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. 2023 May 5;5(5):CD002011.
doi: 10.1002/14651858.CD002011.pub3.

Conventional chest physiotherapy compared to other airway clearance techniques for cystic fibrosis

Eleanor Main  1 , Sarah Rand  1   2
Affiliations

Conventional chest physiotherapy compared to other airway clearance techniques for cystic fibrosis

Eleanor Main et al. Cochrane Database Syst Rev. .

Abstract

Background: Cystic fibrosis (CF) is an inherited life-limiting disorder. Over time persistent infection and inflammation within the lungs contribute to severe airway damage and loss of respiratory function. Chest physiotherapy, or airway clearance techniques (ACTs), are integral in removing airway secretions and initiated shortly after CF diagnosis. Conventional chest physiotherapy (CCPT) generally requires assistance, while alternative ACTs can be self-administered, facilitating independence and flexibility. This is an updated review.

Objectives: To evaluate the effectiveness (in terms of respiratory function, respiratory exacerbations, exercise capacity) and acceptability (in terms of individual preference, adherence, quality of life) of CCPT for people with CF compared to alternative ACTs.

Search methods: We used standard, extensive Cochrane search methods. The latest search was 26 June 2022.

Selection criteria: We included randomised or quasi-randomised controlled trials (including cross-over design) lasting at least seven days and comparing CCPT with alternative ACTs in people with CF.

Data collection and analysis: We used standard Cochrane methods. Our primary outcomes were 1. pulmonary function tests and 2. number of respiratory exacerbations per year. Our secondary outcomes were 3. quality of life, 4. adherence to therapy, 5. cost-benefit analysis, 6. objective change in exercise capacity, 7. additional lung function tests, 8. ventilation scanning, 9. blood oxygen levels, 10. nutritional status, 11. mortality, 12. mucus transport rate and 13. mucus wet or dry weight. We reported outcomes as short-term (seven to 20 days), medium-term (more than 20 days to up to one year) and long-term (over one year).

Main results: We included 21 studies (778 participants) comprising seven short-term, eight medium-term and six long-term studies. Studies were conducted in the USA (10), Canada (five), Australia (two), the UK (two), Denmark (one) and Italy (one) with a median of 23 participants per study (range 13 to 166). Participant ages ranged from newborns to 45 years; most studies only recruited children and young people. Sixteen studies reported the sex of participants (375 males; 296 females). Most studies compared modifications of CCPT with a single comparator, but two studies compared three interventions and another compared four interventions. The interventions varied in the duration of treatments, times per day and periods of comparison making meta-analysis challenging. All evidence was very low certainty. Nineteen studies reported the primary outcomes forced expiratory volume in one second (FEV1)and forced vital capacity (FVC), and found no difference in change from baseline in FEV1 % predicted or rate of decline between groups for either measure. Most studies suggested equivalence between CCPT and alternative ACTs, including positive expiratory pressure (PEP), extrapulmonary mechanical percussion, active cycle of breathing technique (ACBT), oscillating PEP devices (O-PEP), autogenic drainage (AD) and exercise. Where single studies suggested superiority of one ACT, these findings were not corroborated in similar studies; pooled data generally concluded that effects of CCPT were comparable to those of alternative ACTs. CCPT versus PEP We are uncertain whether CCPT improves lung function or has an impact on the number of respiratory exacerbations per year compared with PEP (both very low-certainty evidence). There were no analysable data for our secondary outcomes, but many studies provided favourable narrative reports on the independence achieved with PEP mask therapy. CCPT versus extrapulmonary mechanical percussion We are uncertain whether CCPT improves lung function compared with extrapulmonary mechanical percussions (very low-certainty evidence). The annual rate of decline in average forced expiratory flow between 25% and 75% of FVC (FEF25-75) was greater with high-frequency chest compression compared to CCPT in medium- to long-term studies, but there was no difference in any other outcome. CCPT versus ACBT We are uncertain whether CCPT improves lung function compared to ACBT (very low-certainty evidence). Annual decline in FEF25-75 was worse in participants using the FET component of ACBT only (mean difference (MD) 6.00, 95% confidence interval (CI) 0.55 to 11.45; 1 study, 63 participants; very low-certainty evidence). One short-term study reported that directed coughing was as effective as CCPT for all lung function outcomes, but with no analysable data. One study found no difference in hospital admissions and days in hospital for exacerbations. CCPT versus O-PEP We are uncertain whether CCPT improves lung function compared to O-PEP devices (Flutter device and intrapulmonary percussive ventilation); however, only one study provided analysable data (very low-certainty evidence). No study reported data for number of exacerbations. There was no difference in results for number of days in hospital for an exacerbation, number of hospital admissions and number of days of intravenous antibiotics; this was also true for other secondary outcomes. CCPT versus AD We are uncertain whether CCPT improves lung function compared to AD (very low-certainty evidence). No studies reported the number of exacerbations per year; however, one study reported more hospital admissions for exacerbations in the CCPT group (MD 0.24, 95% CI 0.06 to 0.42; 33 participants). One study provided a narrative report of a preference for AD. CCPT versus exercise We are uncertain whether CCPT improves lung function compared to exercise (very low-certainty evidence). Analysis of original data from one study demonstrated a higher FEV1 % predicted (MD 7.05, 95% CI 3.15 to 10.95; P = 0.0004), FVC (MD 7.83, 95% CI 2.48 to 13.18; P = 0.004) and FEF25-75 (MD 7.05, 95% CI 3.15 to 10.95; P = 0.0004) in the CCPT group; however, the study reported no difference between groups (likely because the original analysis accounted for baseline differences).

Authors' conclusions: We are uncertain whether CCPT has a more positive impact on respiratory function, respiratory exacerbations, individual preference, adherence, quality of life, exercise capacity and other outcomes when compared to alternative ACTs as the certainty of the evidence is very low. There was no advantage in respiratory function of CCPT over alternative ACTs, but this may reflect insufficient evidence rather than real equivalence. Narrative reports indicated that participants prefer self-administered ACTs. This review is limited by a paucity of well-designed, adequately powered, long-term studies. This review cannot yet recommend any single ACT above others; physiotherapists and people with CF may wish to try different ACTs until they find an ACT that suits them best.

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Conflict of interest statement

EM: none.

SR: none.

Figures

1
1
Study flow diagram for 2022 update.
2
2
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
1.1
1.1. Analysis
Comparison 1: Conventional chest physiotherapy (CCPT) versus specific other treatments, Outcome 1: Forced expiratory volume in 1 second (FEV 1) (% predicted)
1.2
1.2. Analysis
Comparison 1: Conventional chest physiotherapy (CCPT) versus specific other treatments, Outcome 2: Forced vital capacity (FVC) (% predicted)
1.3
1.3. Analysis
Comparison 1: Conventional chest physiotherapy (CCPT) versus specific other treatments, Outcome 3: Average forced expiratory flow between 25% and 75% expired FVC (FEF 25–75) (% predicted)
1.4
1.4. Analysis
Comparison 1: Conventional chest physiotherapy (CCPT) versus specific other treatments, Outcome 4: Number of hospital admissions
1.5
1.5. Analysis
Comparison 1: Conventional chest physiotherapy (CCPT) versus specific other treatments, Outcome 5: Number of days in hospital
1.6
1.6. Analysis
Comparison 1: Conventional chest physiotherapy (CCPT) versus specific other treatments, Outcome 6: Schwachman score
2.1
2.1. Analysis
Comparison 2: Conventional chest physiotherapy (CCPT) versus positive expiratory pressure (PEP), Outcome 1: Forced expiratory volume in 1 second (FEV 1) % predicted
2.2
2.2. Analysis
Comparison 2: Conventional chest physiotherapy (CCPT) versus positive expiratory pressure (PEP), Outcome 2: Forced vital capacity (FVC) % predicted
2.3
2.3. Analysis
Comparison 2: Conventional chest physiotherapy (CCPT) versus positive expiratory pressure (PEP), Outcome 3: Average forced expiratory flow between 25% and 75% expired FVC (FEF 25–75) % predicted
2.4
2.4. Analysis
Comparison 2: Conventional chest physiotherapy (CCPT) versus positive expiratory pressure (PEP), Outcome 4: Number of hospital admissions
3.1
3.1. Analysis
Comparison 3: Conventional chest physiotherapy (CCPT) versus high‐frequency chest compression (HFCC)/mechanical percussive (MP), Outcome 1: Forced expiratory volume in 1 second (FEV 1) % predicted
3.2
3.2. Analysis
Comparison 3: Conventional chest physiotherapy (CCPT) versus high‐frequency chest compression (HFCC)/mechanical percussive (MP), Outcome 2: Forced vital capacity (FVC) % predicted
3.3
3.3. Analysis
Comparison 3: Conventional chest physiotherapy (CCPT) versus high‐frequency chest compression (HFCC)/mechanical percussive (MP), Outcome 3: Average forced expiratory flow between 25% and 75% expired FVC (FEF 25–75) % predicted
3.4
3.4. Analysis
Comparison 3: Conventional chest physiotherapy (CCPT) versus high‐frequency chest compression (HFCC)/mechanical percussive (MP), Outcome 4: Number of days in hospital for respiratory exacerbations
3.5
3.5. Analysis
Comparison 3: Conventional chest physiotherapy (CCPT) versus high‐frequency chest compression (HFCC)/mechanical percussive (MP), Outcome 5: Blood oxygen levels
3.6
3.6. Analysis
Comparison 3: Conventional chest physiotherapy (CCPT) versus high‐frequency chest compression (HFCC)/mechanical percussive (MP), Outcome 6: Weight (change from baseline) (kg)
4.1
4.1. Analysis
Comparison 4: Conventional chest physiotherapy (CCPT) versus active cycle of breathing therapy (ACBT)/forced expiratory technique (FET), Outcome 1: Forced expiratory volume in 1 second (FEV 1) % predicted
4.2
4.2. Analysis
Comparison 4: Conventional chest physiotherapy (CCPT) versus active cycle of breathing therapy (ACBT)/forced expiratory technique (FET), Outcome 2: Forced vital capacity (FVC) % predicted
4.3
4.3. Analysis
Comparison 4: Conventional chest physiotherapy (CCPT) versus active cycle of breathing therapy (ACBT)/forced expiratory technique (FET), Outcome 3: Average forced expiratory flow between 25% and 75% expired FVC (FEF 25–75) % predicted
4.4
4.4. Analysis
Comparison 4: Conventional chest physiotherapy (CCPT) versus active cycle of breathing therapy (ACBT)/forced expiratory technique (FET), Outcome 4: Number of participants per group requiring ≥ 1 hospital admission
4.5
4.5. Analysis
Comparison 4: Conventional chest physiotherapy (CCPT) versus active cycle of breathing therapy (ACBT)/forced expiratory technique (FET), Outcome 5: Blood oxygen levels (%)
4.6
4.6. Analysis
Comparison 4: Conventional chest physiotherapy (CCPT) versus active cycle of breathing therapy (ACBT)/forced expiratory technique (FET), Outcome 6: Shwachman score
5.1
5.1. Analysis
Comparison 5: Conventional chest physiotherapy (CCPT) versus oscillating positive expiratory pressure (O‐PEP) devices, Outcome 1: Forced expiratory volume in 1 second (FEV 1) % predicted
5.2
5.2. Analysis
Comparison 5: Conventional chest physiotherapy (CCPT) versus oscillating positive expiratory pressure (O‐PEP) devices, Outcome 2: Forced vital capacity (FVC) % predicted
5.3
5.3. Analysis
Comparison 5: Conventional chest physiotherapy (CCPT) versus oscillating positive expiratory pressure (O‐PEP) devices, Outcome 3: Average forced expiratory flow between 25% and 75% expired FVC (FEF 25–75) % predicted
5.4
5.4. Analysis
Comparison 5: Conventional chest physiotherapy (CCPT) versus oscillating positive expiratory pressure (O‐PEP) devices, Outcome 4: Number of days in hospital
5.5
5.5. Analysis
Comparison 5: Conventional chest physiotherapy (CCPT) versus oscillating positive expiratory pressure (O‐PEP) devices, Outcome 5: Number of days of intravenous antibiotics for respiratory exacerbations
6.1
6.1. Analysis
Comparison 6: Conventional chest physiotherapy (CCPT) versus autogenic drainage (AD), Outcome 1: Forced expiratory volume in 1 second (FEV 1) % predicted
6.2
6.2. Analysis
Comparison 6: Conventional chest physiotherapy (CCPT) versus autogenic drainage (AD), Outcome 2: Forced vital capacity (FVC) % predicted
6.3
6.3. Analysis
Comparison 6: Conventional chest physiotherapy (CCPT) versus autogenic drainage (AD), Outcome 3: Average forced expiratory flow between 25% and 75% expired FVC (FEF 25–75) % predicted
6.4
6.4. Analysis
Comparison 6: Conventional chest physiotherapy (CCPT) versus autogenic drainage (AD), Outcome 4: Number hospital admissions
6.5
6.5. Analysis
Comparison 6: Conventional chest physiotherapy (CCPT) versus autogenic drainage (AD), Outcome 5: Proportion of admissions per number of participants
7.1
7.1. Analysis
Comparison 7: Conventional chest physiotherapy (CCPT) versus exercise, Outcome 1: Forced expiratory volume in 1 second (FEV 1) % predicted
7.2
7.2. Analysis
Comparison 7: Conventional chest physiotherapy (CCPT) versus exercise, Outcome 2: Forced vital capacity (FVC) % predicted
7.3
7.3. Analysis
Comparison 7: Conventional chest physiotherapy (CCPT) versus exercise, Outcome 3: Average forced expiratory flow between 25% and 75% expired FVC (FEF 25–75) % predicted
7.4
7.4. Analysis
Comparison 7: Conventional chest physiotherapy (CCPT) versus exercise, Outcome 4: Number of days in hospital
See this image and copyright information in PMC

Update of

References

References to studies included in this review

Arens 1994 {published data only}
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Bain 1988 {published data only}
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Bauer 1994 {published data only}
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Cerny 1989 {published data only}
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Costantini 2001 {published data only}
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Dadparvar 1995 {published data only}
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Giles 1996 {published data only}
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Gondor 1999 {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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McIlwaine 1991 {published and unpublished data}
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McIlwaine 1997 {published data only}
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McIlwaine 2010 {published data only}
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Reisman 1988 {published data only}
    1. Reisman JJ, Rivington-Law B, Corey M, Marcotte J, Wannamaker E, Harcourt D, et al. Role of conventional physiotherapy in cystic fibrosis. Journal of Pediatrics 1988;113(4):632-6. [CFGD REGISTER: PE12] - PubMed
Sontag 2010 {published data only}
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Steen 1991 {published data only}
    1. Steen HJ, Redmond AO, O'Neill D, Beattie F. Evaluation of the PEP mask in cystic fibrosis. Acta Paediatrica Scandinavia 1991;80(1):51-6. [CFGD REGISTER: PE14b] - PubMed
    1. Steen HJ, Redmond AO, O'Neill D, Beattie F. Has the PEP mask a role in the management of teenage patients? In: 13th Annual Meeting of the European Working Group for Cystic Fibrosis; 1985 Nov 3-8; Jerusalem, Israel. 1985:94. [CFGD REGISTER: PE14a]
Tonnesen 1982 {published data only}
    1. Tonnesen P, Kelstrup M. Self-administered positive end expiratory pressure (PEEP) using a face mask as an alternative to conventional lung physiotherapy. Ugeskrift for Laeger 1982;144(21):1532-6. [CFGD REGISTER: PE5] - PubMed
Tyrrell 1986 {published data only}
    1. Tyrrell JC, Hiller EJ, Martin J. Face mask physiotherapy in cystic fibrosis. Archives of Disease in Childhood 1986;61(6):598-611. [CFGD REGISTER: PE31a] - PMC - PubMed
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van Asperen 1987 {published data only}
    1. Asperen PP, Jackson L, Hennessy P, Brown J. Comparison of a positive expiratory pressure (PEP) mask with postural drainage in patients with cystic fibrosis. Australian Paediatric Journal 1987;23(5):283-4. [CFGD REGISTER: PE10] - PubMed

References to studies excluded from this review

Baldwin 1994 {published data only}
    1. Baldwin DR, Hill AL, Peckham DG, Knox AJ. Effect of addition of exercise to chest physiotherapy on sputum expectoration and lung function in adults with cystic fibrosis. Respiratory Medicine 1994;88(1):49-53. [CFGD REGISTER: PE19] - PubMed
Baran 1977 {published data only}
    1. Baran D, Penalosa A, Degre S. Physical working capacity before and after chest physiotherapy in cystic fibrosis. Cystic Fibrosis 1977;-:239-44. [CFGD REGISTER: PE67]
Bilton 1992 {published data only}
    1. Bilton D, Dodd M, Webb AK. The benefits of exercise combined with physiotherapy in cystic fibrosis. Pediatric Pulmonology 1990;Suppl 5:253. [CFGD REGISTER: PE41a]
    1. Bilton D, Dodd ME, Abbot JV, Webb AK. The benefits of exercise combined with physiotherapy in the treatment of adults with cystic fibrosis. Respiratory Medicine 1992;86(6):507-11. [CFGD REGISTER: PE41b] - PubMed
Braggion 1995 {published data only}
    1. Braggion C, Cappelletti LM, Cornacchia M, Zanolla L, Mastella G. Short-term effects of three chest physiotherapy regimens in patients hospitalized for pulmonary exacerbations of cystic fibrosis: a cross- over randomized study. Pediatric Pulmonology 1995;19(1):16-22. [CFGD REGISTER: PE26c] - PubMed
    1. Cappelletti LM, Cornacchia M, Braggion C, Zanolla L, Mastella G. Short-term effects of 3 physiotherapy (CPT) regimens in cystic fibrosis (CF) patients hospitalized for a pulmonary exacerbation: a cross-over randomized trial. In: 18th European Cystic Fibrosis Conference; 1993 May 21-26; Madrid, Spain. 1993:W9.3. [CFGD REGISTER: PE26a] - PubMed
    1. Cappelletti LM, Cornacchia M, Braggion C, Zanolla L, Matella G. Short-term effects of three chest physiotherapy regimens on patients with cystic fibrosis hospitalized for pulmonary exacerbation: a crossover randomized study. Excerpta Medica International Congree Series 1993;1034:239-46. [CFGD REGISTER: PE26c]
Button 2003 {published data only}PE88
    1. Button BM, Catto-Smith AG, Olinsky A, Phelan PD, Story I. Newborn screening in cystic fibrosis: the physiotherapist's dilemma in safe and effective treatment – to tip or not to tip? American Journal of Respiratory and Critical Care Medicine 1998;157(3 Suppl):A130. [CENTRAL: 404023] [CFGD REGISTER: PE88e]
    1. Button BM, Heine R, Catto-Smith A, Olinsky A, Phelan PD, Story I. A twelve month comparison of standard versus modified chest physiotherapy in twenty infants with cystic fibrosis. Pediatric Pulmonology 1997;Suppl 14:299. [CENTRAL: 208199] [CFGD REGISTER: PE88a]
    1. Button BM, Heine RG, Catto Smith AG, Phelan PD, Olinsky A. Postural drainage and gastro-oesophageal reflux in infants with cystic fibrosis. Archives of Disease in Childhood 1997;76(2):148-50. [CENTRAL: 137610] [CFGD REGISTER: PE88g] [PMID: ] - PMC - PubMed
    1. Button BM, Heine RG, Catto-Smith A, Olinsky A, Phelan PD, Ditchfield M, et al. The five year follow-up of two groups of newly diagnosed infants with CF randomized to receive standard (with tip) or modified (without tip) physiotherapy during infancy. In: 24th European Cystic Fibrosis Conference; 2001 Jun 6-9; Vienna, Austria. 2001:P111. [CENTRAL: 354395] [CFGD REGISTER: PE88d]
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Cantin 2006 {published data only}
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Chatham 2004 {published data only}
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Corten 2020 {published data only}
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    1. PACTR201501001016415. Assisted autogenic drainage (chest physiotherapy) in South African children with cystic fibrosis. trialsearch.who.int/Trial2.aspx?TrialID=PACTR201501001016415 (first received 26 January 2015). [CFGD REGISTER: PE297a]
de Boeck 1984 {published data only}
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Desmond 1983 {published data only}
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Elkins 2005 {published data only}
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Falk 1984 {published data only}
    1. Falk M, Kelstrup M, Andersen JB, Kinoshita T, Falk P, Stovring S, et al. Improving the ketchup bottle method with positive expiratory pressure, PEP, in cystic fibrosis. European Journal of Respiratory Diseases 1984;65(6):423-32. [CFGD REGISTER: PE7] - PubMed
Fitzgerald 2005 {published data only}
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Ghasempour 2019 {published data only}
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Giles 1995 {published data only}
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Grasso 2000 {published data only}
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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 Annual Meeting Cystic Fibrosis Club Abstracts. 1978:49. [CFGD REGISTER: PE30]
Hofmeyr 1986 {published data only}
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    1. Webber BA, Hofmeyr JL, Hodson ME, Batten JC. Evaluation of positive expiratory pressure as an adjunct to postural drainage. In: 13th Annual Meeting of the European Working Group for Cystic Fibrosis; 1985 Nov 3-8; Jerusalem, Israel. 1985:95. [CFGD REGISTER: PE9a]
Holsclaw 1977 {published data only}
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Hristara‐Papadopoulou 2005 {published data only}
    1. Hristara-Papadopoulou A, Tsanakas J. Results of active cycle of breathing techniques and conventional physiotherapy in mucociliary clearance in children with cystic fibrosis. Hippokratia 2007;11(4):202-4. [CFGD REGISTER: PE240a] - PMC - PubMed
    1. Hristara-Papadopoulou A, Varsamis P, Diomou G. Physiotherapy in cystic fibrosis: an empirical comparison of two methods. Zeitschrift fur physiotherapeuten 2005;57(3):536-42. [CFGD REGISTER: PE240b]
Keller 2001 {published data only}
    1. Keller H, Liniger W, Fopp A, Hoch M, Knopfli B. Effects of daily harmonica play during in-hospital care of patients with cystic fibrosis. In: 24th European Cystic Fibrosis Conference; 2001 Jun 6-9; Vienna, Austria. 2001:P339. [CFGD REGISTER: PE126]
Kerrebijn 1982 {published data only}
    1. Kerrebijn KF, Veentjer R, Bonzet VD, Water E. The immediate effect of physiotherapy and aerosol treatment on pulmonary function in children with cystic fibrosis. European Journal of Respiratory Disease 1982;63(1):35-42. [CFGD REGISTER: PE76] - 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 Supplements 1995;151(4):A738. [CFGD REGISTER: PE37]
Klig 1989 {published data only}
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Kluft 1996 {published data only}
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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
Lannefors 1992 {published data only}
    1. Lannefors L, Wollmer P. Mucus clearance in cystic fibrosis – a comparison between postural drainage, PEP-mask and physical exercise. In: 11th International Cystic Fibrosis Congress; 1992 Aug 22-27; Dublin, Ireland. 1992. [CFGD REGISTER: PE46a] - PubMed
    1. Lannefors L, Wollmer P. Mucus clearance with three chest physiotherapy regimes in cystic fibrosis: a comparison between postural drainage, PEP and physical exercise. European Respiratory Journal 1992;5(6):748-53. [CFGD REGISTER: PE46b] - PubMed
Lorin 1971 {published data only}
    1. Lorin MI, Denning CR. Evaluation of postural drainage by measurement of sputum volume and consistency. American Journal of Physical Medicine 1971;50(5):215-9. [CFGD REGISTER: PE80] [MEDLINE: ] - PubMed
Lyons 1992 {published data only}
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    1. Lyons E, Chatham K, Campbell IA, Prescott RJ. Evaluation of the flutter VRP1 device in young adults with cystic fibrosis. In: 11th International Cystic Fibrosis Congress; 1992 Aug 22-27; Dublin, Ireland. 1992:AHP30. [CFGD REGISTER: PE60a]
Maayan 1989 {published data only}
    1. Maayan C, Bar-Yishay E, Yaacobi T, Marcus Y, Katznelson D, Yahav Y, et al. Immediate effect of various treatments on lung function in infants with cystic fibrosis. Respiration 1989;55(3):144-51. [CFGD REGISTER: IB56] - 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.
Marks 2004 {unpublished data only}
    1. Marks J, Hare K, Homnick D. The PercussiveTech HF Device compared to standard chest physiotherapy in patients with cystic fibrosis. In: 13th International Cystic Fibrosis Congress; 2000 Jun 4-8; Stockholm, Sweden. 2000. [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;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
Martinez Rodriguez 2017 {published data only}
    1. Martinez Rodriguez ME, Suarez Cortina L, Maiz Carro L, Ruiz-De-Valbuena M, Jimenez Cosmes L. A pulmonary rehabilitation program to increase adherence to airway clearance techniques for children and adults with cystic fibrosis. Journal of Cystic Fibrosis 2017;16 Suppl 1:S58. [CFGD REGISTER: PE248]
Maxwell 1979 {published data only}
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McCarren 2006 {published data only}
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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 DC. 1982:135. [CFGD REGISTER: PE83]
Natale 1994 {published data only}
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Newhouse 1998 {published data only}
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Oberwaldner 1986 {published data only}
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Orlik 2000 {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. [CFGD REGISTER: PE140] - PubMed
Orlik 2001 {published data only}
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Phillips 1998 {published data only}
    1. Phillips GE, Pike SE, Rosenthal M, Bush A. Holding the baby: head downwards positioning for physiotherapy does not cause gastro-oesophageal reflux. European Respiratory Journal 1998;12(4):954-7. [CFGD REGISTER: PE101] - PubMed
Placidi 2006 {published data only}
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Pryor 1979 {published data only}
    1. Hodson ME, Batten JC, Pryor JA, Webber BA. Evaluation of the forced expiration technique as an adjunct to postural drainage in the treatment of cystic fibrosis. In: 9th Meeting European Working Group for Cystic Fibrosis; 1979 Jun 12-13; Noordwijkerhout, The Netherlands. 1979:57. [CFGD REGISTER: PE78b]
    1. Pryor JA, Webber BA, Hodson ME, Batten JC. Evaluation of the forced expiration technique as an adjunct to postural drainage in treatment of cystic fibrosis. British Medical Journal 1979;2(6187):417-8. [CFGD REGISTER: PE78a] - PMC - PubMed
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Regelmann 1990 {published data only}
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    1. Regelmann WE, Elliott GR, Warwick WJ, Clawson CC. Reduction of sputum Pseudomonas aeruginosa density by antibiotics improves lung function in cystic fibrosis more than do bronchodilators and chest physiotherapy alone. American Review of Respiratory Disease 1990;4(Pt 1):914-21. [CFGD REGISTER: PI65b] - PubMed
Reix 2012 {published data only}
    1. NCT01509235. Self drainage in pediatric cystic fibrosis patients. clinicaltrials.gov/ct2/show/NCT01509235 (first received 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}
    1. Roos S, Birrer P, Rüdeberg A, Kraemer R. First experience with intrapulmonary percussive ventilation (IPV) in the treatment of patients with cystic fibrosis. In: 15th Annual Meeting of the European Working Group for Cystic Fibrosis; 1987; Oslo, Norway. 1987. [CFGD REGISTER: PE34]
Rossman 1982 {published data only}
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Salh 1989 {published data only}
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Samuelson 1994 {published data only}
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Sanchez Riera 1999 {published data only}
    1. Sanchez Riera H, Dapena Fernandez FJ, Gomez Dominguez F, Ortega Ruiz F, Elias Hernandez T, Montemayor Rubio T, et al. Comparative study of the efficacy of 2 respiratory physiotherapy protocols for patients with cystic fibrosis [Estudio comparativo de la eficacia de dos protocolos de fisioterapia respiratoria en pacientes con fibrosis quistica]. Archivos de Bronconeumologia 1999;35(6):275-9. [CFGD REGISTER: PE106] - PubMed
Scherer 1998 {published data only}
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Skopnik 1986 {published data only}
    1. Skopnik H, Waters W, Horwitz AE, Roth B, Genz-Bohm G. Evaluation of knock and vibration therapy and autogenic drainage in cystic fibrosis using a ventilation zintigraphical method [Beurteilung der Klopf- und Vibrations-Therpie und autogene Drainage bei cystischer Fibrose mittels eines ventilationsszintigraphischen Verfahrens]. Monatsschrift fur Kinderheilkunde 1986;134:583. [CFGD REGISTER: PE131]
Steven 1992 {published data only}
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Stites 2006 {published data only}
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Sutton 1985 {published data only}
    1. Sutton PP, Lopez Vidriero MT, Pavia D, Newman SP, Clay MM, Webber B, et al. Assessment of percussion, vibratory-shaking and breathing exercises in chest physiotherapy. European Journal of Respiratory Diseases 1985;66(2):147-52. [CFGD REGISTER: PE81] [MEDLINE: ] - PubMed
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Tannenbaum 2007 {published data only}
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Tonnesen 1984 {published data only}
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van der Schans 1991 {published data only}
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van Hengstum 1988 {published data only}
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Varekojis 2003 {published data only}
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Warwick 1990 {published data only}
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Warwick 1991 {published data only}
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References to other published versions of this review

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