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Airway clearance techniques for bronchiectasis

  1. Annemarie L Lee1,2,3,*,
  2. Angela Burge4,
  3. Anne E Holland2,3,5

Editorial Group: Cochrane Airways Group

Published Online: 31 MAY 2013

Assessed as up-to-date: 19 OCT 2012

DOI: 10.1002/14651858.CD008351.pub2


How to Cite

Lee AL, Burge A, Holland AE. Airway clearance techniques for bronchiectasis. Cochrane Database of Systematic Reviews 2013, Issue 5. Art. No.: CD008351. DOI: 10.1002/14651858.CD008351.pub2.

Author Information

  1. 1

    The University of Melbourne, School of Physiotherapy, Carlton, Victoria, Australia

  2. 2

    Alfred Health, Department of Physiotherapy, Prahan, Australia

  3. 3

    Institute for Breathing and Sleep, Heidelberg, Australia

  4. 4

    The Alfred Hospital, Department of Physiotherapy, Melbourne, Victoria, Australia

  5. 5

    La Trobe University, Department of Physiotherapy, Bundoora, Victoria, Australia

*Annemarie L Lee, annlee@unimelb.edu.au. Annemarie.Lee@alfred.org.au.

Publication History

  1. Publication Status: New
  2. Published Online: 31 MAY 2013

SEARCH

 
Characteristics of included studies [ordered by study ID]
Figueiredo 2010

MethodsRandomised cross-over trial

Study setting: medical department, Brazil

Study duration: 9 days


Participants8 people (mean age 47.4 years) with stable bronchiectasis productive of 47.8 mL sputum per day


InterventionsIntervention: 1 session of oscillating PEP therapy using flutter, performed in seated position for 15 minutes' duration and 5 minutes' coughing after intervention

Control: 1 session of sham oscillating PEP (using flutter valve without sphere or lid). Same sequence of therapy applied
1-week washout period between interventions


OutcomesSputum volume (mL)

Measurement was recorded immediately following completion of the intervention


NotesNo adverse events

Funding: supported by Centers of Excellence Program (PRONEXFAPERJ), Brazilian Council for Scientific and Technological Development (CNPq), Financing for Studies and Projects (FINEP) and Rio de Janeiro State Research Supporting Foundation (FAPERJ)


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskQuote: "This was a randomised, blinded and crossover study. Randomization defined the order of interventions in accordance with a computer-generated sequence using a block size of 4"

Allocation concealment (selection bias)Unclear riskQuote: "The protocol to be applied (Flutter valve or Sham Flutter) was revealed to the investigator only at the onset of each experimental sequence..."

Comment: insufficient information provided

Blinding of participants and personnel (performance bias)
All outcomes
Unclear riskQuote: "One week before the testing protocol, each subject visited the laboratory for an introductory session to become familiar with the equipment and the procedures...In the Sham Flutter intervention, the subjects followed the same sequence of the Flutter Valve intervention, but the metallic sphere and the cover lid of the device were removed (Sham Flutter). Since the patients were not acquainted with the valve, they did not know its proper assembly"

Comment: as participants received training in the intervention, they may have been able to identify the difference in the sham intervention. Personnel were not blinded during delivery of the intervention (see above)

Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "...a second examiner blinded to the applied intervention processed the signals"

Comment: as other examiners were unblinded, blinding of the second examiner could have been compromised, but outcomes are objectively measured and likely to be resistant to any issues with blinding

Incomplete outcome data (attrition bias)
All outcomes
Low riskQuote: "...all completed the study."

Comment: complete data available for reported outcomes

Selective reporting (reporting bias)Low riskComment: all outcomes reported as outlined in the Methods section. Study protocol not available

Other biasLow riskQuote: "After washout period and prior to the second intervention, the patients were re-examined by a physician to ensure that they remained stable"

Quote: "Impedance values preceding Sham Flutter and Flutter Valve interventions were similar"

Comment: no carryover effect observed. No other risks identified

Guimaraes 2012

MethodsRandomised cross-over trial

Study setting: medical department, Brazil

Study duration: 24 days


Participants10 people (mean age 55.9 years) with stable bronchiectasis with a persistent productive cough


InterventionsIntervention 1: single session of oscillating PEP therapy using flutter, performed in seated position for 15 minutes' duration (breathing from total lung capacity until cough occurred) followed by 5 minutes' coughing

Intervention 2: single session of ELTGOL: performed in lateral decubitus position with the affected lung in the dependent position and the individual performing slow expirations with the glottis open from functional residual capacity to the residual volume

Control: 1 session participants in seated position, no manoeuvres performed for 15 minutes followed by 5 minutes of coughing
1 week wash out period between interventions

Before control and interventions sessions, salbutamol and a series of 5 minutes of voluntary coughing were administered


OutcomesSputum volume (dry weight) (g)

Spirometry (FEV1, FVC, FEV1/FVC, FEF25-75)

Static lung volumes (IC, VC, TLC, FRC, RV, RV/TLC, IC/TLC)

All measures were recorded immediately following completion of the intervention


NotesNo adverse events

Funding: sponsors and collaborators were Federal University of Rio de Janeiro Centro Universitário Augusto Motta (from clinicaltrials.gov)


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskQuote: "Patients were submitted to the control protocol and two interventions in a random order. Block randomisation sequences were created by a researcher not involved with recruitment, selection and assessments"

Allocation concealment (selection bias)Low riskQuote: "Sealed opaque envelopes containing patients' assignments were opened at the time of first treatment"

Blinding of participants and personnel (performance bias)
All outcomes
High riskNo information provided

Comment: participants and treating therapist(s) not likely to be blind to group allocation. This may influence outcome measures (spirometry, static lung volumes, sputum dry weight)

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskNo information provided

Comment: outcome assessor(s) not likely to be blind to group allocation. As outcomes are objectively measured (spirometry, static lung volumes, sputum dry weight), it is likely they are resistant to any issues with blinding

Incomplete outcome data (attrition bias)
All outcomes
Low riskQuote: "All individuals tolerated and completed the steps in this study"

Complete data available for reported outcomes

Selective reporting (reporting bias)Low riskProtocol available, all specified outcomes reported

Other biasLow riskQuote: "Measurements of static lung volumes were conducted before the spirometry to avoid any residual effect of dynamic compression of the airways in the plethysmography results"

Comment: attempts to minimise the impact of multiple measures of lung function were made

Kurz 1997

MethodsRandomised cross-over trial

Study setting: medical department, Germany

Study duration: 6 months


Participants9 children with bronchiectasis (aged 6-16 years), with stable bronchiectasis (7 participants had a primary diagnosis of primary ciliary dyskinesia, but were classified as bronchiectasis)


InterventionsIntervention: oscillating PEP using flutter, to use 3 times a day, breathing out 60 times

Control: Sham Oscillating PEP using flutter (without metal ball). Same prescription of therapy applied


OutcomesSpirometry (VC, FEV1, PEFR)

Static lung volumes (FRC)

Measurements were recorded after a 3-month intervention


NotesNo specified run-in period, no details of washout period between interventions

Funding: not stated


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskComment: nothing is stated other than it was randomised

Insufficient information provided

Allocation concealment (selection bias)Unclear riskComment: nothing is stated regarding the concealment of assignment of participants to treatment order

Insufficient information provided

Blinding of participants and personnel (performance bias)
All outcomes
High riskComment: the authors noted that it was possible that the participants were aware of the differences between the devices when they were used as it did not oscillate during the control phase. No comment on the blinding of personnel during the study

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskNo information provided

Comment: outcome assessor(s) not likely to be blind to group allocation. As outcomes are objectively measured (spirometry, static lung volumes), it is likely they are resistant to any issues with blinding

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskComment: report states that 3 participants refused the sham therapy, but it is unclear whether this was during the trial period (withdrawal) or afterwards (refusal after participation)

Selective reporting (reporting bias)Unclear riskNo protocol available. Insufficient information provided

Other biasUnclear riskDuration of washout not reported, which may influence outcomes. Insufficient information provided

Murray 2009

MethodsRandomised cross-over trial

Study setting: Edinburgh

Study duration: 7 months


Participants20 people, median age 73 years, clinically stable (no prescription of antibiotics in 4 weeks prior to participation). Not performing regular chest physiotherapy


InterventionsIntervention: oscillating PEP with Acapella device (regimen of 3 sets of 10 breaths, 2-3 huffs and cough, resistance set at 3) undertaken twice daily (duration of 20-30 minutes) for 3 months

Control: standard medical care with no physiotherapy intervention (oscillating PEP device retained by physiotherapist during the non-treatment phase)

1-month washout period between interventions


OutcomesNumber of exacerbations

Cough-related quality of life (Leicester Cough Questionnaire)

HRQoL (St George's Respiratory Questionnaire)

24-hour sputum volume

Spirometry (FEV1, FVC, FEF25-75)


NotesNo adverse events

No other interventions or changes to care during the study

Funding: this study was funded by a Small Project Grant (NHS Lothian Research and Development Fund, Edinburgh, UK). M. Murray is funded by the Chief Scientist Office (Edinburgh)


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskQuote: "randomisation was determined by computer generation..."

Allocation concealment (selection bias)Unclear riskNo information provided

Unclear whether adequate

Blinding of participants and personnel (performance bias)
All outcomes
High riskNo information provided

Comment: participants and treating therapists not likely to be blind to group allocation. May have affected outcomes (HRQoL, FEV1, FVC, FEF25-75%, number of exacerbations)

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskNo information provided

Comment: outcome assessor(s) not likely to have been blind to group allocation (presumably the same therapist that prescribed the intervention). May have affected primary (HRQoL, sputum volume) or secondary (FEV1, FVC, FEF25-75%, number of exacerbations) outcomes

Incomplete outcome data (attrition bias)
All outcomes
Low riskComplete data available for reported outcomes

Selective reporting (reporting bias)High riskProtocol available, not all outcomes reported

Other biasLow riskAdequate washout period (1 month) applied

Sutton 1988

MethodsRandomised cross-over trial

Study setting: UK

Study duration: 4 occasions


Participants8 people, age range of 36-71 years, mean sputum production of 30 g


InterventionsIntervention: PD (position not disclosed) with forced expiration technique for 20 minutes

Control: resting sitting position

No bronchodilator or normal airway clearance on study morning prior to treatment


OutcomesSpirometry (FEV1, FVC)

Sputum wet weight (g) (during and 30 minutes post treatment)

Radioaerosol clearance (whole lung and inner/outer region clearance)


NotesNo bronchodilator or normal airway clearance on study morning prior to treatment

Funding: not stated


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskQuote: "the treatment schedules, given in randomised order..."

Comment: unclear whether adequate

Allocation concealment (selection bias)Unclear riskNo information provided

Comment: unclear whether adequate

Blinding of participants and personnel (performance bias)
All outcomes
High riskNo information provided

Comment: participants and therapists not likely to have been blind to group allocation. May have affected outcome measures (FEV1, FVC, sputum weight and radioaerosol clearance)

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskNo information provided

Comment: outcome assessors not likely to be blinded to group allocation. May have affected outcome measures (FEV1, FVC, sputum weight and radioaerosol clearance)

Incomplete outcome data (attrition bias)
All outcomes
Low riskComplete data available for reported outcomes

Selective reporting (reporting bias)Low riskComplete data available for reported outcomes

Other biasHigh riskWashout period unclear (presumably consecutive days)

 
Characteristics of excluded studies [ordered by study ID]

StudyReason for exclusion

Ambrosino 1995Mixed disease sample, bronchiectasis data not available (via correspondence with author)

Antunes 2001No appropriate control

Bradley 2006Not an ACT

Briffa 2011Not an ACT

Cecins 1999Mixed disease sample, bronchiectasis data not available (via correspondence with author)

Cegla 1993No appropriate control

Clinkscale 2012No appropriate control

Conway 1992Not an ACT

Crisafulli 2007Not an ACT

Currie 1988Not an ACT, not a randomised trial

Daviskas 2008Not an ACT

Eaton 2007No appropriate control

Gallon 1991No appropriate control

Gokdemir 2011No appropriate control

Hartsell 1987Mixed disease sample, unable to contact author for bronchiectasis data

Hasani 1994Mixed disease sample, data for bronchiectasis not available (via correspondence with author)

Hasani 1995Mixed disease sample, data for bronchiectasis not available (via correspondence with author)

Herrero 2011No appropriate control

Indinnimeo 2007No appropriate control

Joshi 2004Not an ACT

Kaminska 1988Not a randomised trial

Kellett 2001Not an ACT

Kellett 2005Not an ACT

Kellett 2005aNot an ACT

Kellett 2011Not an ACT

Larroquet 1997Not an ACT

Lee 2010Not an ACT

Long 2001Mixed disease sample, unable to contact author for bronchiectasis data

Maa 2007Not an ACT

Mazzocco 1985Not a randomised trial

Moran 2007No appropriate control

Morgan 1999No appropriate control

Mutalithas 2008Not a randomised trial, no appropriate control

Nakamura 2003Not an ACT

Naraparaju 2010No appropriate control

Newall 2005Not an ACT

Newton 1979Not a randomised trial

Noone 1999Not an ACT

Paneroni 2011No appropriate control

Patterson 2003No appropriate control

Patterson 2004No appropriate control

Patterson 2005No appropriate control

Patterson 2005aNo appropriate control

Patterson 2007No appropriate control

Polverino 2012No appropriate control

Santamaria 1998Not a randomised trial

Savci 1998Not a randomised trial

Su 2012No appropriate control

Sutton 1983Mixed disease sample, unable to contact author for bronchiectasis data

Syed 2009No appropriate control

Tambascio 2011No appropriate control

Thompson 2000No appropriate control

Thompson 2002No appropriate control

Tsang 1994Not an ACT

Tsang 2003No appropriate control (via correspondence with author)

Valente 2004No relevant outcomes reported

Venturelli 2013No appropriate control

Volker 1972Not an ACT

Wilson 1995Mixed disease group, bronchiectasis data not available (via correspondence with author)

 
Characteristics of ongoing studies [ordered by study ID]
Hill 2000

Trial name or title

Methods

Participants

Interventions

Outcomes

Starting date

Contact information

NotesIdentified by 2009 search. Requires further information to confirm appropriateness

Murray 2007

Trial name or title

Methods

Participants

Interventions

Outcomes

Starting date

Contact information

NotesIdentified by 2009 search. Requires further information to confirm appropriateness

 
Comparison 1. Positive expiratory pressure-based airways clearance techniques (ACT) versus no ACT (control)

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Stable bronchiectasis: PEP-based ACTs vs. no ACTs (control): sputum volume after 1 session1Mean Difference (Fixed, 95% CI)Totals not selected

 
Summary of findings for the main comparison. Airway clearance techniques for individuals with stable bronchiectasis

ACTs for individuals with stable bronchiectasis

Patient or population: individuals with stable bronchiectasis
Settings: hospital (outpatient department)
Intervention: airway clearance techniques (ACTs)

OutcomesIllustrative comparative risks* (95% CI)Relative effect
(95% CI)
No of participants
(studies)
Quality of the evidence
(GRADE)
Comments

Assumed riskCorresponding risk

ControlAirway clearance techniques (ACTs)

Number of exacerbations of bronchiectasis
Frequency of acute exacerbations of bronchiectasis
Follow-up: mean 3 months
35 per 100125 per 100
(8 to 79)1
RR 0.71
(0.23 to 2.25)
20
(1 study)
⊕⊕⊝⊝
low2,3
Duration of each intervention was 3 months of PEP-based ACT

HospitalisationsSee commentSee commentSee commentSee commentSee commentNot reported

Health-related quality of life (disease-specific)
Health-related quality of life (disease specific). Scale from: 0 to 100 lower score indicates better HRQoL. SGRQ total score consists of weighted scores from 3 domains
Follow-up: mean 3 months
The median health-related quality of life (disease-specific) in the control groups was
-0.7 points1
The median health-related quality of life (disease-specific) in the intervention groups was
8.5 higher1
20
(1 study)
⊕⊕⊝⊝
low2,4

Health-related quality of life (cough-specific)
Leicester Cough Questionnaire. Scale from: 0 to 133. Higher score indicates better HRQOL. Contains 19 questions from 3 domains on a Likert scale
Follow-up: mean 3 months
The median health-related quality of life (cough-specific) in the control groups was
0.0 points1
The median health-related quality of life (cough-specific) in the intervention groups was
1.3 higher1
20
(1 study)
⊕⊕⊝⊝
low2,4

Lung functionSee commentSee commentSee commentSee commentSee commentNo significant difference reported for any lung function test. Unable to perform meta-analysis

SymptomsSee commentSee commentSee commentSee commentSee commentNo studies reported on the effect of ACTs on symptoms

Adverse events (AE)See commentSee commentSee commentSee commentSee comment1 study reported no AE related to use of PEP-based ACTs. 2 studies reported no AEs

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: confidence interval; PEP: positive expiratory pressure; RR: risk ratio; SGRQ: St George's Respiratory Questionnaire.

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

 1 Study was a randomised cross-over trial.
2 Absence of allocation concealment, participants and therapists unblinded, not all outcomes were reported.
3 Small number of participants and few events evident.
4 Small number of participants.