican

tbe

twee

n-gr

oups

diff

eren

cein

mix

edve

nous

oxyg

ensa

tura

tion

(P�

.03)

Hea

rtra

tean

dbl

ood

pres

sure

sign

ific

antly

diff

eren

t(P

�.0

4)be

twee

ngr

oups

over

time,

but

diff

eren

ceno

tcl

inic

ally

impo

rtan

tSt

udie

sev

alua

ting

IPV

Var

gas3

820

05R

CT

Adu

ltIC

Upa

tient

sw

ithC

OPD

exac

erba

tion

G1:

IPV

2se

ssio

nspe

rda

y�

stan

dard

med

ical

ther

apy

17/1

7G

2:St

anda

rdm

edic

alth

erap

y(o

xyge

nvi

ana

sal

cann

ula

with

nebu

lized

salb

utam

olor

terb

utal

ine,

nebu

lized

ipra

trop

ium

brom

ide,

subc

utan

eous

hepa

rin,

cort

icos

tero

ids,

and

antib

iotic

)16

/16

Sign

ific

antly

less

wor

seni

ngof

exac

erba

tion

inG

1(0

%)

than

inG

2(3

5.3%

)N

oho

spita

lde

aths

inei

ther

grou

pSi

gnif

ican

tlylo

nger

stay

inG

2:6.

8�

1.0

dvs

7.9

�1.

3d,

P�

.05

Stud

ies

eval

uatin

gch

est

wal

lco

mpr

essi

onM

ahaj

an14

2011

RC

TA

dult

in-p

atie

nts

with

acut

eas

thm

aor

CO

PDG

1:H

igh-

freq

uenc

ych

est

wal

lco

mpr

essi

on25

/25

G2:

Sham

devi

ce27

/27

No

betw

een-

grou

psi

gnif

ican

tdi

ffer

ence

inad

here

nce

orsa

tisfa

ctio

nSi

gnif

ican

tlygr

eate

rim

prov

emen

tin

Bor

gsc

ore

inG

1:71

%vs

42%

,P

�.0

48N

obe

twee

n-gr

oup

sign

ific

ant

diff

eren

ces

inex

pect

orat

edsp

utum

,ch

ange

inpo

st-b

ronc

hodi

lato

rFE

V1%

,st

ay,

syst

emic

cort

icos

tero

ids

use,

orac

ute

care

visi

ts

CPT

�ch

est

phys

ioth

erap

yR

CT

�ra

ndom

ized

cont

rolle

dtr

ial

FET

�fo

rced

expi

rato

ryte

chni

que

AC

BT

�ac

tive

cycl

eof

brea

thin

gIP

V�

intr

apul

mon

ary

perc

ussi

veve

ntila

tion

NIV

�no

ninv

asiv

eve

ntila

tion

PEP

�po

sitiv

eex

pira

tory

pres

sure



Tab

le5.

Sum

mar

yof

Key

Find

ings

ofSt

udie

sof

Air

way

Cle

aran

ceT

echn

ique

sin

Post

oper

ativ

ePa

tient

s

Firs

tA

utho

rY

ear

Stud

yD

esig

nPo

pula

tion

Gro

ups,

nE

nrol

lmen

t/nFi

nal

Key

Find

ings

Stud

ies

ofC

PTM

acka

y39

2005

RC

TA

dults

unde

rgoi

ngab

dom

inal

surg

ery

G1:

Dee

pbr

eath

ing,

coug

hing

,hu

ffin

g,FE

T�

mob

iliza

tion

29/2

9G

2:M

obili

zatio

non

ly27

/21

No

sign

ific

ant

diff

eren

cein

inci

denc

eof

pulm

onar

yco

mpl

icat

ions

:G

117

%,

G2

15%

Sign

ific

ant

diff

eren

cein

stay

:G

110

.4�

3d,

G2

13.3

�4.

5d

(P�

.008

)D

eneh

y40

2001

RC

TA

dults

adm

itted

for

uppe

rab

dom

inal

surg

ery

G1:

CPT

(dee

pbr

eath

ing

exer

cise

s,su

stai

ned

max

imal

insp

irat

ion,

FET

,co

ughi

ng)

�C

PAP

for

15m

inG

2:C

PT�

CPA

Pfo

r30

min

G3:

CPT

only

G1,

G2,

G3:

57/5

0

Cha

nge

inox

ygen

satu

ratio

nac

ross

time

was

sign

ific

ant

(P�

.001

)N

osi

gnif

ican

tbe

twee

n-gr

oup

diff

eren

ces

infu

nctio

nal

resi

dual

capa

city

,vi

tal

capa

city

,or

S pO

2

Post

oper

ativ

eco

mpl

icat

ions

occu

rred

inal

lgr

oups

:G

111

%,

G2

6%,

G3

22%

,di

ffer

ence

not

sign

ific

ant

Lon

ger

hosp

ital

stay

inth

ose

with

com

plic

atio

ns(P

�.0

2),

but

nobe

twee

n-gr

oup

diff

eren

cein

hosp

ital

stay

deC

harm

oy41

2000

RC

TU

ncom

plic

ated

card

iac

valv

ular

surg

ery

patie

nts,

11–6

3y

old

G1:

Cou

ghas

sist

�br

eath

ing

exer

cise

16/1

6G

2:In

stru

ctio

nsfo

rco

ughi

ng14

/14

No

subj

ects

deve

lope

dpu

lmon

ary

com

plic

atio

nsN

obe

twee

n-gr

oup

diff

eren

ces

inho

spita

lst

ayor

P aO

2

Ate

lect

asis

pres

ent

onpo

stop

erat

ive

day

4,in

depe

nden

tof

trea

tmen

tFa

gevi

kO

lsen

42

1997

RC

TA

dults

unde

rgoi

ngel

ectiv

eop

enab

dom

inal

surg

ery

G1:

CPT

(ear

lym

obili

zatio

n,br

eath

ing

exer

cise

,hu

ffin

g,co

ughi

ng,

and

PEP

for

high

risk

patie

nts)

174/

172

G2:

Con

trol

(no

info

/trea

tmen

tex

cept

for

thos

ew

ithpu

lmon

ary

com

plic

atio

ns)

194/

192

Post

oper

ativ

epu

lmon

ary

com

plic

atio

nsm

ore

freq

uent

inG

2:27

%vs

6%,

P�

.001

Bet

ter

oxyg

ensa

tura

tion

inG

1N

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In a cohort study including mechanically ventilated ICUpatients, Ntoumenopoulos et al evaluated CPT comparedwith standard care for the prevention of ventilator-associ-ated pneumonia (VAP).23 CPT (n � 24 subjects, meanAPACHE II score 20.7 � 6.9) included postural drainageor positioning for at least 20 min, expiratory chest wallvibration (4 sets of 6 cycles, with coughing added forsubjects weaned from ventilator), and suctioning (� 3times). The control group (n � 36, mean APACHE IIscore 18.8 � 5.4) received sham CPT, consisting of car-diopulmonary assessment and occasional musculoskeletalphysical therapy plus re-positioning and suctioning asneeded. Both groups received standard medical and nurs-ing care, which included hemodynamic support, infectioncare, enteral nutrition, antibiotic therapy, and bronchos-copy, as needed. The subjects’ underlying conditions in-cluded COPD (6 in the CPT group, 11 in the controlgroup), cardiomyopathy (1 in the CPT group, 3 in thecontrol group), and cardiac arrest (3 in the CPT group, 5 inthe control group). Groups were similar at baseline interms of risk factors for VAP; however, among the surgi-cal subjects the American Society of Anesthesiologistsscore was higher in the control arm (P � .04). Signifi-cantly more subjects in the control arm developed VAP(14 vs 2, P � .01). The duration of ventilation, ICU stay,and number with lung collapse or consolidation were non-significantly lower in the CPT group: median ventilationdays 4.4 vs 5.2, median ICU days 5.6 vs 5.8, number withlung collapse/consolidation 23 vs 34. We rated this cohortstudy as good quality.

In an RCT that included mechanically ventilated ICUsubjects, 20–85 years old, Chen and colleagues comparedmechanical chest vibration (via vibration pad used in su-pine position, 60 min/session, 6 times/d over 72 h) plusroutine positioning in 50 subjects, to routine positioningalone in 45 subjects.22 Underlying conditions in both groupsincluded sepsis (38%), respiratory failure (37%), and sur-gery (31%). Sixteen percent of subjects had COPD, and27% had had cerebrovascular accident. The subjects werenot significantly different at baseline: mean APACHE IIscore 25.4 � 6.6 in the positioning-only group versus23.1 � 7.2 in the vibration group. Mean dry sputum weightat baseline was 5.74 � 6.23 mg/24 h in the vibration groupand 5.42 � 3.98 mg/24 h in the positioning-only group.After 72 hours, sputum weight was 4.04 � 3.43 mg/24 hin the vibration group versus 3.56 � 3.10 mg/24 h in thepositioning-only group. However, when the investigatorsused generalized estimating equations to address the lon-gitudinal nature of the data and account for correlation, thedifferences in sputum weight were significant betweenT

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groups, with sputum greater in the intervention group(P � .001). The lung collapse index of the vibration groupwas significantly improved, compared with the positioninggroup at 72 hours (mean 0.96 � 0.73 vs 1.60 � 0.91,P � .001). We rated the quality of the outcome of sputumvolume findings as poor.

Paludo et al conducted an RCT with children (29 d to12 y old) hospitalized with acute pneumonia, and com-pared twice-daily CPT and standard pneumonia therapy(n � 51) to standard treatment alone (n � 47).20 CPTsessions were 30 min in duration and included posturaldrainage, thoracic squeezing, chest percussion, vibration,cough stimulation, and suctioning as needed. Standard med-ical therapy included antibiotics, fluids, and oxygen ther-apy as needed. The subjects were similar at baseline. Therewere no significant differences at follow-up in stay, timeto normal breathing frequency, time to normal oxygensaturation, time to normal auscultation, or duration ofwheezing, crackles, or chest in-drawing. The CPT grouphad a longer median duration of coughing (5.0 d vs 4.0 d,P � .04) and longer duration of rhonchi (median 2.0 d vs0.5 d, P � .03) than the medical treatment only group. Werated the quality of the outcomes of stay and time to nor-mal breathing frequency and oxygenation as fair.

In an RCT assessing CPT as an adjunct to medicaltherapy in children with asthma, Asher and colleaguesrandomized subjects hospitalized with acute asthma to pla-cebo (n � 19) or CPT with modalities selected at thediscretion of the therapist (n � 19).24 CPT included relax-ation techniques (positioning, lateral costal or diaphrag-matic breathing, shoulder relaxation), secretion clearancetechniques (postural drainage, coughing, forced expiratorytechnique, vibration, wing flapping), thoracic mobility ex-ercises, and postural correction exercises.

Each subject received a total of 4 treatment or placebosessions. The placebo was a 20-min visit from a hospitalvolunteer who provided emotional support. CPT sessionswere 20–30 min long and included the modalities de-scribed above, selected by the therapist for each child.Relaxation techniques were most frequently used at thefirst and fourth treatment sessions (used in 95% and 84%of sessions, respectively). Secretion clearance techniqueswere used in 79% of the first treatment sessions and 74%of the fourth. The medical therapy included nebulized sal-butamol, theophylline, and steroids, and the use of medicaltherapies were similar at baseline. The subjects’ mean agewas approximately 10 years, the mean onset of asthma wasat roughly age 2, and the mean asthma severity score wasapproximately 2.3 on a scale of 1 (mild) to 3 (severe).Three children (1 in the placebo group, 2 in the CPTgroup) completed the study twice, due to readmissions.Lung function did not differ significantly between thegroups at baseline or follow-up. Sputum production wasmeasured in 26% of the CPT sessions, and the weight

range was 0.7–10.8 g. Stay was non-significantly longer inthe placebo group. We rated the quality of the outcomes ofstay and pulmonary function tests as fair.

An RCT that included children with asthma (ages 4–18 y)admitted with status asthmaticus randomized the subjectsto either CPT plus standard medical therapy (n � 20) orstandard medical therapy alone (n � 20).19 CPT included6 sessions (one each hour over 24 h) of percussion with apneumatic chest percussor for 20 min, after nebulized al-buterol administration. Medical therapy included inhaled�2 agonists and systemic steroids. The investigators mea-sured airway resistance at baseline and follow-up, withimpulse oscillometry, and the initial measurement occurreda mean 12 � 6 hours after admission; thus, the subjectshad some degree of improvement before the baseline mea-surement. Oxygen saturation did not differ from baselineto follow-up in either group, whereas peak flow improvedin both groups from baseline to follow-up (P � .005). Thedifferences in peak flow between the groups were notsignificant. Airway resistance did not change significantlyin either group from baseline to follow-up. The differencesin airway resistance between the groups as a function oftime or steroid use were not significant. We rated thequality of the outcome of oxygenation as poor.

CPT Compared With ACBT. The Management of Ex-acerbations of COPD (MATREX) RCT allocated subjectshospitalized with COPD to either CPT plus ACBT or ACBTalone.15 CPT included manual positioning, percussion dur-ing thoracic expansion, and vibration upon expiration, andACBT techniques included forced expiration. The numberand duration of CPT treatments was up to the discretion ofthe therapist, although the CPT treatments themselves werestandardized. Subjects randomized to ACBT alone receivedadvice on positioning and ACBT to mobilize sputum. Sub-jects in both groups also received standard medical ther-apy. Subjects were followed for 6 months after random-ization, and primary outcomes were scores on the SGRQand European Quality of Life-5 Dimensions (EQ-5D) andvisual analog scales (EQ-VAS). The mean age of the258 subjects randomized to the CPT group was69.08 � 9.85 years, the mean baseline SGRQ total scorewas 68.94 � 14.66, and the mean baseline EQ-VAS was44.95 � 21.03. The ACBT-only arm included 264 subjects(mean age 69.58 � 9.51 y, mean baseline SGRQ totalscore 69.13 � 14.76, mean EQ-VAS 46.64 � 21.42).Differences between the groups at baseline were not sig-nificant.

The CPT subjects received a median of 2 CPT sessions(median duration 11 min, median 2 positions/session). At6 months the between-group differences in COPD-specificquality of life were not significant in the adjusted (forbaseline value and hospital site) or unadjusted intention-to-treat analyses (mean SGRQ symptoms score effect size



in the adjusted analysis 0.04, 95% CI �0.15 to 0.23; meanSGRQ activity score effect size in the adjusted analy-sis �0.02, 95% CI �0.20 to 0.16; mean SGRQ impactscore effect size in the adjusted analysis 0.02, 95% CI�0.15 to 0.18). All of the 95% confidence intervals werewithin the study’s predefined limits for equivalence. Sim-ilarly, quality of life ratings on the EQ-VAS (effect size2.65, 95% CI �2.37 to 7.65) and EQ-5D (effect size �0.01,95% CI �0.07 to 0.06) were not significantly different inthe adjusted or the unadjusted intention-to-treat analyses.Mean stay was not significantly different between thegroups (CPT 16.02 � 16.57 d, ACBT 16.85 � 18.11 d).The mean number of hospital admissions during the6-month follow-up period was 3.47 for the CPT group and3.89 for the ACBT group (significance not reported). At6 months the control group performed significantly betteron the 6-min walk test (mean difference 83.23, 95% CI13.09–153.37). The CPT subjects reported 15 adverse,events, including increased shortness of breath (n � 5),pain (n � 5), arrhythmia (n � 3), bronchospasm (n � 1),and thoracic hematoma (n � 1). The investigators did notconsider these harms that compromised patient safety. Werated the quality of the outcomes of stay, exacerbations/readmissions, and harms of airway clearance techniques asfair, and the quality of the outcomes of dyspnea, exercisetolerance, and quality of life as poor.15

Syed et al included 35 adults with bronchiectasis in acrossover RCT that compared short-term CPT to ACBT.25

They used a convenience sample of subjects undergoingmedical therapy for bronchiectasis, allocating them to ei-ther CPT (percussion and vibration in various posturaldrainage positions, cough, and deep breathing techniquesin 20–30 min sessions every 3 h) or ACBT (huffing, deepbreathing, and relaxed breathing cycles for a maximum of30 min in various postural drainage positions). Interven-tion sequences were separated by 12 hours over 2 days.The mean age of the 35 subjects was 45.8 � 11.2 years,25 were smokers, and 17 had a history of tuberculosis. Thewet weight or volume of expectorated sputum did notdiffer significantly between treatments at follow-up (meanweight difference 0.96 � 17.7 mg, mean volume differ-ence �1.68 � 20.50 mL, P � .05). FVC, FEV1, andFEV1/FVC also did not differ between treatment sequences.The subjects rated ACBT as more comfortable on a 10 cmvisual analog scale (median 8 vs 5 for CPT, P � .004). Werated the quality of the outcomes of pulmonary functionand sputum volume as poor.

CPT Compared With IPV. Paneroni et al evaluated IPVand CPT in a crossover RCT that included 22 subjectswith bronchiectasis.26 The mean age of the subjects was64.4 � 8.9 years, and the mean percent-of-predicted FEV1

was 53 � 30%. The IPV arm included 3 active cyclesalternating high and low pressure for 30 min. CPT in-

cluded forced expiration, postural drainage, percussion,and vibration in 3 positions, for a total of 30 min. Atfollow-up there was no significant difference in mean spu-tum volume or wet or dry sputum weight between thegroups. SpO2

also did not differ between the groups. Heartrate fell significantly from baseline to follow-up in bothgroups, but did not differ between the groups. Breathingfrequency decreased significantly in the IPV group frombaseline, but not for CPT, and the difference between groupsat the final follow-up was also significant (P � .047).Dyspnea improved significantly from baseline (P � .004)in the IPV group also, but the between-group differenceswere not significant. Harms were reported by both groups,and included dry throat, nausea, and/or fatigue (27% ofboth groups). Post-treatment discomfort was lower withIPV than with CPT (P � .03). We rated the quality of theoutcomes as: oxygenation good, sputum volume fair, andheart rate, breathing frequency, dyspnea, and harms poor.

Antonaglia et al randomized subjects with COPD un-dergoing helmet noninvasive ventilation (NIV) to eitherCPT (n � 20) or IPV (n � 20).27 CPT included 25–30 minof chest percussion, mobilization, postural drainage, andexpiration with the glottis open in lateral posture. IPVconsisted of 25–30 min sessions of mouthpiece IPV de-livering high-flow mini-bursts at 225 cycles/min. The sub-jects also received medical treatments as required. Thegroups were similar at baseline: mean age 69 � 7 years inthe CPT group versus 72 � 7 years in the IPV group;median APACHE II score 22 in both groups. Twenty-seven subjects in both groups were hypersecretive (� 30 mLsecretions/d). The investigators assessed differences withan overall analysis of variance, and included data from ahistorical control group in the analysis. Differences be-tween the groups at discharge were not significant formedian breathing frequency, heart rate, or mean arterialpressure. PaCO2

and PaO2/FIO2

differed significantly betweenthe groups at discharge: mean PaCO2

: 64 � 5.2 mm Hg inthe CPT group, 58 � 5.4 in the IPV group, 67 � 4,P � .01; mean PaO2

/FIO2218 � 34.2 mm Hg in the CPT

group, 274 � 14.8 mm Hg in the IPV group,237 � 20 mm Hg in the historical control group, P � .01.The IPV group had higher PaO2

/FIO2and lower PaCO2

. Inboth groups 7 subjects required intubation and mechanicalventilation (vs NIV), but the IPV group required a lowermedian number of hours of ventilatory assistance (61 h vs89 h, P value not reported). Median ICU stay was alsolower for the IPV group (7 d vs 9 d for CPT, P value notreported). Four subjects in the CPT group and 2 in the IPVdeveloped sepsis or pneumonia (P value not reported). Werated the quality of the outcomes of gas exchange, stay,mean arterial pressure, and need for and duration of ven-tilation as fair. We rated the quality of the outcomes ofheart rate and breathing frequency as poor.



Clini and colleagues evaluated the effectiveness of IPVin ICU subjects with tracheostomy recently weaned frommechanical ventilation.18 The 46 subjects included 6 post-cardiac surgery subjects, 8 neuromuscular disease/impair-ment subjects, and 22 COPD or chronic respiratory insuf-ficiency subjects. The groups were similar at baseline, andall the subjects were hypersecretive (� 40 mL secretions/d). The investigators allocated the subjects to either 15 daysof IPV (2 sessions/d) plus CPT (n � 24), or CPT alone(n � 22). CPT in both groups comprised 2 one-hour ses-sions per day of postural and manual drainage, followedby nebulized saline and repeat of the drainage maneuverswith suctioning. In the IPV group PaO2

increased signifi-cantly from baseline (69 � 8 mm Hg to 76 � 9 mm Hg,P � .05), as did PaO2

/FIO2(238 � 51 mm Hg to

289 � 52 mm Hg, P � .005). Maximal expiratory pressurealso significantly increased from baseline to day 15 in theIPV group (34 cm H2O [12%] to 47 cm H2O [1%], P � .005)and as compared with the CPT-only group (P � .05). Themean differences in PaO2

/FIO2and maximal expiratory pres-

sure between the groups were, respectively, 21.65 mm Hg(95% CI �11.75 to 55.05 mm Hg, P � .04) and 9.26 mm Hg(95% CI 1.98–16.54 mm Hg, P � .01). At day 15, 2subjects in the CPT arm and one in the IPV arm had anypulmonary complications. At the 1-month follow-up, noIPV subjects had any complications, whereas 2 in the CPTgroup had pneumonia (P � .05 for comparison of pneu-monia between groups at all time points). We rated thequality of pulmonary function and gas exchange as poor.

PEP Modalities With and Without CPT. In an RCTthat included 30 subjects with bronchiectasis (mean age50.7 � 6.4 y, mean FEV1 21% of predicted), the subjectsreceived Acapella or inspiratory muscle training, in a cross-over study design.45 Acapella treatment included 10 breathsat near maximum capacity followed by breath-hold, activeexhalation, and coughing or huffing after every 5 breaths.Use of the inspiratory muscle trainer similarly included10breaths atmaximal inspiratory effort, followedbybreath-hold, active exhalation, and coughing/huffing after every 5breaths. Treatment occurred at the same time over 3 con-secutive days, with medications administered � 1 hourprior to treatment. The medications included inhaled �-ago-nists (n � 17), inhaled corticosteroids (n � 2), oral anti-biotics (n � 15), and oral corticosteroids (n � 2). Expec-torated sputum was significantly greater in the Acapellagroup: mean � SD 7.16 � 1.12 mL vs 6.46 � 1.08 mL,P � .02, mean difference 0.70 mL, 95% CI 0.13–1.27).The subjects rated Acapella as more useful in clearingsecretions, but ratings of convenience, comfort, and over-all performance did not differ significantly between themodalities. We rated the quality of the outcome of sputumvolume as poor.

In an RCT that included ICU subjects with COPD ex-acerbation, Bellone et al evaluated 3 daily, 30–40 minsessions of PEP plus assisted cough compared with as-sisted cough alone.31 All the subjects received NIV untilthey met the weaning criteria or the criteria for intubation,and all received medical therapy (nebulized salbutamol,nebulized ipratropium bromide, intravenous methylpred-nisolone, antibiotics). The subjects were similar at base-line: PEP group: n � 13, mean age 65 � 7.8 y, meanAPACHE II score 16.6 � 1.1; assisted-cough-only group:n � 14, mean age 64 � 7.7 y, mean APACHE IIscore 17 � 1.2). Sputum production was higher in the PEPgroup at the end of treatment (9.6 � 3.9 g vs 4.7 � 2.5 g,P � .01), and continued to increase in the 60 min follow-ing treatment in the PEP subjects, but not in the assisted-cough-only group. The PEP group also required fewerdays to wean from NIV (4.9 � 0.8 d vs 7.0 � 0.7 d,P � .01). No subjects in the PEP group, and one in theassisted-cough-only group progressed to intubation. PEP-related harms included discomfort from the PEP mask,reported by 2 subjects (15.3%), neither of whom stoppedtreatment during the study. We rated the quality of theoutcomes of duration of ventilation as fair, and that forsputum volume as poor.

In a crossover RCT including mechanically ventilatedICU subjects, Unoki and colleagues compared rib cagecompression (one 5-min session) plus endotracheal suc-tioning to suctioning alone.33 Intervention sequences wereseparated by 3 hours. The subjects (mean age 56.7 � 17.6 y,mean Simplified Acute Physiology score 59.4 � 10.7)were hospitalized for various causes, including intracere-bral hemorrhage (19%), cardiac arrest (19%), pneumonia(12%), and cerebral infarction (12%). Forty-two percent ofthe subjects had radiographic evidence of atelectasis. Spu-tum weight, PaO2

/FIO2, and PaCO2

did not differ signifi-cantly between the intervention periods. The quality of theoutcome of gas exchange was poor.

Studies Assessing the Flutter Valve. Ambrosino andcolleagues compared the effects of the Flutter device topostural drainage plus percussion in 14 subjects hospital-ized with COPD, bronchiectasis, bronchitis, or silicosis,on sputum production and patient discomfort in a cross-over RCT.32 Each subject underwent 2 sessions of posturaldrainage and manual chest percussion or breathing throughthe Flutter device. Each session could be conducted for upto 30 min, at the discretion of the subject, and the subjectcould cough and perform deep breathing as desired duringeach treatment. Treatments were separated by a 24-hourwash-out period, so the study extended over 8 days. Thesubjects continued their standard medical therapiesthroughout the study. At baseline the subjects produced amean of 51 � 27 mL of sputum/d and had a mean FEV1

of 49 � 26% of predicted. Sputum production increased



significantly, by roughly 10 mL, during both treatmentsequences (P � .001, compared with baseline for eachtreatment) and was non-significantly increased over base-line at 60 min post-treatment. The subjects’ self-rated feel-ings of “chest unpleasantness due to sputum” improvedsignificantly from baseline to 60 min post-treatment withboth treatment sequences (P � .001). FEV1, FVC, peakflow, and oxygen saturation remained stable and did notdiffer significantly across the time points. We rated thequality of the outcomes of pulmonary function, oxygen-ation, and sputum volume as poor.

In a single-blind RCT that included 15 subjects hospi-talized with bronchiectasis exacerbation, Tsang and Jonescompared 3 airway clearance modalities (each deliveredonce a day for 15 min until discharge): postural drainageplus breathing and coughing exercises, Flutter and breath-ing/coughing, and breathing/coughing alone.29 Each groupincluded 5 subjects with the mean age/group ranging from66.8 to 64.2 years. Mean percent-of-predicted FEV1 atbaseline ranged from 36.10% to 48.47%. The groups weresimilar at baseline, though there were more smokers in thebreathing/coughing-only group (4/5 vs 1/5 in the postural-drainage-plus-breathing/coughing group, and 3/5 in theFlutter group, P value not reported). Mean stay was sim-ilar among the groups: 7.2 � 3.3 d in the postural-drain-age-plus-breathing/coughing group, 6.2 � 3.83 d in theFlutter group, and 5.2 � 0.84 d in the breathing/coughing-only group. Similarly, the wet weight of sputum expecto-rated did not differ significantly among the groups at anytime point. FVC, FEV1, and peak expiratory flow also didnot differ significantly from baseline to follow-up withinthe groups or between the groups. The subject-rated scoresof effectiveness were higher in the Flutter group than inthe breathing/coughing-only group at all time points(P � .05). The effectiveness scores did not differ signif-icantly between the Flutter and postural-drainage-plus-breathing/coughing group. We rated the quality of the out-come of stay as fair. We rated the quality of the outcomesof pulmonary function and sputum weight as poor.

In a crossover RCT that included 20 mechanically ven-tilated subjects with pulmonary infection and hypersecre-tion in an adult ICU, Chicayban et al compared Flutter tonormal pressure controlled ventilation.28 The subjects weremechanically ventilated for a mean 21.6 days, had a meanAPACHE II score of 21.7, and 75% had VAP. The sub-jects received normal ventilation or two 15-min sessionsof Flutter, separated by a 6-hour wash-out period. At fol-low-up immediately after the intervention, secretion pro-duction was greater in the Flutter group: 5.1 � 0.5 mL vs3.3 � 0.3 mL (P � .001). In the Flutter group staticcompliance increased significantly from baseline(P � .001), as did peak flow (P � .008) and expiratoryflow at 75% of tidal volume (P � .005). Respiratory me-chanics did not change significantly in the control sub-

jects. In the Flutter group mean airway pressure increasedsignificantly from baseline (P � .05), and compared withthe control group (P � .05). The end-tidal partial pressureof CO2 increased significantly from baseline in the controlgroup (P � .05) and in the Flutter subjects as comparedwith the control group (P � .05). Oxygen saturation alsoincreased significantly in the Flutter group, compared withcontrol (P � .05). We rated as good the quality of theoutcomes of oxygenation and arterial pressure. We ratedas fair the quality of the outcomes of pulmonary function,gas exchange, heart rate, and sputum volume.

Samransamruajkit and colleagues randomized children(6–16 y old) hospitalized for acute asthma to either Flutter(15–20 min session) plus medical therapy, or medical ther-apy alone.30 Subjects in the medical therapy group alsohad instructions to cough. The baseline age and pulmonarycharacteristics were similar between the groups, except forinitial asthma score (mean 5.9 in Flutter group vs 4.45 inthe medical treatment group, P � .01) and oxygen require-ment (mean 30 in the Flutter group vs 25 in the medicaltreatment group, P � .05). At day 3 of the study thebetween-group differences in oxygen saturation, FIO2

, andasthma score were not significant; however, only 5 sub-jects in each group remained at that point. The mean post-treatment asthma score had decreased significantly in theFlutter group, compared with the medical-treatment groupon day 2 (1.3 � 0.3 vs 2.5 � 0.3, P � .01). Stay was notsignificantly different between the groups, and no seriousadverse events were reported in the Flutter group (harmsnot specified). We rated the quality of the outcomes ofoxygenation and stay as fair. We rated the quality forpulmonary function as poor.

Studies Evaluating Postural Drainage. Berney andDenehy included 20 mechanically ventilated ICU subjectsin a crossover RCT that compared postural drainage plusmanual hyperinflation followed by ventilatory hyperinfla-tion to postural drainage plus ventilator hyperinflation fol-lowed by manual hyperinflation.34 In both groups the footof the bed was elevated and the subjects were placed in aside-lying position before undergoing 6 sets of 6 manualor ventilator hyperinflation breaths and suctioning. Thesubjects received both treatments, separated by 2 hours, oneach of 2 days. The subjects (mean age 45.2 y, APACHE IIscore range 10–22) had spinal injury (n � 12, 10 withquadriplegia), multiple trauma (n � 4), respiratory failure(n � 1), and other indications. After the 2-day study themean sputum production in the manual hyperinflation groupwas 6.53 g (95% CI 5.86–7.20) and 6.01 g in the ventilatorhyperinflation group (95% CI 4.83–7.19 g); those weightsdid not differ significantly: mean difference 2.65 g, 95% CI1.79–3.54 g). Both treatments significantly improved(P � .001) static pulmonary compliance from baseline,with a mean percentage improvement of 9.7% with man-



ual hyperinflation (95% CI 46.5–54.9) and 11.6% withventilator hyperinflation (95% CI 45.5–54.7). Mean arte-rial pressure, heart rate, and arterial oxygen saturation didnot change adversely with either treatment. We rated thequality of the outcome of sputum weight as poor.

Ntoumenopoulos and colleagues assessed the effects ofmanual hyperinflation plus postural drainage, comparedwith usual care, on pulmonary complications in mechan-ically ventilated trauma subjects in an RCT.35 The subjectsin the manual hyperinflation group (n � 22) received 6hyperinflation breaths, repeated 4 times, in postural drain-age positions, for 20 min, plus suctioning as needed be-tween sets and routine turning. The control subjects (n � 24)received routine nursing care (suctioning as needed andturning twice an hour). The groups were similar at baseline(treatment group: mean age 38.85 � 16.62 y, meanAPACHE II score 12.3 � 3.8; control group: meanage 41.20 � 20.15 y, mean APACHE II score 14.1 � 7.4).Days on mechanical ventilation, ICU days, and level ofpulmonary dysfunction (worst daily PaO2

/FIO2) were simi-

lar between the groups at follow-up. Four subjects in thetreatment group and 8 in the control were withdrawn fromthe study per protocol, because of suspected pneumonia; 3subjects in the treatment and 4 in the control group werediagnosed with pneumonia. We rated the quality of theoutcomes of pulmonary function, stay, and duration ofventilation as good.

An RCT by Krause et al included mechanically venti-lated ICU subjects with atelectasis of the lower lobes, andcompared standard postural drainage to modified posturaldrainage.36 Subjects were 13–85 years old and had con-ditions that included bronchial obstruction (n � 2), ribfracture or surgery (n � 5), pleural effusion (n � 3),pneumonia (n � 3), Guillain-Barre syndrome (n � 1), andpneumothorax/hemothorax (n � 3). The subjects received15 min of either standard postural drainage (one of 4 po-sitions, depending on the location of lung collapse, eachincluding elevation of the foot of the bed,) following in-halation of mucolytics (n � 9), or modified postural drain-age (supine, side-lying, or 1/4 prone positioning, depend-ing on location of lung collapse) following mucolytics(n � 8). Both groups received percussion for 5 min, andsuctioning following positioning. The study did not reportwhether or not the subjects were statistically similar atbaseline. The standard drainage group required a mean of3 treatments to resolve the collapse, compared with 4.5 inthe modified-postural-drainage group (P value not re-ported). Arterial blood gas values (PaO2

, oxygen saturation,diffusion capacity, alveolar/arterial oxygen difference, re-spiratory index, and venous shunt value) improved morefrom baseline to final treatment in the standard-postural-drainage group, though the differences were not signifi-cant. We rated the quality of the outcome of gas exchangeas fair.

Barker and Adams conducted an RCT to assess theeffects of a single session of commonly used CPT modal-ities on pulmonary function and oxygenation in mechan-ically ventilated subjects with acute lung injury.37 Thesubjects were randomly allocated to either supine position-ing plus suctioning (n � 5, mean age 73 � 2.6 y), lateraldecubitus positioning plus suctioning (n � 5, mean age70 � 7.4 y), or lateral decubitus positioning plus 6 manualhyperinflation breaths plus suctioning (n � 7, mean age70 � 16.3 y). The subjects were hospitalized with sepsis(n � 7), aspiration pneumonia (n � 5), community-ac-quired pneumonia (n � 4), and pancreatitis (n � 1). Thestudy does not indicate if the baseline differences amongthe groups were significant. Venous oxygenation satura-tion did not change significantly over time within or amongthe groups, though it was lower in the lateral-decubitus-positioning-plus-suctioning group at all time points(P � .03). PaCO2

and PaO2/FIO2

also did not differ withingroups or among groups at the 60-min follow-up. Dy-namic compliance and mean arterial pressure did not differamong the groups at follow-up. Heart rate varied signifi-cantly within and among groups over time (P � .05). Werated the quality of the outcome of gas exchange as fair.We rated the quality of the outcomes of heart rate andmean arterial pressure as poor.

Studies Evaluating Intrapulmonary Percussive Venti-lation. Vargas et al conducted an RCT comparing stan-dard medical and oxygen therapy to standard therapy plusIPV via face mask in ICU subjects with COPD.38 The 16subjects in the IPV group had a mean age of 69.2 years anda mean FEV1 of 39% of predicted. Those values in thestandard therapy group were 70.2 years and 38%. Thegroups were not significantly different at baseline. IPVsubjects received the same medical treatment as the con-trol group (supplemental oxygen, nebulized salbutamol orterbutaline, nebulized ipratropium bromide, subcutaneousheparin, corticosteroids, oral methylprednisolone, antibi-otic, correction of electrolyte abnormalities) plus 2 daily30-min IPV sessions (mean duration of therapy 3 � 1 d).No subject in either group received any additional airwayclearance modalities. Six subjects in the standard treat-ment group had a worsening of exacerbation and requiredNIV, compared with 0 subjects in the IPV group (P � .05).Stay was also significantly longer in the standard therapygroup (7.9 � 1.3 d vs 6.8 � 1 d, P � .05). Breathingfrequency and PaCO2

decreased significantly from baselineto the end of the first IPV session in the IPV group, whereasPaO2

increased (P � .05); these values were not reportedfor the standard therapy group. We rated the quality of theoutcomes of pulmonary function, need for ventilation, ox-ygenation, and stay as fair. We rated the quality of theoutcome of breathing frequency as poor.



Studies Evaluating Chest Wall Compression. Mahajanand colleagues assessed hospitalized adults (� 18 y old)with physician-diagnosed acute asthma and/or COPD inan RCT sponsored by the manufacturer of the pneumaticvest evaluated.14 The investigators randomly allocated25 subjects (median age 46.5 y) to high-frequency chestwall compression (the Vest, Hill-Rom, St Paul, Minne-sota) and 27 subjects (median age 50.4 y) to sham chestwall compression, which provided a sensation of vibrationbut without air flow oscillation. The subjects also receivedstandardized medical treatment (albuterol, systemic or in-haled corticosteroids, supplemental oxygen, other medica-tions as needed). Roughly 60% of subjects in each grouphad asthma, and 40% had COPD. Baseline characteristicsdid not differ significantly between groups; subjects inboth groups had a median of one hospitalization in theyear preceding the current admission.

After 60 total minutes of treatment or sham treatmentadministered over 2 days, dyspnea was significantly im-proved in the treatment group, compared with the shamgroup (median change in Borg dyspnea score �1.5 vs 0,P � .048). The differences in spontaneously expectoratedsputum, FEV1%, and hospital stay were not significant.Four subjects in each group reported an acute care visit(hospitalization or emergency department visit) in the 30-day follow-up period. Subject satisfaction and adherenceto both the treatment and the sham treatment were high.We rated the quality of all the outcomes (pulmonary func-tion, dyspnea, sputum, stay, and time to readmission) asgood.14

Studies in Postoperative Subjects

Studies Evaluating CPT. Johnson and colleagues strat-ified subjects by degree of atelectasis in an RCT that com-pared CPT modalities of graduated intensity (combina-tions of early ambulation plus deep breathing, sustainedmaximal inspirations, and percussion) in post-coronary-artery-bypass subjects.44 The investigators randomly allo-cated subjects with minimal atelectasis on chest x-ray toeither early mobilization plus deep breathing (group 1,n � 48) or early mobilization plus deep breathing plussustained maximal inspirations (group 2, n � 49). Subjectswith marked atelectasis were allocated to either early mo-bilization plus deep breathing plus sustained maximal in-spirations (group 3, n � 64) or all of those modalities pluspercussion (group 4, n � 63). Mobilization included grad-uated increases in activity. Deep breathing instructionswere for 5 deep breaths/hour daily, recorded by the subjectin a log. Sustained maximal inspiration comprised stackedinhalations to total lung capacity, with a 5-second breath-hold, for 5 repetitions, conducted once each waking hour,with position changes as tolerated. Percussion sessions(3/d) consisted of 1 or 2 cupped hand percussions/s to the

chest wall during the total lung capacity phase of a sus-tained maximal inspiration.

The subjects were similar at baseline in all preoperativeand pulmonary function parameters except, as per proto-col, degree of atelectasis. All the pulmonary function val-ues (vital capacity, FEV1, functional residual capacity, max-imum expiratory pressure, negative inspiratory pressure,carbon monoxide diffusion) deteriorated significantly inall groups from baseline to discharge (P � .001), thoughthe discharge values did not differ significantly among thegroups. ICU stay was significantly greater (P � .05) ingroup 3 (2.3 � 0.8 d) and group 4 (2.3 � 0.6 d) than ingroups 1 or 2 (both groups stay 2.0 � 0.5 d). Hospital staywas significantly longer (P � .05) in group 3 (9 � 2.7 d)and group 4 (10 � 8.5 d) than in the other groups (8 � 1.5 dor 1.6 d). Eight subjects in group 1, 10 in group 2, 14 ingroup 3, and 13 in group 4 met the criteria for pneumonia,with an overall incidence of 12%. No subjects developedrespiratory failure, and none required repeat ICU admis-sion because of respiratory complications. Percussion wasassociated with minor complications; however, only datafor falling oxygen saturation (below 90% in 7/295 treat-ments) and tachycardia (12/295 treatments) were reported.None of those episodes was associated with important bloodpressure changes. We rated the quality of the outcomes ofpulmonary function, stay, and pulmonary complications aspoor.44

In a related study, Johnson et al randomized subjectsundergoing cardiac valve surgery to the same regimen ofeither early mobilization and deep breathing exercises plussustained maximal inspirations (group 1) or early mobili-zation, deep breathing exercises, sustained maximal inspi-rations, and 2 sessions of percussion/day (group 2).43 Thisstudy most likely involved some of the same subjects asJohnson’s earlier study in bypass subjects,44 though theprecise extent of overlap is unclear. The 41 subjects ingroup 1 and 34 in group 2 were similar in most charac-teristics at baseline; however, the subjects in group 2 wereolder, by approximately 5 years (63 � 12 years vs68 � 10 years, P � .004). Pulmonary function valuesdecreased in both groups from baseline to discharge, withchanges in FVC, functional residual capacity, FEV1%, andcarbon monoxide diffusion reaching statistical significancein both groups (P � .001). Carbon monoxide diffusionwas significantly lower in group 2 than in group 1 atdischarge (15 � 5 mL/min/mm Hg vs 10 � 2.4 mL/min/mm Hg, P � .05), as was negative inspiratory pressure(39 � 19 cm H2O vs 33 � 14 cm H2O, P � .05). Atel-ectasis scores at discharge and ICU stay and hospital staywere similar between the groups. Two subjects in eachgroup developed pneumonia, for an overall incidence of5%. No subject progressed to respiratory failure, and nonerequired ICU readmission for respiratory complications.



We rated the quality of all the outcomes (pulmonary func-tion, heart rate, stay, pulmonary complications) as poor.

In an RCT on CPT following cardiac valve surgery,de Charmoy and Eales allocated surgical subjects to re-ceive either coughing and mobilization instructions (n �14) or CPT (n � 16), including positioning and breathingand coughing exercises, with sessions twice a day on post-operative days 1 and 2 and once a day on days 3 and 4.41

The CPT subjects also received assisted walking at eachtreatment session. The subjects were similar at baseline,with an overall mean age of 29.72 years (range 11–63 y).PaO2

declined significantly in both groups from baseline,but the values at follow-up did not differ significantlybetween the groups. Stay did not differ between the groups.No subjects in either group developed pulmonary compli-cations, including pneumonia. We rated the quality of theoutcomes gas exchange and pulmonary complications aspoor.

In an RCT on the effectiveness of deep breathing andsputum clearance techniques in reducing post-abdominal-surgery pulmonary complications, Mackay et al random-ized 56 subjects to either early post-surgical mobilization(n � 21) or early mobilization plus deep breathing(“coached lateral basal expansion”) exercises and airwayclearance maneuvers (coughing huffing, forced expiratorytechnique).39 The deep breathing group (n � 29) receivedtherapy 3 times a day on postoperative day 1, twice a dayon days 3 and 4, and then daily until the subject wasmobile and had a clear chest assessment for 3 consecutivedays. The subjects were also encouraged to practice thedeep breathing techniques independently during each wak-ing hour. Early mobilization included graduated assistedand independent walking, as tolerated, plus leg flexionexercises, performed independently. One early-mobiliza-tion-only subject (who was later withdrawn from the study)was mistakenly given deep breathing exercises; the inves-tigators analyzed data for that subject by intention-to-treatand with the deep breathing group.

The mean age of the 50 study completers was 66 years,and the groups were similar at baseline: 14 treatment sub-jects and 11 early-mobilization-only subjects had a historyof chronic airway limitation or pulmonary disease. Sur-gery types in both groups included colectomy/hemicolec-tomy (n � 26), bowel resection (n � 4), gastrectomy/esophagectomy (n � 6), and abdominoperineal resection(n � 3). The incidence of postoperative pulmonary com-plications (defined as � 3 respiratory signs, including aus-cultation changes, fever, chest x-ray changes, and increaseor change in sputum), did not differ between the groups(17% in the treatment group vs 14% in the mobilization-only group). The absolute risk reduction was �3.0%(95% CI �0.22 to 0.19%). Stay was longer in the mobi-lization-only group (mean 13 � 4.5 d vs 10.4 � 3.0 d,P � .008, difference in means 2.9, 95% CI 0.77–5.03 d).

Mean ICU stay was similar between the groups, as was theneed for mechanical ventilation: 2 subjects in each grouprequired mechanical ventilation, for 2 d in the controlgroup, and 0.75 d in the treatment group. We rated thequality of the outcomes stay, pulmonary complications,and need for and duration of ventilation as good.39

In another RCT in post-abdominal surgery subjects, Fa-gevik Olsen et al compared preoperative and postoperativeCPT to no CPT on the incidence of pulmonary complica-tions.42 The CPT group (n � 174) underwent preoperativeCPT (10–15 min of breathing exercises, huffing and cough-ing, education about positioning and mobilization) on theday before surgery, and postoperative CPT (15–20 minsessions conducted hourly by the subject, and includingdeep breathing plus huffing and coughing) thereafter foran unspecified duration. The investigators also preopera-tively classified the subjects in each group as low or highrisk, based on age � 50 years plus one of: smoker orrecent ex-smoker, body mass index � 30 kg/m2, pulmo-nary disease with need for daily medication, or history ofother condition causing reduced ventilatory function. Highrisk subjects in the CPT group also received PEP mask forrespiratory resistance training during breathing exercises.The control subjects received no preoperative training andno postoperative CPT unless a pulmonary complicationwas diagnosed, at which point they received CPT plus PEPmask. The groups did not differ significantly at baseline.Postoperative pulmonary complications (defined as oxy-gen saturation � 92% or 2 of: fever, negative auscultation,or radiologic evidence of pneumonia or atelectasis) werediagnosed in 10 (6%) CPT subjects, 6 of whom wereconsidered high risk, and 52 (27%, 20 considered highrisk) in the control arm (P � .001). Among the obesesubjects, 3 CPT subjects and 27 control subjects developedcomplications (P � .001). One CPT subject and 13 controlsubjects were diagnosed with pneumonia, for an overallincidence rate of 4%. Vital capacity and peak expiratoryflow declined significantly in all subjects from baseline tofollow-up, but differences between groups were not sig-nificant. Hospital stay was also not significantly different(mean 8.8 � 4.5 d in the CPT group, 9.0 � 5.1 in thecontrol group). The study did not indicate the duration ormodalities of CPT provided to the 52 control subjects withpulmonary complications, who presumably received post-operative CPT per protocol. We rated the quality of theoutcomes of pulmonary function and complications, heartrate, and stay as poor.

Studies Evaluating PEP Modalities With and WithoutCPT. Denehy and colleagues compared twice-daily stan-dard CPT (coughing and deep breathing, including sus-tained maximal inspirations and forced expiratory tech-nique for a minimum of 10 min) to CPT plus either 15 or30 min sessions of CPAP, 4 times per 24 hours, in an RCT



that included post-abdominal surgery subjects.40 The in-vestigators encouraged the subjects in each group to walkearly and to perform deep breathing exercises indepen-dently each hour, though adherence to the protocol was nottracked. Among the 50 study completers, 18 were random-ized to CPT only (mean age 73.3 � 5.8 y, mean preoper-ative FEV1 2.3 � 0.6 L), 17 to 15 min of CPAP (meanage 72.5 � 6.5 y, mean FEV1 2.3 � 0.8 L), and 15 to30 min of CPAP (mean age 70.5 � 6.3 y, meanFEV1 2.4 � 0.6 L). The subjects did not differ signifi-cantly at baseline. Pulmonary function measurements (re-ported for 40/50 subjects) included vital capacity and func-tional residual capacity. Pulmonary function measurementstypically varied across the time points in each group butdid not differ significantly among groups at follow-up onpostoperative day 5. Mean oxygen saturation and stay werealso not significantly different among the groups. Nearly70% of all the subjects had some radiographic evidence oflung collapse or consolidation on the third postoperativeday. Fourteen percent of the subjects across groups (4 inthe CPT-only group, 5 in the 15-min-CPAP group, and 1in the 30-min-CPAP group) had pulmonary complications(defined as fever � 24 h, chest radiograph score of � 2,elevated white cell count, altered sputum, isolation of patho-gen in sputum, or need for additional antibiotics). Werated the quality of the outcomes of oxygenation, pulmo-nary complications, and stay as fair. We rated the qualityof the outcome of pulmonary function as poor.

Haeffener et al conducted an RCT assessing the effectsof incentive spirometry plus expiratory positive airwaypressure, compared with control techniques (coughing in-structions, deep breathing exercises, early mobilization)on pulmonary function and complications in post-coro-nary-artery-bypass-graft subjects.17 The intervention groupperformed the incentive-spirometry protocol twice a dayfor 15–20 min; therapists gradually increased expiratorypressure to a maximum of 15 cm H2O. The incentive-spirometry subjects continued the protocol at home post-discharge, with weekly telephone check-ins by study staff.Lung alterations on chest x-ray (at 1 week post-surgery)were significantly lower among the incentive-spirometrysubjects (P � .001). At the 1-month follow-up, pulmonaryfunction improved from baseline in the incentive-spirom-etry group, whereas in the control group pulmonary func-tion remained 10–26% lower than baseline. Six-min-walkdistance was higher in the incentive-spirometry group (datain figure only, P � .001). We rated the quality of theoutcomes of pulmonary function, exercise tolerance, andstay as poor.

Discussion

The 32 studies that met our review criteria typicallyreported a small magnitude of treatment effect across a

spectrum of interventions. The patient populations variedacross the studies, and included subjects with COPD, bron-chiectasis, and asthma, as well as ICU and trauma patients.The comparators used across studies also varied. While thestudies often measured the same outcomes (eg, stay, ox-ygen saturation), they varied in reporting of outcomes andhow the outcomes were measured (eg, sputum weight vssputum volume). This heterogeneity meant that meta-anal-ysis was not appropriate or feasible.

Variations of CPT were the most frequently studiedintervention, but there is no standardized method for de-livering CPT (Table 6), and inter-therapist variation andstudy technique variation may be important co-factors.Moreover, the subjects were often receiving critical carefor more than one diagnosis, and the airway clearanceoutcomes and care modalities were likely not the primarydeterminant of the subject’s condition or course of illnessor recovery. Therefore, it is difficult to ascribe importantclinical outcomes to the airway clearance intervention un-der study; and often surrogate or intermediate measureswere utilized for comparison data.

We considered most studies of poor quality for the out-comes assessed (Table 7, and see the supplementary ma-terials at http://www.rcjournal.com). Frequently used out-come measures for airway clearance techniques are limitedin their accuracy and reliability, and most are difficult totie to the effects of airway clearance specifically.12,46,47

Some measures, such as sputum weight or volume, havelimited repeatability and specificity. Similarly, pulmonaryfunction test results depend on the subject’s effort andmotivation, may be variably interpreted, and may not ac-curately reflect the effectiveness of a given clearance mo-dality.46-48 We summarize study results by key outcomesbelow.

Sputum Weight or Volume

The studies measured sputum using both weight andvolume. The measurement techniques differed: some stud-ies assessed dry weight, others wet weight, and some useddedicated collection pots or other techniques. Two studiesof poor quality for the outcome of sputum expectoratedcompared CPT and standard care and found no differencesbetween the groups.16,22 For adults with bronchiectasis, acomparison of CPT versus ACBT, rated as poor quality,reported no significant difference in sputum volume orweight.25 Similarly, for adults with bronchiectasis, a com-parison of CPT versus IPV, rated as fair quality, reportedno significant difference in sputum volume or weight.26

Three different studies (all poor quality) of subjects with 3different conditions assessed the effects of PEP versusCPT on sputum weight or in volume. Two studies reportedno significant difference between PEP and the compari-



son.33,45 One small study of adult ICU subjects with COPDreported more sputum in the intervention group.31

Three studies compared the Flutter device to a controlintervention: 2 poor quality studies reported no significantdifference.29,32 The third small study of ventilated adultICU subjects reported more sputum in the interventiongroup.31 One poor quality study of postural drainage re-ported no significant difference in sputum measurements,33

whereas one good quality study of chest wall compressionwith a vest in patients with asthma and COPD reported nosignificant difference in sputum between the interventiongroup and the sham vest group.14

Oxygenation and Gas Exchange

Seven studies of CPT in various populations, includingchildren with asthma,19,20,30 adults with COPD16 or bron-chiectasis,26 and mechanically ventilated or postoperativesubjects40,42 reported no significant between-group differ-ences in oxygenation. Those studies were of good,26

fair,16,19,20,42 and poor30,40 quality for this outcome. Onegood study of Flutter in mechanically ventilated subjects,

and one fair study of IPV in subjects with COPD reportedimproved oxygenation in the intervention arms.28,38

Measurement of arterial blood gases, an indirect andinvasive measure of the effectiveness of airway clear-ance interventions, was evaluated in 9 studies, all ofwhich reported no significant difference in values be-tween the groups: 2 were fair quality, and 4 were poorquality.18,32,33,36-38,41 A fair quality study of the Flutterdevice reported better values for adult ventilated subjectsin the intervention group.28 Finally, a fair quality studyreported worse values for subjects with COPD treated withCPT, compared with those treated with IPV.27

Pulmonary Function Tests

Thirteen studies, most of poor quality for pulmonarytest outcomes, reported no significant difference in valuesbetween the groups.14,17,19,24,25,29,32,34,37,40,42,43,44 Threestudies reported improved results: a poor quality study ofIPV � CPT versus CPT in ICU subjects, with COPDreported better pulmonary function tests in the interven-tion group18; and a poor quality study of spirometry plus

Table 6. Components of CPT in Studies Using CPT as a Treatment or Comparator

First Author Year CPT Components*

Paneroni26 2011 FET, postural drainage, percussion, vibration, coughingCross15 2010 Chest percussion, vibration, assisted coughing, positioningChen22 2009 Positioning, mechanical vibrationDiDario19 2009 Mechanical percussionKodric16 2009 Expiration with glottis open in lateral postureSyed25 2009 Postural drainage, manual percussion, vibration, coughing, diaphragmatic breathingPaludo20 2008 Postural drainage, thoracic squeezing, percussion, vibration, cough stimulationTempleton21 2007 Thoracic and pulmonary expansion, respiratory muscle exercise, manual hyperinflation, positioning, vibrationAntonaglia27 2006 Percussion, postural drainage, expiration with glottis open in lateral postureClini18 2006 Postural drainage, manual drainageMackay39 2005 Deep breathing, coughing, huffing, FETTsang29 2003 Postural drainage, deep breathing, coughingBarker37 2002 Positioning, manual hyperinflationBerney34 2002 Postural drainage, manual hyperinflation, ventilator hyperinflationNtoumenopoulos23 2002 Postural drainage, positioning, vibration, coughingDenehy40 2001 Deep breathing exercises, sustained maximal inspiration, FET, coughingde Charmoy41 2000 Positioning, breathing exercises, coughingKrause36 2000 Postural drainage, percussionNtoumenopoulos35 1998 Postural drainage, manual hyperinflationFagevik Olsen42 1997 Breathing exercises, coughing, huffingJohnson43 1996 Deep breathing exercises, sustained maximal inspiration, postural drainage, manual percussionAmbrosino32 1995 Postural drainage, manual chest percussionJohnson44 1995 Deep breathing exercises, sustained maximal inspiration, postural drainage, manual percussionAsher24 1990 Positioning, lateral costal breathing, diaphragmatic breathing, shoulder relaxation, postural drainage, coughing,

FET, vibration, wing flapping, percussion, thoracic mobility exercises, postural correction exercises

* Patients typically also received suctioning, early mobilization, medical therapy, and standard turning per ICU protocols.CPT � chest physiotherapyFET � forced expiratory technique



PEP compared with standard care in postoperative CABGsubjects reported better pulmonary function in the inter-vention group.17 A fair quality study reported that subjectsin the Flutter arm had better pulmonary function, com-pared with those receiving standard care.28

Need for and Progression to or Duration ofMechanical Ventilation

For CPT compared to standard care in ventilated adultICU subjects, 2 studies of fair quality reported ventilationdays. One reported no significant difference in the dura-tion,23 and the other reported a longer duration on theventilator for the CPT (intervention) group.21 A fair qual-ity study in COPD subjects receiving CPT or IPV reportedno group difference in progression to ventilation, but ashorter duration of ventilation in the IPV group.27 Anotherfair quality study of IPV in COPD subjects reported thatfewer IPV subjects progressed to ventilation,38 while in astudy of CPT in postoperative subjects, progression toventilation did not differ between the groups.39 In 2 fairquality studies of NIV31 versus routine ventilation,35 sub-jects receiving PEP31 required fewer ventilator days, butthe duration did not differ in the study of postural drain-age.35

Signs and Symptoms

Four studies rated poor quality for the outcome of heartrate included subjects with COPD,27 bronchiectasis,26 and

postoperative43 or mechanically ventilated ICU subjects.37

Differences in heart rate were not significant between thegroups in any of these studies. Similarly, 3 studies thatassessed mean arterial pressure (one good quality study ofFlutter vs usual care in mechanically ventilated ICU sub-jects, one fair quality study of IPV vs CPT in COPDsubjects, and one poor quality study comparing CPT reg-imens in mechanically ventilated subjects) reported no sig-nificant group differences.

In studies that assessed breathing frequency, one fairquality study reported no differences in time to normalbreathing frequency in children with pneumonia receivingeither CPT or CPT plus usual care.20 One study of IPV insubjects with COPD reported no significant differences.27

Subjects with COPD or bronchiectasis receiving IPV im-proved significantly, compared with those who receivedusual care in 2 poor quality studies.26,38

Two studies, one poor quality study that compared CPTto usual care in COPD patients,16 and one good qualitystudy that compared high-frequency chest wall compres-sion to placebo,14 reported significant improvements indyspnea in the intervention arms. Two poor quality studiesthat compared either IPV to CPT26 or CPT to ACBT15

reported no significant group differences.

Exercise Tolerance

Two studies were considered poor quality for the out-come of exercise tolerance.15,17 One compared CPT plusACBT to ACBT alone, and reported significantly bettertolerance among CPT subjects.15 Similarly, a small studyof PEP versus usual care in postoperative subjects foundimproved walk distance in the PEP group.17

Pulmonary Complications

For adult ventilated ICU subjects, one good quality studyof CPT found reduced risk of VAP, compared to the con-trol intervention,23 and a fair quality study of IPV andstandard care found reduced risk of VAP, compared tostandard care alone.27 In a poor quality study of chestvibration in mechanically ventilated ICU subjects, vibra-tion resulted in less atelectasis, compared to positioning.22

While studies have reported improved outcomes with in-tervention, the literature base is currently small, and theresults are imprecise. Future studies may confirm or changecurrent estimates.

For surgical patients, preoperative training reduced therisk of hospital-acquired pneumonia, compared to no pre-operative training, in a poor quality study.42 Four otherstudies of airway clearance interventions in postoperativesubjects reported no significant difference in complicationrates: one good, one fair, and 2 poor quality studies.39-41,43

Table 7. Numbers of Studies Reporting Key Outcomes, by QualityRating

Outcome

Number of Studies

GoodStudies

FairStudies

PoorStudies

Stay 2 9 5Pulmonary function 1 3 11Sputum weight/volume 1 2 8Oxygenation 2 4 4Gas exchange 0 5 3Pulmonary complications 1 2 4Duration of ventilation 1 4 0Heart rate 0 1 4Dyspnea 1 0 3Harms of airway clearance techniques 0 1 2Mean arterial pressure 1 1 1Breathing frequency 0 1 3Exercise tolerance 0 0 2Quality of life 0 0 2Need for ventilation 1 3 0Hospital readmission (time to

exacerbation)1 1 1

Total 12 37 53



Stay

Stay, another indirect measure of CPT effectiveness,was reported in nearly half of the studies. For CPT com-pared to standard care, 5 studies (3 of poor quality, and 2of fair quality) reported no significant difference.16,20,21,23,24

A fair quality study reported longer stay in COPD subjectstreated with CPT, compared to those treated with IPV.27

Two studies of the Flutter device reported no significantdifference in stay, compared to other standard treat-ments.29,30 A fair quality study of postural drainage andmanual inflation versus standard care reported no signifi-cant difference in stay.35

A good quality study of a chest wall compression vest insubjects with asthma or COPD reported no significant dif-ference in stay, compared to a sham vest.14 Two studies ofIPV versus standard care in ICU subjects reported shorterstay in the subjects who received IPV.18,38

Three studies of airway clearance modalities in postop-erative subjects reported shorter stay in the treatmentgroups.39,40,44 The studies reporting stay were in differentpatient populations, and used different interventions andcomparators, and stay is an indirect outcome measure, sothe studies could not be combined meaningfully.

Exacerbations/Hospital Readmissions

Three studies (one good,14 one fair,15 one poor16 qual-ity) that assessed different interventions (high-frequencychest wall compression or variations of CPT) in subjectswith COPD reported no significant group differences inthe number of admissions or exacerbations.

Quality of Life

Two poor quality studies of subjects with COPD, onethat compared CPT to ACBT,15 and one that comparedCPT with usual care,16 reported no significant group dif-ferences in quality of life as assessed on the SGRQ andother measures.

Harms of Airway Clearance Techniques

Three studies reported harms specific to the airway clear-ance modalities.15,26,34 One poor quality study noted a sig-nificantly lower incidence of harms in the IPV arm, whereasthe others did not report the significance.

Methodologic Considerations and Limitations

The small magnitude of treatment effects, the uncertainand high risks of bias of the included studies, and the smallnumber of studies that used clinically meaningful outcomessignificantly limits the potential impact of the present re-

view’s findings for individuals, guideline panels, andhealthcare policy-makers. More than half of the studieswere rated as having high risk of bias, on the basis ofallocation concealment, but this is in the face of the factthat concealment would be a major challenge in this typeof research. Prior surgical sham studies, however, wouldsuggest that it is possible. The complexity of care, and thefact that many other factors were more powerful drivers ofimportant clinical outcomes, render it difficult to tease outthe specific effect of the interventions on important clin-ical outcomes (Table 8). Indeed, the comparison is fre-quently poorly described or not described, and with “usualcare” lacking standardization, it is challenging to assessthe impact of airway clearance interventions. As shown inthe tables throughout this report, neither the interventionsnor the comparators were consistent across any subset ofstudies. There were few controls for variation in tech-nique, for example among therapists, and the interventionswere typically poorly characterized in terms of durationand quantity. In addition, the studies routinely failed toidentify or capture harms of the intervention.

Nonetheless, although the differences in effect were typ-ically not significant, it is possible that the effects aremeaningful in patients’ experience and perception. It isunclear whether small changes in pulmonary function mea-sured by sputum weight, sputum volume, and blood gasestranslate to subjective changes in patient comfort. Few ofthe studies included any assessment of comfort or qualityof life, and we suggest that comfort and quality of life areimportant areas for further exploration. Important outcomesto consider include exacerbations and health-related qual-ity of life.

Future Research

In building the body of evidence, initial studies shouldestablish the effectiveness of individual interventionsagainst placebo, and then proceed to head to head com-parisons among interventions. Without the placebo-ver-sus-intervention studies, head to head comparisons yield-ing nonsignificant results cannot establish the effectivenessof either intervention. Researchers in this field should beencouraged to use standard RCT methodology, with ran-dom sequence generation, and to develop approaches forgood allocation concealment. In this way, even small stud-ies would be more useful for providing a basis for guid-ance. However, ultimately, because of the complexity ofthe patient condition and the numerous modalities of care,large studies with the ability to match patient and carecharacteristics are essential.

The promising studies in the review should be repeatedwith rigorous methods, and with similar populations, in-terventions, comparators, and outcomes, thus enabling fu-ture meta-analysis to generate adequately powered esti-



Tab

le8.

Sign

ific

ant

Dif

fere

nces

inK

eyFi

nal

Out

com

es*

Firs

tA

utho

rA

rms

FEV

1FV

CFR

CPe

akFl

ow

Lun

g/R

espi

rato

ryC

ompl

ianc

eor

Cap

acity

Max

imal

Exp

irat

ory

Pres

sure

Sput

umW

eigh

t/V

olum

eD

yspn

eaH

eart

Rat

eB

reat

hing

Freq

uenc

y

6-M

inW

alk

Tes

t

Oxy

gen

Satu

ratio

nP a

O2

P aC

O2

P aO

2/F I

O2

Post

oper

ativ

ePu

lmon

ary

Com

plic

atio

ns†

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mon

ia/

VA

P

Hos

pita

lor IC

USt

ay

Nee

dfo

r/Pr

ogre

ssio

nto

Mec

hani

cal

Ven

tilat

ion

Dur

atio

nof

Mec

hani

cal

Ven

tilat

ion

Re-

adm

issi

ons

Qua

lity

of Lif

e

Mah

ajan

1420

11H

FCW

C0

0�

00

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HFC

WC

00

–0

0

Chi

cayb

an28

2011

Flut

ter

��

�0

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dard

vent

ilatio

n–

––

0–

–

Pane

roni

2620

11IP

V0

00

�0

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00

0–

0

Nar

apar

aju45

2010

Aca

pella

�

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irat

ory

mus

cle

trai

ning

–

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ss15

‡20

10C

PT�

AC

BT

0�

00

AC

BT

0–

00

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n2220

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Usu

alca

re–

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ric16

2009

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irat

ion

with

glot

tisop

enin

late

ral

post

ure

00

�0

00

0

Usu

alca

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0–

00

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1920

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0

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alca

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2520

09A

CB

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00

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00

0

Hae

ffen

er17

2008

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omet

ry�

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00

00

��

��

Usu

alca

re0

00

0–

––

–

Palu

do20

2008

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alca

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plet

on21

2007

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00

–

Usu

alca

re0

0�

Ant

onag

lia27

§20

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�0

0�

�

CPT

–0

0–

–

Uno

ki33

2005

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cage

com

pres

sion

�su

ctio

ning

00

0

Suct

ioni

ngal

one

00

0

Var

gas38

2005

IPV

0�

��

Usu

alca

re0

––

–

Mac

kay39

2005

Bre

athi

ngan

dco

ughi

ng0

�0

0

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iliza

tion

only

0–

00

Sam

rans

amru

ajki

t3020

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utte

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�0

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alca

re–

–0

0

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ng29

2003

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ural

drai

nage

�br

eath

ing/

coug

hing

00

00

0

Flut

ter

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eath

ing/

coug

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0

(con

tinue

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Tab

le8.

Con

tinue

d

Firs

tA

utho

rA

rms

FEV

1FV

CFR

CPe

akFl

ow

Lun

g/R

espi

rato

ryC

ompl

ianc

eor

Cap

acity

Max

imal

Exp

irat

ory

Pres

sure

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umW

eigh

t/V

olum

eD

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eaH

eart

Rat

eB

reat

hing

Freq

uenc

y

6-M

inW

alk

Tes

t

Oxy

gen

Satu

ratio

nP a

O2

P aC

O2

P aO

2/F I

O2

Post

oper

ativ

ePu

lmon

ary

Com

plic

atio

ns†

Pneu

mon

ia/

VA

P

Hos

pita

lor IC

USt

ay

Nee

dfo

r/Pr

ogre

ssio

nto

Mec

hani

cal

Ven

tilat

ion

Dur

atio

nof

Mec

hani

cal

Ven

tilat

ion

Re-

adm

issi

ons

Qua

lity

of Lif

e

Bre

athi

ng/

coug

hing

alon

e

00

00

0

Bar

ker37

2002

Posi

tioni

ng�

man

ual

hype

rinf

latio

n�

suct

ioni

ng

00

0

Lat

eral

posi

tioni

ng�

suct

ioni

ng

00

0

Supi

nepo

sitio

ning

�su

ctio

ning

00

0

Nto

umen

opou

los23

2002

CPT

�0

0

Sham

CPT

–0

0

Ber

ney34

2002

Man

ual

hype

rinf

latio

n/ve

ntila

tor

hype

rinf

latio

n

00

Ven

tilat

orhy

peri

nfla

tion/

man

ual

hype

rinf

latio

n

00

Bel

lone

3120

02PE

P�

assi

sted

coug

h�

�

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iste

dco

ugh

––

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ehy40

2001

CPT

00

00

0

CPT

�C

PAP

15m

in0

00

00

CPT

�C

PAP

30m

in0

00

00

deC

harm

oy41

2000

CPT

00

0

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alca

re0

00

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use36

2000

Post

ural

drai

nage

�pe

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sion

00

0

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ifie

dpo

stur

aldr

aina

ge�

perc

ussi

on

00

0

Nto

umen

opou

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1998

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00

0

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00

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vik

Ols

en42

1997

CPT

00

0�

�0

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alca

re0

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––

0

John

son43

1996

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ly mob

iliza

tion

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I

00

00

00

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ly mob

iliza

tion

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I�

perc

ussi

on

00

00

00

(con

tinue

d)



Tab

le8.

Con

tinue

d

Firs

tA

utho

rA

rms

FEV

1FV

CFR

CPe

akFl

ow

Lun

g/R

espi

rato

ryC

ompl

ianc

eor

Cap

acity

Max

imal

Exp

irat

ory

Pres

sure

Sput

umW

eigh

t/V

olum

eD

yspn

eaH

eart

Rat

eB

reat

hing

Freq

uenc

y

6-M

inW

alk

Tes

t

Oxy

gen

Satu

ratio

nP a

O2

P aC

O2

P aO

2/F I

O2

Post

oper

ativ

ePu

lmon

ary

Com

plic

atio

ns†

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mon

ia/

VA

P

Hos

pita

lor IC

USt

ay

Nee

dfo

r/Pr

ogre

ssio

nto

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hani

cal

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tilat

ion

Dur

atio

nof

Mec

hani

cal

Ven

tilat

ion

Re-

adm

issi

ons

Qua

lity

of Lif

e

John

son44

1995

Ear

ly mob

iliza

tion

�de

epbr

eath

ing

(min

imal

atel

ecta

sis)

00

0�

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ly mob

iliza

tion

�de

epbr

eath

ing

�SM

I(m

inim

alat

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tasi

s)

00

0�

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ly mob

iliza

tion

�de

epbr

eath

ing

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I(m

arke

dat

elec

tasi

s)

00

0–

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ly mob

iliza

tion

�de

epbr

eath

ing

�SM

I�

perc

ussi

on(m

arke

dat

elec

tasi

s)

00

0–

Am

bros

ino32

1995

CPT

00

00

0

Flut

ter

00

00

0

Ash

er24

1990

CPT

00

00

0

Plac

ebo

00

00

0

*T

his

tabl

ere

port

sva

lues

/cha

nge

betw

een

grou

psat

fina

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-up

only

.V

alue

sty

pica

llych

ange

dfr

omba

selin

eto

follo

w-u

pw

ithin

each

grou

p.H

arm

sof

airw

aycl

eara

nce

tech

niqu

esw

ere

also

asse

ssed

in3

stud

ies,

14,2

5,30

but

sign

ific

ance

was

not

typi

cally

asse

ssed

.O

nest

udy25

repo

rted

asi

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tlylo

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the

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give

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clud

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grou

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mates of effect. The elements of the intervention should bestandardized, and the characteristics of the comparator welldescribed. As a field, respiratory care should consider as-sessing the degree to which study outcomes are clinicallymeaningful, and agreeing on a set of core outcomes forfuture work.

Summary

In summary, the 32 studies included in this review pro-vide limited evidence for the effectiveness of nonpharma-cologic airway clearance techniques. The evidence we re-viewed indicates that airway clearance techniques areprobably safe for ventilated ICU patients, and confer zeroto small benefit to some clinical outcomes.18,21-23,28,33–37

Consideration may be given to the use of airway clearancetechniques for ventilated ICU patients, to reduce the riskof acquiring pneumonia, based upon 2 studies, which in-cluded 76 subjects.23,27 Based on the current limitedevidence, airway clearance modalities might not be rec-ommended as routine prophylaxis to prevent postopera-tive pulmonary complications in adults.39-43 Similarly,in people with COPD, data from 6 single studies thatspecifically targeted COPD did not provide evidence ofsignificant short-term benefit from airway clearancemodalities.14-16,27,31,38

Our finding of limited evidence is in line with similar,recent reviews of airway clearance in patients with COPDand pneumonia, which have generally found small bene-fits.11,12,49,50 The interventions, comparators, and popula-tions varied considerably across the studies, hamperingour ability to draw firm conclusions. The interventions,including conventional CPT, IPV, and PEP, typically pro-vided small benefits to pulmonary function, gas exchange,oxygenation, and the need for or duration of ventilation,among other outcomes, but the between-group differenceswere generally small and not significant. The harms ofairway clearance techniques were not consistently reported,though airway clearance techniques were generally con-sidered safe in studies that did comment on adverse ef-fects. Further research with clearly characterized popula-tions and interventions is needed to understand the potentialbenefits and harms of these techniques.

ACKNOWLEDGMENTS

We gratefully acknowledge the contributions of the American Associa-tion for Respiratory Care (AARC) Airway Clearance Clinical PracticeGuidelines Committee, whose insights on scoping the literature and re-viewing the studies were invaluable. The committee includes RichardBranson MSc RRT FAARC, Gail Drescher MA RRT, Carl Haas MLSRRT FAARC, Dean Hess PhD RRT FAARC, Ray Masferrer RRTFAARC, Catherine O’Malley RRT-NPS, Bruce Rubin MD MEngr MBAFAARC, Shawna Strickland PhD RRT-NPS AE-C FAARC, Teresa Vol-sko MHHS RRT FAARC.

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