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Bronchial Hygiene Therapy

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Bronchial Hygiene Therapy WHITE PAPER Bronchial Hygiene Therapy OBJECTIVES At the conclusion of this paper the reader should have an understanding of the following: • A background of chest physiotherapy, Figure 1: and rational for use of Positive Expiratory Collateral Ventilation. Pressure (PEP) and oscillatory positive Gas is diffused between alveolar expiratory pressure (OPEP). sacs via the Pores of Kohn and • Benefits of using OPEP in various disease Canals of Lambet. The localization states Cystic Fibrosis (CF), Chronic Obstructive of gas in alveolar sacs behind Pulmonary Disease (COPD/Bronchiectasis) collapsed airways may aid in and post-operative care. the recruitment of lung tissue. • Clinical perspectives on and protocols used for the acapella® choice vibratory PEP therapy system. INTRODUCTION Chest physiotherapy (CPT) is a form of bronchial residual volume in patient with air trapping as resonance frequency6. Work with various disease hygiene which includes, but is not limited seen in patients with CF. The retained gas within states has shown the optimal respiratory system to: postural and autogenic drainage, deep the lungs can, through collateral ventilation, resonance frequency to be 10-35 Hz for asthma7, breathing exercises, manual chest percussion, localize distal to a mucous block and improve and 10-32 Hz for COPD8. and active cycle breathing techniques. Patients 2 mucous clearance in patients with CF . Similarly The acapella® choice vibratory PEP therapy undergoing CPT may complain the treatment increasing airway pressure by PEP can improve system combines high-frequency oscillations is uncomfortable, time-consuming and may the dilation of the airways, or stenting, thereby and PEP into a single treatment. Exhaled air require the assistance of a second person1. Due improving lung function and mucus clearance is opposed as it passes through the device to these concerns, there may be decreased 3 in patients with CF . These actions have been resulting in positive expiratory pressure. patient compliance to CPT at home. Additionally, described in relation to a ketchup bottle, whereby Additionally, this expired flow is intermittently some CPT treatments address only symptoms ketchup is easier to remove from a bottle if air is occluded by a moving magnetic counterweight, of bronchial hygiene such as secretion stasis, 4 behind the ketchup . Therefore, PEP is effective producing air flow oscillations. The use of a rather than the underlying defect, collapsed by localizing air behind mucus blocks through magnetic counterweight allows for usage of the airways. Therefore, due to patient compliance stenting and collateral ventilation. device independent of position (sitting or lying issues and a potential gap in the way bronchial Oscillatory Positive Expiratory Pressure (OPEP) supine, prone or lateral) and still allows for a hygiene is administered, different therapies combines the properties of PEP with airway patient specific therapy by adjustment of the are needed. vibrations, or oscillations. OPEP induces airway magnet positioning. There are 5 levels on the PEP is generated by exhaling against a vibrations due to the oscillatory nature of the acapella® allowing for optimization of frequency, resistance, and this results in an increase in therapy and, therefore, OPEP and vibratory PEP oscillation amplitude, and mean pressure. The airway pressure. PEP therapy is therapeutic are used interchangeably. These oscillations acapella® family of products (Blue, Green, and when the elevated airway pressure is in the decrease the viscoelastic properties of the Choice) have a range of PEP (3-23 cm H20) range of 10-20 cmH2O. During treatment with mucus, easing removal from the airway. The 9,10,11,12,13 and frequency of oscillation (8-21 Hz) 8-12. PEP, the patient maintains tidal breathing, with applied vibration frequency by an OPEP device is This range of oscillatory frequency is within the a slightly active expiration all while breathing most effective for secretion mobilization when range of ciliary beating4 and coincides with the against the resistance of the PEP device. it matches the frequency of ciliary movement, resonant frequency of the respiratory tract Breathing against resistance over a period of which is ~12-15 Hz5. The expectoration of sputum of patients with COPD, 10-32 Hz7. time will increase Functional Residual Capacity can be further improved if the applied pressure (FRC) in patients with atelectasis or reduce frequency coincides with the respiratory-system CYSTIC FIBROSIS (CF) The clinical use of OPEP has been studied in of the body, airway clearance devices such Transient lung function and blood gas a variety of disease states. A common feature as PEP devices, high frequency chest wall concentrations were noted with the use of of these disease states is abnormal mucus compression, mechanical percussion devices Flutter® compared to PEP25. McCarren studied secretion in the airway leading to mucus plugs and OPEP devices. All of these devices and 18 CF patients comparing the physiologic effects and airway obstruction. These obstructions can manipulations aim to aid in the expectoration of vibration to other physiotherapy interventions. lead to infections in the lung causing increased of mucus. This study demonstrated that clinically acapella® 26 mucus secretion. Therefore, the removal of The clinical usefulness of OPEP devices in CF can produce vibrations at 13.5 Hz (±1.7) . This respiratory secretions is of great importance. patients has been studied since the mid-1990s. clinical and bench work indicates that the ® In a disease such as CF, the increased levels of Studies have demonstrated that the use of acapella is capable of producing effective mucus is due to a mutation in the Cystic Fibrosis OPEP may improve sputum expectoration14,15. oscillations (13.5 Hz) at low flows (5 L/min). ® Transmembrane conductance Regulator (CFTR) No difference in sputum production between These parameters make the use of acapella gene. The mutation to the CFTR gene causes OPEP and the control group16,17 has also been especially attractive to those patients with a thick viscous secretion which is difficult for noted in studies. OPEP has shown at least low expiratory flow due to severe air flow 13 patients to expectorate from their lungs. There similar efficacy to active breathing techniques13, obstruction, and of a low age . are several methods of secretion management postural drainage14,18 and autogenic drainage16, for CF patients including physical manipulations PEP therapy19,20,21,22,23 and manual percussion24. Outcome variables First author Institution Population n Study design Major findings measured Pryor Royal Brompton Cystic Fibrosis 24 Randomized Sputum production, Greater sputum production with Hospital, London crossover trial of: Spirometry, SpO2 ACBT (p<0.001). No difference in ® UK ACBT, Flutter +ACBT spirometry of SpO2 values. Konstan Rainbow Babies Cystic Fibrosis 18 Randomized Sputum production Significantly more sputum and Children’s crossover trial of: production with Flutter® Hospital, postural drainage (p<0.001) Cleveland, USA and percussion, Flutter® Newhouse Michigan State Cystic Fibrosis 11 Randomized Sputum production, No difference in sputum University, USA crossover trial of: Spirometry, SpO2 production, significant postural drainage improvements in flow with both and percussion, IPV and Flutter®. Transient ® Flutter , IPV decrease in SpO2 with postural drainage and percussion. Homnick Michigan State Cystic Fibrosis 33 Prospective Spirometry, Hospital stay, No difference in any University, randomized trial of: Number of treatments, measured outcome Michigan, USA postural drainage Clinical score and percussion, Flutter® Gondor All Children’s Cystic Fibrosis 23 Prospective Spirometry, 6 min walk, Similar significant Spirometry Hospital, St. randomized trial of: SpO2, Hospital Stay, and 6 minute walk Petersburg, postural drainage Sputum cultures improvements with postural Florida, USA and percussion, drainage and percussion and ® ® Flutter Flutter . No difference in SpO2, hospital stay or sputum cultures. Significant improvements in FVC ® and FEV1 at 7 days with Flutter . App Albert-Ludwigs- Cystic Fibrosis 17 Prospective Sputum production, No difference in spirometry University Freiburg, randomized Spirometry, Sputum or sputum production. Germany crossover trial of: viscoelasticity Significant decrease in sputum Autogenic drainage, viscoelasticity with Flutter® Flutter® (p<0.01). Oermann Texas Children’s Cystic Fibrosis 29 Prospective Pulmonary function, No difference in pulmonary Hospital randomized modified National function, Modified NIH score, crossover trial of: Institute of Health score, Petty score. HFCWC had Postural drainage Petty Score, Patient significantly higher patient and Percussion, satisfaction score efficacy score than Flutter®. HFCWC, Flutter® Flutter® had significantly higher convenience score than HFCWC or postural drainage and percussion. Outcome variables First author Institution Population n Study design Major findings measured West The Childrens Cystic Fibrosis 23 Prospective Lung function (FEV1, FVC, No statistically significant Hospital at Randomized trial FEF (25-75) and PEF) and differences noted with Westmead. of: PEP mask exercise performance. any of the outcomes Westmead, New or acapella® Total sputum production South Wales, and patient satisfaction Australia McCarren School of Cystic Fibrosis 18 Cross over trial of Expiratory flow rates and acapella® had the highest Physiotherapy, acapella®, Flutter®,
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