airway clearance devices in cystic fibrosis
TRANSCRIPT
7/31/2019 Airway Clearance Devices in Cystic Fibrosis
http://slidepdf.com/reader/full/airway-clearance-devices-in-cystic-fibrosis 1/7
MINI-SYMPOSIUM: AIRWAY CLEARANCE IN CYSTIC FIBROSIS
Airway clearance devices in cystic fibrosis
John H. Marks*
Associate Professor, Department of Pediatrics and Human Development, Michigan State University College of
Human Medicine, East Lansing, and Associate Director, Pediatric Pulmonology and Cystic Fibrosis Center, Michigan
State University-Kalamazoo Center for Medical Studies, Kalamazoo, Michigan, USA
Management of the pulmonary complications of cystic
fibrosis (CF) involves airway clearance therapies (ACTs)
to remove obstructing secretions from the airways. To aid
airway clearance, aerosolized bronchodilators and muco-
lytics are also often used to dilate respiratory passages and
breakdown secretions; other articles in this symposium
discuss these. Conventional manual chest physiotherapy with gravity assisted drainage (CCPT) has long been the
‘gold’ standard method of airway clearance for patients with
CF.1 While CCPT has been shown to aid in clearance of
pulmonary secretions in CF patients, the time involved and
the need for assistance often leads to reduced adherence
to this form of therapy. Several independently administered
airway clearance devices have been shown to be effective
in aiding airway clearance in CF patients, including positive
expiratory pressure (PEP), the Flutter 1 device, the Aca-
pella1, the Cornet1, the intrapulmonary percussive venti-
lation device (IPV), the PercussiveNeb1, and the high
frequency chest wall oscillation devices. This paper will
describe each device, the mechanisms (known and pro-
posed) by which the devices aid airway clearance, and the
clinical evidence based on short- and long-term clinical trials that supports their use in patients with CF.
POSITIVE EXPIRATORY PRESSURE
The PEP device is the simplest and least expensive of the
airway clearance devices. The PEP mask was developed in
Denmark in the late 1970s as an alternative to CCPT. The
mask has a one-way inhalation valve and an expiratory
resistor. Exhalation through the resistor generates positive
pressure in the airways which can be measured with a
manometer or pressure indicator. Resistance orifices of
PAEDIATRIC RESPIRATORY REVIEWS (2007) 8, 17–23
KEYWORDS
airway clearance;
chest physical therapy;
cystic fibrosis;
high frequency chest wall
oscillation;
intrapulmonary
percussive ventilation;
positive expiratory
pressure
Summary Clearance of infected airway secretions is essential to preserve lung function
in patients with cystic fibrosis (CF). Although the value of regular airway clearance
treatments has been shown in many studies, adherence to the prescribed treatments is
not very good (see Making airway clearance successful, pp. 000–000). In the past the only
method available was conventional chest physiotherapy (CCPT; also known as manual
percussion and postural drainage). CCPT remains the ‘gold standard’ of airway clearance
methods and may be the best choice for some patients, such as infants and young
children. However, the many newer methods of airway clearance available now allow CF
patients and their families to choose the techniques and devices that best suits them.
Most of the newer airway clearance devices have been studied in comparison to standard
chest physiotherapy and most studies show no advantage of one method over another.
This review will describe newer airway clearance devices available for CF patients and
discuss evidence for the effectiveness of these devices compared to standard chest
physiotherapy.
ß 2007 Elsevier Ltd. All rights reserved.
* Tel.: +1 269 337 6467; Fax: +1 269 337 6474.
E-mail address: [email protected].
1526-0542/$ – see front matter ß 2007 Elsevier Ltd. All rights reserved.
doi:10.1016/j.prrv.2007.02.003
7/31/2019 Airway Clearance Devices in Cystic Fibrosis
http://slidepdf.com/reader/full/airway-clearance-devices-in-cystic-fibrosis 2/7
different diameters can be chosen so that individual patients
can generate pressures of 10–20 cm H2O. The patient
inhales to mid-lung volumes and then exhales actively with
an inspiration to expiration ratio (I:E) of 1:3 or 1:4. After
about 10 PEP exhalations the patient does a series of huff
coughs, keeping the glottis open. The cycle is repeated
several times over about 20 min or until secretions are nolonger being expectorated. PEP can also be done with a
mouthpiece making sure the cheeks are well supported. A
resistor can also be utilized with a nebulizer so aerosolized
medications can be delivered during inspiration (Fig. 1).
Higher pressure PEP achieving pressures of 60–80 cm H2O
has also been advocated.2
The proposed mechanism of action of PEP is to stabilize
airways and improve aeration to obstructed distal lung units
through colla teral ventilation via pores of Kohn and canals
of Lambert.3 PEP has also been shown to improve the
distribution of ventilation and gas mixing in CF patients.4
Most studies assessing the effectiveness of PEP in CF
patients have demonstrated equivalence compared to tradi-
tional CCPT. One study (16 patients, 8 week crossover
design) showed more improvemen t in forced expiratory
volume in 1 s (FEV1) with CCPT.5 Another study (36
patients, 1 year parallel design) showed greater improve-
ment in FEV1 in the PEP group.6 Four evidence-based
reviews comparing PEP with CCPT and o ther airway clear-
ance methods were published in 2006.7–10 Three Cochrane
Database reviews concluded that there was essentially no
evidence that PEPwas betterthan CCPT or vice versa.There
were trendsthat showed patients preferredPEP over CCPT.
The American College of Chest Physicians Evidence-Based
Clinical Practice Guidelines on Nonpharmacologic Airway Clearance Therapies states, ‘In patients with CF, PEP is
recommended over conventional chest physiotherapy
because it is approximately as effective as chest physiother-
apy, and is inexpensive, safe, and can be self-administered’.10
OSCILLATORY DEVICES
Flutter 1
The Flutter 1 (Axcan Scandipharm, Birmingham, Alabama,
USA) is a small, handheld, mucus clearance device that
provides PEPtherapywith oral airwayoscillations.It is shaped
like a pipe with a hardened plastic mouthpiece at one end, aplastic, protective, perforated cover at the other end, and a
high-density stainless steelball resting in a plastic circularcone
on the inside (Fig. 2). The patient sits comfortably and inhales
to about 75% of inspiratory capacity, then exhales through
the Flutter keeping the stem parallel to the floor. During
exhalation, pressure from the airways is transmitted to the
Flutter causing the steel ball to bounce and roll up and down,
creating several opening and closing cycles with each breath
(Fig. 3). PEP develops in the range of 10–25 cm H2O at an
oscillatory frequency of about 15 Hz. Tilting the device
adjusts the frequency to achieve the greatest amount of
airway vibration (the individual’s pulmonary resonance fre-
quency). Several series of five to ten exhalations each
followed by one or two forceful exhalations and huff coughs
are done over 10–20 min.
The proposed mechanisms of action of the Flutter
include shearing of mucus from airway walls by oscillatory
action, stabilization of airways preventing airway collapse,
accelerating expiratory airflow to move mucus upward to
the trachea, and possibly by altering mucus quality, although
data for direct effec ts of thinning of airway secretions by any
AC device is scant.11
Evidence for effectiveness of the Flutter has been shown
in short- and long-term studies. Expectorated sputum
volume was greater after a 15 min session with the Flutter compared to sessions of CCPT or directed vigorous cough
(18 patients, three-way crossover over 2 weeks).12 Two
studies demonstrated no difference in effectiveness of
Flutter and CCPT during hospital treatment of an acute
18 J. H. MARKS
Figure 2 Top: Flutter device components showing the pipe
stem, cone with steel ball and perforated top. Bottom: the
Acapella device.
Figure 1 Pari PEP device (Pari Respiratory Equipment, Mid-
lothian, Virginia, USA) used with a Pari LC nebulizer. Resistance is
set by choosing one of the various orifices over the exhalation
port (inset). A pressure monitor is at right.
7/31/2019 Airway Clearance Devices in Cystic Fibrosis
http://slidepdf.com/reader/full/airway-clearance-devices-in-cystic-fibrosis 3/7
pulmonary exacerbation.13,14 One study showed the Flut-
ter was less effective than PEP (40 patients over 1 y ear) in
maintaining pulmonary function and clinical scores.15 These
conflicting studies point out the difficulty of drawing con-
clusions as to the efficacy of an AC device when a study is
small and often statistically underpowered.
Acapella1
The Acapella1 (Smiths Medical Inc, Carlsbad, California,
USA) is a handheld airway clearance device (Fig. 2) that
operates on the same principle as the Flutter, i.e. a valve
interrupting expiratory flow generating oscillating PEP.
Utilizing a counterweighted plug and magnet to achieve
valve closure, the Acapella is not gravity dependent like the
Flutter. The Acapella comes in three models, a low flow(<15 L/min), high flow (>15 L/min) and the Acapella
Choice. The high and low flow models have a dial to set
expiratory resistance while the Choice model has a
numeric dial to adjust frequency. All models can be used
with a mask or mouthpiece and can be used in line with a
nebulizer. While these attributes may offer the Acapella
some advantage over the Flutter, no long-term studies have
been done in CF patients. A bench study of the perfor-
mance characteristics of the two devices showed a slight
advantage for the Acapella, with more stable wave form
and a wider range of PEP at low air flow.16
RC-Cornet1
The RC Cornet1 (R. Cegla, Montabaur, Germany) consists
of a semi-circular tube containing a flexible latex-free hose
(Fig. 4). Expiration through the Cornet causes the hose to
flex,buckle and unbuckle, causing oscillating positivepressure
in the airways which fluctuates many times per second. The
mouthpiece can be adjusted to produce the optimal effect.
Operating principle and use are similar to the Flutter valve,
although the Cornet is not gravity dependent and can be
used in any position. Like the Flutter the Cornet cannot be
used in line with a nebulizer. No studies showing the long-
term effectiveness of the Cornet in CF patients are available
yet. The Cornet is available in Europe but not in the USA.
Intrapulmonary Percussive Ventilation
IPV-11
The IPV-11 (Percussionaire, Sand Point, Idaho, USA) is a
positive pressure ventilator device (Fig. 5) that delivers
small bursts of air through a mouthpiece at a rate of
200–300 cycles/min (2–5 Hz) using a sliding venturi to
cause rapid flow interruptions. It entrains an aerosol of
up to 20 ml of saline with or without a bronchodilator over
about 20 min. It delivers a positive pressure at the mouth of
10–30 cm H2O. The optimal effect achieved by pressure
and frequency is determined by direct observation of chest
movement and patient comfort. Oscillations occur mainly
during inhalation, but may occur throughout the respiratory
cycle. The pressure source can be either an oxygen cylinder
or an air compressor.The presumed mechanisms of action of the IPV include
bronchodilation from increased airway pressure and deliv-
ery of nebulized bronchodilator, prevention of airway
collapse, improved distribution of ventilation and stimula-
tion of cough.
Evidence to support the effectiveness of IPV treatment
in CF patients is limited. Three short-term studies and one
long-term study have been published. Two single interven-
tion studies established safety and demonstrated no dif-
ference in effects on pulmonary function and spu tum
production with IPV compared to CCPT and Flutter.17,18
A short-term study in hospitalized CF patients (24 subjects,
crossover design) demonstrated an increased sputum wet
weight after IPV compared to high frequency chest wall
oscillation.19 A 6-month study (16 CF patients, parallel
design) that compared daily IPV with standard bronchodi-
lator aerosol and CCPT showed no significant differences in
pulmonary function, number of hospitalizations, use of oral
or intravenous antibiotics and anthropometrics.20
PercussiveNeb1
The PercussiveNeb1 (P-Neb; Vortran Medical Technology
1, Sacramento, California, USA) is an oral intrapulmonary
AIRWAY CLEARANCE DEVICES 19
Figure 4 The RC-Cornet device.Figure 3 Oscillating up and down action of the steel ball in the
Flutter. (From Flutter 1 mucus clearance device, Instructions for
use, Axcan Scandipharm, Birmingham, Alabama, USA.)
7/31/2019 Airway Clearance Devices in Cystic Fibrosis
http://slidepdf.com/reader/full/airway-clearance-devices-in-cystic-fibrosis 4/7
percussive treatment device that incorporates a large
volume nebulizer (20 ml) for delivery of aerosolized med-
ication with oscillating positive pressure (Fig. 6). Oscillatory
frequency ranges from 6 to 30 Hz with airway pressures of
6–15 cm H2O. The P-Neb oscillates during both inhalation
and exhalation, enhancing aerosol delivery and maintaining
airway patency (Fig. 7). The pressure source is a high-
output compressor capable of delivering a gas flow >60 L/
min. Most of the flow is utilized to operate the modulator
piston that causes the oscillatory effect. The patient fills the
nebulizer reservoir with bronchodilator medication, starts
the compressor and occludes the mouthpiece until the
device begins to cycle. After placing the mouthpiece in the
mouth, the flow is adjusted to accommodate the patient’s
comfort and breathing pattern. Oscillating amplitude can be
adjusted from ‘soft’ to ‘hard’.Presumed mechanisms of action are similar to the IPV
and include bronchodilation, prevention of airway collapse
and shearing of mucus from airway walls, and possible
thinning of secretions by high expiratory percussive flow
(Fig. 8).
There are no published long-term studies of the P-Neb
in CF patients. A single intervention study of the precursor
device, the PercussiveTech HF, in CF patients showed it to
be safe and probably as effective as CCPT.21 A 6-month
study (16 CF patients, parallel design) comparing daily use
of the PercussiveTech HF with the Flutter showed no
differences in pulmonary function or days of hospital or
home intravenous antibiotic use.22
It should be noted that for all the oral positive
expiratory pressure devices, especially when used with
a mouthpiece, the cheeks should be kept flat and rigid
and a nose clip should be considered so that the pressure
and oscillations are primarily delivered to the lower
airways.
High frequency chest wall oscillation
There are two devices utilizing an inflatable vest con-
nected to an air-pulse generating compressor to deliver
20 J. H. MARKS
Figure 6 The PercussiveNeb device.
Figure 7 Mouth pressure and amplituderecording with PTHF
in two CF patients. Top: Pressure recorded shows oscillations at
approximately 10 Hz with an amplitude of 0–6 cm H2O during
inhalation and 8–14 cm H2O during exhalation. Bottom: There
are no oscillations during inhalation and lower amplitude and
frequency during exhalation. (Adapted with permission from
Marks et al.21)
Figure 5 The IPV-1 device.
7/31/2019 Airway Clearance Devices in Cystic Fibrosis
http://slidepdf.com/reader/full/airway-clearance-devices-in-cystic-fibrosis 5/7
high-frequency chest wall oscillation (HFCWO), The
Vest1 (Hill-Rom, St Paul, Minnesota) and the SmartVest1
(Electromed, New Prague, Minnesota) (Fig. 9). The air-
pulse generator rapidly inflates and deflates the vest,
gently compressing and releasing the chest wall several
times per second. Oscillation frequency can be adjusted
from 5 to 25 Hz with pressure to the vest ranging from 3 to 25 cm H2O. The chest wall oscillations are transmitted
to the airways creating mini-coughs. Treatment sessions
generally last 20 to 30 min and consist of short segments at
different frequencies separated by huff coughs. An exam-
ple would be 5 min sessions at 8, 10, 12, 15, 17 and 20 Hz.
Keeping the frequency set at 12 Hz for the entire treat-
ment is a simpler option. Nebulized bronchodilator can be
taken before or during a vest treatment session. Vests
come in different sizes to accommodate children and
adults.
The proposed mechanism of action of HFCWO is
enhancement of mucus transport in three essential ways:
by altering the rheologic properties of mucus, by creating a
cough-like expiratory airflow bias that shears mucus from
the airway walls, and by enhancing ciliary beat frequency, allof which help move mucus toward central airways.23
HFCWO has also been shown to improve distribution
of ventilation.24 One study found that patients with mod-
erate or severe airway obstruction may benefit from lower
vest pressures at frequencies of 10–15 Hz to minimize
decrease in end-expiratory lung volume and maximize
oscillatory flow.25
There is evidence to support the use of HFCWO in CF
patients based on several studies looking at acute and long-
term effects. When comparing HFCWO to oscil lating PEP
and CCPT, the acute effect, as assessed by sputum pro-
duction, showed no difference or superiority of HFCWO
using a vest device compared to CCPT and IPV.26
HFCWO using the Hayek Oscillator (Breasy Medical
Equipment Ltd, London, UK), a rigid cuirass ventilator,
and oscillating PEP using two similar oral airway oscillating
devices (Sensormedics, Yorba Linda, California, USA)
demonstrated, ‘comparable augmenting effects on expec-
torated sputum weight’ with no effect on pulmonary
function.27 Therapy during hospitalization for a pulmonary
exacerbation showed no differences in outcomes with
HFCWO compared to CCPT or PEP as assessed by
sputum production and pulmonary function.28,29 A
short-term crossover trial comparing HFCWO to CCPT
and oscillating PEP found no differences in pulmonary function or clinical score between therapies. Patients
tended to prefer HFCWO.30 A long-term study (16
patients, 22 months with historical controls) showed a
significant decrease in the rate of decline in pulmonary
function during the HFCWO treatment period compared
to standard CPT.31
The Hayek Oscillator was compared to active cycle
of breathing technique (ACBT) in a 2-day crossover
study; HFCWO was found to be less effective than
ACBT.32 No long-term studies using this device have been
published.
CONCLUSION
Several devices have been developed to enhance airway
clearance in CF patients. With the exception of the PEP
valve, these devices all involve airway oscillation, either
orally or via chest wall vibration. The advantage of these
devices is that they can be used by patients independently
without the need for an assistant or caregiver. Most of
these devices have been studied in either short- or long-
term comparisons with CCPT. The studies are generally
underpowered and it is not clear which outcome mea-
surements are most useful for comparing various clear-
AIRWAY CLEARANCE DEVICES 21
Figure 9 The SmartVest1 showing the compressor unit and
vest. (Adapted from SmartVest1 product information, Electro-
med, New Prague, Minnesota, USA.)
Figure 8 Diagram of exhalation without PEP or oscillations
(upper figure) and with oscillatory PEP (lower figure). (Adapted
from PercussiveNeb1 User’s Guide, Vortran Medical Technology
1, Sacramento, California, USA.)
7/31/2019 Airway Clearance Devices in Cystic Fibrosis
http://slidepdf.com/reader/full/airway-clearance-devices-in-cystic-fibrosis 6/7
ance techniques. Short-term studies, especially those
measuring sputum production, are not helpful in demon-
strating equivalence of any airway clearance methods. In
spite of a lack of adequately powered, long-term trials,
two Cochrane evidence-based reviews conclude that
there is evidence that CCPT is generally at least as
effective as these airway clearance devices.
8,9
The ACCPEvidence-Based Clinical Practice Guidelines states, ‘In
patients with CF, devices designed to oscillate gas in
the airway, either directly or by compressing the chest
wall, can be considered as an alternative to chest phy-
siotherapy’.10
Evidence in these reviews also suggests that
these self-administered therapy devices may be preferred
by CF patients, which may lead to increased adherence to
treatment.
REFERENCES
1. Reisman JJ, Rivington-Low B, Corey M. Role of conventional phy-
siotherapy in cystic fibrosis. J Pediatr 1988; 113: 632–666.
2. Oberwaldner B, Evans JC, Zach MS. Forced expirations against a
variable resistance: a new chest physiotherapy method in cystic
fibrosis. Pediatr Pulmonol 1986; 2: 358–367.
3. Andersen JB, Qvist J, Kann T. Recruiting collapsed lung through
collateral channels with positive end-expiratory pressure. Scand J
Respir Dis 1979; 60: 260–266.
4. Darbee JC, Ohtake PJ, Grant BJB, Cerny FJ. Physiologic evidence for
the efficacy of positive expiratory pressure as an airway clearance
technique in patients with cystic fibrosis. Phys Ther 2004; 84: 524– 537.
5. Tyrrell JC, Hiller EJ, Martin J. Face mask therapy in cystic fibrosis. Arch
Dis Child 1986; 61: 598–611.
6. McIlwaine PM, Wong LT, Peacock D, Davidson AG. Long-term
comparative trial of conventional postural drainage and percussion
versus positive expiratory pressure physiotherapy in the treatment of
cystic fibrosis. J Pediatr 1997; 131: 570–574.
7. Elkins MR, Jones A, van der Shans C. Positive expiratory pressure
physiotherapy for airway clearance in people with cystic fibrosis. In:
The Cochrane Library , Issue 2. Chichester:Wiley; 2006.
8. Bradley JM, Moran FM, Elborn JS. Evidence for physical
therapies (airway clearance and physical training) in cystic fibrosis:
An overview of five Cochrane systematic reviews. Respir Med 2006;
100: 191–201.
9. Main E, Prasad A, van der Shans C. Conventional chest physiotherapy
compared to other airway clearance techniques for cystic fibrosis. In:
The Cochrane Library , Issue 1. Chichester: Wiley; 2005.
10. McCool FD, Rosen MJ. Nonpharmacologic airway clearance therapies:
ACCP evidence-based clinical practice guidelines. Chest 2006; 129:
250S–259S.
11. App EM,Kieselmann R, ReinhardtD et al. Sputum rheology changes in
cystic fibrosis lung disease following two different types of physiother-
apy: flutter vs autogenic drainage. Chest 1998; 114: 171–177.
12. Konstan MW, Stern RC, Doershuk CF. Efficacy of the Flutter device for
airway mucus clearance in patients cystic fibrosis. J Pediatr 1994; 124:
689–693.
13. Gondor M, Nixon PA, Mutich R, Rebovich P, Orenstein DM. Compar-
ison of the flutter device and chest physical therapy in the treatment of
cystic fibrosis pulmonary exacerbation. Pediatr Pulmonol 1999; 28: 255–
260.
14. HomnickDN, Anderson K, Marks JH. Comparison of theflutterdevice
to standard chest physiotherapy in hospitalized patients with cystic
fibrosis: a pilot study. Chest 1998; 114: 993–997.
15. McIlwaine PM, Wong LT, Peacock D, Davidson AG. Long-term
comparative trial of positive expiratory pressure versus oscillating
positive expiratory pressure (flutter) physiotherapy in the treatment
of cystic fibrosis. J Pediatr 2001; 138: 845–850.
16. Volsko TA, DiFiore JM, Chatburn RL. Performance comparison of two
oscillating positive expiratory pressure devices: acapella versus flutter.
Respir Care 2003; 48: 124–130.
17. Natale JE, Pfeifle J, Homnick DN. Comparison of intrapulmonary
percussive ventilation and chest physiotherapy. A pilot study in
patients with cystic fibrosis. Chest 1994; 105: 1789–1793.
18. Newhouse PA, White F, Marks JH, Homnick DN. The intrapulmonary
percussive ventilator and flutter device compared to standard chest
physiotherapy in patients with cystic fibrosis. Clin Pediatr 1998; 37: 427–
432.
19. Varekojis SM, Douce FH, Flucke RL et al. A comparison of the
therapeutic effectiveness of and preference for postural drainage
and percussion, intrapulmonary percussive ventilation, and high-fre-
quency chest wall compression in hospitalized cystic fibrosis patients.
Respir Care 2003; 48: 24–28.
20. Homnick DN, White F, de Castro C. Comparison of effects of an
intrapulmonary percussive ventilator to standard aerosol and chest
physiotherapy in treatment of cystic fibrosis. Pediatr Pulmonol 1995;
20: 50–55.
21. Marks JH, Hare KL, Saunders RA, Homnick DN. Pulmonary function
and sputum production in patients with cystic fibrosis: a pilot study
comparing the PercussiveTech HF device and standard chest phy-
siotherapy. Chest 2004; 125: 1507–1511.
22. Marks JH, Homnick DN, Hare K, Cucos D. The PercussiveTech HF
compared to the Flutter device in cystic fibrosis patients: A six month
pilot study. Pediatr Pulmonol 2001; 22(Suppl): 309.
23. Hansen LG, Warwick WJ, Hansen KL. Mucus transport mechanisms in
relation to the effect of high frequency chest compression (HFCC) on
mucus clearance. Pediatr Pulmonol 1994; 17: 113–118.
24. Darbee JC, Kanga JF, Ohtake PJ. Physiologic evidencefor high-frequency chest wall oscillation and positive expiratory pressure breathing in
hospitalized subjectswith cystic fibrosis. PhysTher 2005; 85: 1278–1289.
25. Jones R, Lester R, Brown N. Effect of high frequency chest compres-
sion on respiratory system mechanics in normal subjects and cystic
fibrosis patients. Can Respir J 1995; 2: 40–46.
26. Kluft J, Beker L, Castagnino M, Gaiser J, Chaney H, Fink R. A
comparison of bronchial drainage treatments in cystic fibrosis. Pediatr
Pulmonol 1996; 22: 271–274.
27. Scherer TA, Barandun J, Martinez E, Wanner A, Rubin EM. Effect of
high frequency oral airway and chest wall oscillation and conventional
chest physiotherapy on expectoration in patients with stable cystic
fibrosis. Chest 1998; 113: 1019–1027.
28. Arens R, Gozal D, Omlin K et al. Comparison of high-frequency chest
compression and conventional chest physiotherapy in hospitalized
22 J. H. MARKS
PRACTICE POINTS
Airway clearance devices as alternatives to CCPTallow CF patients to choose the therapy that best
fits their lifestyle and allows greatest independence
Airway clearance devices are preferred by many
patients compared to CCPT and may result in
better adherence.
PEP may be more effective for airway clearance
than CCPT.
Oscillating positive expiratory pressure devices
and HFCWO appear to be at least as effective
as CCPT.
7/31/2019 Airway Clearance Devices in Cystic Fibrosis
http://slidepdf.com/reader/full/airway-clearance-devices-in-cystic-fibrosis 7/7
patients with cystic fibrosis. Am J Respir Crit Care Med 1994; 150: 1154–
1157.
29. Braggion C, Cappelletti LM, Cornacchia M et al. Short-term effects of
three chest physiotherapy regimens in patients hospitalized for pul-
monaryexacerbations of cystic fibrosis: a crossover randomized study.
Pediatr Pulmonol 1995; 19: 16–22.
30. Oermann CM, Sockrider MM, Giles D, Sontag MK, Accurso FJ, Castile
RG. Comparison of high-frequency chest wall oscillation and oscillating
positive pressure in the home management of cystic fibrosis: a pilot
study. Pediatr Pulmonol 2001; 32: 372–377.
31. Warwick W, Hansen L. The long-term effect of high-frequency chest
compression therapy on pulmonary complications of cystic fibrosis.
Pediatr Pulmonol 1991; 11: 265–271.
32. Phillips GE, Pike SE, Jaffe A, Bush A. Comparison of active cycle of
breathing and high-frequency oscillation jacket in children with cystic
fibrosis. Pediatr Pulmonol 2004; 37: 71–75.
AIRWAY CLEARANCE DEVICES 23