Sputum clearance techniques

ACI Respiratory Network

Ruth Dentice
Senior Respiratory Physiotherapist, RPA Hospital

Specialist Physiotherapist - Cardiorespiratory

PhD, Sydney Medical School

Outline

Why airways develop abnormal mucus

clearance
Strategies to combat this:
Airway clearance physiotherapy
Inhalations
Exercise
 Why abnormal mucus clearance?
That depends to some extent on the diagnosis
- Asthma
- COPD
Expiratory airflow restriction:
airflow will limit clearance
Diagnosed via Spirometry
- If non reversible
(with a bronchodilator) = COPD
- Reversible = Asthma
 Bronchodilators
Bronchodilator responsiveness, classically
used to define asthma, can be misleading, as
individuals with bronchiectasis have an
inherent variation in their lung function
response.
Prevalence of bronchodilator airflow
obstruction reversibility = 20-46% in
Bronchiectasis
b2-Agonists may also facilitate airway
clearance by increasing ciliary beat frequency
Balfour-Lynn 2002; Halfhide 2005
 Why abnormal mucus clearance?
That depends to some extent on the diagnosis
- Bronchiectasis
CFTR protein is absent, abnormal or in the wrong position

Sodium and chloride transport is poorly regulated, and too

much water is lost from the airway surface.
abnormal mucus (volume/ viscosity)
impaired cilial action
early peripheral sputum plugging
 Impact of abnormal clearance
- Infection / inflammation

- permanent dilatation of bronchi

- increased airway collapsability

- impaired ventilation & gas exchange

 Improve symptoms & quality of life
Uncontrolled cough and congestion
Energy expenditure to clear sputum
Breathlessness
Risk of complications
- Reflux, haemoptysis, stress incontinence,
pain
Reduce exacerbations and hospitalisations
 Strategies
1. Speed up the movement of the mucus layer
Gravity / airflow
2. Prevent airway collapse or blockage
PEP devices / Relaxed breathing techniques
(AD) / NIV
3. Make the mucus less thick
Oscillation
Hypertonic saline / Mannitol
Antibiotics
 Positioning and postural drainage
PD = positioning a lung segment to enable gravity
to aid movement of secretions from peripheral to
central airways
- Sputum flow vs. reflux risk
- Ventilation distribution
 PD: risk vs. benefit
Risks
- Breathlessness
- Reflux (GORD)
Head down PD indicated if:
- > 30mls sputum/day
- No evidence of GORD
- No excessive breathlessness
- > efficiency than other techniques
 Speeding up expiratory airflow
A slow deep breath in and active exhalation

- Cough, laugh, musical instrument

- Breathing techniques (AD), huff

- Flutter, Bubble PEP

Manual techniques

- Percussion, vibration

? Exercise

- With oscillation (running, bouncing)

Active Cycle of Breathing Technique

Breathing Control 3 second hold

3 or 4 Thoracic Expansion Exercises + percussion
vibration
Breathing Control

Forced Expiration Technique

(1-2 huffs + breathing control)
 Autogenic Drainage
Utilises expiratory airflow
to mobilise secretions
- Reaching the highest
airflow in each
generation of bronchi
without airway
collapse
- Aim for a mucus rattle
rather than a wheeze
 AD Method
Phase 1 Phase 2 Phase 3

TLC Vt
ERV
FRC
RV
2. Prevent airway collapse or blockage

PEP can take many forms

How PEP works

+ +
+ + + +
 +
+
+ +
 PEP

+ + +
+ + +
 PEP

+ +
+ +
+ + + +
+
 PEP

+
+

+
+ + +
+ + + + +
 + + + +

+ +++ +

+ + + +

+ + + +
+++
+
++
++++ ++++ +++ PEP
+ + + +
 Low Pressure PEP: Application
- In sitting (or PD)
- Via face mask or mouthpiece
- 10-20 cmH20 at mid expiration
- Ratio of inspiration to exhalation =1:3
- Breathing is normal volume, slightly active
exhalation
- Avoid complete expiration, maintain seal
- 5-10 breaths, cycle concluded with huff
- Duration =15-20 minutes
 Bubble PEP
No sealed system

Oscillating expiratory flow

A good PEP trial

Infection control

Tube PEP
expiratory flow
Not a closed system
 3. Make the mucus less thick

Oscillating techniques
 Oscillation of the airway
Incorporates the benefits PEP, to prevent early
airway closure in unstable airways

Approximates the cilia beat frequency to

maximise vibration of the bronchial walls.

Oscillation & intermittent acceleration of

expiratory airflow

sputum viscosity by mechanically rupturing the

mucus gel

ease of clearance
 Oscillating PEP: Application
Generally 5-10 slow deep breaths with an inspiratory
hold are followed by exhalation into the device of
choice; the cycle is completed by a huff

The cycle is continued for 10-15 minutes

Flutter Acapella
 Device Selection
Oscillating devices are beneficial when
- Mucus is thick
- Mucus is central, stimulates cough
- Variety

Less helpful when

- Cough control is poor
- Limited expiratory flow
- Cost is a factor (Bubble PEP)
 How much physio?

Dose: 15-30 mins

- x 2 clear cycles, cough free time

Frequency:
- Daily for familiarity
- Twice daily >30mls
- Pre inhaled antibiotics
 Inhalations that make mucus less thick

hydration disrupt mucus cough effect

bacterial
biofilms ?

Dornase alfa Dornase alfa Dornase alfa Dornase alfa

Hypertonic saline Hypertonic saline Hypertonic saline Hypertonic saline
? Mannitol Mannitol Mannitol Mannitol

Shak 1990
Donaldson 2006 King 1997 Robinson 1997 Havasi 2008
Tarran 2001 Daviskas 2010 Robinson 1999 Anderson 2006
 Dornase alfa (Pulmozyme):

- alters mucus
properties
- mucociliary
clearance
- FEV1 short
and long-term

Shak et al (1990); Shah et al (1996); Laube et al (1996); Robinson et al (2000); Jones & Wallis (2010)
 Dornase alfa in Non-CF Brx
Dornase alfa is not associated with any improvement in lung
function or QOL measures.

In-vitro sputum transportability fell following the addition of

dornase alfa to non-CF bronchiectatic sputum.

A 24 week multicentre RCT (n=349) dornase alfa vs. placebo:

Pulmonary exacerbations were more frequent, and FEV1
decline was greater in patients who received dornase alfa.

Wills1996; ODonnell 1998

 Hypertonic Saline
Reduces viscosity of sputum King 1997

Restores airway surface liquid Donaldson & Bennett 2006

Stimulates cough Rodwell 1996, Elkins 2006

Disrupts biofilms Anderson 2008

 Hypertonic saline

- alters mucus properties

- mucociliary clearance
- FEV1 short and long-term

100 Inhalation
% Retention

90

80
Control
70
7% HS

0 20 40 60 80 100 120 140

Time (min)
King et al (1997); Robinson et al (1997, 1999); Donaldson et al (2006); Wark & McDonald (2009)
 Hypertonic saline FEV1
Change in FEV1
In Cystic Fibrosis 0.9%
10 7%
Compared to 8

placebo, significant

FEV1 (% change)
6

4
FEV1 after 2
1 month (4%)
-2

-4
- Maintained 4 12 24 36 48

Weeks
throughout
1 year (2.3%)

Elkins et al (2006)
 Hypertonic saline in non-CF Brx
An RCT (n=40) 6% vs. isotonic saline (0.9%)
twice daily for 12 months with ACBT.
No differences in lung function, number of
exacerbations or QOL at 3, 6 and 12 months
Both groups had significant improvement in
health-related QOL compared to baseline.
However, this study was substantially
underpowered.

Nicolson 2010
 Mannitol (Bronchitol)
- alters mucus properties
- mucociliary clearance
- FEV1 short and long-term

100 Inhalation
% Retention

90

80
Control
70
Mannitol
asked to cough
0 20 40 60 80 100 120 140
Time (min)
Daviskas et al (2010); Robinson et al (1999); Jaques et al (2008); Bilton et al (2009); Minasian et al (2010)
 Inhaled antibiotics
Reduce the concentration of
bacteria and the impact of
infection and inflammation that
makes mucus thicker
Cleaning and timing is
important
- Bronchodilator
- Hypertonic saline/ Mannitol,
physio
- Post: inhaled antibiotic
 Strategies
1. Speed up the movement of the mucus layer
Gravity / airflow
2. Prevent airway collapse or blockage
PEP devices / Relaxed breathing techniques /
NIV
3. Make the mucus less thick
Oscillation
Hypertonic saline / Mannitol
Antibiotics
 Exercise
Increases sputum clearance via expiratory
flow ventilation, airway oscillation.
Prevents deconditioning due to low aerobic
fitness / reduced muscle bulk
Use normal training stimulus
Important role:
- prevent osteoporosis
- prevent deconditioning during hospital stay
- psychological and immune benefits
 The impact of exercise on the CF
airway
Airflow changes
- ventilation and expiratory flow
- No expiratory airflow bias
- Similar coughs compared to rest

Mucus changes
- mucus elasticity with treadmill

Dwyer 2011
 Questions: ruth.dentice@sswahs.nsw.gov.au

Further reading:
Holland and Button 2006 Chron Respir Dis.
3(2):83-91.
Is there a role for airway clearance techniques in
chronic obstructive pulmonary disease?
Bradley, Moran and Elborn 2006 Respir
Med.100(2):191-201.
Evidence for physical therapies (airway clearance
and physical training) in cystic fibrosis: an
overview of five Cochrane systematic reviews.