Mini-symposium: Airway clearance in cystic fibrosis
Airway clearance devices in cystic fibrosis

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Summary

Clearance of infected airway secretions is essential to preserve lung function in patients with cystic fibrosis (CF). Although the value of regular airway clearance treatments has been shown in many studies, adherence to the prescribed treatments is not very good (see Making airway clearance successful, pp. 000–000). In the past the only method available was conventional chest physiotherapy (CCPT; also known as manual percussion and postural drainage). CCPT remains the ‘gold standard’ of airway clearance methods and may be the best choice for some patients, such as infants and young children. However, the many newer methods of airway clearance available now allow CF patients and their families to choose the techniques and devices that best suits them. Most of the newer airway clearance devices have been studied in comparison to standard chest physiotherapy and most studies show no advantage of one method over another. This review will describe newer airway clearance devices available for CF patients and discuss evidence for the effectiveness of these devices compared to standard chest physiotherapy.

Section snippets

Positive expiratory pressure

The PEP device is the simplest and least expensive of the airway clearance devices. The PEP mask was developed in Denmark in the late 1970s as an alternative to CCPT. The mask has a one-way inhalation valve and an expiratory resistor. Exhalation through the resistor generates positive pressure in the airways which can be measured with a manometer or pressure indicator. Resistance orifices of different diameters can be chosen so that individual patients can generate pressures of 10–20 cm H2O. The

Flutter®

The Flutter® (Axcan Scandipharm, Birmingham, Alabama, USA) is a small, handheld, mucus clearance device that provides PEP therapy with oral airway oscillations. It is shaped like a pipe with a hardened plastic mouthpiece at one end, a plastic, protective, perforated cover at the other end, and a high-density stainless steel ball resting in a plastic circular cone on the inside (Fig. 2). The patient sits comfortably and inhales to about 75% of inspiratory capacity, then exhales through the

Conclusion

Several devices have been developed to enhance airway clearance in CF patients. With the exception of the PEP valve, these devices all involve airway oscillation, either orally or via chest wall vibration. The advantage of these devices is that they can be used by patients independently without the need for an assistant or caregiver. Most of these devices have been studied in either short- or long-term comparisons with CCPT. The studies are generally underpowered and it is not clear which

Practice points

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    Airway clearance devices as alternatives to CCPT allow CF patients to choose the therapy that best fits their lifestyle and allows greatest independence

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    Airway clearance devices are preferred by many patients compared to CCPT and may result in better adherence.

  • •

    PEP may be more effective for airway clearance than CCPT.

  • •

    Oscillating positive expiratory pressure devices and HFCWO appear to be at least as effective as CCPT.

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