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Chest physiotherapy: Time for reappraisal
Br. J. Dis. Chest (1988) 82, 127
Review
CHEST PHYSIOTHERAPY: REAPPRAISAL
TIME FOR
PHILIP P. SUTTON Department
of Respiratory Medicine, Aberdeen Royal Infirmary, Foresterhill, Aberdeen AB9 2ZB
Summary
Chest physiotherapy should now be updated with attention to three important features: first, its use should be limited to those patients with actual or potential sputum production and its central aim should be to increase expectoration. Second, it should incorporate the forced expiration technique with postural drainage and omit traditional elements such as percussion and vibration. Third, the additional use of inhaled adrenergic agents and possibly oral high frequency oscillation may increase sputum clearance further.
INTRODUCTION Chest physiotherapy (CP) for a long time has occupied a traditional therapeutic role but until recently it lacked both objective evaluation and precision in its application. Its indiscriminate use at times may disguise the real benefit of CP in certain circumstances and this background fosters an air of scepticism about its true value. Using an objective approach involving inhaled radioaerosol, information about CP and its individual components has recently become available and CP can now be rationalized and applied more effectively and efficiently in clinical respiratory medicine. CP, as discussed here, describes the short-term application of conventional physiotherapy in both acute and stable illness. Much of the background information has been previously reviewed (l-3) and need only be summarized here. The techniques used, along with their objectives, will be outlined and CP regimens will be evaluated in the clinical situation. The individual components of CP will then be examined in detail using recent information from radioaerosol studies and, finally, suggestions made for a new approach to CP. CP in specialized circumstances, e.g. paediatric, intensive therapy or rehabilitation, will not be specifically addressed. TECHNIQUES
AND
OBJECTIVES
The methods used during CP, namely cough (or more recently forced expiratory manoeuvres), postural drainage, percussion, vibration and breathing exercises are all familiar, but often lack a satisfactory explanation of their basic mechanism. Address for correspondence: Hartlepool General Hospital, Holdforth Road, Cleveland TS24 9AH.
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Two important features that need to be known about cough are the linear airflow necessary to ‘shear’ respiratory secretions from tracheobronchial epithelium and the airway generation in which this is effective. In vitro studies by Clarke (4) suggest that the former occurs only with very high velocities in excess of 1000-2500 cm/set (90 kmph!). Because of the rapidly branching structure of the bronchial tree, this may only be achieved in relatively central airways (5,6) although Scherer (7) calculates that under conditions of excess mucus production, cough may be effective to the level of the respiratory bronchioles. At present there is conflicting experimental evidence and Bateman et al. (8) and Oldenburg et al. (9) disagree on the extent and effectiveness of the cough clearance of radioaerosol. The forced expiratory technique (FET) which is fully described by Gaskell and Webber (10) seems to cause less airway collapse (11) and experimentally is more effective than cough alone (12). It was suggested that the use of positive expiratory pressure might also prevent airway collapse and thus enhance sputum clearance (13), but Hofmeyer et al. (14) have shown that such clearance of secretions was actually reduced when a positive expiratory pressure of 12-17 cmH,O was added to a regimen already incorporating postural drainage and forced expiration. Postural drainage is a self-explanatory manoeuvre and there is similar objective evidence of its value in promoting clearance of secretions (15) although it is not clear if it works alone or complements mucociliary clearance or cough. Percussion and vibration aim to loosen respiratory secretions by applying a small blow of varying frequency and amplitude to the chest wall. It is not known if this force is transmitted to airways or whether the process attempts to establish vibrations that are magnified by the natural resonance of the lung. Despite the long-standing clinical impression that the addition of percussion and vibration produce more sputum than postural drainage alone (16) there is no evidence to support this (17-19). Also, aspects of CP such as shaking and percussion seem unpopular and may contribute to the poor compliance with home CP (20). Breathing exercises are popular with both therapist and patient and often give some degree of immediate symptomatic relief, but the improved blood gases occurring at rest are not maintained on exercise (21) and in the long term regular breathing exercises for patients with COAD do not improve ventilation (22-24). It is not known if breathing exercises alone such as incentive spirometry can increase the strength or endurance of respiratory muscles as opposed to general physical training (25). A commonly used adjunct to CP is ‘humidification’ (although air is fully saturated on entering the trachea during nasal breathing). The inhalation of hypertonic saline aerosol enhances mucociliary clearance (26) probably following a reflex increase in secretions, although a direct action on mucociliary transport rates is also possible (27, 28) and certainly the direct hydration of the periciliary fluid is crucial to optimal ciliary transport (29). Palmer (30) also demonstrated that simple water aerosol decreased sputum viscosity but although such bland aerosol therapy, including mist and steam, remains popular, no objective benefit has generally been demonstrated (31)-indeed, steam inhalation is potentially hazardous. The use of intermittent positive pressure breathing (IPPB) was once a common addition to CP especially in North America, but has been shown to be of no benefit in rehabilitation (32) or in the delivery of bronchodilator drugs (33) and even harmful in their long-term use
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(34). The use of adrenergic agents will cause increased ciliary beat frequency, tracheal mucus velocity and whole lung clearance (35) and may thus have a place during CP. The relationship between any bronchodilatation they might confer and increased sputum mobilization has surprisingly not been studied. These represent the possible elements of CP. Although basic mechanisms are often poorly understood and although effects may sometimes be synergistically related to each other, further investigation of individual components is necessary critically to evaluate CP. The possible aims of CP in the short term are variously described: 1. 2. 3. 4.
to to to to
promote sputum mobilization and expectoration. reduce airways obstruction. improve mucociliary function. improve ventilation and gas exchange.
Many of these processes also are complex and interrelated; for example, improved mucociliary function will lead to improved tracheobronchial clearance of secretions as seen with adrenergic stimulation (28) and enhanced expectoration may in turn reduce airway obstruction. Cochrane et al. (36) showed a small but significant increase in FEV, following CP in patients with excess sputum production. Similar improvements in large airways function following sputum mobilization in patients with cystic fibrosis were demonstrated by Tecklin et al. (37), Weller et al. (38) and Webber et al. (39). Feldman et al. (40) also demonstrated improved flow rates at low lung volumes (implying better small airways function) in patients with copious sputum production but in most of these studies there was no correlation between the amount of sputum mobilized and improvement in ventilatory indices. However, changes of improved airways function are small and many studies have found no alteration in pulmonary function indices in large numbers of patients with stable COAD (41, 42). Alternatively, Campbell et al. (43) found an immediate fall in FEV, following CP in 17 patients during an exacerbation of chronic bronchitis and noted that this fall was prevented by prior administration of bronchodilators. This supports the clinical impression that CP in patients with prominent bronchospasm and no excess secretions might worsen airways obstruction and should be avoided or at least deferred until bronchodilators have been given. Airways obstruction from tenacious secretions is well recognized in acute asthma (44) and Wanner (45) suggests that the residual airway obstruction in these patients in remission may be caused by excessive mucus production in peripheral airways. However, effective treatment here is dominated by bronchodilatation and steroid therapy rather than CP, although rehydration is said to help mobilize secretions. Changes in blood gas analysis have been less consistent but at least four studies have demonstrated hypoxia following CP in acute illness (46-49) and there may well be a place for supplementary oxygen in such cases. However, these findings are not universal (50,51) and do not occur during stable illness (42, 52-54). Sputum production is the most apparent result of CP and it can be easily recorded, although swallowed secretions or the inclusion of saliva can sometimes give misleading results. An important point is that CP is only able to increase sputum yield if excess secretions are a feature of the patient’s condition. Many studies have demonstrated that increased sputum yield following combined CP manoeuvres only occurs in patients with
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excess secretions (36, 53, 55) whereas May and Munt (42) and Newton and Stephenson (51) failed to increase sputum yield following similar treatment regimens in patients who were ‘poor’ sputum producers. In general terms this evidence illustrates the central role of enhanced sputum production following CP during stable illness in patients with bronchiectasis, cystic fibrosis and in some patients with COAD characterized by mucus hypersecretion. Increased sputum yield may be thought to reduce airway obstruction but most evidence is against this simple explanation. Nevertheless, Murray (56) summarizes the present position by stating that ‘if the disease is not characterized by excess respiratory secretions then chest physiotherapy has no part in its management’. Thus, excess secretions or sputum production (arbitrarily defined as greater than 30 g daily) is now thought to be an essential prerequisite to increased sputum mobilization by CP. Those patients with no excess secretions probably do not benefit from CP, although in acute illness such patients often receive a ‘trial’ of CP to exclude retained secretions. The prime object of CP is to aid expectoration, although it should be emphasized that the long-term benefits or otherwise of promoting sputum clearance are essentially unknown (57) although it has been suggested that regular CP might break the ‘vicious circle’ which may lead to progression of bronchiectasis (20).
EVIDENCE
FROM
CLINICAL
STUDIES
CP does not seem to alter significantly the outcome of acute exacerbations of COAD (51), even in those patients with respiratory failure (58) although patients in both these series did not have copious sputum. Anthonisen and Riis (59), in a controlled trial of CP in a large number of similar patients, also had found no overall benefit in terms of temperature, sputum volume or arterial gases, also including a subgroup with respiratory failure. In pneumonia, Graham and Bradley (60) found no significant difference in outcome between patients who did or did not receive CP as part of their treatment, but these investigations deliberately excluded those thought to be ‘at risk’. Similarly, Britton et al. (61) found no useful role for CP in primary pneumonia although again patients with preexisting chronic bronchitis and airways obstruction were excluded and details of sputum volume were not given. Despite these criticisms the present attitude is that an uncomplicated pneumonia or exacerbation of chronic bronchitis in the absence of excess secretions is not an indication for CP (62). The minimization of postoperative respiratory complications such as pneumonia and atelectasis is also thought to represent a prominent use of CP but routine postoperative CP is probably of no value either (63) although, paradoxically, established postoperative atelectasis may effectively respond to CP without bronchoscopic removal of secretions in most cases (64). The question of identifying patients with a high risk of developing these complications has been addressed but is unclear at present (65). The presence of significant airways obstruction has been associated with increased postoperative complications by Stein and Cassara (66) and Vraciu and Vraciu (67) as well as smoking history (68), age (69) and site of operation (70). However, the importance of airways obstruction is not a universal finding (71,72) and clinical experience would strongly suggest that other factors, such as excess secretions, are also important but have not been specifically studied.
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PHYSIOTHERAPY
RADIOAEROSOL
STUDIES
The development and application of the inhaled radioaerosol technique allows tracheobronchial secretions throughout the lung fields to be in effect ‘labelled’ and by external monitoring (preferably using a gamma camera to allow direct ‘visualization’ of regions of interest, such as peripheral zones) permits their subsequent clearance to be objectively recorded and thus confers accuracy on the study of CP regimens and evaluation of individual components. So far, techniques and study design have limited its use to short-term studies in patients with stable respiratory illness. Nevertheless, findings are emerging which question some ‘traditional’ attitudes to CP and are summarized in Table I. Table I. CP evidence from radioaerosol studies Investigation
sputum clearance
Vibration PD PD Exercise Cough Cough Cough FET FET+PD PN PN Nebulized saline+CP Nebulized terbutaline+CP OHFO+CP
0 +I0 + + 0 ++ ++ ++
Radioaerosol clearance
Reference
0
(18, 81)
TMV 0 + ++ -t/O ++ + ++ 0 0 +++ +++ +++
(82, 83) (9) (9) (9) (8) (76) (12) (12) (18, 19) (54) (84) (84) (87)
Abbreviations: PD, postural drainage; FET, forced expiration technique; PN, percussion; OHFO, oral high frequency oscillation; TMV, tracheal mucus velocity. (- sputum volumes not given) The normal clearance mechanism of the tracheobronchial tree in health is the mucociliary escalator (and possibly also gravity assisted drainage in the upper lobes) where total secretions are minimal (73). As mucociliary clearance becomes impaired in disease (74), cough and other physical methods of clearance become more important, particularly in the presence of excess secretions (75). Cough and mucociliary clearance are not interchangeable, however, as it is likely that cough clearance is effective only in relatively large airways whereas mucociliary clearance is probably effective to terminal bronchiole level. The role of cough alone in clearing secretions was investigated using a radioaerosol of polystyrene particles by Bateman et al. (55). He found that both cough alone and combined CP regimen (cough, postural drainage, vibration and percussion) were both equally effective in promoting central lung clearance of radioaerosol, but only combined CP and not cough accelerated peripheral lung clearance. Oldenburg et al. (9) and Rossman et al. (76), on the other hand, found directed cough to accelerate both total and peripheral lung clearance in both chronic bronchitic patients and patients with cystic
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fibrosis, to the same degree as various other CP manoeuvres. A non-aerosol study of cough versus chest physiotherapy by deBoeck and Zinman (77) also indicated that cough alone was equally effective as combined CP manoeuvres. These conflicting views on the value of cough may be partly because many of these investigations did not completely distinguish between cough and other forced expiratory manoeuvres. Cough alone was compared with the forced expiratory technique (FET) and with FET plus postural drainage in patients with bronchiectasis by Sutton et al. (12). Sputum yield and radioaerosol clearance was greater following the FET than following cough and the clear superiority of the FET, especially when combined with postural drainage, over cough alone was demonstrated. Clinically the FET combined with postural drainage is equally as effective as conventional physiotherapy (78) but also more efficient, mobilizing more sputum in less time in a group of young patients with cystic fibrosis. Furthermore, the need for an assistant who normally provided percussion during conventional physiotherapy was obviated and an additional important degree of independence was conferred in the domiciliary treatment of these patients (who are known to comply poorly with conventional CP, 79). From this it was felt that the emphasis on cough alone, either spontaneous or ‘directed’ by an attendant, did not maximize the possible sputum clearance and thus could not be relied upon as the sole means of chest physiotherapy. These observations were extended to other components of traditional CP, namely percussion and vibratory shaking (18). Tracheobronchial clearance of radioaerosol was unaffected by the addition of either vibratory shaking or percussion (with and without breathing exercises) to postural drainage. In similar radioaerosol studies, van der Schans et al. (19) and Wollmer et al. (54) also found that the addition of percussion to conventional CP (which included postural drainage and cough) did not improve sputum yield or radioaerosol clearance in patients with excessive tracheobronchial secretions. In two conflicting non-aerosol studies, Denton (80) reported that mechanical percussion increased sputum yield when added to postural drainage and cough in patients with cystic fibrosis, but Murphy et al. (17) showed that the addition of percussion to postural drainage actually decreased sputum production. The only study of vibration alone was performed by Pavia et al. (81) who found no improvement in the rate of tracheobronchial mucociliary clearance or sputum production induced by a vibrating pad. Postural drainage alone will increase sputum yield and analysis of similar patients in two radioaerosol studies (12, 18) would suggest that postural drainage per se promotes clearance of airway secretions and radioaerosol. Chopra et al. (82) found a 40% increase in tracheal mucus velocity (TMV) in anaesthetized dogs following postural drainage and Wong et al. (83) similarly found TMV to increase after postural drainage in patients with cystic fibrosis and adults recovering from acute respiratory viral infection. Oldenburg et al. (9), however, found no alteration to clearance in patients with chronic bronchitis following 40 minutes of 15 degree ‘head down’ postural drainage during which cough was discouraged, although details of sputum volume were not given. Assuming the forced expiration technique (rather than cough) when combined with postural drainage to be the most effective component of CP, then some commonly used adjuncts were investigated to determine if any additive effect could be obtained. Sputum yield and tracheobronchial clearance obtained by this optimal CP regimen was compared to that achieved by similar CP preceded by either nebulized terbutaline or saline (84). It was found that nebulized terbutaline prior to CP in a group of patients with stable
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bronchiectasis resulted in increased sputum yield and radioaerosol clearance above that achieved by CP alone (as well as causing a small but significant improvement in ventilatory function indices which was not seen following nebulized saline). Furthermore, there was a suggestion that terbutaline also enhanced clearance of secretions from peripheral regions, an effect which did not occur with CP alone. The relationships between bronchodilatation and clearance of secretions is not clear, but the minor bronchodilatation obtained may improve CP by increasing flow rates or regional ventilation. Alternative explanations are increased hydration of the periciliary fluid either directly by saline (29) or indirectly by adrenergic stimulation or ion transport and water shift towards the airway lumen (85). Direct application of terbutaline will also increase airways beat frequency, tracheal mucus velocity and whole lung clearance of airways secretions (28, 35). George et al. (86,87) also using a radioaerosol method showed that oral high frequency oscillation (OHFO) could enhance mucociliary clearance and subsequently demonstrated that the use of a simple hand-held oscillator had an additive action to CP in sputum mobilization. Exercise alone (rather than as an adjunct to CP) has been advocated as a means of promoting sputum clearance particularly in cystic fibrosis in both radioaerosol studies (9) and non-aerosol studies (88) but requires further study to quantitate the exertion required and benefit obtained and most physicians would be very reluctant to accept this advice, particularly in these patients. CONCLUSIONS Some of the conflicting results from the recent radioaerosol studies can be explained by the heterogeneity of patients studied, a failure to distinguish between cough and the forced expiration technique, and perhaps a lack of awareness of the importance of sputum volume in selection of patients. Nevertheless, sufficient evidence has now accrued particularly from radioaerosol studies to propose a rationalization of CP and to suggest the following guidelines. 1. The illness should be characterized by sputum production. CP is probably of no value in uncomplicated pneumonia, exacerbations of COAD without sputum production or routine postoperative care. 2. Cough alone is inadequate to maintain effective tracheobronchial toilet. The forced expiration technique mobilizes more sputum than cough alone particularly when combined with postural drainage and these are probably the most important elements of CP. After instruction, patients can continue this treatment without assistance at home if required. 3. Percussion and vibratory shaking have no direct value. Their addition to a CP regimen which uses the FET and postural drainage does not result in increased sputum yield. 4. Prior use of nebulized bronchodilators may increase sputum yield above that achieved by optimal CP. REFERENCES 1. Rochester DF, Goldberg SK. Techniques of respiratory physical therapy. Am Rev Resp Dis 1980;122: 133-46.
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81. Pavia D, Thomson ML, Phillipakos D. A preliminary study of the effect of a vibrating pad on bronchial clearance. Am Rev Resp Dis 1976;113:92-6. 82. Chopra SK, Taplin GV, Simmons DU, Robinson GD, Elam D, Coulson A. Effects of hydration and physical therapy on tracheal transport velocity. Am Rev Resp Dis 1977;15:1009-14. 83. Wong JW, Keens TG, Wannamaker EM, Crozier DN, Levison H, Aspin N. Effects of gravity on tracheal mucus transport rates in normal subjects and in patients with cystic fibrosis. Paediatrics
1977;6-0:114652.
84. Sutton PP, Gemmell HG, Davidson J, Lawtie N, Legge JS, Friend JAR. An assessment of nebulised saline and terbutaline as an adjunct to chest physiotherapy. Thorax 1986;41:235(P). 85. Nadel JA, Davis B, Phipps RJ. Control of mucus secretion and ion transport in airways. Ann Rev Physiol 1979;41:36%81. 86. George RJD, Johnson MA. Pavia D, Agnew JE, Clarke SW, Geddes DM. Increase in mucociliary clearance in normal man induced by oral high frequency oscillation. Thorax 1985;40:433-7. 87. George RJD, Pavia D, Lopez-Vidriero MT, et al. Oral high frequency oscillation (OHFO) asan adjunct to physiotherapy (PHYSIO) in cystic fibrosis (CF). Thorax 1986;41:235(P). 88. Zach MS, Purrey B, Obewalder B. Effect of swimming on forced expiration and sputum clearance in cystic fibrosis. Lancet 1981;ii:1201-3.
Date accepted 9 June 1987
CORRIGENDUM Re: Sakula, A. (1988) Br. J. Dis. Chest 82, 23 Selman Waksman (1888-1973),
discoverer of streptomycin:
a centenary review
Page 29: The biographical details of Hubert Arthur Lechevalier have been incorrectly given as (1926-1983). The dates should read (b. 1926). I
I
Review
CHEST PHYSIOTHERAPY: REAPPRAISAL
TIME FOR
PHILIP P. SUTTON Department
of Respiratory Medicine, Aberdeen Royal Infirmary, Foresterhill, Aberdeen AB9 2ZB
Summary
Chest physiotherapy should now be updated with attention to three important features: first, its use should be limited to those patients with actual or potential sputum production and its central aim should be to increase expectoration. Second, it should incorporate the forced expiration technique with postural drainage and omit traditional elements such as percussion and vibration. Third, the additional use of inhaled adrenergic agents and possibly oral high frequency oscillation may increase sputum clearance further.
INTRODUCTION Chest physiotherapy (CP) for a long time has occupied a traditional therapeutic role but until recently it lacked both objective evaluation and precision in its application. Its indiscriminate use at times may disguise the real benefit of CP in certain circumstances and this background fosters an air of scepticism about its true value. Using an objective approach involving inhaled radioaerosol, information about CP and its individual components has recently become available and CP can now be rationalized and applied more effectively and efficiently in clinical respiratory medicine. CP, as discussed here, describes the short-term application of conventional physiotherapy in both acute and stable illness. Much of the background information has been previously reviewed (l-3) and need only be summarized here. The techniques used, along with their objectives, will be outlined and CP regimens will be evaluated in the clinical situation. The individual components of CP will then be examined in detail using recent information from radioaerosol studies and, finally, suggestions made for a new approach to CP. CP in specialized circumstances, e.g. paediatric, intensive therapy or rehabilitation, will not be specifically addressed. TECHNIQUES
AND
OBJECTIVES
The methods used during CP, namely cough (or more recently forced expiratory manoeuvres), postural drainage, percussion, vibration and breathing exercises are all familiar, but often lack a satisfactory explanation of their basic mechanism. Address for correspondence: Hartlepool General Hospital, Holdforth Road, Cleveland TS24 9AH.
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Two important features that need to be known about cough are the linear airflow necessary to ‘shear’ respiratory secretions from tracheobronchial epithelium and the airway generation in which this is effective. In vitro studies by Clarke (4) suggest that the former occurs only with very high velocities in excess of 1000-2500 cm/set (90 kmph!). Because of the rapidly branching structure of the bronchial tree, this may only be achieved in relatively central airways (5,6) although Scherer (7) calculates that under conditions of excess mucus production, cough may be effective to the level of the respiratory bronchioles. At present there is conflicting experimental evidence and Bateman et al. (8) and Oldenburg et al. (9) disagree on the extent and effectiveness of the cough clearance of radioaerosol. The forced expiratory technique (FET) which is fully described by Gaskell and Webber (10) seems to cause less airway collapse (11) and experimentally is more effective than cough alone (12). It was suggested that the use of positive expiratory pressure might also prevent airway collapse and thus enhance sputum clearance (13), but Hofmeyer et al. (14) have shown that such clearance of secretions was actually reduced when a positive expiratory pressure of 12-17 cmH,O was added to a regimen already incorporating postural drainage and forced expiration. Postural drainage is a self-explanatory manoeuvre and there is similar objective evidence of its value in promoting clearance of secretions (15) although it is not clear if it works alone or complements mucociliary clearance or cough. Percussion and vibration aim to loosen respiratory secretions by applying a small blow of varying frequency and amplitude to the chest wall. It is not known if this force is transmitted to airways or whether the process attempts to establish vibrations that are magnified by the natural resonance of the lung. Despite the long-standing clinical impression that the addition of percussion and vibration produce more sputum than postural drainage alone (16) there is no evidence to support this (17-19). Also, aspects of CP such as shaking and percussion seem unpopular and may contribute to the poor compliance with home CP (20). Breathing exercises are popular with both therapist and patient and often give some degree of immediate symptomatic relief, but the improved blood gases occurring at rest are not maintained on exercise (21) and in the long term regular breathing exercises for patients with COAD do not improve ventilation (22-24). It is not known if breathing exercises alone such as incentive spirometry can increase the strength or endurance of respiratory muscles as opposed to general physical training (25). A commonly used adjunct to CP is ‘humidification’ (although air is fully saturated on entering the trachea during nasal breathing). The inhalation of hypertonic saline aerosol enhances mucociliary clearance (26) probably following a reflex increase in secretions, although a direct action on mucociliary transport rates is also possible (27, 28) and certainly the direct hydration of the periciliary fluid is crucial to optimal ciliary transport (29). Palmer (30) also demonstrated that simple water aerosol decreased sputum viscosity but although such bland aerosol therapy, including mist and steam, remains popular, no objective benefit has generally been demonstrated (31)-indeed, steam inhalation is potentially hazardous. The use of intermittent positive pressure breathing (IPPB) was once a common addition to CP especially in North America, but has been shown to be of no benefit in rehabilitation (32) or in the delivery of bronchodilator drugs (33) and even harmful in their long-term use
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(34). The use of adrenergic agents will cause increased ciliary beat frequency, tracheal mucus velocity and whole lung clearance (35) and may thus have a place during CP. The relationship between any bronchodilatation they might confer and increased sputum mobilization has surprisingly not been studied. These represent the possible elements of CP. Although basic mechanisms are often poorly understood and although effects may sometimes be synergistically related to each other, further investigation of individual components is necessary critically to evaluate CP. The possible aims of CP in the short term are variously described: 1. 2. 3. 4.
to to to to
promote sputum mobilization and expectoration. reduce airways obstruction. improve mucociliary function. improve ventilation and gas exchange.
Many of these processes also are complex and interrelated; for example, improved mucociliary function will lead to improved tracheobronchial clearance of secretions as seen with adrenergic stimulation (28) and enhanced expectoration may in turn reduce airway obstruction. Cochrane et al. (36) showed a small but significant increase in FEV, following CP in patients with excess sputum production. Similar improvements in large airways function following sputum mobilization in patients with cystic fibrosis were demonstrated by Tecklin et al. (37), Weller et al. (38) and Webber et al. (39). Feldman et al. (40) also demonstrated improved flow rates at low lung volumes (implying better small airways function) in patients with copious sputum production but in most of these studies there was no correlation between the amount of sputum mobilized and improvement in ventilatory indices. However, changes of improved airways function are small and many studies have found no alteration in pulmonary function indices in large numbers of patients with stable COAD (41, 42). Alternatively, Campbell et al. (43) found an immediate fall in FEV, following CP in 17 patients during an exacerbation of chronic bronchitis and noted that this fall was prevented by prior administration of bronchodilators. This supports the clinical impression that CP in patients with prominent bronchospasm and no excess secretions might worsen airways obstruction and should be avoided or at least deferred until bronchodilators have been given. Airways obstruction from tenacious secretions is well recognized in acute asthma (44) and Wanner (45) suggests that the residual airway obstruction in these patients in remission may be caused by excessive mucus production in peripheral airways. However, effective treatment here is dominated by bronchodilatation and steroid therapy rather than CP, although rehydration is said to help mobilize secretions. Changes in blood gas analysis have been less consistent but at least four studies have demonstrated hypoxia following CP in acute illness (46-49) and there may well be a place for supplementary oxygen in such cases. However, these findings are not universal (50,51) and do not occur during stable illness (42, 52-54). Sputum production is the most apparent result of CP and it can be easily recorded, although swallowed secretions or the inclusion of saliva can sometimes give misleading results. An important point is that CP is only able to increase sputum yield if excess secretions are a feature of the patient’s condition. Many studies have demonstrated that increased sputum yield following combined CP manoeuvres only occurs in patients with
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excess secretions (36, 53, 55) whereas May and Munt (42) and Newton and Stephenson (51) failed to increase sputum yield following similar treatment regimens in patients who were ‘poor’ sputum producers. In general terms this evidence illustrates the central role of enhanced sputum production following CP during stable illness in patients with bronchiectasis, cystic fibrosis and in some patients with COAD characterized by mucus hypersecretion. Increased sputum yield may be thought to reduce airway obstruction but most evidence is against this simple explanation. Nevertheless, Murray (56) summarizes the present position by stating that ‘if the disease is not characterized by excess respiratory secretions then chest physiotherapy has no part in its management’. Thus, excess secretions or sputum production (arbitrarily defined as greater than 30 g daily) is now thought to be an essential prerequisite to increased sputum mobilization by CP. Those patients with no excess secretions probably do not benefit from CP, although in acute illness such patients often receive a ‘trial’ of CP to exclude retained secretions. The prime object of CP is to aid expectoration, although it should be emphasized that the long-term benefits or otherwise of promoting sputum clearance are essentially unknown (57) although it has been suggested that regular CP might break the ‘vicious circle’ which may lead to progression of bronchiectasis (20).
EVIDENCE
FROM
CLINICAL
STUDIES
CP does not seem to alter significantly the outcome of acute exacerbations of COAD (51), even in those patients with respiratory failure (58) although patients in both these series did not have copious sputum. Anthonisen and Riis (59), in a controlled trial of CP in a large number of similar patients, also had found no overall benefit in terms of temperature, sputum volume or arterial gases, also including a subgroup with respiratory failure. In pneumonia, Graham and Bradley (60) found no significant difference in outcome between patients who did or did not receive CP as part of their treatment, but these investigations deliberately excluded those thought to be ‘at risk’. Similarly, Britton et al. (61) found no useful role for CP in primary pneumonia although again patients with preexisting chronic bronchitis and airways obstruction were excluded and details of sputum volume were not given. Despite these criticisms the present attitude is that an uncomplicated pneumonia or exacerbation of chronic bronchitis in the absence of excess secretions is not an indication for CP (62). The minimization of postoperative respiratory complications such as pneumonia and atelectasis is also thought to represent a prominent use of CP but routine postoperative CP is probably of no value either (63) although, paradoxically, established postoperative atelectasis may effectively respond to CP without bronchoscopic removal of secretions in most cases (64). The question of identifying patients with a high risk of developing these complications has been addressed but is unclear at present (65). The presence of significant airways obstruction has been associated with increased postoperative complications by Stein and Cassara (66) and Vraciu and Vraciu (67) as well as smoking history (68), age (69) and site of operation (70). However, the importance of airways obstruction is not a universal finding (71,72) and clinical experience would strongly suggest that other factors, such as excess secretions, are also important but have not been specifically studied.
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PHYSIOTHERAPY
RADIOAEROSOL
STUDIES
The development and application of the inhaled radioaerosol technique allows tracheobronchial secretions throughout the lung fields to be in effect ‘labelled’ and by external monitoring (preferably using a gamma camera to allow direct ‘visualization’ of regions of interest, such as peripheral zones) permits their subsequent clearance to be objectively recorded and thus confers accuracy on the study of CP regimens and evaluation of individual components. So far, techniques and study design have limited its use to short-term studies in patients with stable respiratory illness. Nevertheless, findings are emerging which question some ‘traditional’ attitudes to CP and are summarized in Table I. Table I. CP evidence from radioaerosol studies Investigation
sputum clearance
Vibration PD PD Exercise Cough Cough Cough FET FET+PD PN PN Nebulized saline+CP Nebulized terbutaline+CP OHFO+CP
0 +I0 + + 0 ++ ++ ++
Radioaerosol clearance
Reference
0
(18, 81)
TMV 0 + ++ -t/O ++ + ++ 0 0 +++ +++ +++
(82, 83) (9) (9) (9) (8) (76) (12) (12) (18, 19) (54) (84) (84) (87)
Abbreviations: PD, postural drainage; FET, forced expiration technique; PN, percussion; OHFO, oral high frequency oscillation; TMV, tracheal mucus velocity. (- sputum volumes not given) The normal clearance mechanism of the tracheobronchial tree in health is the mucociliary escalator (and possibly also gravity assisted drainage in the upper lobes) where total secretions are minimal (73). As mucociliary clearance becomes impaired in disease (74), cough and other physical methods of clearance become more important, particularly in the presence of excess secretions (75). Cough and mucociliary clearance are not interchangeable, however, as it is likely that cough clearance is effective only in relatively large airways whereas mucociliary clearance is probably effective to terminal bronchiole level. The role of cough alone in clearing secretions was investigated using a radioaerosol of polystyrene particles by Bateman et al. (55). He found that both cough alone and combined CP regimen (cough, postural drainage, vibration and percussion) were both equally effective in promoting central lung clearance of radioaerosol, but only combined CP and not cough accelerated peripheral lung clearance. Oldenburg et al. (9) and Rossman et al. (76), on the other hand, found directed cough to accelerate both total and peripheral lung clearance in both chronic bronchitic patients and patients with cystic
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fibrosis, to the same degree as various other CP manoeuvres. A non-aerosol study of cough versus chest physiotherapy by deBoeck and Zinman (77) also indicated that cough alone was equally effective as combined CP manoeuvres. These conflicting views on the value of cough may be partly because many of these investigations did not completely distinguish between cough and other forced expiratory manoeuvres. Cough alone was compared with the forced expiratory technique (FET) and with FET plus postural drainage in patients with bronchiectasis by Sutton et al. (12). Sputum yield and radioaerosol clearance was greater following the FET than following cough and the clear superiority of the FET, especially when combined with postural drainage, over cough alone was demonstrated. Clinically the FET combined with postural drainage is equally as effective as conventional physiotherapy (78) but also more efficient, mobilizing more sputum in less time in a group of young patients with cystic fibrosis. Furthermore, the need for an assistant who normally provided percussion during conventional physiotherapy was obviated and an additional important degree of independence was conferred in the domiciliary treatment of these patients (who are known to comply poorly with conventional CP, 79). From this it was felt that the emphasis on cough alone, either spontaneous or ‘directed’ by an attendant, did not maximize the possible sputum clearance and thus could not be relied upon as the sole means of chest physiotherapy. These observations were extended to other components of traditional CP, namely percussion and vibratory shaking (18). Tracheobronchial clearance of radioaerosol was unaffected by the addition of either vibratory shaking or percussion (with and without breathing exercises) to postural drainage. In similar radioaerosol studies, van der Schans et al. (19) and Wollmer et al. (54) also found that the addition of percussion to conventional CP (which included postural drainage and cough) did not improve sputum yield or radioaerosol clearance in patients with excessive tracheobronchial secretions. In two conflicting non-aerosol studies, Denton (80) reported that mechanical percussion increased sputum yield when added to postural drainage and cough in patients with cystic fibrosis, but Murphy et al. (17) showed that the addition of percussion to postural drainage actually decreased sputum production. The only study of vibration alone was performed by Pavia et al. (81) who found no improvement in the rate of tracheobronchial mucociliary clearance or sputum production induced by a vibrating pad. Postural drainage alone will increase sputum yield and analysis of similar patients in two radioaerosol studies (12, 18) would suggest that postural drainage per se promotes clearance of airway secretions and radioaerosol. Chopra et al. (82) found a 40% increase in tracheal mucus velocity (TMV) in anaesthetized dogs following postural drainage and Wong et al. (83) similarly found TMV to increase after postural drainage in patients with cystic fibrosis and adults recovering from acute respiratory viral infection. Oldenburg et al. (9), however, found no alteration to clearance in patients with chronic bronchitis following 40 minutes of 15 degree ‘head down’ postural drainage during which cough was discouraged, although details of sputum volume were not given. Assuming the forced expiration technique (rather than cough) when combined with postural drainage to be the most effective component of CP, then some commonly used adjuncts were investigated to determine if any additive effect could be obtained. Sputum yield and tracheobronchial clearance obtained by this optimal CP regimen was compared to that achieved by similar CP preceded by either nebulized terbutaline or saline (84). It was found that nebulized terbutaline prior to CP in a group of patients with stable
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bronchiectasis resulted in increased sputum yield and radioaerosol clearance above that achieved by CP alone (as well as causing a small but significant improvement in ventilatory function indices which was not seen following nebulized saline). Furthermore, there was a suggestion that terbutaline also enhanced clearance of secretions from peripheral regions, an effect which did not occur with CP alone. The relationships between bronchodilatation and clearance of secretions is not clear, but the minor bronchodilatation obtained may improve CP by increasing flow rates or regional ventilation. Alternative explanations are increased hydration of the periciliary fluid either directly by saline (29) or indirectly by adrenergic stimulation or ion transport and water shift towards the airway lumen (85). Direct application of terbutaline will also increase airways beat frequency, tracheal mucus velocity and whole lung clearance of airways secretions (28, 35). George et al. (86,87) also using a radioaerosol method showed that oral high frequency oscillation (OHFO) could enhance mucociliary clearance and subsequently demonstrated that the use of a simple hand-held oscillator had an additive action to CP in sputum mobilization. Exercise alone (rather than as an adjunct to CP) has been advocated as a means of promoting sputum clearance particularly in cystic fibrosis in both radioaerosol studies (9) and non-aerosol studies (88) but requires further study to quantitate the exertion required and benefit obtained and most physicians would be very reluctant to accept this advice, particularly in these patients. CONCLUSIONS Some of the conflicting results from the recent radioaerosol studies can be explained by the heterogeneity of patients studied, a failure to distinguish between cough and the forced expiration technique, and perhaps a lack of awareness of the importance of sputum volume in selection of patients. Nevertheless, sufficient evidence has now accrued particularly from radioaerosol studies to propose a rationalization of CP and to suggest the following guidelines. 1. The illness should be characterized by sputum production. CP is probably of no value in uncomplicated pneumonia, exacerbations of COAD without sputum production or routine postoperative care. 2. Cough alone is inadequate to maintain effective tracheobronchial toilet. The forced expiration technique mobilizes more sputum than cough alone particularly when combined with postural drainage and these are probably the most important elements of CP. After instruction, patients can continue this treatment without assistance at home if required. 3. Percussion and vibratory shaking have no direct value. Their addition to a CP regimen which uses the FET and postural drainage does not result in increased sputum yield. 4. Prior use of nebulized bronchodilators may increase sputum yield above that achieved by optimal CP. REFERENCES 1. Rochester DF, Goldberg SK. Techniques of respiratory physical therapy. Am Rev Resp Dis 1980;122: 133-46.
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CHEST
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Date accepted 9 June 1987
CORRIGENDUM Re: Sakula, A. (1988) Br. J. Dis. Chest 82, 23 Selman Waksman (1888-1973),
discoverer of streptomycin:
a centenary review
Page 29: The biographical details of Hubert Arthur Lechevalier have been incorrectly given as (1926-1983). The dates should read (b. 1926). I
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