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Evaluation of directed coughing in cystic fibrosis
Br. J. Dis. Chest (1988) 82, 138
EVALUATION OF DIRECTED COUGHING IN CYSTIC FIBROSIS J. BAIN, J. BISHOP AND A. OLINSKY Physiotherapy Medicine, Department
Department and Professorial Department of Thoracic Royal Children’s Hospital, Victoria, Australia, and of Paediatrics, University of Melbourne, Melbourne, Australia
Summary
Supervised directed coughing was compared to conventional physiotherapy (postural drainage, vibration and/or percussion and coughing) in 38 patients with cystic fibrosis aged 9-18 years admitted to hospital with an exacerbation of their pulmonary symptoms. Assessment included objective measures of pulmonary function and sputum characteristics. Both treatment groups showed significant improvement at the end of the 2-week period. When the patients were graded according to their pulmonary disease, those with mild-moderate disease demonstrated a significant improvement in both treatment groups whereas those with severe lung disease showed little improvement with either treatment. Directed coughing is as effective as conventional physiotherapy in the management of patients with cystic fibrosis admitted to hospital for treatment of an exacerbation of their pulmonary symptoms. INTRODUCTION Cystic fibrosis is now the most common cause of incapacitating chronic respiratory disease in children and adolescents of European descent. Chest physiotherapy, which usually involves postural drainage, percussion, vibrations and breathing exercises, has long been an accepted part of the management of these children and young adults. Such physiotherapy commences, for most of these patients, on diagnosis and continues for the rest of their lives. It is imperative that such a long-term intervention, which intrudes so much into the lives of the patients and their families, be soundly based. Physiotherapy treatment procedures to enhance mucociliary clearance have developed predominantly on an empirical basis (1). There have been few controlled studies assessing the value of chest physiotherapy as a whole, or its various components. In a study of eight patients Desmond et al. (2) showed that following a 3-week period without chest physiotherapy the pulmonary status worsened. This trend was reversed by reintroducing the physiotherapy regimen of percussion, vibration and coughing. In an Correspondence to: Dr A. Olinsky, Director, Professorial Department of Thoracic Medicine, Royal Children’s Hospital, Parkville 3052, Victoria, Australia
BAIN.
BISHOP,
OLINSKY:
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IN CF
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acute study, Rossman et al. (3) demonstrated that vigorous regimented coughing was as effective as conventional physiotherapy, in removing pulmonary secretions. The shortterm effect on pulmonary function, in patients with cystic fibrosis and moderate lung disease, was studied by De Boeck and Zinman (4) and they showed that vigorous coughing produced a similar improvement in flow rates as did a complete physiotherapy session. The results of that study suggested the need for further investigation of the long-term effectiveness of coughing alone versus complete physiotherapy. This study was undertaken to compare the current physiotherapy regimen of postural drainage, percussion, vibrations and coughing with supervised directed coughing, in patients admitted to hospital for treatment of an acute exacerbation of their pulmonary symptoms. Materials and Methods All patients with cystic fibrosis who were hospitalized with an exacerbation of their pulmonary symptoms were asked to participate in the study. To be included in the study, the patients had to meet the following criteria: be over 7 years of age, have an effective cough, be able to expectorate sputum and reliably perform pulmonary function tests. All newly diagnosed patients were excluded, as were patients admitted for other problems such as meconium ileus equivalent, elective or acute surgery, haemoptysis, pneumothorax and asthma. On admission all patients had a chest radiograph. They performed pulmonary function tests and a sputum specimen was obtained for culture. Their height and weight were measured. On the results of the chest radiograph, value of the forced expiratory volume in one second (FEVi) and the volume of sputum cleared, the patients were graded according to their pulmonary status (grade 2=mild to moderate lung disease, grade 3=severe lung disease) by one of the three consultants of the Professorial Department of Thoracic Medicine (5). There was a high correlation between the three independent observers. Patients were then divided, using stratified randomization, into one of the two physiotherapy treatment groups. The study was designed so as to control for the severity of the disease and to ensure that all operators would be treating the patients in a similar manner. All patients were initially treated with oral flucloxacillin and intravenous gentamicin. If necessary antibiotics were changed depending on sputum culture sensitivities. Patients in both groups had physiotherapy treatment three times a day for 14 days. Nebulized salbutamol was administered prior to each physiotherapy treatment. The week-day morning and afternoon treatments were done by the staff physiotherapist allocated to that particular patient for the 14 days of the study. The evening treatment was done by the ward nursing staff. On the weekends, the patients were seen by the physiotherapist rostered on duty in the mornings and by the ward nursing staff in the afternoon and evening. All patients received one-to-one treatments in uninterrupted sessions.None exercised prior to physiotherapy treatments or before the pulmonary function tests. Treatment
I (postural
drainage
regimen)
Standard postural drainage positions were used (6). Four lung segments were drained at each treatment. The selection of segments to be drained was based on the latest chest radiograph. If this showed generalized changes or a clear chest the segments drained were: anterior segments of left and right upper lobes, lateral segment of right lower lobe, lateral segment of left lower lobe and posterior basal segments of both lower lobes. For each drainage position the following treatment was done. Step 1. Two minutes percussion (clapping) over the segment, followed by:
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Step 2. Six to eight vibrations over the segment as the patient gently and completely exhaled, followed by: Step 3. The coughing sequence. In the sitting position the patient did five quick, shallow huffs or pants, followed by three forced expiratory huffs and then coughed effectively until all the loosened sputum was cleared from the larger airways. The coughing sequence was then repeated. The patient then resumed the same drainage position and the percussion, vibrations and coughing sequence were repeated once more. This regimen was continued until all four segments were drained (a minimum of 16 coughs per treatment was required). There was no time limit for this treatment, but it was kept as close to 3&35 minutes as possible. Treatment 2 (directed
huffing
and coughing
regimen)
The treatment was conducted over a 35minute time period. The patient remained seated throughout the treatment and every 5 minutes was directed to perform the huffing and coughing sequence twice. The patient did five quick, shallow huffs or pants, followed by three forced expiratory huffs and then coughed effectively until all loosened sputum was cleared from the larger airways. The sequence was then repeated. Fifteen to 30 minutes following the first physiotherapy treatment on day one and the last treatment on day 15, each patient performed pulmonary function tests. Vital capacity (VC), forced expiratory volume in one second (FEV,) and forced expiratory flow between 25% and 75% vital capacity (FEF& were measured with a standard water filled spirometer according to recommended techniques (7). Total lung capacity (TLC) and residual volume (RV) were calculated from measurements of thoracic gas volume (TGV) made in an integrated flow, pressure compensated total body plethysmograph. Maximum expiratory flow-volume curves (MEFV) were performed in the body plethysmograph and expiratory flow was measured at 70%, 60% and 40% of TLC and corrected for lung volume by dividing by TLC and expressed as TLC/s. Maximum static inspiratory and expiratory pressures at the mouth (PI,,, and PE,,,) were measured as previously described (8). Ear oximetry was measured with a Hewlett Packard ear oximeter. Sputum was also collected after these two physiotherapy sessions.The sputum was weighed and the volume measured. In addition the colour and consistency was noted and graded on a scale of l-5. Colour l=light yellow, 5=dark green/brown. Consistency l=thin, 5=thick and tenacious. Data analysis
Two-tailed paired t-tests and Wilcoxon signed-rank tests were used to analyse the differences between day 1 and day 15 in each treatment group. Analysis of variance was also performed to test for treatment effect, effect of severity of disease and any interaction between them. Significance was taken at KO.05. Intra-rater and inter-rater reliability studies were done on the subjective data, i.e. grading, sputum colour-so that the treatment was standardized. The study was approved by the Hospital Ethics Committee and informed consent was obtained.
RESULTS Forty-six patients took part in the study, 29 males and 17 females. Their ages ranged from 9 to 18 years, with a mean of 13 years. Twenty-three patients were allocated to each treatment group. Eight patients, four from each group, failed to complete the study and were excluded from further analysis. Four were withdrawn due to a febrile illness which
lasted for several days, one due to lack of compliance with the study, one because of a large haemoptysis, one patient was withdrawn at parent’s request and one was discharged before the study had been completed. The remaining 38 constituted the study group. There were 19 patients in each treatment group. There were 18 with grade 2 lung disease
BAIN,
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Table I Total group
n
Age (years) Weight (kg) Height (cm) Sex VC (%pred) FEV, (% pred)
Treatment 1
Treatment 2
19 *12.0 *33 .o $146.0 9F t78.6 t59.1
19 13.0 (9-16) 31 .O (25-65) 142.0 (127-178) SF 14M 76.1 (16.4) 55.6 (19.7)
(9-18) (25-60) (122-128) 10M (24.5) (27.5)
*Median (range). tMean (SD). Table II Grade 2 patients
Grade 3 patients
Treatment 1
Treatment 2
Treatment 1
Treatment 2
n
9
9
Age (years) Weight (kg) Height (cm) Sex VC (%pred) FEVl (% pred)
*12.0 (9-16) *32.0 (25-51) *135 .O (122-172) 7F 2M
11.0 (9-16) 32.0 (25-65) 142 .O (127-178) 2F 7M 87.2 (12.9) 70.4 (19.1)
10 13.5 (10-18) 33.5 (28-60) 153 .O (135-178) 2F 8M 65.3 (16.1) 40.5 (14.0)
10 13.5 (9-15) 30.0 (26-52) 143 .o (138-174) 3F 7M 66.1 (12.6) 42.3 (5.7)
t93.4 (24.2) t79.8 (23.8)
*Median (range). tMean (SD).
and 20 with grade 3. There was no statistical difference between the two treatment groups with regard to age, height, weight, VC % predicted or FEV, % predicted (Table I) nor any difference between the treatment groups of the grade 2 and grade 3 patients (Table II). The results of the pulmonary function tests at the beginning and end of the study period for the two treatment groups are shown in Table III. There was significant improvement in VC, FEV, FEF2S75, v60% TLC/s, PI,,, and oximetry in both treatment groups while RV/TLC and PE,,, were also significantly different in treatment 2. Comparison of the differences between day 1 and day 15 between treatment 1 and treatment 2 showed no significant difference. Analysing the results for grade 2 patients (Table IV) and grade 3 patients (Table V) revealed a similar pattern although grade 3 patients showed very little change between day 1 and day 15 in both treatment groups. Analysis of the sputum collected at the one physiotherapy session on day 1 and that obtained at the session on day 15 (Table VI) showed an improvement in both treatment categories for the total group of patients. When the patients were graded according to disease severity the improvement appeared to be confined to the treatment 2 category (directed coughing alone). However,
n
*Mean
(SD).
VC (%pred) FEVl (% pred) FEFsT5 (% pred) RV/TLC v60% TLC/s PE,,, WW PI,,, &Pa) Oximetry (%sat.)
19
19 *78.6 (24.5) 59.1 (27.5) 33.5 (24.0) 0.52 (0.14) 0.162 (0.209) 13.2 (4.2) 9.7 (2.4) 92.8 (2.8) 87.0 (25.9) 67.5 (27.0) 41.7 (28.3) 0.48 (0.13) 0.245 (0.262) 13.6 (3.7) 10.7 (3.0) 93.9 (2.3)
Day 15
1
Day 1
Treatment
Total group
Eo.05 P
P
NS
P-CO.05 P
Significance of difference between day 1 and day 15 (P value)
Table III
Day 15
19 84.4 (14.8) 66.0 (18.7) 39.8 (27.5) 0.44 (0.11) 0.194 (0.210) 15.1 (4.0) 11.0 (2.4) 94.1 (1.7)
19 76.1 (16.4) 55.6 (19.7) 31.5 (26.7) 0.51 (0.13) 0.098 (0.159) 13.5 (3.1) 10.2 (2.7) 92.3 (2.5)
2
Day 1
Treatment
P
Significance of difference between day 1 and day 15 (P value)
(SD).
107.2 (19.9) 89.0 (17.3) 61.8 (24.5) 0.39 (0.08) 0.426 (0.268) 13.4 (4.0) 10.2 (2.7) 94.6 (1.9)
*93.4 (24.2) 79.8 (23.8) 50.9 (23.0) 0.43 (0.12) 0.294 (0.232) 11.6 (2.8) 9.5 (2.3) 93.8 (2.6)
VC (%pred) FEVl (% pred) FEJLz (% pred) RV/TLC v60% TLC/s PE,,, (kP4 PL, @Pa) Oximetry (%sat.)
*Mean
9
Day 15
9
_
Day 1
n
1
Treatment
Grade 2 patients
NS
EO.05 P
P-CO.05
NS
P
Significance of difference between day 1 and day 15 (P value)
Table IV
2
87.2 (12.9) 70.4 (19.1) 49.2 (30.9) 0.44 (0.14) 0.181 (0.203) 13.8 (3.5) 11.0 (3.0) 93.0 (1.7)
9
Day 1
Treatment
95.8 (12.0) 80.4 (15.7) 57.9 (30.7) 0.38 (0.09) 0.330 (0.229) 16.3 (4.5) 11.5 (2.8) 94.6 (1.0)
9
Day 15
P
NS
EO.05 P
Ko.05 P
Significance of difference between day 1 and day 15 (P value)
2 5 0 z r;j
E
c z vi 2 a s E ;rl tl
0
E
r 2 ta z
14.6 9.8 (4.8) (2.6) 91.8 (2.7)
PE,,, @Pa) PI,, Wa) Oximetry (% sat.)
(SD).
*65.3 (16.1) 40.5 (14.1) 17.9 (10.4) 0.60 (0.09) 0.042 (0.077)
VC (%pred) FEVl (% pred) FEFUT5 (% pred) RV/TLC hO% TLC/s
*Mean
10
1
n
Day 1
Treatment
Grade 3 patients
13.9 11.2 (3.6) (3.3) 93.3 (2.5)
10 68.8 (14.5) 48.1 (17.8) 23.6 (17.2) 0.55 (0.12) 0.083 (0.107)
Day 15
NS
NS
NS
NS
NS
NS
NS
Significance of difference between day 1 and day 15 (P value)
Table V
2
13.1 9.5 (2.9) (2.2) 91.7 (3.0)
10 66.1 (12.6) 42.3 (5.7) 15.6 (3.2) 0.57 (0.07) 0.023 (0.025)
Day 1
Treatment
14.0 10.6 (3.5) (2.0) 93.7 (2.2)
10 74.2 (8.0) 53.0 (9.4) 23.5 (6.9) 0.50 (0.10) 0.072 (0.077)
Day 15
NS
Eo.01
NS
PCO.05
P
P-CO.05
NS
Significance of difference between day 1 and day 15 (P value)
34.5 26.7 3.9 1.5
Grade 3 patients Volume (ml) Weight (g) Colour Consistency
(SD).
26.1 20.1 3.0 2.2
Grade 2 patients Volume (ml) Weight (g) Colour Consistency
*Mean
*30.5 23.6 3.5 1.8
Total group Volume (ml) Weight (g) Colour Consistency
1
(15.5) (13.0) (0.6) (1.1)
(20.6) (16.0) (1.1) (1.7)
(18.1) (14.5) (0.9) (1.4)
Day 1
Treatment
27.8 27.8 3.7 2.7
16.9 13.0 2.3 3.7
22.6 17.3 3.1 3.2
(7.8) (7.8) (0.7) (2.5)
(9.9) (7.5) (0.7) (1.4)
(10.2) (7.9) (0.9) (2.0)
Day 15
.-
NS
NS
NS
NS
NS
NS
NS
NS
I-0.05
P-CO.05 P
Significance of difference between day 1 and day 15 (P value)
Table VI
43.2 (17.1) 34.7 (13.6) 4.2 (0.6) 1.0 (1.1)
31.3 (18.6) 26.2 (17.5) 3.6 (1.0) 1.6 (2.0)
37.6 (18.3) 30.7 (15.8) 3.9 (0.9) 1.3 (1.6)
Day 1
Treatment
2
(16.2) (15.3) (1.0) (1.2)
34.0 (15.0) 28.1 (14.0) 3.8 (0.9) 2.4 (1.1)
23.9 (16.7) 18.9 (16.0) 3.0 (1.0) 3.1 (1.3)
29.2 23.7 3.4 2.7
Day 15
._-
P-CO.05
NS
NS
PCO.05
NS
NS
P-CO.05 P
P-CO.05 P-CO.05 P
Significance of difference between day 1 and day 15 (P value)
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a comparison of the differences between day 1 and day 15 were not significant between treatment 1 and treatment 2. DISCUSSION In this study, we have demonstrated that there was no significant difference in the improvement in pulmonary function tests and sputum characteristics in patients with cystic fibrosis hospitalized for a 2-week period for treatment of an exacerbation of their pulmonary symptoms using either the conventional physiotherapy regimen or a directed supervised coughing regimen in addition to treatment with appropriate antibiotics. Chest physiotherapy to enhance mucociliary clearance has long been considered one of the major interventions in the management of the pulmonary disease in cystic fibrosis despite the fact that there have been few studies documenting its efficacy. Desmond et al. (2) showed that in patients with mild to moderate lung disease a 3-week period without chest physiotherapy resulted in increased airflow limitation which was reversed when regular physiotherapy was resumed. Although postural drainage, percussion and/or vibration and coughing have been advocated as the basis of this therapy there has been little objective evaluation of the effectiveness of the various components. Oldenberg et al. (9), using a radiolabelled aerosol, studied the effects of postural drainage, exercise and cough in eight patients with chronic bronchitis. They found that coughing greatly accelerated total lung and peripheral mucus clearance whereas exercise resulted in smaller changes than did cough. Postural drainage in which coughing was prohibited did not alter the clearance rates. On the other hand Lorin and Denning (lo), in a study of 17 patients with cystic fibrosis with varying degrees of pulmonary involvement, showed that postural drainage produced over twice the volume of sputum as an equal period of only coughing. They interpreted their results to indicate that postural drainage was an effective process for dislodging pulmonary secretions from small peripheral airways. No objective measures of pulmonary function, however, were made. Pulmonary function tests were performed by Tecklin and Holsclaw (11) in 26 patients with cystic fibrosis before and following bronchial drainage which included percussion, vibration and coughing. They found significant improvement in routine pulmonary function tests and suggested that bronchial drainage was effective in clearing the larger, more proximal airways. The efficacy of physiotherapy with objective measures of pulmonary function was also studied by Feldman et al. (12) in nine patients with cystic fibrosis and 10 with chronic bronchitis. They found that postural drainage with coughing resulted in significant improvement in lung function predominantly in measures of flows at low lung volumes whereas flows at high lung volumes were less consistent. They, like other investigators, found that there was no correlation between the volume of sputum produced and changes in lung function. In recent years the forced expiration technique, when used as part of a postural drainage treatment, has been suggested to be a more efficient means of clearing bronchial secretions than postural drainage (13,14). In these studies no changes in pulmonary function were seen after a single treatment. However, in a recently published study (15), conducted over 3 days, significant improvement in pulmonary function was found in 12 patients with cystic fibrosis.
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Coughing is the end point of any physiotherapy programme and it has been suggested that coughing alone might be just as effective as full conventional physiotherapy. There have been a few very short-term studies that have evaluated coughing alone versus conventional physiotherapy. De Boeck and Zinman (4) compared vigorous coughing alone with complete chest physiotherapy in nine patients with cystic fibrosis who had moderate airflow obstruction and they demonstrated no significant difference in functional response between the two treatment groups. Bateman et al. (16) using labelled radioactive tracer particles in six patients with chronic obstructive lung disease showed that cough alone was as effective as conventional physiotherapy (including cough) in clearing central airways. However, physiotherapy was found to be more effective in clearing peripheral airways. The reasons for the discrepancy in the published results is not clear. Patient selection, duration of therapy, physiotherapy and coughing techniques and assessment parameters are factors that need to be controlled. In our study patients in the two treatment groups were matched as closely as possible. They were hospitalized for 2 weeks and were supervised for the whole study period in an attempt to control for as many variables as possible. Furthermore, dividing the patients into two subgroups allowed for the severity of the lung disease. It is interesting but not altogether suprising that the patients in grade 3 did not demonstrate as much improvement in the parameters assessed as did those in grade 2, regardless of the treatment category. This study has shown that directed coughing is as effective as conventional physiotherapy in the management of patients hospitalized for treatment of an acute exacerbation of their pulmonary symptoms. It is a method that can be applied in a group situation and would be particularly useful where physiotherapy resources are limited. It is readily accepted by the patients and can be self-administered, thus encouraging a degree of independence. The role of directed coughing as a form of physiotherapy in the longterm management of these patients needs to be further explored. ACKNOWLEDGEMENTS We would like to thank the members of the physiotherapy department and the nursing staff for their cooperation and assistance with the study and Professor L. I. Landau who was instrumental in initiating the study. REFERENCES 1. Kirilloff LH, Owens GR, Rogers RM, Mazzocco MC. Does chest physical therapy work? Chest 1985;88:43&44.
2. Desmond KJ, Schwink WF, Thomas E, Beaudry PH, Coates AL. Immediate and long-term effects of chest physiotherapy in patients with cystic fibrosis. J Pediat 1983;103:53%-42. 3. Rossman CM, Waldes R, Sampson D, Newhouse MT. Effect of chest physiotherapy on the removal of mucus in patients with cystic fibrosis. Am Rev Resp Dis 1982;126:131-5. 4. De Boeck C, Zinman R. Cough versus chest physiotherapy. Am Rev Resp Dis 1984;129:182-4. 5. Holzer FJ, Olinsky A, Phelan PD. Variability of airway hyperreactivity and allergy in cystic fibrosis. Arch Dis Child 1981;56:455-9. 6. Thacker EW. Postural drainage and respiratory control. 2nd ed. London: Lloyd-Luke (Medical Books) Ltd, 1963.
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7. ATS Statement-Snowbird Workshop on Standardization of Spirometry. Am Rev Resp Dis 1979;119:831-8. 8. Wagener JS, Hibbert ME, Landau LI. Maximal respiratory pressures in children. Am Rev Resp Dis 1984;129:973-5. 9. Oldenburg FA, Dolovich MB, Montgomery JM, Newhouse MT. Effects of postural drainage, exercise, and cough on mucus clearance in chronic bronchitis. Am Rev Resp Dis 1979;120:73945. 10. Lorin MI, Denning CR. Evaluation of postural drainage by measurement of sputum volume and consistency. Am J Phys Med 1971;50:215-19. 11. Tecklin JS, Holsclaw DS. Evaluation of bronchial drainage in patients with cystic fibrosis. Phys Ther 1975;55:10814. 12. Feldman J, Traver GA, Taussig LM. Maximal expiratory flows after postural drainage. Am Rev Resp Dis 1979:119:239-45.
13. Pryor JA, Webber BA. An evaluation of the forced expiration technique as an adjunct to postural drainage. Physiotherapy 1979;65:304-7. 14. Pryor JA, Webber BA, Hodson ME, Batten JC. Evaluation of the forced expiration technique as an adjunct to postural drainage in treatment of cystic fibrosis. Br Med J 1979;2:417-18. 15. Webber BA, Hofmeyr JL, Morgan MDL, Hodson ME. Effects of postural drainage, incorporating the forced expiration technique, on pulmonary function in cystic fibrosis. Br J Dis Chest 1986;80:353-9. 16. Bateman JRM, Newman SP, Daunt KM, Sheahan NF, Pavia D, Clarke SW. Is cough as effective as chest physiotherapy in the removal of excessive tracheobronchial secretions? Thoraxl981;36:683-7.
Date accepted 15 March
1987
EVALUATION OF DIRECTED COUGHING IN CYSTIC FIBROSIS J. BAIN, J. BISHOP AND A. OLINSKY Physiotherapy Medicine, Department
Department and Professorial Department of Thoracic Royal Children’s Hospital, Victoria, Australia, and of Paediatrics, University of Melbourne, Melbourne, Australia
Summary
Supervised directed coughing was compared to conventional physiotherapy (postural drainage, vibration and/or percussion and coughing) in 38 patients with cystic fibrosis aged 9-18 years admitted to hospital with an exacerbation of their pulmonary symptoms. Assessment included objective measures of pulmonary function and sputum characteristics. Both treatment groups showed significant improvement at the end of the 2-week period. When the patients were graded according to their pulmonary disease, those with mild-moderate disease demonstrated a significant improvement in both treatment groups whereas those with severe lung disease showed little improvement with either treatment. Directed coughing is as effective as conventional physiotherapy in the management of patients with cystic fibrosis admitted to hospital for treatment of an exacerbation of their pulmonary symptoms. INTRODUCTION Cystic fibrosis is now the most common cause of incapacitating chronic respiratory disease in children and adolescents of European descent. Chest physiotherapy, which usually involves postural drainage, percussion, vibrations and breathing exercises, has long been an accepted part of the management of these children and young adults. Such physiotherapy commences, for most of these patients, on diagnosis and continues for the rest of their lives. It is imperative that such a long-term intervention, which intrudes so much into the lives of the patients and their families, be soundly based. Physiotherapy treatment procedures to enhance mucociliary clearance have developed predominantly on an empirical basis (1). There have been few controlled studies assessing the value of chest physiotherapy as a whole, or its various components. In a study of eight patients Desmond et al. (2) showed that following a 3-week period without chest physiotherapy the pulmonary status worsened. This trend was reversed by reintroducing the physiotherapy regimen of percussion, vibration and coughing. In an Correspondence to: Dr A. Olinsky, Director, Professorial Department of Thoracic Medicine, Royal Children’s Hospital, Parkville 3052, Victoria, Australia
BAIN.
BISHOP,
OLINSKY:
DIRECTED
COUGHING
IN CF
139
acute study, Rossman et al. (3) demonstrated that vigorous regimented coughing was as effective as conventional physiotherapy, in removing pulmonary secretions. The shortterm effect on pulmonary function, in patients with cystic fibrosis and moderate lung disease, was studied by De Boeck and Zinman (4) and they showed that vigorous coughing produced a similar improvement in flow rates as did a complete physiotherapy session. The results of that study suggested the need for further investigation of the long-term effectiveness of coughing alone versus complete physiotherapy. This study was undertaken to compare the current physiotherapy regimen of postural drainage, percussion, vibrations and coughing with supervised directed coughing, in patients admitted to hospital for treatment of an acute exacerbation of their pulmonary symptoms. Materials and Methods All patients with cystic fibrosis who were hospitalized with an exacerbation of their pulmonary symptoms were asked to participate in the study. To be included in the study, the patients had to meet the following criteria: be over 7 years of age, have an effective cough, be able to expectorate sputum and reliably perform pulmonary function tests. All newly diagnosed patients were excluded, as were patients admitted for other problems such as meconium ileus equivalent, elective or acute surgery, haemoptysis, pneumothorax and asthma. On admission all patients had a chest radiograph. They performed pulmonary function tests and a sputum specimen was obtained for culture. Their height and weight were measured. On the results of the chest radiograph, value of the forced expiratory volume in one second (FEVi) and the volume of sputum cleared, the patients were graded according to their pulmonary status (grade 2=mild to moderate lung disease, grade 3=severe lung disease) by one of the three consultants of the Professorial Department of Thoracic Medicine (5). There was a high correlation between the three independent observers. Patients were then divided, using stratified randomization, into one of the two physiotherapy treatment groups. The study was designed so as to control for the severity of the disease and to ensure that all operators would be treating the patients in a similar manner. All patients were initially treated with oral flucloxacillin and intravenous gentamicin. If necessary antibiotics were changed depending on sputum culture sensitivities. Patients in both groups had physiotherapy treatment three times a day for 14 days. Nebulized salbutamol was administered prior to each physiotherapy treatment. The week-day morning and afternoon treatments were done by the staff physiotherapist allocated to that particular patient for the 14 days of the study. The evening treatment was done by the ward nursing staff. On the weekends, the patients were seen by the physiotherapist rostered on duty in the mornings and by the ward nursing staff in the afternoon and evening. All patients received one-to-one treatments in uninterrupted sessions.None exercised prior to physiotherapy treatments or before the pulmonary function tests. Treatment
I (postural
drainage
regimen)
Standard postural drainage positions were used (6). Four lung segments were drained at each treatment. The selection of segments to be drained was based on the latest chest radiograph. If this showed generalized changes or a clear chest the segments drained were: anterior segments of left and right upper lobes, lateral segment of right lower lobe, lateral segment of left lower lobe and posterior basal segments of both lower lobes. For each drainage position the following treatment was done. Step 1. Two minutes percussion (clapping) over the segment, followed by:
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Step 2. Six to eight vibrations over the segment as the patient gently and completely exhaled, followed by: Step 3. The coughing sequence. In the sitting position the patient did five quick, shallow huffs or pants, followed by three forced expiratory huffs and then coughed effectively until all the loosened sputum was cleared from the larger airways. The coughing sequence was then repeated. The patient then resumed the same drainage position and the percussion, vibrations and coughing sequence were repeated once more. This regimen was continued until all four segments were drained (a minimum of 16 coughs per treatment was required). There was no time limit for this treatment, but it was kept as close to 3&35 minutes as possible. Treatment 2 (directed
huffing
and coughing
regimen)
The treatment was conducted over a 35minute time period. The patient remained seated throughout the treatment and every 5 minutes was directed to perform the huffing and coughing sequence twice. The patient did five quick, shallow huffs or pants, followed by three forced expiratory huffs and then coughed effectively until all loosened sputum was cleared from the larger airways. The sequence was then repeated. Fifteen to 30 minutes following the first physiotherapy treatment on day one and the last treatment on day 15, each patient performed pulmonary function tests. Vital capacity (VC), forced expiratory volume in one second (FEV,) and forced expiratory flow between 25% and 75% vital capacity (FEF& were measured with a standard water filled spirometer according to recommended techniques (7). Total lung capacity (TLC) and residual volume (RV) were calculated from measurements of thoracic gas volume (TGV) made in an integrated flow, pressure compensated total body plethysmograph. Maximum expiratory flow-volume curves (MEFV) were performed in the body plethysmograph and expiratory flow was measured at 70%, 60% and 40% of TLC and corrected for lung volume by dividing by TLC and expressed as TLC/s. Maximum static inspiratory and expiratory pressures at the mouth (PI,,, and PE,,,) were measured as previously described (8). Ear oximetry was measured with a Hewlett Packard ear oximeter. Sputum was also collected after these two physiotherapy sessions.The sputum was weighed and the volume measured. In addition the colour and consistency was noted and graded on a scale of l-5. Colour l=light yellow, 5=dark green/brown. Consistency l=thin, 5=thick and tenacious. Data analysis
Two-tailed paired t-tests and Wilcoxon signed-rank tests were used to analyse the differences between day 1 and day 15 in each treatment group. Analysis of variance was also performed to test for treatment effect, effect of severity of disease and any interaction between them. Significance was taken at KO.05. Intra-rater and inter-rater reliability studies were done on the subjective data, i.e. grading, sputum colour-so that the treatment was standardized. The study was approved by the Hospital Ethics Committee and informed consent was obtained.
RESULTS Forty-six patients took part in the study, 29 males and 17 females. Their ages ranged from 9 to 18 years, with a mean of 13 years. Twenty-three patients were allocated to each treatment group. Eight patients, four from each group, failed to complete the study and were excluded from further analysis. Four were withdrawn due to a febrile illness which
lasted for several days, one due to lack of compliance with the study, one because of a large haemoptysis, one patient was withdrawn at parent’s request and one was discharged before the study had been completed. The remaining 38 constituted the study group. There were 19 patients in each treatment group. There were 18 with grade 2 lung disease
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Table I Total group
n
Age (years) Weight (kg) Height (cm) Sex VC (%pred) FEV, (% pred)
Treatment 1
Treatment 2
19 *12.0 *33 .o $146.0 9F t78.6 t59.1
19 13.0 (9-16) 31 .O (25-65) 142.0 (127-178) SF 14M 76.1 (16.4) 55.6 (19.7)
(9-18) (25-60) (122-128) 10M (24.5) (27.5)
*Median (range). tMean (SD). Table II Grade 2 patients
Grade 3 patients
Treatment 1
Treatment 2
Treatment 1
Treatment 2
n
9
9
Age (years) Weight (kg) Height (cm) Sex VC (%pred) FEVl (% pred)
*12.0 (9-16) *32.0 (25-51) *135 .O (122-172) 7F 2M
11.0 (9-16) 32.0 (25-65) 142 .O (127-178) 2F 7M 87.2 (12.9) 70.4 (19.1)
10 13.5 (10-18) 33.5 (28-60) 153 .O (135-178) 2F 8M 65.3 (16.1) 40.5 (14.0)
10 13.5 (9-15) 30.0 (26-52) 143 .o (138-174) 3F 7M 66.1 (12.6) 42.3 (5.7)
t93.4 (24.2) t79.8 (23.8)
*Median (range). tMean (SD).
and 20 with grade 3. There was no statistical difference between the two treatment groups with regard to age, height, weight, VC % predicted or FEV, % predicted (Table I) nor any difference between the treatment groups of the grade 2 and grade 3 patients (Table II). The results of the pulmonary function tests at the beginning and end of the study period for the two treatment groups are shown in Table III. There was significant improvement in VC, FEV, FEF2S75, v60% TLC/s, PI,,, and oximetry in both treatment groups while RV/TLC and PE,,, were also significantly different in treatment 2. Comparison of the differences between day 1 and day 15 between treatment 1 and treatment 2 showed no significant difference. Analysing the results for grade 2 patients (Table IV) and grade 3 patients (Table V) revealed a similar pattern although grade 3 patients showed very little change between day 1 and day 15 in both treatment groups. Analysis of the sputum collected at the one physiotherapy session on day 1 and that obtained at the session on day 15 (Table VI) showed an improvement in both treatment categories for the total group of patients. When the patients were graded according to disease severity the improvement appeared to be confined to the treatment 2 category (directed coughing alone). However,
n
*Mean
(SD).
VC (%pred) FEVl (% pred) FEFsT5 (% pred) RV/TLC v60% TLC/s PE,,, WW PI,,, &Pa) Oximetry (%sat.)
19
19 *78.6 (24.5) 59.1 (27.5) 33.5 (24.0) 0.52 (0.14) 0.162 (0.209) 13.2 (4.2) 9.7 (2.4) 92.8 (2.8) 87.0 (25.9) 67.5 (27.0) 41.7 (28.3) 0.48 (0.13) 0.245 (0.262) 13.6 (3.7) 10.7 (3.0) 93.9 (2.3)
Day 15
1
Day 1
Treatment
Total group
Eo.05 P
P
NS
P-CO.05 P
Significance of difference between day 1 and day 15 (P value)
Table III
Day 15
19 84.4 (14.8) 66.0 (18.7) 39.8 (27.5) 0.44 (0.11) 0.194 (0.210) 15.1 (4.0) 11.0 (2.4) 94.1 (1.7)
19 76.1 (16.4) 55.6 (19.7) 31.5 (26.7) 0.51 (0.13) 0.098 (0.159) 13.5 (3.1) 10.2 (2.7) 92.3 (2.5)
2
Day 1
Treatment
P
Significance of difference between day 1 and day 15 (P value)
(SD).
107.2 (19.9) 89.0 (17.3) 61.8 (24.5) 0.39 (0.08) 0.426 (0.268) 13.4 (4.0) 10.2 (2.7) 94.6 (1.9)
*93.4 (24.2) 79.8 (23.8) 50.9 (23.0) 0.43 (0.12) 0.294 (0.232) 11.6 (2.8) 9.5 (2.3) 93.8 (2.6)
VC (%pred) FEVl (% pred) FEJLz (% pred) RV/TLC v60% TLC/s PE,,, (kP4 PL, @Pa) Oximetry (%sat.)
*Mean
9
Day 15
9
_
Day 1
n
1
Treatment
Grade 2 patients
NS
EO.05 P
P-CO.05
NS
P
Significance of difference between day 1 and day 15 (P value)
Table IV
2
87.2 (12.9) 70.4 (19.1) 49.2 (30.9) 0.44 (0.14) 0.181 (0.203) 13.8 (3.5) 11.0 (3.0) 93.0 (1.7)
9
Day 1
Treatment
95.8 (12.0) 80.4 (15.7) 57.9 (30.7) 0.38 (0.09) 0.330 (0.229) 16.3 (4.5) 11.5 (2.8) 94.6 (1.0)
9
Day 15
P
NS
EO.05 P
Ko.05 P
Significance of difference between day 1 and day 15 (P value)
2 5 0 z r;j
E
c z vi 2 a s E ;rl tl
0
E
r 2 ta z
14.6 9.8 (4.8) (2.6) 91.8 (2.7)
PE,,, @Pa) PI,, Wa) Oximetry (% sat.)
(SD).
*65.3 (16.1) 40.5 (14.1) 17.9 (10.4) 0.60 (0.09) 0.042 (0.077)
VC (%pred) FEVl (% pred) FEFUT5 (% pred) RV/TLC hO% TLC/s
*Mean
10
1
n
Day 1
Treatment
Grade 3 patients
13.9 11.2 (3.6) (3.3) 93.3 (2.5)
10 68.8 (14.5) 48.1 (17.8) 23.6 (17.2) 0.55 (0.12) 0.083 (0.107)
Day 15
NS
NS
NS
NS
NS
NS
NS
Significance of difference between day 1 and day 15 (P value)
Table V
2
13.1 9.5 (2.9) (2.2) 91.7 (3.0)
10 66.1 (12.6) 42.3 (5.7) 15.6 (3.2) 0.57 (0.07) 0.023 (0.025)
Day 1
Treatment
14.0 10.6 (3.5) (2.0) 93.7 (2.2)
10 74.2 (8.0) 53.0 (9.4) 23.5 (6.9) 0.50 (0.10) 0.072 (0.077)
Day 15
NS
Eo.01
NS
PCO.05
P
P-CO.05
NS
Significance of difference between day 1 and day 15 (P value)
34.5 26.7 3.9 1.5
Grade 3 patients Volume (ml) Weight (g) Colour Consistency
(SD).
26.1 20.1 3.0 2.2
Grade 2 patients Volume (ml) Weight (g) Colour Consistency
*Mean
*30.5 23.6 3.5 1.8
Total group Volume (ml) Weight (g) Colour Consistency
1
(15.5) (13.0) (0.6) (1.1)
(20.6) (16.0) (1.1) (1.7)
(18.1) (14.5) (0.9) (1.4)
Day 1
Treatment
27.8 27.8 3.7 2.7
16.9 13.0 2.3 3.7
22.6 17.3 3.1 3.2
(7.8) (7.8) (0.7) (2.5)
(9.9) (7.5) (0.7) (1.4)
(10.2) (7.9) (0.9) (2.0)
Day 15
.-
NS
NS
NS
NS
NS
NS
NS
NS
I-0.05
P-CO.05 P
Significance of difference between day 1 and day 15 (P value)
Table VI
43.2 (17.1) 34.7 (13.6) 4.2 (0.6) 1.0 (1.1)
31.3 (18.6) 26.2 (17.5) 3.6 (1.0) 1.6 (2.0)
37.6 (18.3) 30.7 (15.8) 3.9 (0.9) 1.3 (1.6)
Day 1
Treatment
2
(16.2) (15.3) (1.0) (1.2)
34.0 (15.0) 28.1 (14.0) 3.8 (0.9) 2.4 (1.1)
23.9 (16.7) 18.9 (16.0) 3.0 (1.0) 3.1 (1.3)
29.2 23.7 3.4 2.7
Day 15
._-
P-CO.05
NS
NS
PCO.05
NS
NS
P-CO.05 P
P-CO.05 P-CO.05 P
Significance of difference between day 1 and day 15 (P value)
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a comparison of the differences between day 1 and day 15 were not significant between treatment 1 and treatment 2. DISCUSSION In this study, we have demonstrated that there was no significant difference in the improvement in pulmonary function tests and sputum characteristics in patients with cystic fibrosis hospitalized for a 2-week period for treatment of an exacerbation of their pulmonary symptoms using either the conventional physiotherapy regimen or a directed supervised coughing regimen in addition to treatment with appropriate antibiotics. Chest physiotherapy to enhance mucociliary clearance has long been considered one of the major interventions in the management of the pulmonary disease in cystic fibrosis despite the fact that there have been few studies documenting its efficacy. Desmond et al. (2) showed that in patients with mild to moderate lung disease a 3-week period without chest physiotherapy resulted in increased airflow limitation which was reversed when regular physiotherapy was resumed. Although postural drainage, percussion and/or vibration and coughing have been advocated as the basis of this therapy there has been little objective evaluation of the effectiveness of the various components. Oldenberg et al. (9), using a radiolabelled aerosol, studied the effects of postural drainage, exercise and cough in eight patients with chronic bronchitis. They found that coughing greatly accelerated total lung and peripheral mucus clearance whereas exercise resulted in smaller changes than did cough. Postural drainage in which coughing was prohibited did not alter the clearance rates. On the other hand Lorin and Denning (lo), in a study of 17 patients with cystic fibrosis with varying degrees of pulmonary involvement, showed that postural drainage produced over twice the volume of sputum as an equal period of only coughing. They interpreted their results to indicate that postural drainage was an effective process for dislodging pulmonary secretions from small peripheral airways. No objective measures of pulmonary function, however, were made. Pulmonary function tests were performed by Tecklin and Holsclaw (11) in 26 patients with cystic fibrosis before and following bronchial drainage which included percussion, vibration and coughing. They found significant improvement in routine pulmonary function tests and suggested that bronchial drainage was effective in clearing the larger, more proximal airways. The efficacy of physiotherapy with objective measures of pulmonary function was also studied by Feldman et al. (12) in nine patients with cystic fibrosis and 10 with chronic bronchitis. They found that postural drainage with coughing resulted in significant improvement in lung function predominantly in measures of flows at low lung volumes whereas flows at high lung volumes were less consistent. They, like other investigators, found that there was no correlation between the volume of sputum produced and changes in lung function. In recent years the forced expiration technique, when used as part of a postural drainage treatment, has been suggested to be a more efficient means of clearing bronchial secretions than postural drainage (13,14). In these studies no changes in pulmonary function were seen after a single treatment. However, in a recently published study (15), conducted over 3 days, significant improvement in pulmonary function was found in 12 patients with cystic fibrosis.
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IN CF
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Coughing is the end point of any physiotherapy programme and it has been suggested that coughing alone might be just as effective as full conventional physiotherapy. There have been a few very short-term studies that have evaluated coughing alone versus conventional physiotherapy. De Boeck and Zinman (4) compared vigorous coughing alone with complete chest physiotherapy in nine patients with cystic fibrosis who had moderate airflow obstruction and they demonstrated no significant difference in functional response between the two treatment groups. Bateman et al. (16) using labelled radioactive tracer particles in six patients with chronic obstructive lung disease showed that cough alone was as effective as conventional physiotherapy (including cough) in clearing central airways. However, physiotherapy was found to be more effective in clearing peripheral airways. The reasons for the discrepancy in the published results is not clear. Patient selection, duration of therapy, physiotherapy and coughing techniques and assessment parameters are factors that need to be controlled. In our study patients in the two treatment groups were matched as closely as possible. They were hospitalized for 2 weeks and were supervised for the whole study period in an attempt to control for as many variables as possible. Furthermore, dividing the patients into two subgroups allowed for the severity of the lung disease. It is interesting but not altogether suprising that the patients in grade 3 did not demonstrate as much improvement in the parameters assessed as did those in grade 2, regardless of the treatment category. This study has shown that directed coughing is as effective as conventional physiotherapy in the management of patients hospitalized for treatment of an acute exacerbation of their pulmonary symptoms. It is a method that can be applied in a group situation and would be particularly useful where physiotherapy resources are limited. It is readily accepted by the patients and can be self-administered, thus encouraging a degree of independence. The role of directed coughing as a form of physiotherapy in the longterm management of these patients needs to be further explored. ACKNOWLEDGEMENTS We would like to thank the members of the physiotherapy department and the nursing staff for their cooperation and assistance with the study and Professor L. I. Landau who was instrumental in initiating the study. REFERENCES 1. Kirilloff LH, Owens GR, Rogers RM, Mazzocco MC. Does chest physical therapy work? Chest 1985;88:43&44.
2. Desmond KJ, Schwink WF, Thomas E, Beaudry PH, Coates AL. Immediate and long-term effects of chest physiotherapy in patients with cystic fibrosis. J Pediat 1983;103:53%-42. 3. Rossman CM, Waldes R, Sampson D, Newhouse MT. Effect of chest physiotherapy on the removal of mucus in patients with cystic fibrosis. Am Rev Resp Dis 1982;126:131-5. 4. De Boeck C, Zinman R. Cough versus chest physiotherapy. Am Rev Resp Dis 1984;129:182-4. 5. Holzer FJ, Olinsky A, Phelan PD. Variability of airway hyperreactivity and allergy in cystic fibrosis. Arch Dis Child 1981;56:455-9. 6. Thacker EW. Postural drainage and respiratory control. 2nd ed. London: Lloyd-Luke (Medical Books) Ltd, 1963.
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7. ATS Statement-Snowbird Workshop on Standardization of Spirometry. Am Rev Resp Dis 1979;119:831-8. 8. Wagener JS, Hibbert ME, Landau LI. Maximal respiratory pressures in children. Am Rev Resp Dis 1984;129:973-5. 9. Oldenburg FA, Dolovich MB, Montgomery JM, Newhouse MT. Effects of postural drainage, exercise, and cough on mucus clearance in chronic bronchitis. Am Rev Resp Dis 1979;120:73945. 10. Lorin MI, Denning CR. Evaluation of postural drainage by measurement of sputum volume and consistency. Am J Phys Med 1971;50:215-19. 11. Tecklin JS, Holsclaw DS. Evaluation of bronchial drainage in patients with cystic fibrosis. Phys Ther 1975;55:10814. 12. Feldman J, Traver GA, Taussig LM. Maximal expiratory flows after postural drainage. Am Rev Resp Dis 1979:119:239-45.
13. Pryor JA, Webber BA. An evaluation of the forced expiration technique as an adjunct to postural drainage. Physiotherapy 1979;65:304-7. 14. Pryor JA, Webber BA, Hodson ME, Batten JC. Evaluation of the forced expiration technique as an adjunct to postural drainage in treatment of cystic fibrosis. Br Med J 1979;2:417-18. 15. Webber BA, Hofmeyr JL, Morgan MDL, Hodson ME. Effects of postural drainage, incorporating the forced expiration technique, on pulmonary function in cystic fibrosis. Br J Dis Chest 1986;80:353-9. 16. Bateman JRM, Newman SP, Daunt KM, Sheahan NF, Pavia D, Clarke SW. Is cough as effective as chest physiotherapy in the removal of excessive tracheobronchial secretions? Thoraxl981;36:683-7.
Date accepted 15 March
1987