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Airway clearance techniques in acute exacerbations of COPD: a survey of Australian physiotherapy practice
Physiotherapy 99 (2013) 101–106
Airway clearance techniques in acute exacerbations of COPD: a survey of Australian physiotherapy practice Christian R. Osadnik a,∗ , Christine F. McDonald b,c , Anne E. Holland a,c,d a
b
School of Physiotherapy, La Trobe University, Bundoora, Victoria, 3086, Australia Department of Respiratory and Sleep Medicine, Austin Health, Heidelberg, Victoria, 3084, Australia c Institute for Breathing and Sleep, Austin Health, Heidelberg, Victoria, 3084, Australia d Department of Physiotherapy, Alfred Health, Prahran, Victoria, 3181, Australia
Abstract Objectives To identify airway clearance techniques (ACTs) used to treat patients with acute exacerbations of chronic obstructive pulmonary disease (AECOPD) and identify factors underpinning their utilisation, including therapists’ knowledge of the literature. Design Cross-sectional postal survey using Likert scales and multiple-choice responses. Setting 112 ‘large’ or ‘principal referral’ Australian public hospitals. Participants 189 physiotherapists from 89 hospitals (response rate 81%). Main outcome measures Purpose designed survey measuring self-reported rate of ACT prescription; perception of ACT indications, aims, importance and effectiveness; factors influencing ACT choice; and knowledge of the evidence. Results Most physiotherapists (123/189, 65%) prescribed ACTs for 60–100% of patients with AECOPDs. The most frequently prescribed ACTs were physical exercise (169/189, 89%), the forced expiratory technique (153/189, 81%) and the active cycle of breathing technique (149/189, 79%). Most were rated highly effective. Physiotherapists who perceived the role of ACTs to be important to patients’ overall management (137/189, 73%) and those with less than 5 years cardiorespiratory experience (113/189, 60%) prescribed ACTs significantly more frequently than others. The main factors influencing ACT choice were precautions/contraindications to individual techniques (148/189, 78%) and degree of dyspnoea (136/189, 72%). The primary aim of ACT prescription was to clear sputum (178/189, 94%). Understanding of the evidence for ACTs in AECOPDs was mixed, with 43% citing it as supportive, 30% inconclusive and 19% unsure. Conclusions Australian physiotherapists frequently prescribe ACTs for patients with AECOPDs and perceive their role to be important. Physical exercise is frequently prescribed for airway clearance and warrants further investigation. © 2012 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved. Keywords: Pulmonary disease, chronic obstructive; Acute exacerbation; Health care surveys; Physical therapy modalities; Mucociliary clearance; Airway clearance techniques
Introduction Chronic obstructive pulmonary disease (COPD) is a disabling respiratory condition with a rising global prevalence [1]. It is defined by airflow obstruction that is not fully ∗ Correspondence: School of Physiotherapy, La Trobe University, Alfred Health Clinical School, Level 4, The Alfred Centre, 99 Commercial Road, Melbourne, Victoria, 3004, Australia. Tel.: +61 3 9479 6744; fax: +61 3 9533 2104. E-mail addresses: [email protected], [email protected] (C.R. Osadnik), [email protected] (C.F. McDonald), [email protected] (A.E. Holland).
reversible and is characterised by chronic and progressive breathlessness, cough and sputum production [2]. Chronic cough and sputum are independent risks of premature COPDrelated death [3–5] and are closely associated with frequent exacerbations [6]. Acute exacerbations of COPD (AECOPD) are clinically important events known to negatively affect quality of life [7,8], lung function [9,10], healthcare utilisation [11] and mortality [12]. Early therapy can enhance recovery and quality of life [13] and exercises to remove sputum from the airways (‘airway clearance techniques’) may be important. Airway clearance techniques (ACTs) work via manipulation of lung volumes, gas flow, pulmonary pressures and compressive forces to shear sputum
0031-9406/$ – see front matter © 2012 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.physio.2012.01.002
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along the airway lumen towards the mouth [14,15]. This process is essential for effective clearance of secretions in conditions where mucociliary dysfunction is present, such as COPD [15,16]. The clinical impact of ACTs during AECOPD is difficult to ascertain. There is a lack of strong evidence regarding their benefits [17–19] and their role is not universally advocated in international COPD management guidelines [2,20–22]. Awareness and interpretation of this evidence is likely to vary between therapists and may explain some of the global variability in clinical practice for patients with AECOPD. For example, the most frequently used ACT in the United Kingdom is the active cycle of breathing technique [23] whereas in Canada it is ‘conventional chest physiotherapy’ techniques (e.g. postural drainage, percussion, vibration) [24]. In Australia and New Zealand, the active cycle of breathing technique and deep breathing exercises are widely used for patients with COPD [25], however it is unclear whether this practice relates to individuals with acute or stable disease. Physiotherapists also reported that choice of ACT was significantly influenced by the ‘use of best practice’. There has been no documentation to date of clinicians’ knowledge of ‘best practice’ in this area, nor of the specific factors underpinning their clinical reasoning such as perceptions of the importance and effectiveness of airway clearance therapy. An understanding of these factors, as well as the true extent of ACT prescription for patients with an AECOPD may also provide important insight into the impact of this therapy on healthcare resources.
relating to physiotherapy experience, current practice or awareness of the literature (e.g. how frequently do you prescribe the ACTs?), only single responses were requested. Multiple responses were allowed for questions relating to clinical reasoning (e.g. ‘what do you consider to be important indications for ACTs in patients with AECOPD?’), including one ‘other’ free text response option. An initial draft was reviewed by two physiotherapists for content and face validity and a final draft was piloted on a representative cohort of five cardiorespiratory physiotherapists from one Australian state who were known to the research team but were ineligible to participate in the study. Minor amendments to wording were made without additional pilot testing. A copy of the survey is available in the online supplement. Supplementary material related to this article can be found, in the online version, at doi:10.1016/ j.physio.2012.01.002. For the purpose of this study, an AECOPD was defined as an admission to hospital for the management of problems relating to an acute exacerbation of previously diagnosed COPD, but excluded those requiring non-invasive ventilation or intubation. COPD included emphysema and/or chronic bronchitis and excluded asthma, bronchiectasis and cystic fibrosis. An ACT was defined as any physiotherapy technique used with the primary intent of clearing sputum from the airways. Setting and participants
Objective This study aimed to (a) identify current physiotherapy practice of ACTs during AECOPD in Australia; (b) examine perceptions of ACT importance and effectiveness; (c) explore factors which influence ACT prescription; and (d) identify physiotherapists’ knowledge of the evidence for ACTs during AECOPD. Method Design We created a new survey in accordance with evidencebased recommendations [26,27] to address the unique aims of this cross-sectional study as no appropriate validated tool existed. A review of previous similar studies and a comprehensive search of databases Medline, CINAHL, Embase and the Cochrane library were conducted in September 2009 and, with consultation with experts in the clinical field, gaps in the literature were identified and a set of corresponding clinical questions was generated in accordance with the study aims. To maximise the brevity of the survey, most questions were designed using 5-point Likert scales (e.g. ‘very often/always’, ‘often’, ‘sometimes’, ‘rarely’, ‘very rarely/never’) or multiple-choice responses. For questions
One paper-based survey was mailed to a ‘senior cardiorespiratory physiotherapist’ at all ‘principal referral’ and ‘large’ Australian public hospitals, identified via an Australian Government health resource [28]. Each survey was assigned a unique code for de-identification and follow-up purposes and was accompanied with an explanatory statement and reply-paid envelope. Recipients were instructed to distribute the survey to ‘all physiotherapists who usually treat patients with an AECOPD’, as the study aimed to document individual knowledge and opinion rather than consensus, site-specific practice. One reminder letter and an additional survey was sent to hospitals that did not reply within 3 weeks to maximise response rates. Surveys were only excluded from analysis when respondents indicated that patients with an AECOPD were not usually managed at their hospital. Individual consent was implied by return of completed surveys. Outcomes The main outcomes of this survey included: frequency of ACT prescription; perception of ACT effectiveness and importance; perception of the indications and aims of prescribing ACTs; factors influencing choice of ACTs; and knowledge of the ACT literature.
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Data analysis
Perceptions
Data were analysed using SPSS v.17 statistical package. Calculations of frequencies and percentages were made for nominal (categorical) data. Likert scales were analysed as ordinal data and, where clinically appropriate, pooled into fewer categories (e.g. dichotomised) to investigate relationships between variables (e.g. years of practice and knowledge of ACT literature) via the Chi-squared test (alpha set at 0.05).
Despite variation in the prescription of different ACTs (Fig. 1), physiotherapists widely perceived all ACTs to be effective (combined ‘very effective’ and ‘effective’) at clearing sputum. No obvious relationship was evident between the ACTs used by therapists and those perceived as being easy (combined ‘very easy’ and ‘easy’) for patients to master. Most (137/189, 73%) physiotherapists felt sputum clearance was a very or fairly important aspect of the overall management of patients with an AECOPD. Twice as many physiotherapists with less than 5 years cardiorespiratory experience (42% vs 21%) described their role as ‘very important’ compared to those with more cardiorespiratory experience (χ2 = 9.391, P = 0.052). A significantly greater proportion of respondents who perceived ACTs to be important (combined ‘very important’ and ‘fairly important’) prescribed them frequently compared to those who perceived their role to be less important (χ2 = 7.715, P = 0.021).
Results Demographic data Responses were received from 91/112 (81%) Australian hospitals of which 63% were situated in major cities, 25% from inner regional areas (i.e. rural, close to urban centres), 10% outer regional areas (i.e. rural, far from urban centres), and 2% remote areas (i.e. isolated from urban centres) [29]. Two hospitals indicated that they did not manage patients with an AECOPD and were not included in the data analysis. A median of one (range 1–9) survey from each site yielded 189 surveys for final analysis. There was an even proportion of physiotherapists with less than (90/189, 48%) or greater than 5 years experience. More physiotherapists (113/189, 60%) had worked in the cardiorespiratory field for less than 5 years. Current practice ACTs were prescribed frequently (more than 60% of all patients with an AECOPD) by two-thirds (123/189, 65%) of physiotherapists, however treatment duration was almost always (170/189, 90%) short (5–20 minutes). Those with less than 5 years cardiorespiratory experience prescribed ACTs significantly more often than those with more than 5 years experience (χ2 = 5.729, P = 0.017). The ACTs most frequently prescribed by physiotherapists (combined ‘very often/always’ and ‘often’ responses) were physical exercise (169/189, 89%), the forced expiratory technique or ‘huff’ (153/189, 81%), active cycle of breathing technique (149/189, 79%) and cough (138/189, 73%). Gravity-assisted postural drainage (11/189, 6%), autogenic drainage (9/189, 5%), ‘other ACTs’ (free text response option) (7/189, 4%) including nebulisation therapy, non-invasive ventilation, singing and chest stroking (described only as ‘a Russian technique’) and mechanical vibration (0/189, 0%) were prescribed infrequently. Fig. 1 shows that techniques classified as breathing exercises (active cycle of breathing technique, sustained maximal inspiration, deep breathing exercises or autogenic drainage) and physical exercise were prescribed considerably more than positive expiratory pressure (any oscillatory or nonoscillatory form) and conventional chest physiotherapy techniques.
Clinical reasoning The most frequently identified indicators for ACTs were ‘difficulty managing secretions’ (185/189, 98%), ‘a recent change in sputum characteristics’ (171/189, 91%), ‘signs of an infectious AECOPD’ (148/189, 78%) and the ‘need for education’ (145/189, 77%). Those least frequently identified were ‘the presence of secretions’ (85/189, 45%) and ‘anyone with a productive cough’ (80/189, 42%). A significantly greater proportion of physiotherapists with less than 5 years’ cardiorespiratory experience perceived ‘a recent change in sputum characteristics’ (χ2 = 8.676, P = 0.003) and ‘anyone with a productive cough’ (χ2 = 5.685, P = 0.017) as indicators for ACTs in patients with AECOPD compared to those with more cardiorespiratory experience. The most commonly reported aims of prescribing ACTs were ‘to clear sputum’ (178/189, 94%), ‘enhance recovery from the AECOPD’ (129/189, 68%), ‘improve oxygen saturation’ (128/189, 68%) and ‘prevent pulmonary complications’ (118/189, 62%). They were rarely prescribed to reduce mortality (52/189, 28%), cough frequency (49/190, 26%) or antibiotic need (24/190, 13%). The most common factors influencing physiotherapists’ choice of ACT included ‘contraindications or precautions to individual techniques’ (148/189, 78%), ‘the degree of dyspnoea or work of breathing’ (136/189, 72%) and ‘access to resources or equipment’ (125/189, 66%). No consensus opinion of when to cease ACTs was apparent. The most common endpoints were ‘when there is no evidence of sputum’ (81/189, 43%) and ‘when sputum characteristics return to baseline’ (77/189, 41%). Only 2% (4/189) of physiotherapists felt it appropriate to cease ACTs ‘whenever the patient wants to stop’ and 1% (2/189) ‘upon hospital discharge’.
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Fig. 1. Incidence of ACT use, effectiveness and ease of mastery, by classification.
Knowledge of the ACT literature Physiotherapists’ understanding of the evidence for ACTs in patients with an AECOPD varied considerably. Only 4/189 (2%) felt it refuted (weakly) the effectiveness of ACTs, whilst 56/189 (30%) rated it conflicting/inconclusive, 43/189 (23%) weakly supportive, 39/189 (21%) strongly supportive and 35/189 (18%) unsure, with 12/189 (6%) missing. Responses did not differ between physiotherapists with less than or greater than 5 years cardiorespiratory experience (χ2 = 4.956, P = 0.292). A significantly greater proportion of respondents that perceived ACTs to be important felt the literature supported (combined ‘strong support’ and ‘weak support’) the role of ACTs in an AECOPD compared to those who did not perceive their role to be important (χ2 = 9.800, P = 0.007). Physiotherapists who felt the literature strongly supported the role for ACTs during an AECOPD did not differ significantly from others in terms of cardiorespiratory experience, rate of ACT prescription or perception of the importance of ACTs. Conclusion This is the first study to document the relationship between current practice, clinical reasoning strategies and opinions and knowledge of the ACT literature by Australian physiotherapists for patients with AECOPD. It addresses an important gap in the medical literature and provides useful insight into clinical practice in an area where treatment efficacy is unclear [17–19]. The high response rate of this study (81%) affirms that our findings are likely to reflect Australian physiotherapy practice and therefore enables comparison with practice in the United Kingdom [23] and Canada [24]. A major finding from this study was the high rate of ACT prescription. This widespread practice appears disproportionate to previous findings of randomised controlled trials of the effectiveness of ACTs during AECOPD [30–34]. Despite treatment duration being relatively short, the resources in
terms of staff and equipment required to provide this therapy would undoubtedly contribute significantly to the high direct healthcare costs associated with COPD hospitalisations, estimated as 63% of the total COPD healthcare burden in Australia [35]. This highlights the importance of clarifying the value of ACTs in this population and the need for further research in this area. This survey showed that ACTs were prescribed significantly more by those physiotherapists who perceived their role as being important (the majority). This demonstrates an important link between beliefs and practice and may potentially explain the ongoing use of ACTs in the absence of clear evidence [17–19]. Physiotherapists with less than 5 years cardiorespiratory experience were also shown to prescribe ACTs significantly more than those with greater experience, however they did not perceive their role to be any more important. The reason for this variability in ACT prescription was not clear. They did not interpret the medical literature differently but did report a significantly greater consideration of certain clinical indicators that they felt warranted the use of ACTs. This possibly reflects an experience-based difference in clinical reasoning strategies, which has previously been documented in acute cardiorespiratory physiotherapy [36–38]. As there are no guidelines to recommend how often ACTs should be prescribed it is difficult to know whether one subgroup of the profession is ‘right’ or ‘wrong’. The utilisation of different ACTs varied considerably and appeared unrelated to their perceived effectiveness to clear sputum or patients’ ease to master (refer Fig. 1). Factors such as the suitability of individual ACTs (including dyspnoea) for individuals and access to resources or equipment reportedly influenced ACT choice. We did not explore the relationship between these factors and specific ACTs, but feel they may partially explain the lower use of conventional chest physiotherapy techniques (due to orthopnoea or risk of gastro-oesophageal reflux) and positive expiratory pressure (due to access to equipment).
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The high utilisation of breathing exercises by Australian physiotherapists is consistent with previous studies in Australia [25] and the United Kingdom [23], however the widespread use of physical exercise as an ACT has not previously been documented. This finding was unexpected as there have been very few studies on this topic to date. A randomised crossover study involving eight subjects with stable chronic bronchitis showed significantly increased scintigraphic measures of (total lung) mucus clearance by 7.5% following 20 minutes of interval cycle ergometry. The magnitude of this treatment effect was greater than for postural drainage which showed no significant improvement but considerably less than coughing which increased mucus clearance by 40.8% [39]. It is conceivable that exercise-induced changes in respiratory rate and/or lung volumes could enhance intrapulmonary shearing of pulmonary secretions and facilitate airway clearance. It is not clear, however, how this process would be affected by the abnormal lung mechanics typical of COPD (e.g. early airway collapse, gas trapping, dynamic hyperinflation) and by some of the changes typical of an AECOPD (e.g. worsened airflow limitation, work of breathing and ventilation-perfusion mismatching). We did not ask respondents whether the widespread use of physical exercise as an ACT related to purposes of physical rehabilitation, that is, whether its prescription was intended to address both therapeutic goals, however all relevant survey items were worded specifically to address its role in airway clearance. Given the popularity of this technique, research that clarifies the efficacy of exercise as an ACT appears needed. This study suggests that Australian physiotherapists perceive ACTs to be indicated more for patients who are acutely unwell (e.g. infective exacerbations, difficulty managing secretions) rather than for those who are simply productive (with or without expectoration). The most common aims of prescribing ACTs (clearing sputum, improving oxygenation and preventing complications) indicated a trend towards the use of short-term outcomes and a relative lack of emphasis on outcomes relevant to patients and healthcare providers such as quality of life, exacerbation frequency and healthcare utilisation. With increasing recognition of the importance of these (latter) outcomes in the management of COPD, it is likely that the effectiveness of ACTs on such outcomes will need to be determined in order to justify their ongoing use. There was considerable variation in therapists’ perception of the evidence for ACTs in AECOPD that was unrelated to their experience or frequency of ACT prescription. In addition, almost half the responses were ‘unsure’, missing or incorrect according to our definition (‘strong support’). Whilst this may simply reflect the challenging nature of the current literature, which comprises a diverse range of techniques, outcomes and variable effects [18], it also reinforces the need for clinicians of all levels of experience to develop and maintain highly refined skills of critical appraisal. For until irrefutable consensus is reached on the value of ACTs in patients with an AECOPD, complex research findings such as these must be accurately translated into practice if the
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ongoing provision of therapy is to be justified. Whilst we noted a significant relationship between therapists’ perception of the importance of ACTs (important or not important) and the supportiveness of the literature (supportive or not supportive), we could not determine which influenced the other. For example, did stronger (or weaker) opinion of the value of ACTs increase (or decrease) one’s perception of the strength of the evidence or did perception of the strength of the evidence influence one’s opinion of the clinical value of ACTs? The findings from this study were derived from a large cohort of physiotherapists spanning a comprehensive and diverse range of hospitals across all publically funded settings in Australia in which people with COPD receive acute care. The high response rate means it is a likely accurate summary of current national practice that should serve as a useful comparison for other settings or countries. As the questionnaire was designed specifically for this study its reliability is unknown. Other limitations may have included the lack of representation of private sector hospitals and unknown accuracy relating to the questionnaire’s distribution within each facility (i.e. whether it actually reached the intended target population). In conclusion, this study has shown that Australian physiotherapists frequently prescribe ACTs for patients with an AECOPD and perceive their role to be important. Understanding of the evidence for ACTs during an AECOPD appears variable and highlights an area for continued improvement in today’s clinical environment, particularly in the absence of consensus regarding ACT effectiveness. As physiotherapists report prescribing ACTs to address short-term goals, a shift towards more patient-oriented or healthcare-oriented outcomes such as exacerbations, quality of life and healthcare utilisation appears indicated. Physical exercise is being widely prescribed for the purpose of airway clearance. Further investigations of its effects are warranted in order to validate this practice. Ethical approval: La Trobe University Faculty Human Ethics Committee (Ref. No. FHEC09/122). Funding: Christian Osadnik was supported by a La Trobe University Postgraduate (PhD) Research Scholarship. Conflict of interest: None declared.
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Available online at www.sciencedirect.com
Airway clearance techniques in acute exacerbations of COPD: a survey of Australian physiotherapy practice Christian R. Osadnik a,∗ , Christine F. McDonald b,c , Anne E. Holland a,c,d a
b
School of Physiotherapy, La Trobe University, Bundoora, Victoria, 3086, Australia Department of Respiratory and Sleep Medicine, Austin Health, Heidelberg, Victoria, 3084, Australia c Institute for Breathing and Sleep, Austin Health, Heidelberg, Victoria, 3084, Australia d Department of Physiotherapy, Alfred Health, Prahran, Victoria, 3181, Australia
Abstract Objectives To identify airway clearance techniques (ACTs) used to treat patients with acute exacerbations of chronic obstructive pulmonary disease (AECOPD) and identify factors underpinning their utilisation, including therapists’ knowledge of the literature. Design Cross-sectional postal survey using Likert scales and multiple-choice responses. Setting 112 ‘large’ or ‘principal referral’ Australian public hospitals. Participants 189 physiotherapists from 89 hospitals (response rate 81%). Main outcome measures Purpose designed survey measuring self-reported rate of ACT prescription; perception of ACT indications, aims, importance and effectiveness; factors influencing ACT choice; and knowledge of the evidence. Results Most physiotherapists (123/189, 65%) prescribed ACTs for 60–100% of patients with AECOPDs. The most frequently prescribed ACTs were physical exercise (169/189, 89%), the forced expiratory technique (153/189, 81%) and the active cycle of breathing technique (149/189, 79%). Most were rated highly effective. Physiotherapists who perceived the role of ACTs to be important to patients’ overall management (137/189, 73%) and those with less than 5 years cardiorespiratory experience (113/189, 60%) prescribed ACTs significantly more frequently than others. The main factors influencing ACT choice were precautions/contraindications to individual techniques (148/189, 78%) and degree of dyspnoea (136/189, 72%). The primary aim of ACT prescription was to clear sputum (178/189, 94%). Understanding of the evidence for ACTs in AECOPDs was mixed, with 43% citing it as supportive, 30% inconclusive and 19% unsure. Conclusions Australian physiotherapists frequently prescribe ACTs for patients with AECOPDs and perceive their role to be important. Physical exercise is frequently prescribed for airway clearance and warrants further investigation. © 2012 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved. Keywords: Pulmonary disease, chronic obstructive; Acute exacerbation; Health care surveys; Physical therapy modalities; Mucociliary clearance; Airway clearance techniques
Introduction Chronic obstructive pulmonary disease (COPD) is a disabling respiratory condition with a rising global prevalence [1]. It is defined by airflow obstruction that is not fully ∗ Correspondence: School of Physiotherapy, La Trobe University, Alfred Health Clinical School, Level 4, The Alfred Centre, 99 Commercial Road, Melbourne, Victoria, 3004, Australia. Tel.: +61 3 9479 6744; fax: +61 3 9533 2104. E-mail addresses: [email protected], [email protected] (C.R. Osadnik), [email protected] (C.F. McDonald), [email protected] (A.E. Holland).
reversible and is characterised by chronic and progressive breathlessness, cough and sputum production [2]. Chronic cough and sputum are independent risks of premature COPDrelated death [3–5] and are closely associated with frequent exacerbations [6]. Acute exacerbations of COPD (AECOPD) are clinically important events known to negatively affect quality of life [7,8], lung function [9,10], healthcare utilisation [11] and mortality [12]. Early therapy can enhance recovery and quality of life [13] and exercises to remove sputum from the airways (‘airway clearance techniques’) may be important. Airway clearance techniques (ACTs) work via manipulation of lung volumes, gas flow, pulmonary pressures and compressive forces to shear sputum
0031-9406/$ – see front matter © 2012 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.physio.2012.01.002
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along the airway lumen towards the mouth [14,15]. This process is essential for effective clearance of secretions in conditions where mucociliary dysfunction is present, such as COPD [15,16]. The clinical impact of ACTs during AECOPD is difficult to ascertain. There is a lack of strong evidence regarding their benefits [17–19] and their role is not universally advocated in international COPD management guidelines [2,20–22]. Awareness and interpretation of this evidence is likely to vary between therapists and may explain some of the global variability in clinical practice for patients with AECOPD. For example, the most frequently used ACT in the United Kingdom is the active cycle of breathing technique [23] whereas in Canada it is ‘conventional chest physiotherapy’ techniques (e.g. postural drainage, percussion, vibration) [24]. In Australia and New Zealand, the active cycle of breathing technique and deep breathing exercises are widely used for patients with COPD [25], however it is unclear whether this practice relates to individuals with acute or stable disease. Physiotherapists also reported that choice of ACT was significantly influenced by the ‘use of best practice’. There has been no documentation to date of clinicians’ knowledge of ‘best practice’ in this area, nor of the specific factors underpinning their clinical reasoning such as perceptions of the importance and effectiveness of airway clearance therapy. An understanding of these factors, as well as the true extent of ACT prescription for patients with an AECOPD may also provide important insight into the impact of this therapy on healthcare resources.
relating to physiotherapy experience, current practice or awareness of the literature (e.g. how frequently do you prescribe the ACTs?), only single responses were requested. Multiple responses were allowed for questions relating to clinical reasoning (e.g. ‘what do you consider to be important indications for ACTs in patients with AECOPD?’), including one ‘other’ free text response option. An initial draft was reviewed by two physiotherapists for content and face validity and a final draft was piloted on a representative cohort of five cardiorespiratory physiotherapists from one Australian state who were known to the research team but were ineligible to participate in the study. Minor amendments to wording were made without additional pilot testing. A copy of the survey is available in the online supplement. Supplementary material related to this article can be found, in the online version, at doi:10.1016/ j.physio.2012.01.002. For the purpose of this study, an AECOPD was defined as an admission to hospital for the management of problems relating to an acute exacerbation of previously diagnosed COPD, but excluded those requiring non-invasive ventilation or intubation. COPD included emphysema and/or chronic bronchitis and excluded asthma, bronchiectasis and cystic fibrosis. An ACT was defined as any physiotherapy technique used with the primary intent of clearing sputum from the airways. Setting and participants
Objective This study aimed to (a) identify current physiotherapy practice of ACTs during AECOPD in Australia; (b) examine perceptions of ACT importance and effectiveness; (c) explore factors which influence ACT prescription; and (d) identify physiotherapists’ knowledge of the evidence for ACTs during AECOPD. Method Design We created a new survey in accordance with evidencebased recommendations [26,27] to address the unique aims of this cross-sectional study as no appropriate validated tool existed. A review of previous similar studies and a comprehensive search of databases Medline, CINAHL, Embase and the Cochrane library were conducted in September 2009 and, with consultation with experts in the clinical field, gaps in the literature were identified and a set of corresponding clinical questions was generated in accordance with the study aims. To maximise the brevity of the survey, most questions were designed using 5-point Likert scales (e.g. ‘very often/always’, ‘often’, ‘sometimes’, ‘rarely’, ‘very rarely/never’) or multiple-choice responses. For questions
One paper-based survey was mailed to a ‘senior cardiorespiratory physiotherapist’ at all ‘principal referral’ and ‘large’ Australian public hospitals, identified via an Australian Government health resource [28]. Each survey was assigned a unique code for de-identification and follow-up purposes and was accompanied with an explanatory statement and reply-paid envelope. Recipients were instructed to distribute the survey to ‘all physiotherapists who usually treat patients with an AECOPD’, as the study aimed to document individual knowledge and opinion rather than consensus, site-specific practice. One reminder letter and an additional survey was sent to hospitals that did not reply within 3 weeks to maximise response rates. Surveys were only excluded from analysis when respondents indicated that patients with an AECOPD were not usually managed at their hospital. Individual consent was implied by return of completed surveys. Outcomes The main outcomes of this survey included: frequency of ACT prescription; perception of ACT effectiveness and importance; perception of the indications and aims of prescribing ACTs; factors influencing choice of ACTs; and knowledge of the ACT literature.
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Data analysis
Perceptions
Data were analysed using SPSS v.17 statistical package. Calculations of frequencies and percentages were made for nominal (categorical) data. Likert scales were analysed as ordinal data and, where clinically appropriate, pooled into fewer categories (e.g. dichotomised) to investigate relationships between variables (e.g. years of practice and knowledge of ACT literature) via the Chi-squared test (alpha set at 0.05).
Despite variation in the prescription of different ACTs (Fig. 1), physiotherapists widely perceived all ACTs to be effective (combined ‘very effective’ and ‘effective’) at clearing sputum. No obvious relationship was evident between the ACTs used by therapists and those perceived as being easy (combined ‘very easy’ and ‘easy’) for patients to master. Most (137/189, 73%) physiotherapists felt sputum clearance was a very or fairly important aspect of the overall management of patients with an AECOPD. Twice as many physiotherapists with less than 5 years cardiorespiratory experience (42% vs 21%) described their role as ‘very important’ compared to those with more cardiorespiratory experience (χ2 = 9.391, P = 0.052). A significantly greater proportion of respondents who perceived ACTs to be important (combined ‘very important’ and ‘fairly important’) prescribed them frequently compared to those who perceived their role to be less important (χ2 = 7.715, P = 0.021).
Results Demographic data Responses were received from 91/112 (81%) Australian hospitals of which 63% were situated in major cities, 25% from inner regional areas (i.e. rural, close to urban centres), 10% outer regional areas (i.e. rural, far from urban centres), and 2% remote areas (i.e. isolated from urban centres) [29]. Two hospitals indicated that they did not manage patients with an AECOPD and were not included in the data analysis. A median of one (range 1–9) survey from each site yielded 189 surveys for final analysis. There was an even proportion of physiotherapists with less than (90/189, 48%) or greater than 5 years experience. More physiotherapists (113/189, 60%) had worked in the cardiorespiratory field for less than 5 years. Current practice ACTs were prescribed frequently (more than 60% of all patients with an AECOPD) by two-thirds (123/189, 65%) of physiotherapists, however treatment duration was almost always (170/189, 90%) short (5–20 minutes). Those with less than 5 years cardiorespiratory experience prescribed ACTs significantly more often than those with more than 5 years experience (χ2 = 5.729, P = 0.017). The ACTs most frequently prescribed by physiotherapists (combined ‘very often/always’ and ‘often’ responses) were physical exercise (169/189, 89%), the forced expiratory technique or ‘huff’ (153/189, 81%), active cycle of breathing technique (149/189, 79%) and cough (138/189, 73%). Gravity-assisted postural drainage (11/189, 6%), autogenic drainage (9/189, 5%), ‘other ACTs’ (free text response option) (7/189, 4%) including nebulisation therapy, non-invasive ventilation, singing and chest stroking (described only as ‘a Russian technique’) and mechanical vibration (0/189, 0%) were prescribed infrequently. Fig. 1 shows that techniques classified as breathing exercises (active cycle of breathing technique, sustained maximal inspiration, deep breathing exercises or autogenic drainage) and physical exercise were prescribed considerably more than positive expiratory pressure (any oscillatory or nonoscillatory form) and conventional chest physiotherapy techniques.
Clinical reasoning The most frequently identified indicators for ACTs were ‘difficulty managing secretions’ (185/189, 98%), ‘a recent change in sputum characteristics’ (171/189, 91%), ‘signs of an infectious AECOPD’ (148/189, 78%) and the ‘need for education’ (145/189, 77%). Those least frequently identified were ‘the presence of secretions’ (85/189, 45%) and ‘anyone with a productive cough’ (80/189, 42%). A significantly greater proportion of physiotherapists with less than 5 years’ cardiorespiratory experience perceived ‘a recent change in sputum characteristics’ (χ2 = 8.676, P = 0.003) and ‘anyone with a productive cough’ (χ2 = 5.685, P = 0.017) as indicators for ACTs in patients with AECOPD compared to those with more cardiorespiratory experience. The most commonly reported aims of prescribing ACTs were ‘to clear sputum’ (178/189, 94%), ‘enhance recovery from the AECOPD’ (129/189, 68%), ‘improve oxygen saturation’ (128/189, 68%) and ‘prevent pulmonary complications’ (118/189, 62%). They were rarely prescribed to reduce mortality (52/189, 28%), cough frequency (49/190, 26%) or antibiotic need (24/190, 13%). The most common factors influencing physiotherapists’ choice of ACT included ‘contraindications or precautions to individual techniques’ (148/189, 78%), ‘the degree of dyspnoea or work of breathing’ (136/189, 72%) and ‘access to resources or equipment’ (125/189, 66%). No consensus opinion of when to cease ACTs was apparent. The most common endpoints were ‘when there is no evidence of sputum’ (81/189, 43%) and ‘when sputum characteristics return to baseline’ (77/189, 41%). Only 2% (4/189) of physiotherapists felt it appropriate to cease ACTs ‘whenever the patient wants to stop’ and 1% (2/189) ‘upon hospital discharge’.
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Fig. 1. Incidence of ACT use, effectiveness and ease of mastery, by classification.
Knowledge of the ACT literature Physiotherapists’ understanding of the evidence for ACTs in patients with an AECOPD varied considerably. Only 4/189 (2%) felt it refuted (weakly) the effectiveness of ACTs, whilst 56/189 (30%) rated it conflicting/inconclusive, 43/189 (23%) weakly supportive, 39/189 (21%) strongly supportive and 35/189 (18%) unsure, with 12/189 (6%) missing. Responses did not differ between physiotherapists with less than or greater than 5 years cardiorespiratory experience (χ2 = 4.956, P = 0.292). A significantly greater proportion of respondents that perceived ACTs to be important felt the literature supported (combined ‘strong support’ and ‘weak support’) the role of ACTs in an AECOPD compared to those who did not perceive their role to be important (χ2 = 9.800, P = 0.007). Physiotherapists who felt the literature strongly supported the role for ACTs during an AECOPD did not differ significantly from others in terms of cardiorespiratory experience, rate of ACT prescription or perception of the importance of ACTs. Conclusion This is the first study to document the relationship between current practice, clinical reasoning strategies and opinions and knowledge of the ACT literature by Australian physiotherapists for patients with AECOPD. It addresses an important gap in the medical literature and provides useful insight into clinical practice in an area where treatment efficacy is unclear [17–19]. The high response rate of this study (81%) affirms that our findings are likely to reflect Australian physiotherapy practice and therefore enables comparison with practice in the United Kingdom [23] and Canada [24]. A major finding from this study was the high rate of ACT prescription. This widespread practice appears disproportionate to previous findings of randomised controlled trials of the effectiveness of ACTs during AECOPD [30–34]. Despite treatment duration being relatively short, the resources in
terms of staff and equipment required to provide this therapy would undoubtedly contribute significantly to the high direct healthcare costs associated with COPD hospitalisations, estimated as 63% of the total COPD healthcare burden in Australia [35]. This highlights the importance of clarifying the value of ACTs in this population and the need for further research in this area. This survey showed that ACTs were prescribed significantly more by those physiotherapists who perceived their role as being important (the majority). This demonstrates an important link between beliefs and practice and may potentially explain the ongoing use of ACTs in the absence of clear evidence [17–19]. Physiotherapists with less than 5 years cardiorespiratory experience were also shown to prescribe ACTs significantly more than those with greater experience, however they did not perceive their role to be any more important. The reason for this variability in ACT prescription was not clear. They did not interpret the medical literature differently but did report a significantly greater consideration of certain clinical indicators that they felt warranted the use of ACTs. This possibly reflects an experience-based difference in clinical reasoning strategies, which has previously been documented in acute cardiorespiratory physiotherapy [36–38]. As there are no guidelines to recommend how often ACTs should be prescribed it is difficult to know whether one subgroup of the profession is ‘right’ or ‘wrong’. The utilisation of different ACTs varied considerably and appeared unrelated to their perceived effectiveness to clear sputum or patients’ ease to master (refer Fig. 1). Factors such as the suitability of individual ACTs (including dyspnoea) for individuals and access to resources or equipment reportedly influenced ACT choice. We did not explore the relationship between these factors and specific ACTs, but feel they may partially explain the lower use of conventional chest physiotherapy techniques (due to orthopnoea or risk of gastro-oesophageal reflux) and positive expiratory pressure (due to access to equipment).
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The high utilisation of breathing exercises by Australian physiotherapists is consistent with previous studies in Australia [25] and the United Kingdom [23], however the widespread use of physical exercise as an ACT has not previously been documented. This finding was unexpected as there have been very few studies on this topic to date. A randomised crossover study involving eight subjects with stable chronic bronchitis showed significantly increased scintigraphic measures of (total lung) mucus clearance by 7.5% following 20 minutes of interval cycle ergometry. The magnitude of this treatment effect was greater than for postural drainage which showed no significant improvement but considerably less than coughing which increased mucus clearance by 40.8% [39]. It is conceivable that exercise-induced changes in respiratory rate and/or lung volumes could enhance intrapulmonary shearing of pulmonary secretions and facilitate airway clearance. It is not clear, however, how this process would be affected by the abnormal lung mechanics typical of COPD (e.g. early airway collapse, gas trapping, dynamic hyperinflation) and by some of the changes typical of an AECOPD (e.g. worsened airflow limitation, work of breathing and ventilation-perfusion mismatching). We did not ask respondents whether the widespread use of physical exercise as an ACT related to purposes of physical rehabilitation, that is, whether its prescription was intended to address both therapeutic goals, however all relevant survey items were worded specifically to address its role in airway clearance. Given the popularity of this technique, research that clarifies the efficacy of exercise as an ACT appears needed. This study suggests that Australian physiotherapists perceive ACTs to be indicated more for patients who are acutely unwell (e.g. infective exacerbations, difficulty managing secretions) rather than for those who are simply productive (with or without expectoration). The most common aims of prescribing ACTs (clearing sputum, improving oxygenation and preventing complications) indicated a trend towards the use of short-term outcomes and a relative lack of emphasis on outcomes relevant to patients and healthcare providers such as quality of life, exacerbation frequency and healthcare utilisation. With increasing recognition of the importance of these (latter) outcomes in the management of COPD, it is likely that the effectiveness of ACTs on such outcomes will need to be determined in order to justify their ongoing use. There was considerable variation in therapists’ perception of the evidence for ACTs in AECOPD that was unrelated to their experience or frequency of ACT prescription. In addition, almost half the responses were ‘unsure’, missing or incorrect according to our definition (‘strong support’). Whilst this may simply reflect the challenging nature of the current literature, which comprises a diverse range of techniques, outcomes and variable effects [18], it also reinforces the need for clinicians of all levels of experience to develop and maintain highly refined skills of critical appraisal. For until irrefutable consensus is reached on the value of ACTs in patients with an AECOPD, complex research findings such as these must be accurately translated into practice if the
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ongoing provision of therapy is to be justified. Whilst we noted a significant relationship between therapists’ perception of the importance of ACTs (important or not important) and the supportiveness of the literature (supportive or not supportive), we could not determine which influenced the other. For example, did stronger (or weaker) opinion of the value of ACTs increase (or decrease) one’s perception of the strength of the evidence or did perception of the strength of the evidence influence one’s opinion of the clinical value of ACTs? The findings from this study were derived from a large cohort of physiotherapists spanning a comprehensive and diverse range of hospitals across all publically funded settings in Australia in which people with COPD receive acute care. The high response rate means it is a likely accurate summary of current national practice that should serve as a useful comparison for other settings or countries. As the questionnaire was designed specifically for this study its reliability is unknown. Other limitations may have included the lack of representation of private sector hospitals and unknown accuracy relating to the questionnaire’s distribution within each facility (i.e. whether it actually reached the intended target population). In conclusion, this study has shown that Australian physiotherapists frequently prescribe ACTs for patients with an AECOPD and perceive their role to be important. Understanding of the evidence for ACTs during an AECOPD appears variable and highlights an area for continued improvement in today’s clinical environment, particularly in the absence of consensus regarding ACT effectiveness. As physiotherapists report prescribing ACTs to address short-term goals, a shift towards more patient-oriented or healthcare-oriented outcomes such as exacerbations, quality of life and healthcare utilisation appears indicated. Physical exercise is being widely prescribed for the purpose of airway clearance. Further investigations of its effects are warranted in order to validate this practice. Ethical approval: La Trobe University Faculty Human Ethics Committee (Ref. No. FHEC09/122). Funding: Christian Osadnik was supported by a La Trobe University Postgraduate (PhD) Research Scholarship. Conflict of interest: None declared.
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