New Directions in Chest Physiotherapy

Condensed from the talk by Gale Hoffman, R.R.T., R.C.P.

Fall 1994

Gale Hoffman, Assistant Director of the Respiratory Care Department at Lucile Salter Packard Children's Hospital at Stanford gave an impressive introduction to respiratory therapies that might be used as alternatives to our standard chest physiotherapy (CPT).

Autogenic Drainage (AD) was first introduced in 1968 in Europe, but has only recently become popular in the U.S. Although there is very little literature on AD, many swear by it. AD is performed with very careful breath control, putting the highest possible airflow behind secretions, starting at the smallest airways and moving the mucus out to the larger airways. Each step is followed by "huff" coughing. Ms. Hoffman stressed the importance of using huff coughing several times during her talk, saying it was less stressful and required less energy than ordinary coughing. A huff cough is performed by taking in a deep breath, holding it for one to three seconds and letting it out in a quick forced exhalation with an open glottis (whisper "huff" as you cough). While AD is advantageous in that it requires no equipment, Hoffman says it can be hard to learn and she does not recommend trying it before eight years of age.

Positive Expiratory Pressure (PEP) started in Denmark approximately 15 years ago. With the help of a PEP device, the individual is expected to exhale actively (not forcibly, which promotes wheezing) against the pressure the device creates. Again, this is followed by huff coughing. Ms. Hoffman said that PEP was a slightly better method for stabilizing airways.

The Flutter valve was newly approved this summer for use in the U.S. It looks like a large whistle-shaped device. The patient places it in the mouth, breathes in around it, closes the mouth and exhales. During exhalation, a ball inside oscillates and sends vibrations into the airways which help to dislodge secretions. After five to ten such breaths, the patient increases the expiratory flow for two to three breaths. This is followed by huff coughing. Ms. Hoffman noted the following advantages: the Flutter has been shown to be more effective than chest physiotherapy, it is very easy to learn, and is highly portable. It costs approximately $120 and is more durable than a PEP device.

Finally, Ms. Hoffman introduced Intrapulmonary Percussive Ventilation Therapy (IPV). This device was initially built for high-frequency ventilation in adults, but this usage has had limited acceptance. While not cheap (the machine costs approximately $3,000), the IPV is an excellent secretion-clearance device. It can provide oscillations on inspiration and expiration. Patients select the frequency of oscillations, which may be different for each individual. A working source pressure around the oscillations is generated only during exhalation. It administers the aerosol and the CPT at the same time, therefore reducing treatment time. This machine utilizes a very efficient nebulizer. Because of the weight of the device (it has an air compressor inside it), the IPV is a less portable form of respiratory therapy.

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