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Meta-Analysis
. 2020 Apr 30;4(4):CD006842.
doi: 10.1002/14651858.CD006842.pub5.

Oscillating devices for airway clearance in people with cystic fibrosis

Lisa Morrison  1 , Stephanie Milroy  2
Affiliations
Meta-Analysis

Oscillating devices for airway clearance in people with cystic fibrosis

Lisa Morrison et al. Cochrane Database Syst Rev. .

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: 29 July 2019. In addition we searched the trials databases ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform. Latest search of trials databases: 15 August 2019.

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, assessed the quality of the included studies and assessed the evidence using GRADE.

Main results: The searches identified 82 studies (330 references); 39 studies (total of 1114 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 13 studies did blind the outcome assessors. The quality of the evidence across all comparisons ranged from low to very low. Forced expiratory volume in one second was the most frequently measured outcome and while many of the studies reported an improvement in those people using a vibrating device compared to before the study, there were few differences when comparing the different devices to each other or to other airway clearance techniques. One study identified an increase in frequency of exacerbations requiring antibiotics whilst using high frequency chest wall oscillation when compared to positive expiratory pressure (low-quality evidence). 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 and due to the low- or very low-quality evidence, it is not clear whether these were due to the particular intervention. Participant satisfaction was reported in 13 studies but again with low- or very low-quality evidence and not consistently 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.

Trial registration: ClinicalTrials.gov NCT00717873 NCT01753869.

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 Milroy: none known.

Figures

1
1
Study flow diagram.
2
2
Risk of bias: review authors' judgments about each risk of bias item presented as percentages across all included studies.
3
3
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
1.1
1.1. Analysis
Comparison 1: Oscillating devices (OD) versus positive expiratory pressure (PEP), Outcome 1: FEV1 post‐intervention [% predicted]
1.2
1.2. Analysis
Comparison 1: Oscillating devices (OD) versus positive expiratory pressure (PEP), Outcome 2: FEV1 change from baseline [% predicted]
1.3
1.3. Analysis
Comparison 1: Oscillating devices (OD) versus positive expiratory pressure (PEP), Outcome 3: FEF25-75 post intervention [% predicted]
1.4
1.4. Analysis
Comparison 1: Oscillating devices (OD) versus positive expiratory pressure (PEP), Outcome 4: FEF25-75 change from baseline [% predicted]
1.5
1.5. Analysis
Comparison 1: Oscillating devices (OD) versus positive expiratory pressure (PEP), Outcome 5: FVC post intervention [% predicted]
1.6
1.6. Analysis
Comparison 1: Oscillating devices (OD) versus positive expiratory pressure (PEP), Outcome 6: FVC change from baseline [% predicted]
1.7
1.7. Analysis
Comparison 1: Oscillating devices (OD) versus positive expiratory pressure (PEP), Outcome 7: Sputum volume [ml]
1.8
1.8. Analysis
Comparison 1: Oscillating devices (OD) versus positive expiratory pressure (PEP), Outcome 8: Sputum weight [g]
1.9
1.9. Analysis
Comparison 1: Oscillating devices (OD) versus positive expiratory pressure (PEP), Outcome 9: Quality of life indices
1.10
1.10. Analysis
Comparison 1: Oscillating devices (OD) versus positive expiratory pressure (PEP), Outcome 10: Number of hospitalizations
1.11
1.11. Analysis
Comparison 1: Oscillating devices (OD) versus positive expiratory pressure (PEP), Outcome 11: Pulmonary exacerbations (at 1 year)
1.12
1.12. Analysis
Comparison 1: Oscillating devices (OD) versus positive expiratory pressure (PEP), Outcome 12: Exercise performance % change from baseline
1.13
1.13. Analysis
Comparison 1: Oscillating devices (OD) versus positive expiratory pressure (PEP), Outcome 13: Participant satisfaction
2.1
2.1. Analysis
Comparison 2: Oscillating devices (OD) versus breathing techniques, Outcome 1: FEV1 post‐intervention [% predicted]
2.2
2.2. Analysis
Comparison 2: Oscillating devices (OD) versus breathing techniques, Outcome 2: FEV1 change from baseline [% predicted]
2.3
2.3. Analysis
Comparison 2: Oscillating devices (OD) versus breathing techniques, Outcome 3: FEF25-75 absolute post‐treatment values [% predicted]
2.4
2.4. Analysis
Comparison 2: Oscillating devices (OD) versus breathing techniques, Outcome 4: FVC post‐intervention [% predicted]
2.5
2.5. Analysis
Comparison 2: Oscillating devices (OD) versus breathing techniques, Outcome 5: FVC change from baseline [% predicted]
2.6
2.6. Analysis
Comparison 2: Oscillating devices (OD) versus breathing techniques, Outcome 6: Sputum volume [g]
2.7
2.7. Analysis
Comparison 2: Oscillating devices (OD) versus breathing techniques, Outcome 7: Sputum weight (wet) [g]
3.1
3.1. Analysis
Comparison 3: Oscillating devices (OD) versus conventional physiotherapy (CPT), Outcome 1: FEV1 post intervention [% predicted]
3.2
3.2. Analysis
Comparison 3: Oscillating devices (OD) versus conventional physiotherapy (CPT), Outcome 2: FEV1 change from baseline [% predicted]
3.3
3.3. Analysis
Comparison 3: Oscillating devices (OD) versus conventional physiotherapy (CPT), Outcome 3: FEF25-75 post intervention [% predicted]
3.4
3.4. Analysis
Comparison 3: Oscillating devices (OD) versus conventional physiotherapy (CPT), Outcome 4: FEF25-75 change from baseline [% predicted]
3.5
3.5. Analysis
Comparison 3: Oscillating devices (OD) versus conventional physiotherapy (CPT), Outcome 5: FVC [% predicted]
3.6
3.6. Analysis
Comparison 3: Oscillating devices (OD) versus conventional physiotherapy (CPT), Outcome 6: Residual volume [% change from baseline]
3.7
3.7. Analysis
Comparison 3: Oscillating devices (OD) versus conventional physiotherapy (CPT), Outcome 7: Sputum weight (dry) [g]
3.8
3.8. Analysis
Comparison 3: Oscillating devices (OD) versus conventional physiotherapy (CPT), Outcome 8: Sputum weight (wet) [g]
3.9
3.9. Analysis
Comparison 3: Oscillating devices (OD) versus conventional physiotherapy (CPT), Outcome 9: Six minute walking distance [metres]
3.10
3.10. Analysis
Comparison 3: Oscillating devices (OD) versus conventional physiotherapy (CPT), Outcome 10: Oxygen saturation (SaO2 ) [% change from baseline]
3.11
3.11. Analysis
Comparison 3: Oscillating devices (OD) versus conventional physiotherapy (CPT), Outcome 11: Days of hospitalization
3.12
3.12. Analysis
Comparison 3: Oscillating devices (OD) versus conventional physiotherapy (CPT), Outcome 12: Patient satisfaction / overall preference (short term)
3.13
3.13. Analysis
Comparison 3: Oscillating devices (OD) versus conventional physiotherapy (CPT), Outcome 13: Patient satisfaction / overall preference (long term)
4.1
4.1. Analysis
Comparison 4: Flutter versus HFCWO, Outcome 1: FEV1 [% predicted]
4.2
4.2. Analysis
Comparison 4: Flutter versus HFCWO, Outcome 2: FEF25-75 [% predicted]
4.3
4.3. Analysis
Comparison 4: Flutter versus HFCWO, Outcome 3: FVC [% predicted]
4.4
4.4. Analysis
Comparison 4: Flutter versus HFCWO, Outcome 4: Treatment satisfaction (long term)
5.1
5.1. Analysis
Comparison 5: IPV (400 bpm) versus IPV (200 bpm), Outcome 1: FEV1 change from baseline [% predicted]
5.2
5.2. Analysis
Comparison 5: IPV (400 bpm) versus IPV (200 bpm), Outcome 2: FVC change from baseline [% predicted]
See this image and copyright information in PMC

Update of

References

References to studies included in this review

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Dingemans 2018b {published data only}
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    1. ISRCTN75391385. Analysis of the Pseudomonas aeruginosa biofilm in the respiratory samples of cystic fibrosis patients [Effect of intrapulmonary percussive ventilation on Pseudomonas aeruginosa biofilm formation and virulence]. www.who.int/trialsearch/Trial2.aspx?TrialID=ISRCTN75391385 (first received 06 February 2013). [CENTRAL: CN-01879891] [CFGD REGISTER: PE271]
Giles 1996 {published data only}
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Gondor 1999 {published data only}
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Gotz 1995 {published data only}
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Grzincich 2008 {published data only}
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Hansen 1990 {published data only}
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Hare 2002 {published data only}
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Homnick 1995 {published data only}
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Homnick 1998 {published data only}
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Kluft 1996 {published data only}
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Lyons 1992 {published data only}
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Marks 2001 {published data only}
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McIlwaine 2001 {published data only}
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McIlwaine 2013 {published data only}
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Milne 2004 {published data only}
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Modi 2010a {published data only}
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Modi 2010b {published data only}
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Newbold 2005 {published data only}
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Oermann 2001 {published data only}
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Osman 2010 {published data only}
    1. NCT00817947. Airway clearance using high frequency chest wall oscillation [An assessment of the short-term effects of the airway clearance technique of high frequency chest wall oscillation in people with cystic fibrosis]. clinicaltrials.gov/ct2/show/NCT00817947 (first received 07 January 2009). [CENTRAL: CN-01523471] [CFGD REGISTER: PE264]
    1. Osman LP, Roughton M, Hodson ME, Pryor JA. High frequency chest wall oscillation in cystic fibrosis. Journal of Cystic Fibrosis 2008; 7(Suppl 2):295. [CFGD REGISTER: PE171a]
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Padman 1999a {published data only}
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Padman 1999b {published data only}
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Patel 2013 {published data only}
    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] 5500125000000289
Phillips 2004 {published data only}
    1. Phillips GE, Pike S, Jaffe A, Bush A. Comparison of the active cycle of breathing techniques and external high frequency oscillation jacket for clearance of secretions in children with cystic fibrosis. Thorax 1998; 53(Suppl 4):A61. [CFGD REGISTER: PE114a]
    1. Phillips GE, Pike SE, Jaffe A, Bush A. Comparison of active cycle of breathing and high-frequency oscillation jacket in children with cystic fibrosis. Pediatric Pulmonology 2004; 37(1):71-5. [CFGD REGISTER: PE114b] - PubMed
Pike 1999 {published data only}
    1. Pike SE, Machin AC, Dix KJ, Pryor JA, Hodson ME. Comparison of flutter VRPI and forced expirations (FE) with active cycle of breathing techniques (ACBT) in subjects with cystic fibrosis (CF). The Netherlands Journal of Medicine 1999; 54(Suppl):S55-6. [CFGD REGISTER: PE102]
Prasad 2005 {published data only}
    1. Main E, Tannenbaum E, Stanojevic S, Scrase E, Prasad A. The effects of positive expiratory pressure (PEP) or oscillatory positive pressure (RC Cornet®) on FEV1 and lung clearance index over a twelve month period in children with CF. Pediatric Pulmonology 2006; 41(Suppl 29):351. [CFGD REGISTER: PE157c]
    1. Prasad A, Tannenbaum E, Bryon M, Main E. One year trial of two airway clearance techniques in children with cystic fibrosis: limitations of the quality of well-being scale. Pediatric Pulmonology 2005; 40(Suppl 28):323. [CFGD REGISTER: PE157a]
    1. Tannenbaum E, Prasad SA, Main E, Scrase E. Long-term effects of positive expiratory pressure (PEP) or oscillatory positive pressure (RC Cornet®) on FEV1 and perceived health in children with CF. In: Proceedings of 28th European Cystic Fibrosis Conference; 2005 June 22-25; Crete, Greece. 2005:S100. [CFGD REGISTER: PE157b]
Pryor 1994 {published data only}
    1. Pryor JA, Webber BA, Hodson ME, Warner JO. The Flutter VRP1 as an adjunct to chest physiotherapy in cystic fibrosis. In: 11th International Cystic Fibrosis Congress; 1992; Dublin, Ireland. 1992:WP 102. [CFGD REGISTER: PE25b] - PubMed
    1. Pryor JA, Webber BA, Hodson ME, Warner JO. The Flutter VRP1 as an adjunct to chest physiotherapy in cystic fibrosis. Respiratory Medicine 1994; 88(9):677-81. [CFGD REGISTER: PE25b] - PubMed
Pryor 2010 {published data only}
    1. NCT00890370. Should any one airway clearance technique BE recommended for people with cystic fibrosis? [A comparison of five airway clearance techniques in the treatment of adults with cystic fibrosis]. clinicaltrials.gov/ct2/show/NCT00890370 (first received 29 April 2009). [CENTRAL: CN-01500662] [CFGD REGISTER: PE164c]
    1. Pryor JA, Tannenbaum E, Cramer D, Scott SF, Burgess J, Gyi K, et al. A comparison of five airway clearance techniques in the treatment of people with Cystic Fibrosis [abstract]. Journal of Cystic Fibrosis 2006; 5(Suppl):S76. [CFGD REGISTER: PE164a] - PubMed
    1. Pryor JA, Tannenbaum E, Scott SF, Burgess J, Cramer D, Gyi K, et al. Beyond postural drainage and percussion: Airway clearance in people with cystic fibrosis. Journal of Cystic Fibrosis 2010; 9(3):187-92. [CFGD REGISTER: PE164b] - PubMed
San Miguel Pagola 2016 {published data only}
    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] - PubMed
    1. NCT02303808. Positive expiratory pressure during inhalation of hypertonic saline in patients with cystic fibrosis [Effect of introducing a positive expiratory pressure device during inhalation of hypertonic saline in patients with cystic fibrosis: a randomized crossover trial]. clinicaltrials.gov/show/nct02303808 (first received 01 December 2014). [CENTRAL: CN-01550578] [CFGD REGISTER: BD229c]
    1. 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] - PubMed
    1. San Miguel-Pagola M, Reychler G, Cebrià I Iranzo MA, Gómez-Romero M, Díaz-Gutiérrez F, Herrero-Cortina B. Impact of hypertonic saline nebulisation combined with oscillatory positive expiratory pressure on sputum expectoration and related symptoms in cystic fibrosis: a randomised crossover trial. Physiotherapy 2019; 107:243-51. [DOI: 10.1016/j.physio.2019.11.001] - DOI - PubMed
van Winden 1998 {published data only}
    1. Winden CMQ, Visser A, Hop W, Sterk PJ, Beckers S, Jongste JC. Effects of Flutter and PEP-MASK on expectoration and lung function in cystic fibrosis. Israel Journal of Medical Sciences 1996; 32(Suppl):S275. [CFGD REGISTER: PE62a]
    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(1):143-7. [CFGD REGISTER: PE62b] - PubMed
Varekojis 2003a {published data only}
    1. Castile R, Tice J, Flucke R, Filbrun D, Varekojis S, McCoy K. Comparison of three sputum clearance methods in in-patients with cystic fibrosis. Pediatric Pulmonology 1998; 26(Suppl 17):329. [CFGD REGISTER: PE93a] [MEDLINE: ]
    1. Varekojis SM, Douce FH, Flucke RL, Filbrun DA, Tice JS, McCoy KS, et al. A comparison of the therapeutic effectiveness of and preference for postural drainage and percussion, intrapulmonary percussive ventilation, and high-frequency chest wall compression in hospitalized cystic fibrosis patients. Respiratory Care 2003; 48(1):24-8. [CFGD REGISTER: PE93b] - PubMed
Varekojis 2003b {published data only}
    1. Castile R, Tice J, Flucke R, Filbrun D, Varekojis S, McCoy K. Comparison of three sputum clearance methods in in-patients with cystic fibrosis. Pediatric Pulmonology 1998; 26(Suppl 17):329. [CFGD REGISTER: PE93a] [MEDLINE: ]
    1. Varekojis SM, Douce FH, Flucke RL, Filbrun DA, Tice JS, McCoy KS, et al. A comparison of the therapeutic effectiveness of and preference for postural drainage and percussion, intrapulmonary percussive ventilation, and high-frequency chest wall compression in hospitalized cystic fibrosis patients. Respiratory Care 2003; 48(1):24-8. [CFGD REGISTER: PE93b] - PubMed
Warwick 1990 {published data only}
    1. Warwick WJ, Wielnski CI. Matched pair comparison of manual chest physical therapy (CPT) and the thairapy bronchial drainage vest (ThBVD) system. Pediatric Pulmonology 1990; 9 Suppl 5:177. [CFGD REGISTER: PE43]
Warwick 2004 {published data only}
    1. Warwick WJ, Wielinski CL, Hansen LG. Comparison of expectorated sputum after manual chest physical therapy and high-frequency chest compression. Biomedical Instrumentation Technology 2004; 38(6):470-5. [CFGD REGISTER: PE153] - PubMed
West 2010 {published data only}
    1. West K, Wallen M, Follett J. Acapella vs. PEP mask therapy: a randomised trial in children with cystic fibrosis during respiratory exacerbation. Physiotherapy Theory and Practice 2010; 26(3):143-9. [CENTRAL: 753270] [CFGD REGISTER: PE213] [PMID: ] - PubMed
Wheatley 2018 {published data only}
    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: PE208a] 5500125000000288
    1. Wheatley CM, Baker SE, Daines CM, Phan H, Martinez MG, Morgan WJ, et al. Influence of the Vibralung acoustical percussor on pulmonary function and sputum expectoration in individuals with cystic fibrosis. Therapeutic Advances in Respiratory Disease 2018; 12:1-15. [CENTRAL: CN-01652453] [CFGD REGISTER: PE208b] [EMBASE: 624227485] - PMC - PubMed

References to studies excluded from this review

Amelina 2014 {published data only}
    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] [PMID: ] - PubMed
    1. Krasovskij S, Amelina E, Usacheva M, Samoylenko V, Krilova N. High frequency chest wall oscillation (HFCWO) in the treatment of acute pulmonary exacerbation in adult cystic fibrosis (CF) patients. European Respiratory Society Annual Congress; 2013 Sept 7-11; Barcelona, Spain 2013; 42:741s. [ABSTRACT NO: P3599] [CENTRAL: 990024] [CFGD REGISTER: PE226a]
Borka 2012 {published data only}
    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. [CFGD REGISTER: PE198] - PubMed
Cantin 2005 {published data only}
    1. Cantin AM, Bacon M, Berthiaume Y. Mechanical airway clearance using the Frequencer electro-acoustical transducer in cystic fibrosis. Clinical and Investigative Medicine 2006; 29(3):159-65. [CENTRAL: CN-00622988] [CFGD REGISTER: PE159b] [EMBASE: 43927076] - PubMed
    1. Cantin AM, Berthiaume Y. Clearance of airway secretions with the Frequencer in patients with cystic fibrosis. Pediatric Pulmonology 2004; 38(Suppl 27):322. [CFGD REGISTER: PE159a]
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(11):636-9. [CFGD REGISTER: PE18] - PubMed
Clinkscale 2012 {published data only}
    1. Clinkscale D, Spihlman K, Watts P, Rosenbluth D, Kollef MH. A randomized trial of conventional chest physical therapy versus high frequency chest wall compressions in intubated and non-intubated adults. Respiratory Care 2012; 57(2):221-8. [CENTRAL: CN-00834114] [CFGD REGISTER: PE263b] [CTG: ] [EMBASE: 2012083464] [PMID: ] - PubMed
    1. NCT00717873. Evaluation of high-frequency chest wall oscillation [Evaluation of high-frequency chest wall oscillation using the vest airway clearance system compared to conventional chest physical therapy at Barnes-Jewish hospital]. clinicaltrials.gov/ct2/show/NCT00717873 (first received 18 July 2008). [CENTRAL: CN-01953577] [CFGD REGISTER: PE263a]
Dosman 2003 {published data only}
    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] 5500100000002353 - PubMed
Dunn 2013 {published data only}
    1. Dunn C, Davies Z, Everson C, Zirbes J, Kim L, Milla C. Study of acute effects on pulmonary function and sputum production with high frequency chest oscillation (HFCWO) and postural drainage aided by handheld percussion (P-HP). Pediatric Pulmonology 2013; 48 Suppl 36:359. [ABSTRACT NO: 421] [CFGD REGISTER: PE205b] 5500125000000287
    1. Dunn C, Davies Z, Kim L, Zirbes J, Everson C, Milla C. Comparison of acute effects of conventional high frequency chest oscillation (HFCWO) and hand held percussor (Electro-Flo 5000) for airway clearance in cystic fibrosis patients. Journal of Cystic Fibrosis 2013; 12 Suppl 1:S103. [ABSTRACT NO: 215] [CFGD REGISTER: PE205a] 5500100000011676
Dwyer 2017 {published data only}
    1. Dwyer TJ, Zainuldin R, Daviskas E, Bye PT, Alison JA. Effects of treadmill exercise versus Flutter(R) on respiratory flow and sputum properties in adults with cystic fibrosis: a randomised, controlled, cross-over trial. BMC Pulmonary Medicine 2017; 17(1):14. [CFGD REGISTER: PE239 ] [PMID: ] - PMC - PubMed
Elkins 2004 {published data only}
    1. Elkins MR, Eberl S, Alison J, Bye P. The effect of bi-level non-invasive ventilation on mucociliary clearance in subjects with cystic fibrosis. Pediatric Pulmonology 2004; 38(Suppl 27):315. [CFGD REGISTER: OV20]
Elkins 2005 {published data only}
    1. Elkins MR, Eberl S, Constable C, White J, Robinson M, Daviskas E, et al. The effect of manual chest physiotherapy, positive expiratory pressure (PEP), and oscillating PEP on mucociliary clearance in subjects with cystic fibrosis. Pediatric Pulmonology 2005; 40(Suppl 28):321. [CFGD REGISTER: PE158]
Fainardi 2011 {published data only}
    1. Fainardi V, Longo F, Faverzani S, Tripodi MC, Chetta A, Pisi G. Short-term effects of high-frequency chest compression and positive expiratory pressure in patients with cystic fibrosis. Journal of Clinical Medicine Research 2011; 3(6):279-84. [CENTRAL: 983057] [CFGD REGISTER: PE211] [PMID: ] - PMC - PubMed
Grosse‐Onnebrink 2017 {published data only}
    1. Grosse-Onnebrink J, Mellies U, Olivier M, Werner C, Stehling F. Chest physiotherapy can affect the lung clearance index in cystic fibrosis patients. Pediatric Pulmonology 2017; 52(5):625-31. [CENTRAL: 1343708] [CFGD REGISTER: PE238] [PMID: ] - PubMed
Hartsell 1978 {published data only}
    1. Hartsell M, Traver G, Taussig LM. Comparison of manual percussion and vibration (P &V) vs. mechanical vibration (MV) alone on maximal expiratory flows. In: 19th Cystic Fibrosis Club Abstracts. 1978:49. [CFGD REGISTER: PE30]
Jarad 2010 {published data only}
    1. Jarad NA, Powell T, Smith CE, Cartwright P, Nedwell J. The efficacy, preference and safety of a novel method of sputum clearance, hydro acoustic therapy, on adult patients with cystic fibrosis. Thorax 2006; 61(Suppl 2):ii120; P194. [CFGD REGISTER: PE172a]
    1. Jarad NA, Powell T, Smith E. Evaluation of a novel sputum clearance technique--hydro-acoustic therapy (HAT) in adult patients with cystic fibrosis: a feasibility study. Chronic Respiratory Diseases 2010; 7(4):217-27. [CFGD REGISTER: PE172b] - PubMed
Kempainen 2007 {published data only}
    1. Kempainen R, Hazelwood A, Williams C, Dunitz J, Billings J, Milla C. Comparison of airway clearance efficacy of sine and triangular wave high frequency chest wall oscillation in patients with cystic fibrosis. Pediatric Pulmonology 2006; 41 Suppl 29:351. [CFGD REGISTER: PE166a]
    1. Kempainen RR, Milla C, Dunitz J, Savik K, Hazelwood A, Williams C, et al. Comparison of settings used for high-frequency chest-wall compression in cystic fibrosis. Respiratory Care 2010; 55(6):695-701. [CENTRAL: 761016] [CFGD REGISTER: PE166c] [PMID: ] - PubMed
    1. Kempainen RR, Williams CB, Hazelwood A, Rubin BK, Milla CE. Comparison of high-frequency chest wall oscillation with differing waveforms for airway clearance in cystic fibrosis. Chest 2007; 132(4):1227-32. [CFGD REGISTER: PE166b] - PubMed
Kirkpatrick 1995 {published data only}
    1. Kirkpatrick KR, Howard D, Ter-Pogossian M, Kollef MH. A direct comparison of manual chest percussion with acoustic percussion, an experimental treatment for cystic fibrosis. American Journal of Respiratory and Critical Care Medicine 1995; 151(4 Suppl):A738. [CFGD REGISTER: PE37]
Konstan 1994 {published data only}
    1. Konstan MW, Stern RC, Doershuk CF. Efficacy of the Flutter device for airway mucus clearance in patients with cystic fibrosis. Journal of Pediatrics 1994; 124(5 (Pt 1)):689-93. [CFGD REGISTER: PE22] - PubMed
Kraemer 1996 {published data only}
    1. Kraemer D, Liedtke C, Casaulta Aebischer C. Bronchodilator inhalation (BD) treatment in sequence with flutter VRP1 chest physiotherapy (CPT) in patients with cystic fibrosis. Israel Journal of Medical Sciences 1996; 32(Suppl):S192. [CFGD REGISTER: IB72a]
    1. Liedtke D, Casaulta Aebischer C, Martin N, Schibler A, Kraemer R. Mucociliar clearance (MCC) in patients with cystic fibrosis (CF) - Efficacy of beta2-inhalation therapy (beta2) in combination with respiratory physiotherapy [abstract] [Mukoziliare Clearance bei (MCC) bei Patienten mit cystischer Fibrose (CF) - Effizienz der beta2-Inhalationstherapie (beta2) in Kombination mit Atemphysiotherapie (APT)]. Schweizerische Medizinische Wochenschrift 1996; 126(Suppl 78):29S. [CFGD REGISTER: IB72b]
Lagerkvist 2006 {published data only}
    1. Lagerkvist AL, Sten G, Lindblad A, Redfors S. Chest physiotherapy with positive expiratory pressure (PEP) and oscillating positive expiratory pressure (flutter) in patients with cystic fibrosis-a comparative study. In: Proceedings of 21st European Cystic Fibrosis Conference; 1997 June 1-6; Davos, Switzerland. 1997:132. [CFGD REGISTER: PE87a]
    1. Lagerkvist AL, Sten GM, Redfors SB, Lindblad AG, Hjalmarson O. Immediate changes in blood-gas tensions during chest physiotherapy with positive expiratory pressure and oscillating positive expiratory pressure in patients with cystic fibrosis. Respiratory Care 2006; 51(10):1154-61. [CFGD REGISTER: PE87b] - PubMed
Leemans 2018 {published data only}
    1. Leemans G, De Hondt A, Ides K, Van Holsbeke C, Belmans D, Becker BC, et al. Evaluation of a mobile HFCWO device in patients with cystic fibrosis. Pediatric Pulmonology 2018; 53 Supplement 2:337. [CENTRAL: CN-01785500] [CFGD REGISTER: PE259] [EMBASE: 624049602]
Lindemann 1992 {published data only}
    1. Lindemann H. The value of physical therapy with VRP 1-Desitin ("Flutter") [Zum Stellenwert der Physiotherapie mit dem VRP 1-Desitin ("Flutter")]. Pneumologie 1992; 46(12):626-30. [CFGD REGISTER: PE17] - PubMed
Majaesic 1996 {published data only}
    1. Majaesic CM, Montgomery M, Jones R, King M. Reduction in sputum viscosity using high frequency chest compressions (HFCC) compared to conventional chest physiotherapy (CCP). Pediatric Pulmonology 1996; Suppl 13:308. [CFGD REGISTER: PE73]
Marks 1998 {published data only}
    1. Marks JH, Fooy C, Anderson K, Homnick DN. Nebulized albuterol delivered with positive expiratory pressure (PEP) and the flutter device in patients with cystic fibrosis: an assessment of bronchodilator response compared to standard nebulizer therapy. American Journal of Respiratory and Critical Care Medicine 1998; 157(3 Suppl):A130. [CFGD REGISTER: IB86]
Marks 2004 {published data only}
    1. Marks J, Hare K, Homnick D. The PercussiveTech HF device compared to standard chest physiotherapy in patients with cystic fibrosis. In: Proceedings of the 13th International Cystic Fibrosis Congress; 2000 June 4-8; Stockholm, Sweden. 2000:151. [CFGD REGISTER: PE109b]
    1. Marks JH, Hare KL, Homnick DN. Pulmonary function and sputum production in patients with cystic fibrosis: a pilot study comparing the percussive tech HF device and standard chest physiotherapy. Pediatric Pulmonology 1999; 28(Suppl 19):290. [CFGD REGISTER: PE109a] - PubMed
    1. Marks JH, Hare KL, Saunders RA, Homnick DN. Pulmonary function and sputum production in patients with cystic fibrosis: a pilot study comparing the PercussiveTech HF device and standard chest physiotherapy. Chest 2004; 125(4):1507-11. [CFGD REGISTER: PE109c] - PubMed
McCarren 2006 {published data only}
    1. McCarren B, Alison JA. Comparison of vibration to other physiotherapy interventions for secretion clearance. European Respiratory Journal 2005; 26(Suppl 49):497s. [CFGD REGISTER: PE160a]
    1. McCarren B, Alison JA. Physiological effects of vibration in subjects with cystic fibrosis. European Respiratory Journal 2006; 27(6):1204-9. [CFGD REGISTER: PE160b] - PubMed
Morris 1982 {published data only}
    1. Morris D, Barbero G, Konig P, Woodruff C, Kline J, Martinez R. The effect of mechanical and manual percussion on pulmonary function in cystic fibrosis patients. In: 23rd Annual Meeting Cystic Fibrosis Club Abstracts; 1982 May 14; Washington D.C. 1982:135. [CFGD REGISTER: PE83]
Natale 1994 {published data only}
    1. Natale JE, Pfeifle J, Homnick DN. Comparison of intrapulmonary percussive ventilation and chest physiotherapy. A pilot study in patients with cystic fibrosis. Chest 1994; 105(6):1789-93. [CFGD REGISTER: PE23] - PubMed
NCT01923753 {published data only}
    1. NCT01923753. A short-term comparative study of aerosure for airway clearance in patients with cystic fibrosis [A short-term comparative study of aerosure for airway clearance in patients with cystic fibrosis]. clinicaltrials.gov/ct2/show/NCT01923753 (first received 16 August 2013). [CENTRAL: CN-01489595] [CFGD REGISTER: PE265]
NCT02600039 {published data only}
    1. NCT02600039. The short-term effect of ELTGOL on pulmonary ventilation valued through electrical impedance tomography in cystic fibrosis patients [The short-term effect of ELTGOL on pulmonary ventilation valued through electrical impedance tomography in cystic fibrosis patients: randomized crossover study]. clinicaltrials.gov/ct2/show/NCT02600039 (first received 09 November 2015). [CENTRAL: CN-01553568] [CFGD REGISTER: PE272]
NCT03261219 {published data only}
    1. NCT03261219. IPV vs CPT for airway clearance during CF exacerbation [Intrapulmonary percussive ventilation vs chest physiotherapy vest in airway clearance during cystic fibrosis pulmonary exacerbation]. clinicaltrials.gov/ct2/show/NCT03261219 (first received 24 August 2017). [CENTRAL: CN-01586398] [CFGD REGISTER: PE267]
Newhouse 1998 {published data only}
    1. Newhouse P, White F, Marks J, Homnick D. Pulmonary function testing and sputum production in patients with cystic fibrosis: A pilot study comparing the flutter device, intrapulmonary percussive ventilator, and standard chest physiotherapy. Pediatric Pulmonology 1995; Suppl 12:269. [CFGD REGISTER: PE56a]
    1. Newhouse PA, White F, Marks JH, Homnick DN. The intrapulmonary percussive ventilator and flutter device compared to standard chest physiotherapy in patients with cystic fibrosis. Clinical Pediatrics 1998; 37(7):427-32. [CFGD REGISTER: PE56b] - PubMed
O'Neil 2017 {published data only}
    1. NCT01753869. Timing of hypertonic saline inhalation relative to airways clearance in cystic fibrosis [Timing of hypertonic saline inhalation relative to airways clearance in cystic fibrosis]. clinicaltrials.gov/ct2/show/NCT01753869 (first received 20 December 2012). [CENTRAL: CN-01539465] [CFGD REGISTER: BD231c]
    1. O'Neil K, Moran F, Bradbury I, Downey DG, Rendall J, Tunney MM, et al. Exploring the timing of hypertonic saline (HTS) and airways clearance techniques (ACT) in cystic fibrosis (CF): a crossover study. Thorax 2016; 71 Suppl 3:A134. [ABSTRACT NO: P95] [CENTRAL: 1253123] [CFGD REGISTER: BD231a]
    1. O'Neill K, Moran F, Tunney MM, Elborn JS, Bradbury I, Downey DG, et al. Timing of hypertonic saline and airway clearance techniques in adults with cystic fibrosis during pulmonary exacerbation: Pilot data from a randomised crossover study. BMJ Open Respiratory Research 2017; 4(1):e000168. [CENTRAL: 1297377] [CFGD REGISTER: BD231b] [CTG: ] [DOI: 10.1136/bmjresp-2016-000168] [EMBASE: 614069626] - DOI - PMC - PubMed
Orlik 2000a {published data only}
    1. Orlik T. Evaluation of the efficiency of selected thoracic physiotherapy methods used in the treatment of patients with cystic fibrosis [Ocena efektywnosci wybranych metod fizjoterapii klatki piersiowej stosowanej w leczeniu chorych na mukowiscydoze]. Medycyna Wieku Rozwojowego 2000; 4(3):233-46. - PubMed
Orlik 2000b {published data only}
    1. Orlik T. Estimation of autodrainage methods in a selected group of cystic fibrosis patients with home environment factors taken into consideration [Ocena metod autodren azu w wybranej grupie chorych na mukowiscydoze z uwzglednieniem czynnika strodowiskowego]. Medycyna Wieku Rozwojowego 2000; 4(3):247-59. [CFGD REGISTER: PE141] - PubMed
Orlik 2001 {published data only}
    1. Orlik T, Sands D. Long-term evaluation of effectiveness for selected chest physiotherapy methods used in the treatment of cystic fibrosis [Dlugofalowa ocena skutecznosci wybranych metod fizjoterapii klatki piersiowej stoswanych w leczeniu chorych na mukowiscydoze]. Medycyna Wieku Rozwojowego 2001; 5(3):245-57. - PubMed
    1. Orlik T, Sands D. Long-term study of efficiencies of select physiotherapy methods used in the treatment of cystic fibrosis. In: Proceedings of 24th European Cystic Fibrosis Conference; 2001 June 6-9; Vienna, Austria. 2001:P113.
Radtke 2018 {published data only}
    1. NCT02750722. Exercise and oscillatory positive expiratory pressure therapy in cystic fibrosis [Acute effects of combined exercise and oscillatory positive expiratory pressure therapy on sputum properties and lung diffusion capacity in cystic fibrosis: a randomized crossover trial]. clinicaltrials.gov/ct2/show/NCT02750722 (first received 25 April 2016). [CENTRAL: CN-01557680] [CFGD REGISTER: PE255d]
    1. Radtke T, Boeni L, Bohnacker P, Maggi-Bebba M, Fischer P, Kriemler S, et al. Acute effects of combined exercise and oscillatory positive expiratory pressure therapy on sputum properties and lung diffusing capacity in cystic fibrosis: a randomized, controlled, crossover trial. European Respiratory Journal 2018; 52(Suppl 62):PA3418. [CENTRAL: CN-01915241] [CFGD REGISTER: PE255e] [EMBASE: 626624799] - PMC - PubMed
    1. Radtke T, Boni L, Bohnacker P, Fischer P, Benden C, Dressel H. The many ways sputum flows - dealing with high within-subject variability in cystic fibrosis sputum rheology. Respiratory Physiology & Neurobiology 2018; 254:36-9. [CENTRAL: CN-01607707] [CFGD REGISTER: PE255c] [EMBASE: 2000702039] [PMID: ] - PubMed
    1. Radtke T, Boni L, Bohnacker P, Maggi-Beba M, Fischer P, Kriemler S, et al. Acute effects of combined exercise and oscillatory positive expiratory pressure therapy on sputum properties and lung diffusing capacity in cystic fibrosis: a randomized, controlled, crossover trial. BMC Pulmonary Medicine 2018; 18(1):99. [CENTRAL: CN-01611277] [CFGD REGISTER: PE255a] [EMBASE: 622563058] [PMID: ] - PMC - PubMed
    1. Radtke T, Boni L, Bohnacker P, Maggi-Bebba M, Fischer P, Kriemler S, et al. Acute effects of combined exercise and oscillatory positive expiratory pressure therapy on sputum properties and lung diffusing capacity in cystic fibrosis: a randomised, controlled, crossover trial. Journal of Cystic Fibrosis 2018; 17(Suppl 3):S15. [CENTRAL: CN-01746901] [CFGD REGISTER: PE255b] [EMBASE: 622931153] - PMC - PubMed
Roos 1987 {published data only}
    1. Roos S, Birrer P, Rudeberg A, Kraemer R. First experience with intrapulmonary percussive ventilation (IPV) in the treatment of patients with cystic fibrosis. In: Proceedings of the 15th Annual Meeting of the European Working Group for Cystic Fibrosis. 1987. [CENTRAL: CN-00291555] [CFGD REGISTER: PE34]
Salh 1989 {published data only}
    1. Salh W, Bilton D, Dodd M, Webb AK. Effect of exercise and physiotherapy in aiding sputum expectoration in adults with cystic fibrosis. Thorax 1989; 44(12):1006-8. [CFGD REGISTER: PE63] - PMC - PubMed
Scherer 1998 {published data only}
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Skopnik 1986 {published data only}
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References to other published versions of this review

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