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. 2021 Dec 15;12(12):CD009595.
doi: 10.1002/14651858.CD009595.pub3.

Autogenic drainage for airway clearance in cystic fibrosis

Paul Burnham  1 , Gemma Stanford  2   3 , Ruth Stewart  4
Affiliations

Autogenic drainage for airway clearance in cystic fibrosis

Paul Burnham et al. Cochrane Database Syst Rev. .

Abstract

Background: Autogenic drainage is an airway clearance technique that was developed by Jean Chevaillier in 1967. The technique is characterised by breathing control using expiratory airflow to mobilise secretions from smaller to larger airways. Secretions are cleared independently by adjusting the depth and speed of respiration in a sequence of controlled breathing techniques during exhalation. The technique requires training, concentration and effort from the individual but it has previously been shown to be an effective treatment option for those who are seeking techniques to support and promote independence. However, at a time where the trajectory and demographics of the disease are changing, it is important to systematically review the evidence demonstrating that autogenic drainage is an effective intervention for people with cystic fibrosis.

Objectives: To compare the clinical effectiveness of autogenic drainage in people with cystic fibrosis with other physiotherapy airway clearance techniques.

Search methods: We searched the Cochrane Cystic Fibrosis Trials Register, compiled from electronic database searches and handsearching of journals and conference abstract books. We also searched the reference lists of relevant articles and reviews, as well as two ongoing trials registers (02 February 2021). Date of most recent search of the Cochrane Cystic Fibrosis Trials Register: 06 July 2021.

Selection criteria: We identified randomised and quasi-randomised controlled studies comparing autogenic drainage to another airway clearance technique or no therapy in people with cystic fibrosis for at least two treatment sessions.

Data collection and analysis: Data extraction and assessments of risk of bias were independently performed by three authors. The authors assessed the quality of the evidence using the GRADE system. The authors contacted seven teams of investigators for further information pertinent to their published studies.

Main results: Searches retrieved 64 references to 37 individual studies, of which eight (n = 212) were eligible for inclusion. One study was of parallel design with the remaining seven being cross-over in design; participant numbers ranged from 4 to 75. The total study duration varied between four days and two years. The age of participants ranged between seven and 63 years with a wide range of disease severity reported. Six studies enrolled participants who were clinically stable, whilst participants in two studies received treatment whilst hospitalised with an infective exacerbation. All studies compared autogenic drainage to one (or more) other recognised airway clearance technique. Exercise is commonly used as an alternative therapy by people with cystic fibrosis; however, there were no studies identified comparing exercise with autogenic drainage. The certainty of the evidence was generally low or very low. The main reasons for downgrading the level of evidence were the frequent use of a cross-over design, outcome reporting bias and the inability to blind participants. The review's primary outcome, forced expiratory volume in one second, was the most common outcome measured and was reported by all eight studies; only three studies reported on quality of life (also a primary outcome of the review). One study reported on adverse events and described a decrease in oxygen saturation levels whilst performing active cycle of breathing techniques, but not with autogenic drainage. Seven of the eight included studies measured forced vital capacity and three of the studies used mid peak expiratory flow (per cent predicted) as an outcome. Six studies reported sputum weight. Less commonly used outcomes included oxygen saturation levels, personal preference, hospital admissions, intravenous antibiotics and pseudomonas gene expression. There were no statistically significant differences found between any of the techniques used with respect to the outcomes measured except when autogenic drainage was described as being the preferred technique of the participants in one study over postural drainage and percussion.

Authors' conclusions: Autogenic drainage is a challenging technique that requires commitment from the individual. As such, this intervention merits systematic review to ensure its effectiveness for people with cystic fibrosis, particularly in an era where treatment options are changing rapidly. From the studies assessed, autogenic drainage was not found to be superior to any other form of airway clearance technique. Larger studies are required to better evaluate autogenic drainage in comparison to other airway clearance techniques in view of the relatively small number of participants in this review and the complex study designs. The studies recruited a range of participants and were not powered to assess non-inferiority. The varied length and design of the studies made the analysis of pooled data challenging.

Trial registration: ClinicalTrials.gov NCT01057524.

PubMed Disclaimer

Conflict of interest statement

Paul Burnham declares that he 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.

Gemma Stanford is the Principal Investigator in one of the studies assessed for inclusion in the review update. This study was independently assessed by the other review authors (PB and RS) and, following this, was added to the list of excluded studies.

Ruth Stewart declares no potential conflict of interest.

Figures

1
1
Study flow diagram.
2
2
Risk of bias graph: review authors' judgements 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: AD versus PD&P, Outcome 1: FEV₁ (change in % predicted)
1.2
1.2. Analysis
Comparison 1: AD versus PD&P, Outcome 2: Hospital admissions
1.3
1.3. Analysis
Comparison 1: AD versus PD&P, Outcome 3: FVC (change in % predicted)
1.4
1.4. Analysis
Comparison 1: AD versus PD&P, Outcome 4: FEF25-75% (change in % predicted)
2.1
2.1. Analysis
Comparison 2: AD versus spontaneous cough, Outcome 1: FEV₁ (% predicted)
2.2
2.2. Analysis
Comparison 2: AD versus spontaneous cough, Outcome 2: FVC (% predicted)
2.3
2.3. Analysis
Comparison 2: AD versus spontaneous cough, Outcome 3: Sputum weight (g)
3.1
3.1. Analysis
Comparison 3: AD versus ACBT, Outcome 1: FEV₁ (L)
4.1
4.1. Analysis
Comparison 4: AD versus PEP, Outcome 1: FEV₁ (L)
4.2
4.2. Analysis
Comparison 4: AD versus PEP, Outcome 2: FEV₁ (% predicted)
4.3
4.3. Analysis
Comparison 4: AD versus PEP, Outcome 3: FVC (% predicted)
4.4
4.4. Analysis
Comparison 4: AD versus PEP, Outcome 4: Sputum weight (g)
5.1
5.1. Analysis
Comparison 5: AD versus Cornet®, Outcome 1: FEV₁ (L)
6.1
6.1. Analysis
Comparison 6: AD versus Flutter®, Outcome 1: FEV1 (L)
6.2
6.2. Analysis
Comparison 6: AD versus Flutter®, Outcome 2: FVC (L)
6.3
6.3. Analysis
Comparison 6: AD versus Flutter®, Outcome 3: Sputum volume wet (g)
7.1
7.1. Analysis
Comparison 7: AD versus IPV , Outcome 1: AD versus IPV 200 FEV1 % predicted (change from baseline)
7.2
7.2. Analysis
Comparison 7: AD versus IPV , Outcome 2: AD versus IPV 400 FEV1 % predicted (change from baseline)
7.3
7.3. Analysis
Comparison 7: AD versus IPV , Outcome 3: AD versus IPV 200 FVC % predicted (change from baseline)
7.4
7.4. Analysis
Comparison 7: AD versus IPV , Outcome 4: AD versus IPV 400 with AD FVC % predicted (change from baseline)
See this image and copyright information in PMC

Update of

References

References to studies included in this review

App 1998 {published data only}
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McIlwaine 1991 {published and unpublished data}
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    1. McIlwaine PM, Wong LTK, Pirie GE, Davidson AGF. Long-term comparative trial of conventional percussion and drainage physiotherapy versus autogenic drainage in cystic fibrosis. In: 11th International Cystic Fibrosis Congress; 1992; Dublin, Ireland. 1992:AHP32. [CFGD REGISTER: PE47b] 5500100000004465
Miller 1995 {published data only}
    1. Hall DO, Miller S, Clayton CB, Nelson R. Chest physiotherapy in cystic fibrosis: A comparative study of autogenic drainage and the active cycle of breathing technique. In: 19th European Cystic Fibrosis Conference; 1994 May 29- Jun 3; Paris, France. 1994:O64. [CFGD REGISTER: PE28a] - PMC - PubMed
    1. Miller S, Hall DO, Clayton CB, Nelson R. Chest physiotherapy in cystic fibrosis: A comparative study of autogenic drainage and the active cycle of breathing techniques with postural drainage. Thorax 1995;50(2):165-9. [CFGD REGISTER: PE28c] - PMC - PubMed
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Pfleger 1992 {published data only}
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    1. Theißl B, Pfleger A, Oberwaldner B, Zach M. Chest physiotherapy (PT) in cystic fibrosis (CF) - a comparative study of high-pressure PEP and autogenic drainage. Pediatric Pulmonology 1990;9(Suppl 5):259. [CFGD REGISTER: PE16b] - PubMed
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    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/show/NCT00890370 (first received 29 April 2009). [CENTRAL: CN-01500662] [CFGD REGISTER: PE164c]
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References to studies excluded from this review

ACTRN12611000160932 {published data only}
    1. ACTRN12611000160932. Quality of life, days in hospital, lung function and fitness before and after attending the outpatient cystic fibrosis (CF) physiotherapy service [Children and adolescents with cystic fibrosis attending the Women's and Children's Hospital Ambulatory Cystic Fibrosis Physiotherapy Clinic - effect on quality of life, number of occupied bed days, pulmonary function and exercise capacity.]. www.anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12611000160932 (first posted 21 January 2011).
Corten 2020 {published data only}
    1. Corten L, Morrow BM. The use of assisted autogenic drainage in children with cystic fibrosis; a pilot randomized controlled study. Physiotherapy Practice and Research 2020;41(1):79-89. [CFGD REGISTER: PE297b] [DOI: 10.3233/PPR-190148] - DOI
    1. PACTR201501001016415. Assisted autogenic drainage (chest physiotherapy) in South African children with cystic fibrosis. www.who.int/trialsearch/Trial2.aspx?TrialID=PACTR201501001016415 (first approved 26 January 2013). [CFGD REGISTER: PE297a]
CTRI/2020/10/028509 {published data only}
    1. Comparison of two different chest physiotherapy techniques in participants undergone upper abdominal surgery [Effectiveness of incentive spirometry and breathing exercise with active cycle of breathing technique vs autogenic drainage on peak expiratory flow rate in participants following upper abdominal surgery ]. www.who.int/trialsearch/Trial2.aspx?TrialID=CTRI/2020/10/028509 30 November 2020;(11). [CENTRAL: CN-02186346]
Davies 2012 {published data only}
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Giles 1995 {published data only}
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Helper 2020 {published data only}
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Herrero 2016 {published data only}
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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
NCT01854788 {published data only}
    1. NCT01854788. A comparative study of three airway clearance techniques with different autonomy degrees in non cystic fibrosis bronchiectasis: randomized cross-over trial. clinicaltrials.gov/ct2/show/NCT01854788 (first posted 16 May 2013).
NCT02840136 {published data only}
    1. NCT02840136. Optimisation, valorisation and application of LC-MS/MS based monitoring of antibiotic concentrations in sputum of cystic fibrosis patients - Part 3: non-blank sputum samples for method optimisation and validation. clinicaltrials.gov/ct2/show/NCT02840136 (first posted 21 July 2016).
NCT03522480 {published data only}
    1. The effectiveness of the Jamboxx respiratory therapy device: study 2 [The effectiveness of the Jamboxx respiratory therapy device in treatment of patients with decreased respiratory function. Study 2: children with cystic fibrosis for long term evaluation]. clinicaltrials.gov/show/NCT03522480 (first posted 11 May 2018). [CENTRAL: CN-01599501] [CFGD REGISTER: PE301]
NCT03655249 {published data only}
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NCT04187924 {published data only}
    1. NCT04187924. Effects of the addition of the SIMEOX device on autogenic drainage in patients with cystic fibrosis. clinicaltrials.gov/ct2/show/NCT04187924 (first posted 05 December 2019).
NCT04527796 {published data only}
    1. NCT04527796. Influence of a residential rehabilitation program on body composition in patients with cystic fibrosis (children and adults). clinicaltrials.gov/ct2/show/NCT04527796 (first posted 27 August 2020).
Poncin 2017 {published data only}
    1. NCT02411981. Short-term effects of chest physiotherapy on ventilation inhomogeneity in non-CF bronchiectasis. clinicaltrials.gov/ct2/show/NCT02411981 (first posted 08 April 2016).
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Prusak 2020 {published data only}
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Reix 2012 {published data only}
    1. NCT01509235. Self drainage in pediatric cystic fibrosis patients. clinicaltrials.gov/show/NCT01509235 (date first posted 12 January 2012). [CFGD REGISTER: PE183c]
    1. Reix P, Aubert F, Kassai B, Bige V, Bellon G. Better satisfaction of cystic fibrosis paediatric patients with autogenic drainage associated to exercise compared to conventional chest physiotherapy. Journal of Cystic Fibrosis 2009;8(Suppl 2):S73. [ABSTRACT NO: 293] [CFGD REGISTER: PE183a]
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Roos 1987 {published data only}
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San Miguel‐Pagola 2020 {published data only}
    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 cysticfibrosis: a randomized crossover trial]. clinicaltrials.gov/ct2/show/NCT02303808 (first posted 25 November 2014).
    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 June 2020;107:243-251. [DOI: 10.1016/j.physio.2019.11.001] - DOI - PubMed
Skopnik 1986 {published data only}
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Sokol 2012 {published and unpublished data}
    1. Sokol G, Hakimi R, Better R, Efrati O. The short term effect of airway clearance using the “Cough Assist” on lung function in patients with cystic fibrosis [Abstract]. In: Journal of Cystic Fibrosis. Conference: 35th European Cystic Fibrosis Conference; Dublin, Ireland. Vol. 11 . June 2012:S104, [ABSTRACT NO: 188]. [CENTRAL: CN-00848818] [CFGD REGISTER: PE196a]
Sokol 2012a {published and unpublished data}
    1. Sokol G, Hakimi R, Vilozni D, Beter R, Rubinstein E, Larea Yona O, et al. The short term effect of the “cough assist”and “autogenic drainage” physiotherapy on lung function in patients with cystic fibrosis [Abstract]. 26th Annual North American Cystic Fibrosis Conference (October 11th-13th 2012); Orlando, Florida. In: Pediatric Pulmonology. Vol. 47 . 2012:Suppl 35, 365-366 [ABSTRACT NO: 394]. [CENTRAL: CN-01030594] [CFGD REGISTER: PE196b]
Stanford 2019 {published data only}
    1. NCT01885650. The addition of non-invasive ventilation to airway clearance techniques in adults with cystic fibrosis (NIV) [Non-invasive ventilation (NIV) for positive pressure support. A randomised cross-over trial to evaluate the short-term effects of NIV as an adjunct to airway clearance techniques in adults with cystic fibrosis.]. clinicaltrials.gov/ct2/show/NCT01885650 Date first received: 17 June 2013.
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van Ginderdeuren 2001 {published data only}
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van Ginderdeuren 2008 {published data only}
    1. Ginderdeuren F, Verbanck S, Van Cauwelaert K, Vanlaethem S, Schuermans D, Vincken W, et al. Chest physiotherapy in cystic fibrosis: short-term effects of autogenic drainage preceded by wet inhalation of saline versus autogenic drainage preceded by intrapulmonary percussive ventilation with saline. Respiration; International Review of Thoracic Diseases 2008;76(2):175-80. [CFGD REGISTER: BD178] 5500100000004752 - PubMed
van Ginderdeuren 2011 {published data only}
    1. Ginderdeuren F, Vanlaethem S, Eyns H, De Schutter I, Dewachter E, Malfroot A. Influence of inhaled hypertonic saline (NaCI 6%) before or during autogenic drainage on sputum weight, oxygen saturation, heart frequency and dyspnoea in cystic fibrosis. Journal of Cystic Fibrosis 2011;10 Suppl 1:S62. [CFGD REGISTER: BD164] 5500100000010552
Vendrusculo 2019 {published data only}
    1. Vendrusculo FM, Johnstone Z, Dhouieb E, Donadio MVF, Cunningham S, Urquhart DS. Airway clearance physiotherapy can reduce dead space and lead to improvements in ventilatory inhomogeniety during exercise in patients with cystic fibrosis: a pilot study. Journal of Cystic fibrosis 2017;16 Suppl 1:S8. [ABSTRACT NO.: WS04.6] [CFGD REGISTER: PE250a]
    1. Vendrusculo FM, Johnstone Z, Dhouieb E, Donadio MVF, Cunningham S, Urquhart DS. Airway clearance physiotherapy improves ventilatory dynamics during exercise in patients with cystic fibrosis: a pilot study. Archives of Disease in Childhood 2019;104(1):37-42. [CENTRAL: CN-01610807] [CFGD REGISTER: PE250b] [EMBASE: 622462575] [PMID: ] - PubMed
Warwick 1990 {published data only}
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References to ongoing studies

NCT04010253 {published data only}
    1. NCT04010253. Impact of bronchial drainage technique by the medical device Simeox® on respiratory function and symptoms in adult patients with cystic fibrosis [Impact of bronchial drainage by the medical device Simeox® on function and respiratory symptoms compared to manual autogenous drainage physiotherapy in adult cystic fibrosis patients]. clinicaltrials.gov/show/NCT04010253 first posted 08 July 2019. [CENTRAL: CN-01953083] [CFGD REGISTER: PE302]

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References to other published versions of this review

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