Long-term comparative trial of positive expiratory pressure versus oscillating positive expiratory pressure (flutter) physiotherapy in the treatment of cystic fibrosis

doi:10.1067/mpd.2001.114017

The Journal of Pediatrics

Volume 138, Issue 6, June 2001, Pages 845-850

https://doi.org/10.1067/mpd.2001.114017 Get rights and content

Abstract

Objective: The objective was to evaluate the long-term effects of physiotherapy with an oscillating positive pressure device (“flutter”) compared with physiotherapy with the use of a positive expiratory pressure (PEP) mask in patients with cystic fibrosis (CF). Study design: Forty children with CF were randomly assigned to performing physiotherapy with the PEP mask or the flutter device for 1 year. Clinical status, pulmonary function, and compliance were measured at regular intervals throughout the study. Results: The flutter group demonstrated a greater mean annual rate of decline in forced vital capacity compared with the PEP group (–8.62 ± 15.5 vs 0.06 ± 7.9; P =.05) with a similar trend in forced expiratory volume in 1 second (–10.95 ± 19.96 vs –1.24 ± 9.9; P =.08). There was a significant decline in Huang scores (P =.05), increased hospitalizations (18 vs 5; P =.03), and antibiotic use in the flutter group. Conclusion: Flutter was not as effective in maintaining pulmonary function in this group of patients with CF compared with PEP and was more costly because of the increased number of hospitalizations and antibiotic use.(J Pediatr 2001;138:845-50)

Section snippets

Patients

Patients with CF attending BC’s Children’s Hospital CF Clinic (n = 40, 24 boys), aged 7 to 17 years, with Shwachman scores 54 to 98 and forced expiratory volume in 1 second 47% to 107% predicted for age, sex, and height were enrolled. Informed consent was obtained as approved by the University of British Columbia Ethical Review committee. The diagnosis of CF was confirmed by the Gibson-Cooke sweat test.¹⁸ At entry to the study all patients were performing the PEP technique as their daily home

Results

A broad range of pulmonary function was represented (FEV₁ 47% to 107% predicted). Both groups appeared to be evenly matched with regard to FEV₁, age, colonization with Pseudomonas aeruginosa, Shwachman score, and sex (Table).

Table. Characteristics of patients on enrollment

Empty Cell	PEP	Flutter
Empty Cell	Group A	Group B
Mean FVC (%)	92.40 ± 12.93	90.81 ± 15.35
Mean FEV₁ (%)	84.45 ± 16.32	81.25 ± 16.32
Mean FEF_25-75 (%)	59.45 ± 22.96	54.85 ± 17.48
Mean Shwachman	86.45 ± 9.77	84.90 ± 8.52
Pseudomonas aeruginosa colonization	8/20	10/20

Discussion

This study compared the efficacy of physiotherapy with the flutter device versus the PEP technique. Although we could not mask (“blind”) the patient or physiotherapist as to which technique the patient with CF was performing, the clinic physicians assessing the patients and the respiratory therapist performing pulmonary function testing were blinded as to which physiotherapy technique the patients were using. Compliance (or adherence) also was an important issue in this study, because it is one

Acknowledgements

The authors thank Anna Gravelle and Sharon Gyorgy from the Division of Biochemical Diseases and Cystic Fibrosis Clinic, the physiotherapy staff at B.C.’s Children’s Hospital, and the safety monitoring committee for this study.

References (31)

LW Matthews et al.
A therapeutic regimen for patients with cystic fibrosis
J Pediatr
(1964)
KJ Desmond et al.
Immediate and long-term effects of chest physiotherapy in patients with cystic fibrosis
J Pediatr
(1983)
JJ Reisman et al.
Role of conventional physiotherapy in cystic fibrosis
J Pediatr
(1988)
MW Konstan et al.
Efficacy of the flutter device for airway mucus clearance in patients with CF
J Pediatr
(1994)
EM App et al.
Sputum rheology changes in cystic fibrosis lung disease following two different types of physiotherapy
Chest
(1998)
MA Passero et al.
Patient reported compliance with cystic fibrosis therapy
Clin Pediatr
(1981)
T McDonnell et al.
Hypoxemia during chest physiotherapy in patients with cystic fibrosis
Ir J Med Sci
(1986)
Y Vandenplas et al.
Esophageal pH monitoring data during chest physiotherapy
J Pediatr Gastroenterol Nutr
(1991)
J Thomas et al.
Chest physical therapy management of patients with cystic fibrosis. A meta-analysis
Am J Respir Crit Care Med
(1995)
AL. Coates
Chest physiotherapy in cystic fibrosis: spare the hand and spoil the cough?
J Pediatr
(1997)

M Falk et al.

Improving the ketchup bottle method with positive expiratory pressure (PEP)

Eur J Respir Dis

(1984)

AG Davidson et al.

Comparative trial of positive expiratory pressure, autogenic drainage and conventional percussion and drainage techniques

Pediatr Pulmon

(1988)

P Tonnesen et al.

Positive expiratory pressure (PEP) as lung physiotherapy in cystic fibrosis: a pilot study

Eur J Respir Dis

(1984)

JC Tyrrell et al.

Face mask physiotherapy in cystic fibrosis

Arch Dis Child

(1986)

JL Hofmeyer et al.

Evaluation of positive expiratory pressure as an adjunct to chest physiotherapy in the treatment of cystic fibrosis

Thorax

(1986)

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The results demonstrated significant improvements in the amount of sputum per day.17 The importance of airway clearance therapies (ACTs) as a primary therapy for patients with CF has been confirmed and various ACTs have been developed.34-37 Thus, a study focused on the effectiveness of ACBT and AD on airway clearance, in terms of the wet weight of the expectorated sputum, in patients with bronchiectasis.
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The results of this updating review reinforced the data of a previous systematic review regarding the beneficial impact of ACBT for the short-term improvement in respiratory tract secretions clearance and pulmonary function. ACBT is effective in increasing the expectorated sputum volume, in reducing viscoelasticity of the secretion and in relieving symptoms such as dyspnea.
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Positive expiratory pressure (PEP) devices are an important element of the management of cystic fibrosis, and of other respiratory diseases. Whereas there have been reports in the literature of contamination of airway clearance devices and their surfaces by microbial pathogens, there is little evidence available regarding such contamination and its contribution to respiratory infection.
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Patients' home-use clearance devices were brought to a routine clinic appointment and collected for microbiology sampling and analysis. The patients were provided with replacement devices. Nineteen such devices were collected from 17 patients, reflecting use of multiple devices by some patients. Swabs were taken and cultured from each patient's used device, the patient's airway, as well as from new unopened and unused devices that acted as controls.
Seven of 19 devices (37%) tested positive for presence of pathogenic bacteria. Device-cleaning methods varied among patients and non-sterilization methods were found to be ineffective at removing pathogens. Microbial species found on the devices did not correlate with those identified from airway swabs.
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The proportions of the different airway clearance techniques recorded for people with CF in the UK are broadly comparable with Canada, except for a bias towards PEP over oscillating PEP in Canada. This difference may be explained by several Canadian studies which found that PEP therapy is more effective than flutter devices (a form of oscillating PEP) [28] and postural drainage [29]. Interestingly, data from the 2011 Canadian registry report differed from this study: 34% of people with CF used PEP, 29% used percussion, 9% used other techniques, 8% used no airway clearance, 7% used autogenic drainage or ‘breathing exercises’, 7% used high-frequency chest wall oscillation and 6% used flutter devices [30].
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Forced expiratory techniques and oscillating PEP are the most common airway clearance techniques used by people with CF in the UK, and postural drainage and high-frequency chest wall oscillation are the least common techniques. This is significant in terms of planning airway clearance technique trials, where postural drainage has been used traditionally as the comparator. The use of airway clearance techniques varies between countries, but the reasons for these differences are unknown.
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^☆: Supported by Telethon Funds, B.C.’s Children’s Hospital, Vancouver, British Columbia, Canada.

^☆☆: Reprint requests: A. G. F. Davidson, MD, B.C.’s Children’s Hospital - Room 2C66, 4480 Oak St, Vancouver, British Columbia V6H 3V4, Canada.

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Original ArticlesLong-term comparative trial of positive expiratory pressure versus oscillating positive expiratory pressure (flutter) physiotherapy in the treatment of cystic fibrosis☆,☆☆

Abstract

Section snippets

Patients

Results

Discussion

Acknowledgements

J Pediatr

J Pediatr

J Pediatr

J Pediatr

Chest

Patient reported compliance with cystic fibrosis therapy

Clin Pediatr

Hypoxemia during chest physiotherapy in patients with cystic fibrosis

Ir J Med Sci

Esophageal pH monitoring data during chest physiotherapy

J Pediatr Gastroenterol Nutr

Chest physical therapy management of patients with cystic fibrosis. A meta-analysis

Am J Respir Crit Care Med

Chest physiotherapy in cystic fibrosis: spare the hand and spoil the cough?

J Pediatr

Improving the ketchup bottle method with positive expiratory pressure (PEP)

Eur J Respir Dis

Comparative trial of positive expiratory pressure, autogenic drainage and conventional percussion and drainage techniques

Pediatr Pulmon

Positive expiratory pressure (PEP) as lung physiotherapy in cystic fibrosis: a pilot study

Eur J Respir Dis

Face mask physiotherapy in cystic fibrosis

Arch Dis Child

Evaluation of positive expiratory pressure as an adjunct to chest physiotherapy in the treatment of cystic fibrosis

Thorax

Original Articles
Long-term comparative trial of positive expiratory pressure versus oscillating positive expiratory pressure (flutter) physiotherapy in the treatment of cystic fibrosis☆,☆☆