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Meta-Analysis
. 2017 May 4;5(5):CD006842.
doi: 10.1002/14651858.CD006842.pub4.

Oscillating devices for airway clearance in people with cystic fibrosis

Lisa Morrison  1 , Stephanie Innes  2
Affiliations
Meta-Analysis

Oscillating devices for airway clearance in people with cystic fibrosis

Lisa Morrison et al. Cochrane Database Syst Rev. .

Update in

Abstract

Background: Chest physiotherapy is widely prescribed to assist the clearance of airway secretions in people with cystic fibrosis. Oscillating devices generate intra- or extra-thoracic oscillations orally or external to the chest wall. Internally they create variable resistances within the airways, generating controlled oscillating positive pressure which mobilises mucus. Extra-thoracic oscillations are generated by forces outside the respiratory system, e.g. high frequency chest wall oscillation. This is an update of a previously published review.

Objectives: To identify whether oscillatory devices, oral or chest wall, are effective for mucociliary clearance and whether they are equivalent or superior to other forms of airway clearance in the successful management of secretions in people with cystic fibrosis.

Search methods: We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register comprising references identified from comprehensive electronic database searches and hand searches of relevant journals and abstract books of conference proceedings. Latest search of the Cystic Fibrosis Trials Register: 27 April 2017.In addition we searched the trials databases ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform. Latest search of trials databases: 26 April 2017.

Selection criteria: Randomised controlled studies and controlled clinical studies of oscillating devices compared with any other form of physiotherapy in people with cystic fibrosis. Single-treatment interventions (therapy technique used only once in the comparison) were excluded.

Data collection and analysis: Two authors independently applied the inclusion criteria to publications and assessed the quality of the included studies.

Main results: The searches identified 76 studies (302 references); 35 studies (total of 1138 participants) met the inclusion criteria. Studies varied in duration from up to one week to one year; 20 of the studies were cross-over in design. The studies also varied in type of intervention and the outcomes measured, data were not published in sufficient detail in most of these studies, so meta-analysis was limited. Few studies were considered to have a low risk of bias in any domain. It is not possible to blind participants and clinicians to physiotherapy interventions, but 11 studies did blind the outcome assessors.Forced expiratory volume in one second was the most frequently measured outcome. One long-term study (seven months) compared oscillatory devices with either conventional physiotherapy or breathing techniques and found statistically significant differences in some lung function parameters in favour of oscillating devices. One study identified an increase in frequency of exacerbations requiring antibiotics whilst using high frequency chest wall oscillation when compared to positive expiratory pressure. There were some small but significant changes in secondary outcome variables such as sputum volume or weight, but not wholly in favour of oscillating devices. Participant satisfaction was reported in 15 studies but this was not specifically in favour of an oscillating device, as some participants preferred breathing techniques or techniques used prior to the study interventions. The results for the remaining outcome measures were not examined or reported in sufficient detail to provide any high level evidence.

Authors' conclusions: There was no clear evidence that oscillation was a more or less effective intervention overall than other forms of physiotherapy; furthermore there was no evidence that one device is superior to another. The findings from one study showing an increase in frequency of exacerbations requiring antibiotics whilst using an oscillating device compared to positive expiratory pressure may have significant resource implications. More adequately-powered long-term randomised controlled trials are necessary and outcomes measured should include frequency of exacerbations, individual preference, adherence to therapy and general satisfaction with treatment. Increased adherence to therapy may then lead to improvements in other parameters, such as exercise tolerance and respiratory function. Additional evidence is needed to evaluate whether oscillating devices combined with other forms of airway clearance is efficacious in people with cystic fibrosis.There may also be a requirement to consider the cost implication of devices over other forms of equally advantageous airway clearance techniques. Using the GRADE method to assess the quality of the evidence, we judged this to be low or very low quality, which suggests that further research is very likely to have an impact on confidence in any estimate of effect generated by future interventions.

PubMed Disclaimer

Conflict of interest statement

Lisa Morrison declares that she has no interest in any of the papers or references within this document and has received no funding in whole or in part for any of this work.

Stephanie Innes: none known.

Figures

Figure 1
Figure 1
Study flow diagram.
Figure 2
Figure 2
Risk of bias: review authors' judgments about each risk of bias item presented as percentages across all included studies.
Figure 3
Figure 3
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
Analysis 1.1
Analysis 1.1
Comparison 1 Oscillating devices (OD) versus positive expiratory pressure (PEP), Outcome 1 FEV₁ post‐intervention [% predicted].
Analysis 1.2
Analysis 1.2
Comparison 1 Oscillating devices (OD) versus positive expiratory pressure (PEP), Outcome 2 FEV₁ change from baseline [% predicted].
Analysis 1.3
Analysis 1.3
Comparison 1 Oscillating devices (OD) versus positive expiratory pressure (PEP), Outcome 3 FEF25‐75 post intervention [% predicted].
Analysis 1.4
Analysis 1.4
Comparison 1 Oscillating devices (OD) versus positive expiratory pressure (PEP), Outcome 4 FEF25‐75 change from baseline [% predicted].
Analysis 1.5
Analysis 1.5
Comparison 1 Oscillating devices (OD) versus positive expiratory pressure (PEP), Outcome 5 FVC post intervention [% predicted].
Analysis 1.6
Analysis 1.6
Comparison 1 Oscillating devices (OD) versus positive expiratory pressure (PEP), Outcome 6 FVC change from baseline [% predicted].
Analysis 1.7
Analysis 1.7
Comparison 1 Oscillating devices (OD) versus positive expiratory pressure (PEP), Outcome 7 Sputum volume [ml].
Analysis 1.8
Analysis 1.8
Comparison 1 Oscillating devices (OD) versus positive expiratory pressure (PEP), Outcome 8 Sputum weight [g].
Analysis 1.9
Analysis 1.9
Comparison 1 Oscillating devices (OD) versus positive expiratory pressure (PEP), Outcome 9 Quality of life indices.
Analysis 1.10
Analysis 1.10
Comparison 1 Oscillating devices (OD) versus positive expiratory pressure (PEP), Outcome 10 Number of hospitalizations.
Analysis 1.11
Analysis 1.11
Comparison 1 Oscillating devices (OD) versus positive expiratory pressure (PEP), Outcome 11 Pulmonary exacerbations (at 1 year).
Analysis 1.12
Analysis 1.12
Comparison 1 Oscillating devices (OD) versus positive expiratory pressure (PEP), Outcome 12 Exercise performance % change from baseline.
Analysis 1.13
Analysis 1.13
Comparison 1 Oscillating devices (OD) versus positive expiratory pressure (PEP), Outcome 13 Participant satisfaction.
Analysis 2.1
Analysis 2.1
Comparison 2 Oscillating devices (OD) versus breathing techniques, Outcome 1 FEV₁ post‐intervention [% predicted].
Analysis 2.2
Analysis 2.2
Comparison 2 Oscillating devices (OD) versus breathing techniques, Outcome 2 FVC post‐intervention [% predicted].
Analysis 2.3
Analysis 2.3
Comparison 2 Oscillating devices (OD) versus breathing techniques, Outcome 3 Sputum volume [g].
Analysis 2.4
Analysis 2.4
Comparison 2 Oscillating devices (OD) versus breathing techniques, Outcome 4 Sputum weight (wet) [g].
Analysis 3.1
Analysis 3.1
Comparison 3 Oscillating devices (OD) versus conventional physiotherapy (CPT), Outcome 1 FEV₁ post intervention [% predicted].
Analysis 3.2
Analysis 3.2
Comparison 3 Oscillating devices (OD) versus conventional physiotherapy (CPT), Outcome 2 FEV₁ change from baseline [% predicted].
Analysis 3.3
Analysis 3.3
Comparison 3 Oscillating devices (OD) versus conventional physiotherapy (CPT), Outcome 3 FEF25‐75 post intervention [% predicted].
Analysis 3.4
Analysis 3.4
Comparison 3 Oscillating devices (OD) versus conventional physiotherapy (CPT), Outcome 4 FEF25‐75 change from baseline [% predicted].
Analysis 3.5
Analysis 3.5
Comparison 3 Oscillating devices (OD) versus conventional physiotherapy (CPT), Outcome 5 FVC [% predicted].
Analysis 3.6
Analysis 3.6
Comparison 3 Oscillating devices (OD) versus conventional physiotherapy (CPT), Outcome 6 Residual volume [% change from baseline].
Analysis 3.7
Analysis 3.7
Comparison 3 Oscillating devices (OD) versus conventional physiotherapy (CPT), Outcome 7 Sputum weight (dry) [g].
Analysis 3.8
Analysis 3.8
Comparison 3 Oscillating devices (OD) versus conventional physiotherapy (CPT), Outcome 8 Sputum weight (wet) [g].
Analysis 3.9
Analysis 3.9
Comparison 3 Oscillating devices (OD) versus conventional physiotherapy (CPT), Outcome 9 Six minute walking distance [metres].
Analysis 3.10
Analysis 3.10
Comparison 3 Oscillating devices (OD) versus conventional physiotherapy (CPT), Outcome 10 Oxygen saturation (SaO2 ) [% change from baseline].
Analysis 3.11
Analysis 3.11
Comparison 3 Oscillating devices (OD) versus conventional physiotherapy (CPT), Outcome 11 Days of hospitalization.
Analysis 3.12
Analysis 3.12
Comparison 3 Oscillating devices (OD) versus conventional physiotherapy (CPT), Outcome 12 Patient satisfaction / overall preference (short term).
Analysis 3.13
Analysis 3.13
Comparison 3 Oscillating devices (OD) versus conventional physiotherapy (CPT), Outcome 13 Patient satisfaction / overall preference (long term).
Analysis 4.1
Analysis 4.1
Comparison 4 Flutter versus HFCWO, Outcome 1 FEV1 [% predicted].
Analysis 4.2
Analysis 4.2
Comparison 4 Flutter versus HFCWO, Outcome 2 FEF25‐75 [% predicted].
Analysis 4.3
Analysis 4.3
Comparison 4 Flutter versus HFCWO, Outcome 3 FVC [% predicted].
Analysis 4.4
Analysis 4.4
Comparison 4 Flutter versus HFCWO, Outcome 4 Treatment satisfaction (long term).
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Update of

References

References to studies included in this review

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References to studies excluded from this review

    1. Amelina EL, Krasovskii SA, Usacheva MV, Krylova NA. [Use of high‐frequency chest wall oscillation in an exacerbation of chronic pyo‐obstructive bronchitis in adult patients with cystic fibrosis]. [Russian]. Terapevticheskii Arkhiv 2014;86(12):33‐6. [CFGD Register: PE226b; CRS: 5500135000000122; PUBMED: 25804037] - PubMed
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    1. Borka P, Gyurkovits K, Bódis J. Comparative study of PEP mask and Flutter on expectoration in cystic fibrosis patients. Acta Physiologica Hungarica 2012;99(3):324‐331. - PubMed
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    1. Cegla UH, Retzow A. Physical therapy with VRP1 in chronic obstructive respiratory tract diseases‐‐results of a multicenter comparative study [Physiotherapie mit dem VRP1 bei chronisch obstruktiven Atemwegserkrankungen‐‐Ergebnisse einer multizentrischen Vergleichsstudie]. Pneumologie 1993;47(11):636‐9. - PubMed
    1. Dosman CF, Zuberbuhler PC, Tabak JI, Jones RL. Effects of positive end‐expiratory pressure on oscillated volume during high frequency chest compression in children with cystic fibrosis. Canadian Respiratory Journal 2003;10(2):94‐8. [CFGD Register: PE144; ] - PubMed

References to studies awaiting assessment

    1. Herrero Cortina B, San Miguel Pagola M, Cebria i Ranzo MA, Gomez Romero M, Diaz Gutierrez F, Reychler G. Short‐term effects of hypertonic saline nebulization combined with oscillatory positive expiratory pressure in cystic fibrosis: randomised crossover trial. Journal of Cystic Fibrosis 2016;15 Suppl 1:S33. [Abstract no: WS21.3; CENTRAL: 1155402; CFGD Register: BD229a; CRS: 5500135000001528]
    2. San Miguel Pagola M, Herrero Cortina B, Cebria i Iranzo MA, Gomez Romero M, Diaz Gutierrez F, Reychler G. Hypertonic saline nebulization combined with oscillatory positive expiratory pressure accelerate sputum clearance in cystic fibrosis: A randomised crossover trial. European Respiratory Journal 2016;48(Suppl 60):PA1369. [CENTRAL: 1343707; CFGD Register: BD229b; CRS: 5500135000001897]
    1. Patel P, Fukushima L, Balekian A, Chou W, Lu A, Gali V, et al. Is Metaneb comparable to high frequency chest compression in the setting of a severe pulmonary exacerbation in adults with cystic fibrosis. Pediatric Pulmonology 2013;48 Suppl 36:359. [Abstract no: 420; CFGD Register: PE209; ]
    1. Wheatley CM, Baker SE, Daines C, Phan H, Morgan WJ, Snyder EM. Influence of the vibralung device on pulmonary function and sputum expectoration in patients with cystic fibrosis. Pediatric Pulmonology 2013;48 Suppl 36:357. [Abstract no: 416; CFGD Register: PE208; ]

Additional references

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    1. Chevaillier J. Autogenic drainage. In: Lawson D editor(s). Cystic Fibrosis: Horizons. London: Churchill Livingstone, 1984:65‐78.
    1. Curtin F, Altman DG, Elbourne E. Meta‐analysis combining parallel and cross‐over clinical trials. I: Continuous outcomes. Statistics in Medicine 2002;21:2131–44. - PubMed
    1. Curtin F, Altman DG, Elbourne E. Meta‐analysis combining parallel and cross‐over clinical trials. III: The issue of carryover. Statistics in Medicine 2002;21:2161‐73. - PubMed
    1. Elbourne DR, Altman DG, Higgins JPT, Curtin F, Worthington HV, Vail A. Meta‐analyses involving cross‐over trials: methodological issues. International Journal of Epidemiology 2002;31(1):140‐9. - PubMed

References to other published versions of this review

    1. Morrison L, Agnew J. Oscillating devices for airway clearance in people with cystic fibrosis. Cochrane Database of Systematic Reviews 2007, Issue 4. [DOI: 10.1002/14651858.CD006842] - DOI - PubMed
    1. Morrison L, Agnew J. Oscillating devices for airway clearance in people with cystic fibrosis. Cochrane Database of Systematic Reviews 2009, Issue 1. [DOI: 10.1002/14651858.CD006842.pub2] - DOI - PubMed
    1. Morrison L, Agnew J. Oscillating devices for airway clearance in people with cystic fibrosis. Cochrane Database of Systematic Reviews 2014, Issue 7. [DOI: 10.1002/14651858.CD006842.pub3] - DOI - PubMed

MeSH terms