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Meta-Analysis
. 2012 Mar 14;2012(3):CD008328.
doi: 10.1002/14651858.CD008328.pub2.

Airway clearance techniques for chronic obstructive pulmonary disease

Christian R Osadnik  1 , Christine F McDonald, Arthur P Jones, Anne E Holland
Affiliations
Meta-Analysis

Airway clearance techniques for chronic obstructive pulmonary disease

Christian R Osadnik et al. Cochrane Database Syst Rev. .

Abstract

Background: Cough and sputum production are common in chronic obstructive pulmonary disease (COPD) and are associated with adverse clinical outcomes. Airway clearance techniques (ACTs) aim to remove sputum from the lungs, however evidence of their efficacy during acute exacerbations of COPD (AECOPD) or stable disease is unclear.

Objectives: To assess the safety and efficacy of ACTs for individuals with AECOPD and stable COPD.

Search methods: We searched the Cochrane Airways Group Specialised Register of trials from inception to October 2011, and PEDro in October 2009.

Selection criteria: We included randomised parallel trials and randomised cross-over trials which compared an ACT to no treatment, cough or sham ACT in participants with investigator-defined COPD, emphysema or chronic bronchitis.

Data collection and analysis: Two review authors independently conducted data extraction and assessed the risk of bias. We analysed data from studies of AECOPD separately from stable COPD, and classified the effects of ACTs as 'immediate' (less than 24 hours), 'short-term' (24 hours to eight weeks) or 'long-term' (greater than eight weeks). One subgroup analysis compared the effects of ACTs that use positive expiratory pressure (PEP) to those that do not.

Main results: Twenty-eight studies on 907 participants were included in the review. Study sample size was generally small (range 5 to 96 people) and overall quality was generally poor due to inadequate blinding and allocation procedures. Meta-analyses were limited by heterogeneity of outcome measurement and inadequate reporting of data.In people experiencing AECOPD, ACT use was associated with small but significant short-term reductions in the need for increased ventilatory assistance (odds ratio (OR) 0.21, 95% confidence interval (CI) 0.05 to 0.85; data from four studies on 171 people), the duration of ventilatory assistance (mean difference (MD) -2.05 days, 95% CI -2.60 to -1.51; mean duration for control groups seven days; data from two studies on 54 people) and hospital length of stay (MD -0.75 days, 95% CI -1.38 to -0.11; mean duration for control groups nine days; one study on 35 people). Data from a limited number of studies revealed no significant long-term benefits of ACTs on the number of exacerbations or hospitalisations, nor any short-term beneficial effect on health-related quality of life (HRQoL) as measured by the St. George's Respiratory Questionnaire (SGRQ) total score (MD -2.30, 95% CI -11.80 to 7.20; one study on 59 people).In people with stable COPD, data from single studies revealed no significant short-term benefit of ACTs on the number of people with exacerbations (OR 3.21, 95% CI 0.12 to 85.20; one study on 30 people), significant short-term improvements in HRQoL as measured by the SGRQ total score (MD -6.10, 95% CI -8.93 to -3.27; one study on 15 people) and a reduced long-term need for respiratory-related hospitalisation (OR 0.27, 95% CI 0.08 to 0.95; one study on 35 participants).The magnitude of effect of PEP-based ACTs on the need for increased ventilatory assistance and hospital length of stay was greater than for non-PEP ACTs, however we found no statistically significant subgroup differences. There was one report of vomiting during treatment with postural drainage and head-down tilt.

Authors' conclusions: Evidence from this review indicates that airway clearance techniques are safe for individuals with COPD and confer small beneficial effects on some clinical outcomes. Consideration may be given to the use of airway clearance techniques for patients with COPD in both acute and stable disease, however current studies suggest that the benefits achieved may be small.

PubMed Disclaimer

Conflict of interest statement

CO, CM and AH are conducting a study which may be included in future updates of this review.

Figures

1
1
Study flow diagram.
2
2
'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.
3
3
'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
4
4
Forest plot of comparison: 1 Acute COPD: ACTs vs no ACTs (control), outcome: 1.5 Need for increased ventilatory assistance (invasive or non‐invasive).
5
5
Forest plot of comparison: 1 Acute COPD: ACTs vs no ACTs (control), outcome: 1.6 Duration of ventilatory assistance (days).
6
6
Forest plot of comparison: 1 Acute COPD: ACTs vs no ACTs (control), outcome: 1.8 Length of hospital stay (days).
1.1
1.1. Analysis
Comparison 1 Acute COPD: ACTs vs no ACTs (control), Outcome 1 Number of AECOPDs (long‐term).
1.2
1.2. Analysis
Comparison 1 Acute COPD: ACTs vs no ACTs (control), Outcome 2 Number of AECOPDs (long‐term).
1.3
1.3. Analysis
Comparison 1 Acute COPD: ACTs vs no ACTs (control), Outcome 3 Need for respiratory hospital admission (long‐term).
1.4
1.4. Analysis
Comparison 1 Acute COPD: ACTs vs no ACTs (control), Outcome 4 Need for respiratory hospital admission (long‐term).
1.5
1.5. Analysis
Comparison 1 Acute COPD: ACTs vs no ACTs (control), Outcome 5 Need for increased ventilatory assistance (invasive or non‐invasive).
1.6
1.6. Analysis
Comparison 1 Acute COPD: ACTs vs no ACTs (control), Outcome 6 Duration of ventilatory assistance (days).
1.7
1.7. Analysis
Comparison 1 Acute COPD: ACTs vs no ACTs (control), Outcome 7 Length of ICU stay (days).
1.8
1.8. Analysis
Comparison 1 Acute COPD: ACTs vs no ACTs (control), Outcome 8 Length of hospital stay (days).
1.9
1.9. Analysis
Comparison 1 Acute COPD: ACTs vs no ACTs (control), Outcome 9 QOL ‐ SGRQ total (short‐term).
1.10
1.10. Analysis
Comparison 1 Acute COPD: ACTs vs no ACTs (control), Outcome 10 FEV1 (L) (short‐term).
1.11
1.11. Analysis
Comparison 1 Acute COPD: ACTs vs no ACTs (control), Outcome 11 VC (L) (short‐term).
1.12
1.12. Analysis
Comparison 1 Acute COPD: ACTs vs no ACTs (control), Outcome 12 FEV1/FVC (%) (short‐term).
1.13
1.13. Analysis
Comparison 1 Acute COPD: ACTs vs no ACTs (control), Outcome 13 Gas exchange: pH (short‐term).
1.14
1.14. Analysis
Comparison 1 Acute COPD: ACTs vs no ACTs (control), Outcome 14 Gas exchange: PaO2 (mmHg) (short‐term).
1.15
1.15. Analysis
Comparison 1 Acute COPD: ACTs vs no ACTs (control), Outcome 15 Gas exchange: PaCO2 (mmHg) (short‐term).
1.16
1.16. Analysis
Comparison 1 Acute COPD: ACTs vs no ACTs (control), Outcome 16 Gas exchange: SpO2 (%) (short‐term).
1.17
1.17. Analysis
Comparison 1 Acute COPD: ACTs vs no ACTs (control), Outcome 17 Breathlessness ‐ Borg scale (short‐term).
1.18
1.18. Analysis
Comparison 1 Acute COPD: ACTs vs no ACTs (control), Outcome 18 Sputum weight, g (immediate).
1.19
1.19. Analysis
Comparison 1 Acute COPD: ACTs vs no ACTs (control), Outcome 19 Sputum volume, ml (immediate).
1.20
1.20. Analysis
Comparison 1 Acute COPD: ACTs vs no ACTs (control), Outcome 20 Sputum volume, ml (24/24) (short‐term).
1.21
1.21. Analysis
Comparison 1 Acute COPD: ACTs vs no ACTs (control), Outcome 21 Mortality (short‐term).
1.22
1.22. Analysis
Comparison 1 Acute COPD: ACTs vs no ACTs (control), Outcome 22 Mortality (long‐term).
1.23
1.23. Analysis
Comparison 1 Acute COPD: ACTs vs no ACTs (control), Outcome 23 Participant withdrawal (immediate).
1.24
1.24. Analysis
Comparison 1 Acute COPD: ACTs vs no ACTs (control), Outcome 24 Participant withdrawal (short‐term).
1.25
1.25. Analysis
Comparison 1 Acute COPD: ACTs vs no ACTs (control), Outcome 25 Participant withdrawal (long‐term).
2.1
2.1. Analysis
Comparison 2 Stable COPD: ACTs vs no ACTs (control), Outcome 1 Number of AECOPDs (short‐term).
2.2
2.2. Analysis
Comparison 2 Stable COPD: ACTs vs no ACTs (control), Outcome 2 Need for respiratory hospital admission (long‐term).
2.3
2.3. Analysis
Comparison 2 Stable COPD: ACTs vs no ACTs (control), Outcome 3 Total number of days hospitalised (long‐term).
2.4
2.4. Analysis
Comparison 2 Stable COPD: ACTs vs no ACTs (control), Outcome 4 QOL ‐ SGRQ total (short‐term).
2.5
2.5. Analysis
Comparison 2 Stable COPD: ACTs vs no ACTs (control), Outcome 5 FEV1 (L) (immediate).
2.6
2.6. Analysis
Comparison 2 Stable COPD: ACTs vs no ACTs (control), Outcome 6 FEV1 (L) (short‐term).
2.7
2.7. Analysis
Comparison 2 Stable COPD: ACTs vs no ACTs (control), Outcome 7 VC (L) (immediate).
2.8
2.8. Analysis
Comparison 2 Stable COPD: ACTs vs no ACTs (control), Outcome 8 VC (L) (short‐term).
2.9
2.9. Analysis
Comparison 2 Stable COPD: ACTs vs no ACTs (control), Outcome 9 Gas exchange: PaO2 (mmHg) (short‐term).
2.10
2.10. Analysis
Comparison 2 Stable COPD: ACTs vs no ACTs (control), Outcome 10 Gas exchange: PaCO2 (mmHg) (short‐term).
2.11
2.11. Analysis
Comparison 2 Stable COPD: ACTs vs no ACTs (control), Outcome 11 Gas exchange: SpO2 (%) (immediate).
2.12
2.12. Analysis
Comparison 2 Stable COPD: ACTs vs no ACTs (control), Outcome 12 Breathlessness, Borg scale (immediate).
2.13
2.13. Analysis
Comparison 2 Stable COPD: ACTs vs no ACTs (control), Outcome 13 Sputum weight, g (immediate).
2.14
2.14. Analysis
Comparison 2 Stable COPD: ACTs vs no ACTs (control), Outcome 14 Sputum volume, ml (immediate).
2.15
2.15. Analysis
Comparison 2 Stable COPD: ACTs vs no ACTs (control), Outcome 15 Mucociliary clearance, scintigraphy (% retention).
2.16
2.16. Analysis
Comparison 2 Stable COPD: ACTs vs no ACTs (control), Outcome 16 Exercise tolerance, 6MWD (m) (short‐term).
2.17
2.17. Analysis
Comparison 2 Stable COPD: ACTs vs no ACTs (control), Outcome 17 Exercise tolerance, 12MWD (m) (long‐term).
2.18
2.18. Analysis
Comparison 2 Stable COPD: ACTs vs no ACTs (control), Outcome 18 Need for antibiotics (short‐term).
2.19
2.19. Analysis
Comparison 2 Stable COPD: ACTs vs no ACTs (control), Outcome 19 Need for antibiotics (long‐term).
2.20
2.20. Analysis
Comparison 2 Stable COPD: ACTs vs no ACTs (control), Outcome 20 Participant withdrawal (short‐term).
2.21
2.21. Analysis
Comparison 2 Stable COPD: ACTs vs no ACTs (control), Outcome 21 Participant withdrawal (long‐term).
See this image and copyright information in PMC

Update of

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Diette 2004 {published data only}
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Elkins 2001 {published data only}
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Elkins 2001a {published data only}
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Esteve 1996 {published data only}
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Falk 1981 {published data only}
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Gallon 1991 {published data only}
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George 1985 {published data only}
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Gervasini 1983 {published data only}
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Guell 2000 {published data only}
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He 1988 {published data only}
    1. He YZ. Medical gymnastics for chronic bronchitis,emphysema or early cor pulmonale during. Chinese Journal of Physical Therapy 1988; Vol. 11, issue 4:207‐8.
Herala 1995 {published data only}
    1. Herala M, Stalenheim G, Boman G. Effects of positive expiratory pressure (PEP), continuous positive airway pressure (CPAP) and hyperventilation in COPD patients with chronic hypercapnea. Upsala Journal of Medical Sciences 1995; Vol. 100, issue 3:223‐32. - PubMed
Ho 2000 {published data only}
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Kaminska 1988 {published data only}
    1. Kaminska TM, Pearson SB. A comparison of postural drainage and positive expiratory pressure in the domiciliary management of patients with chronic bronchial sepsis. Physiotherapy 1988; Vol. 74, issue 5:251‐4.
Krishnan 2009 {published data only (unpublished sought but not used)}
    1. Krishnan J, Ridge A, Walker Harris V, Lewis S, Ivy K, Dalapathi V. Treating exacerbations of asthma or chronic obstructive pulmonary disease (COPD) with high frequency chest wall oscillation (HFCWO) in hospitalized patients [Abstract]. European Respiratory Society Annual Congress, Barcelona, Spain, September 18‐22. 2010:[3869].
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Kurabayashi 1998 {published data only}
    1. Kurabayashi H, Machida I, Handa H, Akiba T, Kubota K. Comparison of three protocols for breathing exercises during immersion in 38 degrees C water for chronic obstructive pulmonary disease. American Journal of Physical Medicine and Rehabilitation 1998; Vol. 77, issue 2:145‐8. - PubMed
Kurabayashi 2000 {published data only}
    1. Kurabayashi H, Machida I, Tamura K, Iwai F, Tamura J, Kubota K. Breathing out into water during subtotal immersion: a therapy for chronic pulmonary emphysema. American Journal of Physical Medicine and Rehabilitation 2000; Vol. 79, issue 2:150‐3. - PubMed
Lewczuk 1998 {published data only}
    1. Lewczuk J, Piszko P, Kowalska‐Superlak M, Jagas J, Wojciak S, Wrabec K. The impact of 2‐year rehabilitation on exercise tolerance and transcutaneous oxygen saturation during exercise in patients with chronic obstructive pulmonary disease [Polish] [Wplyw 2‐letniej rehabilitacji na tolerance wysilku i wysycenie tlenem krwi tetniczej w czasie wysilku u chorych na przewlekla obturacyjna chorobe pluc]. Polskie Archiwum Medycyny Wewnetrznej 1998; Vol. 100, issue 4:331‐6. - PubMed
Marcq 1975 {published data only}
    1. Marcq M, Frans A, Stanescu D, et al. Practical problems in the rehabilitation of coal‐miners with chronic bronchitis at the first stage of respiratory insufficiency. Rehabilitation (London) 1975; Vol. 92:23‐33.
Marcq 1981 {published data only}
    1. Marcq M, Minette A. Fonction cardio‐respiratoire de bronchitiques jeunes, pour la plupart mineurs de charbon, avant et apres kinesitherapie et entrainement a l‚effort. Comparaison avec un groupe temoin (resultats preliminaires). Revue de l'Institut d'Hygiene des Mines 1981; Vol. 36, issue 1:18‐31.
Marrara 2008 {published data only}
    1. Marrara KT, Marino DM, Held PA, Oliveira Junior AD, Jamami M, Lorenzo VAP. Different physical therapy interventions on daily physical activities in chronic obstructive pulmonary disease. Respiratory Medicine 2008; Vol. 102, issue 4:505‐11. - PubMed
McCarroll 2005 {published data only}
    1. McCarroll ML. The effects of exercise and airway clearing devices on chronic pulmonary diseased patients in pulmonary rehabilitation [Dissertation]. Ohio State University, 2005:96p.
McNeill 1955 {published data only}
    1. McNeill RS, McKenzie JM. An assessment of the value of breathing exercises in chronic bronchitis and asthma. Thorax 1955; Vol. 10, issue 3:651‐6. - PMC - PubMed
Mohsenifar 1985 {published data only}
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Moiz 2006 {published data only}
    1. Moiz JA, Kishore K, Belsare DR. A comparison of autogenic drainage and the active cycle of breathing techniques in patients with acute exacerbation of chronic obstructive pulmonary disease. Indian Journal of Physiotherapy and Occupational Therapy 2006:10‐2.
Muzembo 2001 {published data only}
    1. Muzembo Ndundu J, Nkakudulu Bikuku H, Frans A. Respiratory rehabilitation in patients with bronchial asthma and chronic obstructive pulmonary disease (COPD) in Kinshasa. Revue de Pneumologie Clinique 2001; Vol. 57, issue 3:209‐18. - PubMed
Nakayama 1998 {published data only}
    1. Nakayama H, Shibuya M, Yamada SH, Arakawa M, Homma I. In‐phase chest wall vibration decreases dyspnea during arm elevation in chronic obstructive pulmonary disease patients. Internal Medicine 1998; Vol. 37, issue 10:831‐5. - PubMed
Nava 2006 {published data only}
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Padkao 2010 {published data only}
    1. Padkao T, Boonsawat W, Jones CU. Conical‐PEP is safe, reduces lung hyperinflation and contributes to improved exercise endurance in patients with COPD: a randomised cross‐over trial. Journal of Physiotherapy 2010; Vol. 56, issue 1:33‐9. - PubMed
Petersen 1967 {published data only}
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Salhi 2011 {published data only}
    1. Salhi B, Meerbeeck J, Joos GF, Derom E. Effects of whole body vibration in patients with COPD: a randomized study [Abstract]. American Journal of Respiratory and Critical Care Medicine 2011;183:A3968.
Saski 2005 {published data only}
    1. Saski T, Ebihara S, Yasuda H, Yamaya M. Effect of combination of mechanical insufflation‐exsufflation and flutter for sputum removal in elderly patients with dyspnea [Abstract]. American Thoracic Society 2005 International Conference; May 20‐25; San Diego, California 2005:[B52] [Poster: F96].
Saunders 1965 {published data only}
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Savci 2000 {published data only}
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Sergi 1990 {published data only}
    1. Sergi M, Forleo MV, Rizzi M. Chest physiotherapy in cold and long‐term oxygen therapy (LTOT) [abstract]. European Respiratory Journal. Supplement 1990; Vol. 3, issue Suppl 10:413S.
Shen 2008 {published data only}
    1. Shen ZK. Therapeutic effect observation of bailing capsule and medical gymnastics to COPD in paracmasis. Zhongguo Zhong yao za zhi = Zhongguo zhongyao zazhi = China Journal of Chinese Materia Medica 2008; Vol. 33, issue 8:942‐4. - PubMed
Skaria 2008 {published data only}
    1. Skaria S, Arun AJ, Sethi J. Effect of positive expiratory pressure technique over forced expiratory technique on bronchial hygiene in patients with moderate chronic bronchitis. Indian Journal of Physiotherapy and Occupational Therapy 2008; Vol. 2, issue 3.
Soler 2006 {published data only}
    1. Soler JJ, Martinez‐Garcia MA, Roman P, Orero R, Terrazas S, Martinez‐Pechuan A. Effectiveness of a specific program for patients with chronic obstructive pulmonary disease and frequent exacerbations. Archivos de Bronconeumologia 2006; Vol. 42, issue 10:501‐8. - PubMed
Su 2007 {published data only}
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Sutton 1983 {published data only}
    1. Sutton PP, Parker RA, Webber BA, Newman SP, Garland N, Lopez Vidriero MT, et al. Assessment of the forced expiration technique, postural drainage and directed coughing in chest physiotherapy. European Journal Respiratory Diseases 1983; Vol. 64, issue 1:62‐8. - PubMed
Szczegielniak 2006 {published data only}
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Thomas 1988 {published data only}
    1. Thomas SH, Langford JA, George RJ, Geddes DM. Aerosol deposition in the human lung: effect of high‐frequency oscillation on the deposition characteristics of an inhaled nebulized aerosol. Clinical Science 1988; Vol. 75, issue 5:535‐42. - PubMed
Toshima 1990 {published data only}
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van der Schans 1986 {published data only}
    1. Schans CP, Piers DA, Postma DS. Effect of manual percussion on tracheobronchial clearance in patients with chronic airflow obstruction and excessive tracheobronchial secretion. Thorax 1986; Vol. 41, issue 6:448‐52. - PMC - PubMed
Wollmer 1985 {published data only}
    1. Wollmer P, Ursing K, Midgren B, Eriksson L. Inefficiency of chest percussion in the physical therapy of chronic bronchitis. European Journal of Respiratory Diseases 1985; Vol. 66, issue 4:233‐9. - PubMed
Xu 2000 {published data only}
    1. Xu GH. Study on the rehabilitating effects of respiration qigong on the COPD patients [Chinese]. Nanfang Journal of Nursing 2000; Vol. 7:2‐4.
Zakerimoghadam 2006 {published data only}
    1. Zakerimoghadam M, Shaban M, Kazemnejad A, Tavasoli K. The effect of breathing exercises on fatigue level of COPD patients [Persian]. HAYAT: The Journal of Tehran Faculty of Nursing & Midwifery 2006; Vol. 12, issue 3:17‐25.
    1. Zakerimoghadam M, Tavasoli K, Nejad AK, Khoshkesht S. The effect of breathing exercises on the fatigue levels of patients with chronic obstructive pulmonary disease. Acta Medica Indonesiana 2011;43(1):29‐33. - PubMed

References to studies awaiting assessment

Cegla 2000b {published data only}
    1. Cegla UH, Harten A. The RC‐Cornet‐intensified bronchospasmolysis of ipratropiumbromid in COPD. Pneumologie 2000; Vol. 54, issue SH1:S22‐3.
Chakravorty 2011 {published data only}
    1. Chakravorty I, Fasakin C, Austin G, Timbury C, Basu C. Impact of mucociliary clearance with high frequency chest wall oscillation in acute exacerbation of COPD [Abstract]. American Journal of Respiratory and Critical Care Medicine 2011;183:A5047.
Diette 2009 {published data only (unpublished sought but not used)}
    1. Diette G, Bilderback A, Becker B, Kachel D, Wise R, Rand C. Adherence to high‐frequency chest wall oscillation (HFCWO) improves quality of life in COPD [Abstract]. European Respiratory Society Annual Congress, Vienna, Austria, September 12‐16 2009:[P2090].
Esquinas 2010 {published data only}
    1. Esquinas A, Folgad M, Serrano J. Effects of intrapulmonary percussive ventilation as complementary technique in noninvasive mechanical ventilation during exacerbations of COPD [Abstract]. Intensive Care Medicine 2010;36:S388.
Long 2001 {published data only (unpublished sought but not used)}
    1. Long C. The effects of manual chest percussion in patients with chronic obstructive pulmonary disease and bronchiectasis. National Research Register 2001 2001.
Qu 2009 Jul {published data only}
    1. Qu Y, Peng H, Chen P, Xiang X. Combination of chest physiotherapy and intermittent non‐invasive mechanical ventilation for chronic obstructive pulmonary disease patients with respiratory failure [Chinese]. Zhong Nan Da Xue Xue Bao Yi Xue Ban = Journal of Central South University. Medical Sciences 2009;34(7):655‐8. - PubMed
Timbury 2010 {published data only}
    1. Timbury C, Austin G, McGowan J, Basu C, Joshi V, Meek Detal. High frequency chest wall oscillation in acute exacerbation of COPD; a pilot study of feasibility for supported early discharge [Abstract]. European Respiratory Society Annual Congress, Barcelona, Spain, September 18‐22. 2010:[P4105].

Additional references

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