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Meta-Analysis
. 2017 Sep 27;9(9):CD011699.
doi: 10.1002/14651858.CD011699.pub2.

Positive expiratory pressure therapy versus other airway clearance techniques for bronchiectasis

Annemarie L Lee  1 , Angela T Burge, Anne E Holland
Affiliations
Meta-Analysis

Positive expiratory pressure therapy versus other airway clearance techniques for bronchiectasis

Annemarie L Lee et al. Cochrane Database Syst Rev. .

Abstract

Background: People with bronchiectasis experience chronic cough and sputum production and require the prescription of airway clearance techniques (ACTs). A common type of ACT prescribed is positive expiratory pressure (PEP) therapy. A previous review has suggested that ACTs including PEP therapy are beneficial compared to no treatment in people with bronchiectasis. However, the efficacy of PEP therapy in a stable clinical state or during an acute exacerbation compared to other ACTs in bronchiectasis is unknown.

Objectives: The primary aim of this review was to determine the effects of PEP therapy compared with other ACTs on health-related quality of life (HRQOL), rate of acute exacerbations, and incidence of hospitalisation in individuals with stable or an acute exacerbation of bronchiectasis.Secondary aims included determining the effects of PEP therapy upon physiological outcomes and clinical signs and symptoms compared with other ACTs in individuals with stable or an acute exacerbation of bronchiectasis.

Search methods: We searched the Cochrane Airways Group Specialised Register of Trials, PEDro and clinical trials registries from inception to February 2017 and we handsearched relevant journals.

Selection criteria: Randomised controlled parallel and cross-over trials that compared PEP therapy versus other ACTs in participants with bronchiectasis.

Data collection and analysis: We used standard methodological procedures as outlined by Cochrane.

Main results: Nine studies involving 213 participants met the inclusion criteria, of which seven were cross-over in design. All studies included adults with bronchiectasis, with eight including participants in a stable clinical state and one including participants experiencing an acute exacerbation. Eight studies used oscillatory PEP therapy, using either a Flutter or Acapella device and one study used Minimal PEP therapy. The comparison intervention differed between studies. The methodological quality of studies was poor, with cross-over studies including suboptimal or no washout period, and a lack of blinding of participants, therapists or personnel for outcome measure assessment in most studies. Clinical heterogeneity between studies limited meta-analysis.Daily use of oscillatory PEP therapy for four weeks was associated with improved general health according to the Short-Form 36 questionnaire compared to the active cycle of breathing technique (ACBT). When applied for three sessions over one week, minimal PEP therapy resulted in similar improvement in cough-related quality of life as autogenic drainage (AD) and L'expiration Lente Totale Glotte Ouverte en Decubitus Lateral (ELTGOL). Oscillatory PEP therapy twice daily for four weeks had similar effects on disease-specific HRQOL (MD -0.09, 95% CI -0.37 to 0.19; low-quality evidence). Data were not available to determine the incidence of hospitalisation or rate of exacerbation in clinically stable participants.Two studies of a single session comparison of oscillatory PEP therapy and gravity-assisted drainage (GAD) with ACBT had contrasting findings. One study found a similar sputum weight produced with both techniques (SMD 0.54g (-0.38 to 1.46; 20 participants); the other found greater sputum expectoration with GAD and ACBT (SMD 5.6 g (95% CI 2.91 to 8.29: 36 participants). There was no difference in sputum weight yielded between oscillatory PEP therapy and ACBT with GAD when applied daily for four weeks or during an acute exacerbation. Although a single session of oscillatory PEP therapy was associated with less sputum compared to AD (median difference 3.1 g (95% CI 1.5 to 4.8 g; one study, 31 participants), no difference between oscillatory PEP therapy and seated ACBT was evident. PEP therapy had a similar effect on dynamic and static measures of lung volumes and gas exchange as all other ACTs. A single session of oscillatory PEP therapy (Flutter) generated a similar level of fatigue as ACBT with GAD, but greater fatigue was noted with oscillatory PEP therapy compared to ACBT alone. The degree of breathlessness experienced with PEP therapy did not differ from other techniques. Among studies exploring adverse events, only one study reported nausea with use of oscillatory PEP therapy.

Authors' conclusions: PEP therapy appears to have similar effects on HRQOL, symptoms of breathlessness, sputum expectoration, and lung volumes compared to other ACTs when prescribed within a stable clinical state or during an acute exacerbation. The number of studies and the overall quality of the evidence were both low. In view of the chronic nature of bronchiectasis, additional information is needed to establish the long-term clinical effects of PEP therapy over other ACTs for outcomes that are important to people with bronchiectasis and on clinical parameters which impact on disease progression and patient morbidity in individuals with stable bronchiectasis. In addition, the role of PEP therapy during an acute exacerbation requires further exploration. This information is necessary to provide further guidance for prescription of PEP therapy for people with bronchiectasis.

PubMed Disclaimer

Conflict of interest statement

AL: none known.

AB: none known.

AH: none known.

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
Forest plot of comparison: Oscillatory PEP therapy vs ACBT with GAD (single session), Sputum weight (g)
See this image and copyright information in PMC

Update of

References

References to studies included in this review

Altiay 2012 {published data only}
    1. Altiay G, Uzmezoglu B, Sut N, Tuna H, Nuri O. Evaluating flutter device and the active cycle of breathing technique in non‐cystic bronchiectasis. The prospective randomised study. European Respiratory Journal 2012;40(Suppl 56):P2460.
Antunes 2001 {published data only}
    1. Oliveira Antunes LC, Crvalho SM, Borges FD, Assis VL, Godoy I. A study of the conventional chest physiotherapy versus Flutter VRP1 in the treatment of patients carrying bronchiectasis. Salusvita 2001;20(1):23‐33.
Eaton 2007 {published data only}
    1. Eaton T, Young P, Zeng I, Kolbe J. A randomised evaluation of the acute efficacy, acceptability and tolerability of Flutter and active cycle of breathing with and without postural drainage in non‐cystic fibrosis bronchiectasis. Chronic Respiratory Disease 2007;4:23‐30. - PubMed
Guimaraes 2012 {published data only}
    1. Guimaraes SF, Moco VJ, Menezes SL, Dias CM, Salles RE, Lopes AJ. Effects of ELTGOL and Flutter VRP1 on the dynamic and static pulmonary volumes and on the secretion clearance of patients with bronchiectasis. Revista Brasileira de Fisioterapia 2012;16(2):108‐13. - PubMed
    1. NCT01300403. Physiological effects of expiration with the glottis open in lateral posture (ELTGOL) and flutter valve in patients with bronchiectasis [Acute physiological effects of expiration with the glottis open in lateral posture (ELTGOL) and flutter valve in dynamic and static pulmonary volumes of patients with bronchiectasis]. clinicaltrials.gov/show/NCT01300403 (first received 18 February 2011).
Herrero‐Cortina 2015 {published data only}
    1. Herrero B, Polverino E, SanMiguel M, Alcaraz V, Marti D, Vilaro J, et al. Wet sputum as an objective outcome in a randomised crossover trial in NCF‐BE: reliability and responsiveness. European Respiratory Journal 2014;44(Suppl 58):P4274.
    1. Herrero‐Cortina B, Vilaro J, Marti D, Torres A, San Miguel‐Pagola M, Alcaraz V, et al. Short‐term effects of three slow expiratory airway clearance techniques in patients with bronchiectasis: a randomised crossover trial. Physiotherapy 2016;102(4):357‐64. [DOI: ] - PubMed
    1. NCT01854788. Three airway clearance techniques in non cystic fibrosis bronchiectasis [A comparative study of three airway clearance techniques with different autonomy degrees in non cystic fibrosis bronchiectasis: randomized cross‐over trial]. clinicaltrials.gov/show/NCT01854788 (first received 8 August 2012).
    1. Polverino E, Herrero B, Vilaro J, Marti D. Efficacy of airway clearance therapy with different autonomy degrees in nonCF BE: a randomised crossover trial. American Journal of Respiratory and Critical Care Medicine 2012;185:A4876.
Patterson 2005 {published data only}
    1. Patterson JE, Bradley JM, Hewitt O, Bradbury I, Elborn JS. Airway clearance in bronchiectasis: a randomised crossover trial of active cycle of breathing techniques vs Acapella. Respiration 2005;72:239‐42. - PubMed
Semwal 2015 {published data only}
    1. Semwal S, Mitra S, Singh SB. Autogenic drainage versus acapella for airway clearance in patients with bronchiectasis: randomised crossover trial. International Journal of Health Sciences and Research 2015;5(9):323‐7.
Thompson 2002 {published data only}
    1. Thompson CS, Harrison S, Ashley J, Day K, Smith DL. Flutter valve or conventional physiotherapy in productive non‐cystic bronchiectasis? A randomised crossover study. Thorax 2000;55:A71. - PMC - PubMed
    1. Thompson CS, Harrison S, Ashley J, Day K, Smith DL. Randomised crossover study of the flutter device and the active cycle of breathing technique in non‐cystic fibrosis bronchiectasis. Thorax 2002;57:446‐8. - PMC - PubMed
Tsang 2003 {published data only}
    1. Tsang SM, Jones AY. Postural drainage or flutter device in conjunction with breathing and coughing compared to breathing and coughing alone in improving secretion removal and lung function in patients with acute exacerbation of bronchiectasis: a pilot study. Hong Kong Physiotherapy Journal 2003;21:29‐36.

References to studies excluded from this review

Ambrosino 1995 {published data only}
    1. Ambrosino N, Callegari G, Galloni C, Brega S, Pinna G. Clinical evaluation of oscillating positive expiratory pressure for enhancing expectoration in diseases other than cystic fibrosis. Monaldi Archives of Chest Disease 1995;50:269‐75. - PubMed
Amit 2012 {published data only}
    1. Amit VA, Vaishali K, Gopal KA, Shyam K, Zulfeequer, Vishak A. Comparison of quake and RC‐Cornet for airway clearance in bronchiectasis: a randomised crossover trial. International Journal of Health Sciences and Research 2012;2(6):20‐7.
Andrejak 2013 {published data only}
    1. Andrejak C, Monconduit J, Rose D, Toublanc B, Mayeaux I, Rodenstein D, et al. Does using pressure‐controlled ventilation to rest respiratory muscles improve sleep in ICU patients?. Respiratory Medicine 2013;107:534‐41. - PubMed
Barbagallo 2012 {published data only}
    1. Barbagallo M, Ortu A, Spadini E, Salvadori A, Ampollini L, Intermullo E, et al. Prophylactic use of helmet CPAP after pulmonary lobectomy: a prospective randomized controlled study. Respiratory Care 2012;57:1418‐24. - PubMed
Cecins 1999 {published data only}
    1. Cecins N, Jenkins SC, Pengelley J, Ryan G. The active cycle of breathing techniques ‐ to tip of not to tip?. Respiratory Medicine 1999;93:660‐5. - PubMed
Cegla 1993 {published data only}
    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;47:636‐9. - PubMed
Chakrovorty 2011 {published data only}
    1. Chakravorty I, Chahal K, Austin G. A pilot study of the impact of high‐frequency chest wall oscillation in chronic obstructive pulmonary disease patients with mucus hypersecretion. International Journal of Chronic Obstructive Pulmonary Disease 2011;6:693‐9. - PMC - PubMed
Conway 1992 {published data only}
    1. Conway JH, Fleming JS, Perring S, Holgate ST. Humidification as an adjunct to chest physiotherapy in aiding tracheo‐bronchial clearance in patients with bronchiectasis. Respiratory Medicine 1992;86:109‐14. - PubMed
Feng 1998 {published data only}
    1. Feng W, Deng WW, Huang SG, Cheng QJ, Cegla UG, King M. Short‐term efficacy of RC‐Cornet in improving pulmonary function and decreasing cohesiveness of sputum in bronchiectasis patients. Chest 1998;114(Suppl 4):320S.
Figueiredo 2012 {published data only}
    1. Figueiredo PHS, Zin WA, Guimaraes FS. Flutter valve improves respiratory mechanics and sputum production in patients with bronchiectasis. Physiotherapy Research International 2012;17:12‐20. - PubMed
Furumoto 2008 {published data only}
    1. Furumoto A, Ohkusa Y, Chen M, Kawakami K, Masaki H, Sueyasu Y. Additive effect of pneumococcal vaccine and influenza vaccine on acute exacerbation in patients with chronic lung disease. Vaccine 2008;26(33):4284‐9. - PubMed
Gastaldi 2011 {published data only}
    1. Gastaldi A, Tambascio J, Lisboa R. Passarelli R, Tatiana L. Effect of the components of flutter VRP 1 on the transport of respiratory secretions in patients with bronchiectasis. World Physical Therapy; 2011 June 20‐23; Amsterdam. www.abstractstosubmit.com/wpt2011/abstracts/, 2011; Vol. 97:eS395‐6.
    1. NCT01209546. Study of the effect of flutter VRP1 (Pep and Oscillating high frequency) [Study of the effect of flutter VRP1 in patients with bronchiectasis]. clinicaltrials.gov/show/NCT01209546 (first received 12 July 2010).
Gokdemir 2013 {published data only}
    1. Gokdemir Y, Ersu R, Karadag B, Karakoc F. Comparison of conventional chest physiotherapy and high‐frequency chest wall oscillation in primary ciliary dyskinesia. European Respiratory Society Annual Congress 2011;38(55):836s (P4575).
    1. Gokdemir Y, Karadag‐Saygi E, Erdem E, Bayindir O, Ersu R, Karadaq B, et al. Comparison of conventional pulmonary rehabilitation and high‐frequency chest wall oscillation in primary ciliary dyskinesia. Pediatric Pulmonology 2014;49(6):611‐6. - PubMed
    1. Gokdemir Y, Saygi EK, Ersu R, et al. Effectiveness of high frequency chest wall oscillation in primary ciliary dyskinesia cases: is it an alternative therapy? [Primer siilier diskinezili hastalarda yuksek frekansli gotus duvari ossilasyonun etkinlitinin arastirilmasi: bir alternatif tedavi olabilir mi?]. Turkish Society of Physical Medicine and Rehabilitation 2013;59:244.
Goldman 2004 {published data only}
    1. Goldman MD, Daviskas E, Turton JA, Anderson SD. Inhaled mannitol improves lung function assessed by forced oscillation in a placebo controlled trial in patients with bronchiectasis. European Respiratory Journal 2004;24(Suppl 48):470s.
Jao 2010 {published data only}
    1. Jao W‐C, Ho S‐C, Sheng T‐F, Chen L‐F, Lin H‐C, Kuo H‐P. Additive effect of high‐frequency chest wall oscillation (HFCWO) and conventional airway clearance program on the treatment of patients with bronchiectasis. American Journal of Respiratory and Critical Care Medicine 2010;181:A3461.
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;74(5):251‐4.
Kubal 2013 {published data only}
    1. Kubal M, Mody K. Mucus clearance devices in bronchiectasis: Indian experience. European Respiratory Journal 2013;42.
Kurz 1997 {published data only}
    1. Kurz M, Ahrens P, Zielan S, Hofmann D. Physiotherapy in chronic lung disease using the VRP‐1: lung function and clinical data. Pravention und Rehabilitation 1997;9:105‐9.
Landau 1973 {published data only}
    1. Landau LI, Phelan PD. Evaluation of two techniques for measurement of respiratory resistance by forced oscillation. A study in young subjects with obstructive lung disease. Thorax 1973;28:136‐41. - PMC - PubMed
Lavery 2011 {published data only}
    1. Lavery KA, O'Neill B, Parker M, Elborn JS, Bradley JM. Expert patient self‐management program versus usual care in bronchiectasis: a randomized controlled trial. Archives of Physical Medicine and Rehabilitation 2011;92:1194‐1201. - PubMed
Maa 2007 {published data only}
    1. Maa SH, Tsou TS, Wang KY, Wang CH, Lin HC, Huang YH. Self‐administered acupressure reduces the symptoms that limit daily activities in bronchiectasis patients: pilot study findings. Journal of Clinical Nursing 2007;16:794‐804. - PubMed
Mandal 2012 {published data only}
    1. Mandal P, Sighu MK, Kope K, Pollock W, Stevenson LM, Pentland JL, et al. A pilot study of pulmonary rehabilitation and chest physiotherapy versus chest physiotherapy alone in bronchiectasis. Respiratory Medicine 2012;106(12):1647‐54. - PubMed
Marques 2012 {published data only}
    1. Marques A, Bruton A, Barney A, Hall A. Are crackles an appropriate outcome measure for airway clearance therapy?. Respiratory Care 2012;58:1669‐78. - PubMed
Messens 1973 {published data only}
    1. Messen Y, Oger A, Cornette M, Calay G. Double‐blind study of the sulfamethoxazole‐trimethoprim association in the treatment of pulmonary infections. Acta Clinica Belgica 1973;28:92‐9. - PubMed
Morgan 1999 {published data only}
    1. Morgan LC, Maxwell L, Longhi R, Peters MJ, Rutland J. Comparison of Flutter® Device (FD) with postural drainage (PD) in adult patients with non‐CF bronchiectasis. Thoracic Society of Australia & New Zealand, Annual Scientific Meeting, 1999 26 Feb ‐ 3 March, Canberra, Australia. 1999; Vol. 52:P93.
    1. Peters MJ, Morgan LC, Maxwell L, Rutland J. Comparison of flutter device (FD) with postural drainage (PD) in adult patients with bronchiectasis. European Respiratory Society 1999:p3193.
Murray 2009 {published data only}
    1. Murray MP, Pentland JL, Hill AT. A randomised crossover trial of chest physiotherapy in non‐cystic fibrosis bronchiectasis. European Respiratory Journal 2009;34:1086‐92. - PubMed
Naraparaju 2010 {published data only}
    1. Naraparaju S, Vaishali K, Venkatesan P, Acharya V. A comparison of the Acapella and a threshold inspiratory muscle trainer for sputum clearance in bronchiectasis ‐ a pilot study. Physiotherapy Theory and Practice 2014;26:353‐7. - PubMed
NCT00452114 {published data only}
    1. NCT00452114. In‐exsufflator cough assist device in patients with symptomatic bronchiectasis [A randomized, controlled study evaluating the effectiveness of the inexsufflator cough assist device in patients with symptomatic bronchiectasis]. clinicaltrials.gov/ct2/show/NCT00452114 (first received 22 March 2007).
Newall 2005 {published data only}
    1. Newall C, Stockley RA, Hill SL. Exercise training and inspiratory muscle training in patients with bronchiectasis. Thorax 2005;60:943‐8. - PMC - PubMed
Nicolini 2013 {published data only}
    1. Nicolini A, Cardini F, Landucci N, Lanata S, Ferrari‐Bravo M, Barlascini C. Effectiveness of treatment with high‐frequency chest wall oscillation in patients with bronchiectasis. BMC Pulmonary Medicine 2013;13:21. - PMC - PubMed
Osadnik 2014 {published data only}
    1. Osadnik C, Stuart‐Andrew C, Ellis S, Thompson B, McDonald CF, Holland AE. Positive expiratory pressure via mask does not improve ventilation inhomogeneity more than huffing or coughing in individuals with stable chronic obstructive pulmonary disease and chronic sputum expectoration. Respiration 2014;87:38‐44. - PubMed
Patterson 2004 {published data only}
    1. Patterson JE, Bradley JM, Elborn JS. Airway clearance in bronchiectasis: a randomised crossover trial of active cycle of breathing techniques (incorporating postural drainage and vibration) versus test of incremental respiratory endurance. Chronic Respiratory Disease 2004;1(3):127‐130. - PubMed
Patterson 2007 {published data only}
    1. Patterson JE, Bradley JM, Hewitt O, Bradbury I, Elborn JS. Airway clearance during oral antibiotic therapy in bronchiectasis, a randomized trial of acapella versus usual airway clearance. American Thoracic Society International Conference, 2005 May 20‐25, San Diego, California 2005;B25:P917.
    1. Patterson JE, Hewitt O, Kent L, Bradbury I, Elborn JS, Bradley JM. Acapella versus 'usual airway clearance' during acute exacerbation in bronchiectasis: a randomised crossover trial. Chronic Respiratory Disease 2007;4:67‐74. - PubMed
Pryor 1979 {published data only}
    1. Pryor J, Webber B, Hodson M, Batten J. Evaluation of the forced expiration technique as an adjunct to postural drainage. British Medical Journal 1979;18:417‐8. - PMC - PubMed
Punithavathi 2014 {published data only}
    1. Punithavathi N, Ong LM, Irfhan Ali HA, Mohd Izmi A, Dharminy T, Ang AH, et al. A pilot randomised control cross over study evaluating the effectiveness and safety of mechanical percussor compared to conventional chest physiotherapy in adults with productive cough. Medical Journal of Malaysia 2014;69(1):16‐20. - PubMed
Richmond 2016 {published data only}
    1. Richmond M, Lee Son N, Chilvers M, McIlwaine M. Use of technology to measure adherence to and quality of airway clearance techniques. Pediatric Pulmonology 2016;51:371.
Santamaria 1998 {published data only}
    1. Santamaria F, Celentano L, Buonpensiero P, Sarnelli P, Caterino M, Raia V. Positive expiratory pressure treatment. Efficacy in pulmonary disease. Journal of Pediatrics 1998;133:717‐8. - PubMed
Senthill 2015 {published data only}
    1. Senthil P, Suchithra E, Koushik Kumar N. Effectiveness of active cycle of breathing techniques (ACBT) versus ACBT with Acapella on airway clearance in bronchiectasis. International Journal of Physical Education, Sports and Health 2015;1(4):10‐3.
Shabari 2011 {published data only}
    1. Shabari, PV, Alaparthi GK, Vaishali, V. Comparions of Acapella and RC‐Cornet for airway clearance in bronchiectasis ‐ a pilot study. International Journal of Current Research and Review 2011;3(11):138‐48.
Silva 2015 {published data only}
    1. ACTRN12614001072606. Evaluating the ease of secretion clearance with flutter device compared to lung flute in patients with bronchiectasis [Evaluating sputum clearance in bronchiectasis patients using flutter device or lung flute]. www.anzctr.org.au 2013; ACTRN12614001072606. (first received 25 September 2014).
    1. Silva Y, Greer T, Farah C, Li F, Morgan L. Lung flute is comparable to flutter device for sputum clearance in adults with non‐cystic fibrosis bronchiectasis. Respirology 2015;20:114 [TP 143].
Su 2012 {published data only}
    1. Su C‐L, Chang C‐C, Lin Y‐K, Lee K‐T, Lee C‐N, Chiang L‐L. Randomised crossover study of lung expansion therapy using negative pressure and positive pressure in bronchiectasis. Journal of Experimental and Clinical Medicine 2012;4:149‐53.
Sunderram 2000 {published data only}
    1. Sunderram J, Parisi RA, Strobel RJ. Serotonergic stimulation of the genioglossus and the response to nasal continuous positive airway pressure. American Journal of Respiratory and Critical Care Medicine 2000;162:925‐9. - PubMed
Svenningsen 2014 {published data only}
    1. NCT02282202. Evaluation of oscillatory positive expiratory pressure (oPEP) in bronchiectasis and COPD. clinicaltrials.gov/show/NCT02282202 (first received 24 October 2014).
    1. Svenningsen S, Paulin G, Wheatley A, Pike D, Suggett J, McCormack D, et al. Oscillating positive expiratory pressure (oPEP) therapy in chronic obstructive pulmonary disease and bronchiectasis. European Respiratory Journal 2014;44(Suppl 58):P3679.
Syed 2009 {published data only}
    1. Syed N, Maiya AG, Kumar ST. Active cycles of breathing technique (ACBT) versus conventional chest physical therapy on airway clearance in bronchiectasis ‐ a crossover trial. Advances in Physiotherapy 2009;11:193‐8.
Tambascio 2011 {published data only}
    1. Tambascio J, Souza LT, Lisboa RM, Passarelli RDCV, Souza HCDD, Gastaldi AC. The influence of flutter®VRP1 components on respiratory secretion transport of patients with bronchiectasis. American Journal of Respiratory and Critical Care Medicine 2011;183:A6410.
    1. Tambascio J, Souza LT, Lisboa RMh, Passarelli RDCV, Souza HCD, Gastaldi AC. The influence of Flutter VRP1 components of mucus transport of patients with bronchiectasis. Respiratory Medicine 2011;105:1316‐21. - PubMed
Tambascio 2014 {published data only}
    1. NCT01209546. Study of the effect of flutter VRP1 (PEP and oscillating high frequency) [Study of the effect of flutter VRP1 in patients with bronchiectasis]. clinicaltrials.gov/show/NCT01209546 (first received 12 June 2010).
    1. Tambascio J, Baddini‐Martinez JA, Passarelli CV, Goncalves E, Miranda APB, Martinez R, et al. Effects of Flutter ® VRP1 on inflammatory profile, microbiology and transport indexes of respiratory secretions of patients with bronchiectasis. American Journal of Respiratory and Critical Care Medicine 2014;189:A6260.
Valente 2004 {published data only}
    1. Valente AM, Gastaldi AC, Cravo SL, Afonso JL, Sologuren MJ, Guimaraes RC. The effects of two techniques on the characteristics and transport of sputum in patients with bronchiectasis. A pilot study. Physiotherapy 2004;90:158‐64.
Venturelli 2012 {published data only}
    1. NCT00700388. Efficacy of temporary positive expiratory pressure (TPEP) in chronic hypersecretion (UNIKO) [Multicentre controlled trial on efficacy of TPEP device in adult patients with chronic hypersecretion]. clinicaltrials.gov/show/NCT00700388 (first received 17 June 2008).
    1. Venturelli E, Crisafulli E, DeBiase A, Righi A, Berighi D, Cavicchioli PP, et al. Efficacy of temporary positive expiratory pressure (TPEP) in patients with chronic lung diseases and chronic mucus hypersecretion. The UNIKO project: a multicentre randomised controlled trial. Clinical Rehabilitation 2012;27(4):336‐46. - PubMed
Vishteh 2011 {published data only}
    1. Vishteh HRK, Ghorbani F, Masoudnia M, Mahmoudian S, Shafaghi S, Najafizadeh K. Comparison of two physiotherapic methods in bronchiectasis: active cycle of breathing technique (ACBT) and oscillating physiotherapy device. European Respiratory Journal 2011;38(Suppl 55):2982.

References to studies awaiting assessment

Fazzi 2010 {published data only}
    1. Fazzi P, D'Abrosca A, Cristofani R. The effects of T‐PEP on ventilation lung scan in patients with bronchiectasis: protocol for a randomized controlled trial. European Respiratory Journal 2010:p639.
NCT03013452 {published data only}
    1. NCT03013452. Oscillating PEP vs autogenic drainage in people with bronchiectasis (oPEP vs AD) [A randomised controlled trial of long term airway clearance with oscillating positive end expiratory pressure device versus autogenic drainage in people with bronchiectasis]. clinicaltrials.gov/show/NCT03013452 (first received 1 January 2017).

References to ongoing studies

ACTRN12614001233617 {published data only}
    1. ACTRN12614001233617. Does the bubble­positive expiratory pressure (PEP) device improve secretion clearance compared to the active cycle of breathing technique (ACBT) or no intervention (control) in people with non­cystic fibrosis bronchiectasis?. www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=367418&isRe... (first received 12 November 2014).
NCT01929356 {published data only}
    1. NCT01929356. Chest physiotherapy on lung function parameters in primary ciliary dyskinesia [The influence of chest physiotherapy on lung function parameters in primary ciliary dyskinesia]. clinicaltrials.gov/ct2/show/NCT01929356 (first received 22 August 2013).
NCT02324855 {published data only}
    1. NCT02324855. Long term airway clearance therapy in non cystic fibrosis bronchiectasis: a randomized controlled trial. clinicaltrials.gov/ct2/show/NCT02324855 (first received 1 December 2014).
NCT02411981 {published data only}
    1. NCT02411981. Effect of chest physiotherapy (CPT) on lung clearance index (LCI) in non cystic fibrosis (CF) bronchiectasis [Short term effects of chest physiotherapy on ventilation inhomogeneity in non‐CF bronchiectasis]. clinicaltrials.gov/ct2/show/NCT02411981 (first received 3 April 2015).
NCT02509637 {published data only}
    1. NCT02509637. Acute effects of a flutter device and chest wall compression on respiratory system impedance in bronchiectasis patients. clinicaltrials.gov/NCT02509637 (first received 3 July 2015).
NCT02906826 {published data only}
    1. NCT02906826. Adherence to airway clearance. Novel approaches to improving adherence. clinicaltrials.gov/show/NCT02906826 (first received 26 August 2016).

Additional references

Aliberti 2016
    1. Aliberti S, Masefield S, Polverino E, Soyza A, Loebinger MR, Menendez R, et al. Research priorities in bronchiectasis: a consensus statement from the EMBARC Clinical Research Collaboration. European Respiratory Journal 2016;48:632‐47. - PubMed
Altaus 2009
    1. Altaus P. Oscillating PEP. In: International Physiotherapy Group for Cystic Fibrosis, editor(s). Physiotherapy for people with cystic fibrosis: from infant to adults. 4th Edition. Karup: European Cystic Fibrosis Society, 2009:18‐22.
App 1998
    1. App E, Kieselmann R, Reinhardt D, Lindemann H, Dasgupta B, King M, et al. Sputum rheology changes in cystic fibrosis lung disease following two different types of physiotherapy. Flutter vs autogenic drainage. Chest 1998;114:171‐7. - PubMed
Barker 2002
    1. Barker AF. Bronchiectasis. New England Journal of Medicine 2002;346:1383‐93. - PubMed
Bhalla 1991
    1. Bhalla M, Turcios N, Aponte V, Jenkins M, Leitman B, McCauley D, et al. Cystic fibrosis: scoring system with thin‐section CT. Radiology 1991;179:783‐8. - PubMed
Boucher 2010
    1. Boucher RC. Bronchiectasis: a continuum of ion transport dysfunction or multiple hits?. American Journal of Respiratory and Critical Care Medicine 2010;181:1017‐9. - PubMed
Butler 2008
    1. Butler S, Hill LJ, Harrison J, Reed P, Nikora G, Takai G, et al. Is there a difference in airway clearance practices between children with non cystic fibrosis bronchiectasis and cystic fibrosis?. New Zealand Journal of Physiotherapy 2008;36:112‐7.
Calverley 2005
    1. Calverley P, Koulouris N. Flow limitation and dynamic hyperinflation: key concepts in modern respiratory physiology. European Respiratory Journal 2005;25(1):186‐99. - PubMed
Campbell 1986
    1. Campbell T, Ferguson N, McKinlay R. The use of a simple self‐administered method of positive expiratory pressure (PEP) in chest physiotherapy after abdominal surgery. Physiotherapy 1986;72:498‐500.
Chalmers 2014
    1. Chalmers J, Goeminne P, Aliberti S, McDonnell MJ, Lonni S, Davidson J, et al. The bronchiectasis severity index. An international derivation and validation study. American Journal of Respiratory and Critical Care Medicine 2014;189(5):576–85. - PMC - PubMed
Chang 2002
    1. Chang AB, Grimwood K, Mulholland EK, Torzillo PJ. Bronchiectasis in Indigenous children in remote Australian communities. Medical Journal of Australia 2002;177:200‐4. - PubMed
Chang 2008
    1. Chang AB, Grimwood K, Maguire G, King PT, Morris PS, Torzillo PJ. Management of bronchiectasis and chronic suppurative lung disease in Indigenous children and adults from rural and remote Australian communities. Medical Journal of Australia 2008;189(7):386‐93. - PubMed
Chang 2010
    1. Chang AB, Bell SC, Byrnes CA, Grimwood K, Holmes PW, King PT, et al. Chronic suppurative lung disease and bronchiectasis in children and adults in Australia and New Zealand. A position statement from the Thoracic Society of Australia and New Zealand and the Australian Lung Foundation. Medical Journal of Australia 2010;193(6):356‐65. - PubMed
Chang 2015
    1. Chang AB, Bell SC, Torzillo PJ, King PT, Maguire GP, Byrnes CA, et al. Chronic suppurative lung disease and bronchiectasis in children and adults in Australia and New Zealand Thoracic Society of Australia and New Zealand guidelines. Medical Journal of Australia 2015;202(1):21‐3. - PubMed
Cole 1986
    1. Cole J. Inflammation: a two‐edged sword ‐ the model of bronchiectasis. European Review of Respiratory Disease 1986;147:6‐15. - PubMed
Cortese 2016
    1. Cortese R, Mennitti MC, Mariani F, PIloni D, Aliberti S, Otlaviani S, et al. Bronchiectasis in patients with alpha1‐antitrypsin deficiency: prevalence and characteristics. European Respiratory Journal 2016;48(Suppl 60):PA737.
Darbee 2004
    1. Darbee J, Ohtake P, Grant B, Cerny FJ. Physiological evidence for the efficacy of positive expiratory pressure as an airway clearance technique in patients with cystic fibrosis. Physical Therapy 2004;84:524‐37. - PubMed
Deeks 2008
    1. Deeks JJ, Higgins JPT, Altman DG, editor(s). Chapter 9: Analysing data and undertaking meta‐analyses. In: Higgins JP, Green S, editor(s). Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 (updated March 2011). The Cochrane Collaboration, 2011. Available from handbook.cochrane.org.
Dwyer 2011
    1. Dwyer TJ, Alison JA, McKeough ZJ, Daviskas E, Bye PT. Effects of exercise on respiratory flow and sputum properties in patients with cystic fibrosis. Chest 2011;139(4):870‐7. - PubMed
Egger 1997
    1. Egger M, Davey Smith G, Schneider M, Minder C. Bias in meta­analysis detected by a simple, graphical test. BMJ 1997;315:629‐34. - PMC - PubMed
Elkins 2006
    1. Elkins MR, Jones A, Schans C. Positive expiratory pressure physiotherapy for airway clearance in people with cystic fibrosis. Cochrane Database of Systematic Reviews 2006;Issue 2:CD003147. [DOI: 10.1002/14651858.CD003147.pub3] - DOI - PubMed
Falk 1984
    1. Falk M, Kelstrup M, Andersen J, Kinoshita T, Falk P, Støvring S, et al. Improving the ketchup bottle method with positive expiratory pressure, PEP, in cystic fibrosis. European Journal of Respiratory Disease 1984;65:423‐32. - PubMed
Gaga 1998
    1. Gaga M, Bentley AM, Humbert M, Barkans J, O'Brien F, Wathen CG, et al. Increases in CD4+ T lymphocytes, macrophages, neutrophils and interleukin 8 positive cells in the airways of patients with bronchiectasis. Thorax 1998;53:685‐91. - PMC - PubMed
Gallon 1992
    1. Gallon A. The use of percussion. Physiotherapy 1992;78:85‐9.
Goeminne 2012
    1. Goeminne PC, Scheers H, Decraene A, Seys S, Dupont LJ. Risk factors for morbidity and death in non‐cystic fibrosis bronchiectasis: a retrospective, cross‐sectional analysis of CT diagnosed bronchiectasis patients. Respiratory Research 2012;13:21. - PMC - PubMed
Goeminne 2014
    1. Goeminne PC, Nawrot TS, Ruttens D, Seys S, Dupont LJ. Mortality in non‐cystic fibrosis bronchiectasis: a prospective cohort analysis. Respiratory Medicine 2014;108(2):287‐96. - PubMed
Gonem 2014
    1. Gonem S, Scadding A, Soares M, Singpuri A, Gustafsson P, Ohri C, et al. Lung clearance index in adults with non‐cystic fibrosis bronchiectasis. Respiratory Research 2014;15:59. - PMC - PubMed
Groth 1985
    1. Groth S, Stafanger G, Dirksen H, Andersen JB, Falk M, Kelstrup M. Positive expiratory pressure (PEP‐mask) physiotherapy improves ventilation and reduces volume of trapped gas in cystic fibrosis. Bulletin European de Physiopathologie Respiratoire 1985;21(4):339‐43. - PubMed
Higgins 2011
    1. Higgins JP, Green S, editor(s). Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0. (updated March 2011). The Cochrane Collaboration, 2011. Available from handbook.cochrane.org.
Horsley 2009
    1. Horsley A. Lung clearance index in the assessment of airways disease. Respiratory Medicine 2009;103(6):793‐9. - PubMed
Johnstone 2013
    1. Johnstone CL, James R, Mackney JH. The current use of positive expiratory pressure (PEP) therapy by public hospital physiotherapists in New South Wales. New Zealand Journal of Physiotherapy 2013;41(3):88‐93.
Karadag 2005
    1. Karadag B, Karakoc F, Ersu R, Kut A, Bakac S, Dagli E. Non‐cystic fibrosis bronchiectasis in children: a persisting problem in developing countries. Respiration 2005;72(3):233‐8. - PubMed
King 2006
    1. King PT, Holdsworth SR, Freezer NJ, Villanueva E, Holmes PW. Characterisation of the onset and presenting clinical features of adult bronchiectasis. Respiratory Medicine 2006;100:2183‐9. - PubMed
Koulouris 2003
    1. Koulouris N, Retsou S, Kosmas E, Dimakou K, Malagari K, Mantzikopoulos G, et al. Tidal expiratory flow limitation, dyspnoea and exercise capacity in patients with bilateral bronchiectasis. European Respiratory Journal 2003;21(5):743‐8. - PubMed
Kwak 2010
    1. Kwak HJ, Moon JY, Choi YW, Kim TH, Sohn JW, Yoon HJ, et al. High prevalence of bronchiectasis in adults: analysis of CT findings in a health screening program. Tohoku Journal of Experimental Medicine 2010;222(4):237‐42. - PubMed
Lapin 2002
    1. Lapin C. Mixing and matching airway clearance techniques to patients. Pediatric Pulmonology 2000;Suppl 21:144‐6.
Lee 2008
    1. Lee AL, Button BM, Denehy L. Current physiotherapy practice in Australia and New Zealand for patients with chronic obstructive pulmonary disease and bronchiectasis. New Zealand Journal of Physiotherapy 2008;32:49‐58.
Lee 2013
    1. Lee AL, Burge AT, Holland AE. Airway clearance techniques for bronchiectasis. Cochrane Database of Systematic Reviews 2015, Issue 11. [DOI: 10.1002/14651858.CD008351.pub3] - DOI - PMC - PubMed
Lee 2015
    1. Lee AL, Williamson HC, Lorensini S, Spencer LM. The effects of oscillating positive expiratory pressure therapy in adults with stable non‐cystic fibrosis bronchiectasis: a systematic review. Chronic Respiratory Disease 2015;12(1):36‐46. - PubMed
Martinez‐Garcia 2005
    1. Martinez‐Garcia MA, Perpiñá‐Tordera M, Román‐Sánchez P, Soler‐Cataluña JJ. Quality‐of‐life determinants in patients with clinically stable bronchiectasis. Chest 2005;128(2):739‐45. - PubMed
Martinez‐Garcia 2007
    1. Martinez‐Garcia MA, Soler‐Cataluna J‐J, Perpina‐Tordera M, Roman‐Sanchez P, Soriano J. Factors associated with lung function decline in adult patients with stable non‐cystic fibrosis bronchiectasis. Chest 2007;32(5):1565‐72. - PubMed
Martins 2012
    1. Martins JA, Dornelas de Andrade A, Britto RR, Lara R, Parreira VF. Effect of slow expiration with glottis opened in lateral posture (ELTGOL) on mucus clearance in stable patients with chronic bronchitis. Respiratory Care 2012;57(3):420‐6. - PubMed
McCarren 2006
    1. McCarren B, Alison J. Physiological effects of vibration in subjects with cystic fibrosis. European Respiratory Journal 2006;27:1204‐9. - PubMed
McCullough 2014
    1. McCullough A, Tunney M, Quittner A, Elborn JS, Bradley J, Hughes C. Treatment adherence and health outcomes in patients with bronchiectasis. BMC Pulmonary Medicine 2014;14:107. - PMC - PubMed
McCullough 2014a
    1. McCulllough A, Tunney M, Elborn J, Bradley J, Hughes C. 'All illness is personal to that individual': a qualitative study of patients' perspectives on treatment adherence in bronchiectasis. Health Expectations 2015;18(6):2477‐88. - PMC - PubMed
McIlwaine 2001
    1. McIlwaine PM, Wong L, Peacock D, Davidson AGF. Long‐term comparative trial of positive expiratory pressure versus oscillating positive expiratory pressure (flutter) physiotherapy in the treatment of cystic fibrosis. Journal of Pediatrics 2001;138(6):845‐50. - PubMed
McIlwaine 2015
    1. McIlwaine M, Button BM, Dwan K. Positive expiratory pressure physiotherapy for airway clearance in people with cystic fibrosis. Cochrane Database of Systematic Reviews 2015, Issue 6. [DOI: 10.1002/14651858.CD003147.pub4] - DOI - PubMed
McShane 2013
    1. McShane P, Naureckas ET, Tino G, Strek ME. Non‐cystic fibrosis bronchiectasis. American Journal of Respiratory and Critical Care Medicine 2013;188(6):647‐56. - PubMed
Monteagudo 2016
    1. Monteagudo M, Rodriguez‐Blanco T, Barrecheguren M, Simonet P, Miravitlles M. Prevalence and incidence of bronchiectasis in Catalonia, Spain: a population‐based study. Respiratory Medicine 2016;121:26‐31. - PubMed
Mutalithas 2008
    1. Mutalithas K, Watkin G, Willig B, Wardlaw A, Pavord ID, Birring SS. Improvement in health status following bronchopulmonary hygiene physical therapy in patients with bronchiectasis. Respiratory Medicine 2008;102(8):1140‐4. - PubMed
Newbold 2008
    1. Newbold M, Tullis E, Corey M, Ross B, Brooks D. The flutter device versus the PEP mask in the treatment of adults with cystic fibrosis. Physiotherapy Canada 2008;57(3):199‐207.
O'Neill 2002
    1. O'Neill B, Bradley JM, McArdle N, MacMahon J. The current physiotherapy management of patients with bronchiectasis: a UK survey. International Journal of Clinical Practice 2002;56(1):34‐5. - PubMed
Oberwaldner 1986
    1. Oberwaldner B, Evans J, Zach M. Forced expirations against a variable resistance: a new chest physiotherapy method in cystic fibrosis. Pediatric Pulmonology 1986;2:358‐67. - PubMed
Oberwaldner 1991
    1. Oberwaldner B, Theissl B, Rucker A, Zach MS. Chest physiotherapy in hospitalised patients with cystic fibrosis: a study of lung function effects and sputum production. European Respiratory Journal 1991;4:152‐8. - PubMed
Olsen 2015
    1. Olsen MF, Lannefors L, Westerdahl E. Positive expiratory pressure: common clinical applications and physiological effects. Respiratory Medicine 2015;109(3):297‐307. - PubMed
Pasteur 2000
    1. Pasteur MC, Helliwell SM, Houghton SJ, Webb SC, Foweraker JE, Caulden RA, et al. An investigation into causative factors in patients with bronchiectasis. American Journal of Respiratory and Critical Care Medicine 2000;162:1277‐84. - PubMed
Pasteur 2010
    1. Pasteur MC, Bilton D, Hill AT, on behalf of the British Thoracic Society Bronchiectasis (non‐CF) Guideline Group, a sub‐group of the British Thoracic Society Standards of Care Committee. British Thoracic Society guideline for non‐CF bronchiectasis. Thorax 2010;65(Suppl 1):1‐64.
Prasad 1993
    1. Prasad SA. Current concepts in physiotherapy. Journal of the Royal Society of Medicine 1993;86(Suppl 20):23‐9. - PMC - PubMed
Quint 2016
    1. Quint JK, Millett ER, Joshi M, Navaratnam V, Thomas SL, Hurst JR, et al. Changes in the incidence, prevalence and mortality of bronchiectasis in the UK from 2004 to 2013: a population‐based cohort study. European Respiratory Journal 2016;47(1):186‐93. - PMC - PubMed
Quittner 2015
    1. Quittner AL, O'Donnell A, Salathe M, Lewis S, Montgomery A, O'Riordan T, et al. Quality of life questionnaire‐Bronchiectasis: final psychometric analyses and determination of minimal important difference scores. Thorax 2015;70(1):12‐20. - PubMed
Review Manager (RevMan) [Computer program]
    1. Nordic Cochrane Centre, The Cochrane Collaboration. Review Manager 5 (RevMan 5). Version 5.3. Copenhagen: Nordic Cochrane Centre, The Cochrane Collaboration, 2014.
Ringshausen 2013
    1. Ringshausen FC, Roux A, Pletz MW, Hamalainen N, Welte T, Rademacher J. Bronchiectasis‐associated hospitalisations in Germany, 2005‐2011: a population‐based study of disease burden and trends. PLOS One 2013;8(8):E71109. - PMC - PubMed
Roberts 2010
    1. Roberts JH, Hubbard R. Trends in bronchiectasis in England and Wales. Respiratory Medicine 2010;104(7):981‐5. - PubMed
Schoni 1989
    1. Schoni M. Autogenic drainage: a modern approach to physiotherapy in cystic fibrosis. Journal of the Royal Society of Medicine 1989;82:32‐7. - PMC - PubMed
Seitz 2010
    1. Seitz A, Olivier KN, Steiner CA, Montes de Oca R, Holland SM, Prevots DR. Trends and burden of bronchiectasis‐associated hospitalisations in the United States 1993 ‐ 2006. Chest 2010;138(4):944‐9. - PMC - PubMed
Seitz 2012
    1. Seitz AE, Olivier KN, Adjemian J, Holland SM, Prevots R. Trends in bronchiectasis amongst Medicare beneficiaries in the United States, 2000 to 2007. Chest 2012;142(2):432‐9. - PMC - PubMed
Säynäjäkangas 1997
    1. Säynäjäkangas O, Keistinen T, Tuuponen T, Kivelä SL. Bronchiectasis in Finland: trends in hospital treatment. Respiratory Medicine 1997;91(7):395‐8. - PubMed
Twiss 2005
    1. Twiss J, Metcalfe R, Edwards E, Byrnes C. New Zealand national incidence of bronchiectasis "too high" for a developed country. Archives of Diseases of Childhood 2005;90(7):737‐40. - PMC - PubMed
Van der Schans 1991
    1. Schans C, Mark T, Vries G, Piers DA, Beekhuis H, Dankert‐Roelse JE, et al. Effect of positive expiratory pressure breathing in patients with cystic fibrosis. Thorax 1991;46:252‐6. - PMC - PubMed
Van Winden 1998
    1. Winden CMQ, Visser A, Hop W, Sterk PJ, Beckers S, Jongste JC. Effects of flutter and PEP mask physiotherapy on symptoms and lung function in children with cystic fibrosis. European Respiratory Journal 1998;12:143‐7. - PubMed
Volsko 2013
    1. Volsko TA. Airway clearance therapy: finding the evidence. Respiratory Care 2013;58(10):1669‐78. - PubMed
Warwick 1991
    1. Warwick WJ, Hansen LG. The long‐term effect of high frequency chest compression therapy on pulmonary complications of cystic fibrosis. Pediatric Pulmonology 1991;11(3):265‐71. - PubMed
Weycker 2005
    1. Weycker D, Edelsberg J, Oster G, Tino G. Prevalence and economic burden of bronchiectasis. Clinics in Pulmonary Medicine 2005;12:205‐9.
Wilkinson 2014
    1. Wilkinson M, Sugumar K, Milan S, Hart A, Crockett A, Crossingham I. Mucolytics for bronchiectasis. Cochrane Database of Systematic Reviews 2014, Issue 5. [DOI: 10.1002/14651858.CD001289.pub2] - DOI - PMC - PubMed
Williams 1994
    1. Williams M. Chest physiotherapy and cystic fibrosis: why is the most effective form of treatment still unclear?. Chest 1994;106(6):1872‐82. - PubMed

References to other published versions of this review

Lee 2015a
    1. Lee AL, Burge A, Holland AE. Positive expiratory pressure therapy versus other airway clearance techniques for bronchiectasis. Cochrane Database of Systematic Reviews 2015, Issue 5. [DOI: 10.1002/14651858.CD011699] - DOI - PMC - PubMed

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