Alternatives to Chest Physiotherapy

Notes on a talk given at the Annual CFRI Conference by Gale Hoffman, R.R.T., R.C.P.

Fall 1995

Gale Hoffman, R.R.T., R.C.P., and Assistant Director of Respiratory Care at Packard Children's Hospital at Stanford, reviewed current alternatives to chest physiotherapy (CPT), the time-honored method of airway clearance in the United States. She acknowledged the myriad complaints associated with CPT, including that it is uncomfortable, time-consuming and requires a second person to assist. Poor compliance was also a problem. More recently, caregivers providing frequent CPT are struggling with repetitive motion injuries, such as carpal tunnel syndrome and neck and shoulder injuries, and are also looking for alternatives.

On this note, she outlined other choices available, stressing that CF patients should be instructed in the use of all airway clearance therapies. Hoffman noted that varying therapies work differently depending on one's temperament, lifestyle, age, compliance level and health. She encouraged CF patients of all ages to keep abreast of all the techniques and try them again and again to be certain the current choice is indeed the most effective one.

Hoffman began her discussion with the introduction of Positive Expiratory Pressure (PEP), in which the patient uses a pressurized breath (the PEP device provides resistance to the breath) to splint open the airway. The patient can then move the mucus from the peripheral airways into the small airways and finally into the larger airways where one can cough up the mucus plug. She noted that PEP can be used in children as young as four years old, it takes less time than CPT, is relatively inexpensive, is easy to learn and requires no second person to provide the therapy.

The second method discussed was Autogenic Drainage (AD), a complex three-staged breathing procedure which again brings mucus from the tiny peripheral airways into the large airways where it can be expectorated. Hoffman noted many advantages to AD including increased sputum production and that it can be performed without help, anywhere, any time and without any devices. She cautioned that AD was harder to learn and suggested patients be at least 12 before trying it. The method requires concentration and is not for everyone, although it appeared to be popular among adults with CF attending our conference.

The third method discussed was the newly-approved Flutter valve. The patient inhales, then places the Flutter in the mouth and exhales into a chamber holding a metal ball. The metal ball oscillates, causing vibrations which travel into the patient's lungs shaking free mucus plugs the patient can cough up. Like PEP, this device is relatively inexpensive, easy to use (for children as young as four), requires no second person, cuts therapy time and has been shown to be more effective in clearing secretions than CPT.

Hoffman very briefly covered IPV (Intrapulmonary Percussive Ventilation) and the High-frequency chest Wall Oscillator (the vest) therapies. These methods are less popular because of the cost of the equipment needed, but they are effective airway clearance devices, easier than CPT and should be explored in the hunt for the best respiratory therapy!

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