The Science Journal of the American Association for Respiratory Care

2000 OPEN FORUM Abstracts

Airway Clearance Strategies in Cystic Fibrosis

S. Ammani Prasad MCSP Cystic Fibrosis Unit, Great Ormond Street Hospital for Children, London, UK

Lung disease is the major contributory factor to the morbidity and much of the mortality associated with cystic fibrosis (CF). Persistent infection and inflammation result in severe bronchial damage and respiratory insufficiency. Active clearance of bronchopulmonary secretions has long been an integral part of the respiratory management of CF. Airway clearance techniques aim in the short term to reduce airway resistance and improve ventilation and in the long term to slow the progressive damage to the lungs. Though the efficacy for chest physiotherapy in achieving these aims does not have a sound scientific basis (van der Schans 2000), particularly in the asymptomatic individual, the rationale for treatment is supported by evidence of early manifestation of infection and inflammation within the lungs (Konstan 1994, Armstrong 1995).
Traditionally chest physiotherapy constituted postural drainage and percussion administered to the patient by an assistant. With improved longevity, greater emphasis is placed on independence and quality of life and to this end several independently performed airway clearance techniques have been developed. These include the active cycle of breathing techniques, autogenic drainage, oscillatory PEP devices, high frequency chest wall oscillation and positive expiratory pressure (Prasad 2000). Each technique aims to facilitate independence, improve adherence and minimize the treatment related burden placed upon the patient. Examination of the literature to date, including comprehensive reviews of existing data (Thomas 1995, Williams 1994), does not offer any indisputable evidence as to which of the techniques is best. This is in part explained by the fact that most comparative studies of airway clearance techniques are of short duration, have insufficient subject numbers and the clinical application of techniques varies between studies. Despite these difficulties however, it is unlikely that there will be a simple answer to which technique is "best" and the primary aim of treatment should be to formulate a flexible management plan based on individual needs in order to provide maximum therapeutic value to each patient.
References
Konstan MW, Hilliard KA, Norvell TM, Berger M. Bronchoalveolar lavage findings in cystic fibrosis patients with stable, clinically mild lung disease suggest ongoing infection and inflammation. Am J Res Crit Care Med 1994;150:448-454
Armstrong DS, Grimwood K, Carzino R, et al. Lower respiratory tract infection and inflammation in infants with newly diagnosed cystic fibrosis. BMJ 1995;310:1571-1572
Prasad SA, Tannenbaum E, Mikelson C. Physiotherapy in cystic fibrosis. J R Soc Med 2000;93 (suppl. 38):27-36
Thomas J, Cook DJ, Brooks D. Chest physical therapy management of cystic fibrosis. A meta-analysis. J Res & Crit Care Med 1995;151:846-850
van der Schans C, Prasad SA, Main E. Conventional chest physiotherapy compared to any form of chest physiotherapy in cystic fibrosis (Cochrane Protocol). In: The Cochrane Libraray, Issue 2, 2000. Oxford: update software
Williams MT. Chest physiotherapy and cystic fibrosis. Why is the most effective form of treatment still unclear? Chest 1994;106:1872-1882

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