SPUTUM CLEARANCE for spontaneously-breathing patients – manual and mechanical techniques, cough, minitracheostomy, drugs and cough
(SEE ALSO – cystic fibrosis, humidification)

BTS GUIDELINES for the management of cough in adults (2006). Thorax, 61 (Suppl 1) i1-i24

AARC (2015) Clinical Practice Guideline: effectiveness of pharmacologic airway clearance therapies in hospitalized patients. Respir Care; 60(7):1071-7. doi: 10.4187/respcare.04165
• β2-agonists can increase ciliary beat frequency in healthy subjects, but do not have a significant impact on mucus clearance in people with lung disease, and anticholinergics may reduce mucus secretion, do not improve mucus clearance

AARC (2013) Clinical Practice Guideline: effectiveness of nonpharmacologic airway clearance therapies in hospitalized patients. Respir Care; 58(2):2187-2193

AARC Clinical Practice GUIDELINE: Use of positive airway pressure adjuncts to bronchial hygiene therapy. Respir Care, 38, 5, 516–21

AARC Clinical Practice GUIDELINE (1993): Directed cough. Respir Care, 8, 5, 495–9


NICE GUIDELINES on urinary incontinence.

video on the Acapella:

Al-Hajjaj MS (2017) Management of chronic unexplained cough. Ann Rehab Med; 40(2):1-2

Alves LA et al (2008) Performance analysis of the Flutter CRP1 under different flows and angles. Respir Care, 53, 3, 316-23

Andersen T (2013) Laryngeal response patterns to mechanical insufflation-exsufflation in healthy subjects.Am J Phys Med Rehabil; 92(10):920-9.

Anderson J, Hasney K, Beaumont N (2005) Systematic review of techniques to enhance peak cough flow and maintain vital capacity in neuromuscular disease: the case for mechanical insufflation–exsufflation. Phys Ther Rev, 10, 1, 25-33

Andrews J, Sathe NA, Krishnaswami S et al (2013) Nonpharmacologic airway clearance techniques in hospitalized patients: a systematic review. Respir Care; 58(12):2160-2186

Baldwin (1994) Effect of addition of exercise to chest physiotherapy on sputum expectoration and lung function in CF adults. Respir Med, 88, 49-53
• exercise increases mucociliary clearance

Beach L, Denehy L, Lee A (2013) The efficacy of minitracheostomy for the management of sputum retention: a systematic review. Physiother; 99(4):271-7

Bennett WD, Laube BL, Corcoran T et al (2013). Multisite comparison of mucociliary and cough clearance measures using standardized methods. J Aerosol Med Pulm Drug Deliv, 26(3):157-164. doi:10.1089/jamp.2011.0909

Button BM et al (1994) Postural drainage exacerbates gastroesophageal reflux in patients with lung disease. Ped Research, 36, 1, 2.
• gastrooesophageal reflux worsened by head-down PD

Bye (1997) Exercise performance and rehabilitation in CF. Crit Rev Phys Rehab Med. 9, 1, 1-33
• exercise increases mucociliary clearance

Cantin AM, Bacon M, Berthiaume Y (2006) Mechanical airway clearance using the frequencer electro-acoustical transducer in cystic fibrosis. Clin Invest Med, 29, 3, 159-65.

Cecins NM, Jenkins SC, Pengelley J, Ryan G (2002) The active cycle of breathing techniques--to tip or not to tip? Respir Med, 93, 660-5
• head-down tip during ACBT may reduce adherence

Chen EY, Daley D (2012) Functionalized carboxyl nanoparticles enhance mucus dispersion and hydration. Sci Rep, 2, 211

Clinkscale D, Spihlman K, Watts P et al (2012) A randomized trial of conventional chest physical therapy versus high frequency chest wall compressions in intubated and non-intubated adults. Respir Care, 57, 2, 221-8

Cross J, Elender J (2012) Findings from the MATREX study: a treatment protocol for the delivery of manual chest therapy in respiratory care. Respir Care, 57, 8, 1263-6

Dallimore K, Jenkins S (1998) Respiratory and cardiovascular responses to manual chest percussion in normal subjects. Austr J Physioth, 44, 267-74
• chest percussion increases sputum volume, oxygen consumption and heart rate

Deakins K, Chatburn RL (2002) A comparison of intrapulmonary percussive ventilation and conventional chest physiotherapy for the treatment atelectasis in the pediatric patient. Respir Care, 47, 10, 1162-7

Döring G (2004) Early intervention and prevention of lung disease in cystic fibrosis: a European consensus. J Cyst Fibr, 3, 2, 67-91

Eaton T (2007) A randomized evaluation of the acute efficacy, acceptability and tolerability of Flutter and active cycle of breathing with and without postural drainage in non-cystic fibrosis bronchiectasis. Chron Respir Dis, 4: 23-30
• ACBT with postural drainage is more effective than ACBT alone or the Flutter, but is more acceptable to patients than the Flutter:

Elkins MR, Jones A, van der Schans C (2004) Positive expiratory pressure physiotherapy for airway clearance in people with cystic fibrosis. The Cochrane Database of Systematic Reviews 2004, Issue 1. Art. No.: CD003147. DOI: 10.1002/14651858.CD003147.pub2
• PEP is preferred by some patients

Elliott S (2014) A retrospective analysis of the use of EZPAP positive pressure device by respiratory physiotherapists. Ass Chartered Physiotherapists Respir Care J; 45:4-14

Feng W, Deng WW (1998) Short-term efficacy of RC-Cornet in bronchiectasis. Chest, 114, 320
• the Cornet decreases sputum viscosity

Fink JB (2002) Positive pressure techniques for airway clearance. Resp Care, 47, 786-96
• mechanism of PEP therapy

Goodfellow LT (2002) Bronchial hygiene therapy. Am J Nurs, 102, 1, 37-42

Hardy (1993) Advances in our understanding of CF. Resp Care, 38, 282-9.
• autogenic drainage improves airflow in small airways which are normally inaccessible

Haas CS, Loik PS, Gay SE (2007) Airway clearance applications in the elderly and in patients
with neurologic or neuromuscular compromise. Respir Care, 52, 10,1362–1381

Hassam M, Williams M (2003) Education via simulation: teaching safe chest percussion for pre-term infants. HK Physiother J, 21, 22-8

Herrero-Cortina B, Vilaró J, D. Martí D et al (2015) Short-term effects of three slow expiratory airway clearance techniques in patients with bronchiectasis: a randomised crossover trial. J Physiotherapy; 101(1):e206–e207. doi: dx.doi.org/10.1016/j.physio.2015.03.372

Hess DR (2007) Airway clearance: physiology, pharmacology, techniques, and practice. Respir Care, 52, 10, 1392–1396

Holland AE, Button BM (2006) Is there a role for airway clearance techniques in chronic obstructive pulmonary disease? Chronic Respir Dis, 3, 2, 83-91
• PEP and autogenic drainage are thought to be effective, but it may be advisable to avoid techniques that involve forced expiration

Homnick DN (2007) Mechanical insufflation-exsufflation for airway mucus clearance. Respir Care, 52, 10, 1296–1305
• includes physiology of cough

Houtmeyers (1999) Regulation of mucociliary clearance. Eur Resp J, 13, 1177-88

Iyer VN, Lim KG (2013) Chronic cough: an update. Mayo Clin Proc;88(10):1115-26. doi: 10.1016/j.mayocp.2013.08.007.

Jarad NA, Powell T, Smith E (2010) Evaluation of a novel sputum clearance technique—hydro-acoustic therapy in adult patients with cystic fibrosis. Chronic Resp Dis, 7, 4, 217-27
• acoustic waves can clear secretions by creating vibrations through a fluid, for patients who are willing to sit in a bath

Jones E, Beagen K, Tetlow S et al (2005) reliability of vibrations and shaking as a respiratory technique. ACPRC Journal, 37, 25-34

Jones CU, Kluayhomthong S, Chaisuksant S et al (2013) Breathing exercise using a new breathing device increases airway secretion clearance in mechanically ventilated patients. Heart Lung; 42(3):177-182

Kamikawa N, Taito S, Makoto Takahashi M et al (2016) Effect of different levels of pressure relieving air-mattress firmness on cough strength. PLoS ONE; 11(1): e0146714. doi: 10.1371/journal.pone.0146714

King M (1997) Mucoactive therapy. Ped Pulmonol, suppl.14, 122-3
• how oscillations reduce viscosity of secretions

Laghia F (2017) Determinants of cough effectiveness in patients with respiratory muscle weakness. Resp Physiol Neurobiol; 240: 17–25

Lai SK, Wang Y-Y, Wirtz D et al (2010) Micro- and macrorheology of mucus. Adv Drug Deliv Rev, 61(2): 86–100

Lester MK, Flume PA (2009) Airway-clearance therapy guidelines and implementation. Respir Care, 54, 6, 733-50

Lewis LK, Williams MT, Olds TS (2012) The active cycle of breathing technique: a systematic review and meta-analysis. Respir Med; 106(2):155-72. doi: 10.1016/j.rmed.2011.10.014

Luginbuehl H, Baeyens J-P, Kuhn A et al (2016) Pelvic floor muscle reflex activity during coughing – an exploratory and reliability study. Ann Physical Rehab Med; 59(5-6):302-307. doi: 10.1016/j.rehab.2016.04.005

Main E, Grillo L, Rand S (2015) Airway clearance strategies in cystic fibrosis and non-cystic fibrosis bronchiectasis. Semin Respir Crit Care Med; 36(2):251-66. doi: 10.1055/s-0035-1546820

McCarren B, Alison JA, Herbert RD (2006) Vibration and its effect on the respiratory system. Austr J Physiother, 52, 39-43
• vibrations create greater peak expiratory flow than chest compressions.

McKoy NA, Wilson LM, Saldanha IJ et al (2016) Active cycle of breathing technique for cystic fibrosis. Cochrane Database Syst Rev ;7:CD007862. doi: 10.1002/14651858.CD007862.pub4
• ACBT has similar outcomes to other clearance techniques

McIlwaine M, Wong LT, Chilvers M et al (2010) Long-term comparative trial of two different physiotherapy techniques; postural drainage with percussion and autogenic drainage, in the treatment of cystic fibrosis. Pediatr Pulmonol; 45(11):1064-9. doi: 10.1002/ppul.21247
• patients tend to prefer AD to CPT

Morice AH (2006) Recommendations for the management of cough in adults. Thorax, 61(Suppl I), i1–i24. doi:10.1136/thx.2006.065144

Munkholm M, Mortensen J (2013) Mucociliary clearance: pathophysiological aspects. Clin Physiol Funct Imaging; 34(3):171–177. doi: 10.1111/cpf.12085

Myers TR (2007) Positive expiratory pressure and oscillatory positive expiratory pressure therapies. Respiratory Care, 52, 10, 1308-26
• PEP and Flutter compared, with no evidence of inferiority to other methods.

Nadel JA (2013) Mucous hypersecretion and relationship to cough.
Pulm Pharmacol Ther; 26(5):510-3

Newbold E et al (2005) The Flutter device versus the PEP mask in the treatment of adults with cystic fibrosis. Physiother Canada, 57, 199-207
• effects of flutter and PEP mask are equivalent.

Olsén FM, Westerdahl E (2009) Positive expiratory pressure for patients with chronic obstructive pulmonary disease – a systematic review. Respiration, 77, 1, 110-8

Osadnik CR, McDonald CF, Holland AE (2014) Clinical issues of mucus accumulation in COPD. Internat J Chron Obstruct Pulmon Dis; 9:301-302

Osadnik CR, McDonald CF, Jones AP (2012) Airway clearance techniques for chronic obstructive pulmonary disease. Cochrane Database Syst Rev; 3:CD00832
• modest benefits from airway clearance techniques for people with COPD in the acute and chronic states.

O’Shea M, Morgan C (2012) Lung herniation after cough-induced rupture of intercostal muscle. N Engl J Med, 366, 1, 74

Paneroni M, Clini E, Simonelli C et al (2011) Safety and efficacy of short-term intrapulmonary percussive ventilation in patients with bronchiectasis. Respir Care, 56, 7, 984-8. doi: 10.4187/respcare.01098

Patel AS, Watkin G, Willig B et al (2011) Improvement in health status following cough-suppression physiotherapy for patients with chronic cough. Chron Respir Dis, 8, 253-8
• control of unnecessary coughing by education, breathing retraining and vocal hygiene

Park H et al (2012) Effect of high-frequency chest wall oscillation on pulmonary function after pulmonary lobectomy for non-small cell lung cancer. Critical Care Medicine, 40, 9, 2583–9.
• high frequency oscillation has been found effective postoperatively

Peek K, Carey M, Sanson-Fisher R et al (2016) Physiotherapists' perceptions of patient adherence to prescribed self-management strategies: a cross-sectional survey of Australian physiotherapists. Disabil Rehabil; 39(19):1932-1938. doi: 10.1080/09638288.2016.1212281

Ragavan AJ (2010) Interactions of airflow oscillation, tracheal inclination, and mucus elasticity significantly improve simulated cough clearance. Chest, 137, 355-361
• airflow oscillation and sitting upright facilitates mucus clearance

Ramos EM, Ramos D, Moreira GL et al (2015) Viscoelastic properties of bronchial mucus after respiratory physiotherapy in subjects with bronchiectasis. Respir Care; 60(5):724-30. doi: 10.4187/respcare.02429

Ramos EM, Vanderlei LC, Ito JT et al (2016) Acute mucociliary clearance response to aerobic exercise in smokers. Respir Care; 60(11):1575-84. doi: 10.4187/respcare.04093

Rogers DF (2005) The role of airway secretions in COPD: pathophysiology, epidemiology and pharmacotherapeutic options. COPD, 2, 3, 341-353
• different mucus hypersecretory phenotypes in COPD

Rubin BK (2002) Physiology of airway mucus clearance. Respir Care, 47, 761-8
• mucus, cilia, surfactant, cough, ‘chest physical therapy’

Rush EC (2013) Water: neglected, unappreciated and under researched. Eur J Clin Nutr; 67(5):492-495. doi:10.1038/ejcn.2013.11

Ryan NM, Gibson PG, Birring SS (2016) Arnold’s nerve cough reflex: evidence for chronic cough as a sensory vagal neuropathy. J Thorac Dis; 6(Suppl 7): S748–S752. doi: 10.3978/j.issn.2072-1439.2014.04.22

Savci S (2000) A comparison of autogenic drainage and the active cycle of breathing in COPD. J.Cardiopulm.Rehab. 20, 37-43 Eur.Resp.J, 11, 1389-91
• AD showed greater increase in SaO2 and peak flow than ACBT

Sears PR, Thompson K, Knowles MR et al (2013) Human airway ciliary dynamics. Am J Physiol Lung Cell Mol Physiol; 304(3):L170-83

Sethi S, Yin J, Anderson PK (2014) Lung flute improves symptoms and health status in COPD with chronic bronchitis: a 26 week randomized controlled trial. Clin Transl Med; 3:29. doi: 10.1186/s40169-014-0029-y
• ‘lung flute’ is similar to the Cornet, but this study on people with COPD did not describe treatment for the control group

Sontag MK et al (2010) Lessons learned from a randomized trial of airway secretion clearance techniques in CF. Ped Pulmonol, 45, 291-300
• satisfaction is higher with the vest or flutter than with postural drainage

Strickland SL (2015) Year in review 2014: airway clearance. Respir Care; 60(4):603-605. doi: 10.4187/respcare.04095

Svenningsenab S (2017) Noncystic fibrosis bronchiectasis: regional abnormalities and response to airway clearance therapy using pulmonary functional magnetic resonance imaging. Academic Radiol; 24(1):4–12
• oscillatory PEP improves ventilation, symptoms, exercise capacity and quality of life for people with bronchiectasis

Syed N (2009) Active cycles of breathing technique (ACBT) versus conventional chest physical therapy on airway clearance in bronchiectasis – a crossover trial. Adv Physiother, 11, 4, 193-8
• both techniques equally effective, but patients tend to prefer ACBT

Thompson CS, Harrison S, Ashley J (2002) Randomised crossover study of the flutter device and the active cycle of breathing technique in non-cystic fibrosis bronchiectasis. Thorax, 57, 446-8
• flutter is as effective as ACBT for bronchiectasis
Toussaint M, Pernet K, Steens M et al (2016) Cough augmentation in subjects with Duchenne Muscular Dystrophy: comparison of air stacking via a resuscitator bag versus mechanical ventilation. Respir Care; 61(1):61-7. doi: 10.4187/respcare.04033
• both methods achieved mean air stacking-assisted cough peak flow values of >160 l/min. An inexpensive resuscitator bag can improve cough capacity and is simple to use, which may improve access to respiratory care in people with a weak cough

Tsang SMH, Jones AYM (2003) Postural drainage or flutter device in conjunction with breathing and coughing compared to breathing and coughing alone. Hong Kong Physiotherapy J, 21, 29-35
• breathing techniques are as good as postural drainage and flutter for bronchiectasis

Volsko TA, DiFiore JM, Chatburn RL (2003) Performance comparison of two oscillating positive expiratory pressure devices: acapella versus flutter. Respir Care, 48, 124-30.
• mechanism of both devices, including ability of acapella to be used at any angle

Vianello A (2005) Mechanical insufflation-exsufflation improves outcomes for neuromuscular disease patients with respiratory tract infections. Am J Phys Med Rehabil, 84, 83-8.

Volsko TA (2013) Airway clearance therapy: finding the evidence. Respir Care; 58(10):1669-78

Williams MT, Parsons DW, Frick RA (2000) Energy expenditure during physiotherapist-assisted and self-treatment in CF. Physiother Theory Pract, 16, 57-67.

Willis LD (2015) Mechanical insufflation-exsufflation: the good, the bad, and the ugly. Respir Care; 60(7):1081-1082

AARC = American Association for Respiratory Care
ACBT = active cycle of breathing techniques
CF = cystic fibrosis
ERS = European Respiratory Society
FEV1 = forced expiratory volume in one second
PD = postural drainage
PEP = positive expiratory pressure