Airway Clearance Techniques for Cystic Fibrosis

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By ACCORDANT HEALTH SERVICES

Airway clearance techniques (ACTs) loosen thick, sticky mucus so it can be cleared from the lungs. ACTs help the lungs to work better. If you have CF, ACTs can help you stay healthy and breathe easier. ACTs should begin when CF is diagnosed and should go on for the rest of life.

Most ACTs are easy to do. Here are the daily ACTs most often used by those with CF:

Coughing and Huffing
The most basic ACT is a natural one--coughing. Coughing is a reflex that moves mucus from the lungs in a forceful way. People with CF cough much more than other people. Most healthy people cough less than 16 times a day. People with CF cough an average of 643 times a day. Some cough as often as 1,569 times a day. Coughing so much can be tiring!

After an ACT, a person must cough to clear their airway. Many people use a huff cough after an ACT. Huffing is a gentle, less tiring way to cough. Huffing is done by tightening the stomach muscles, taking a deep breath, and then pushing air out fast, with the mouth open. Coughing this way has been compared to what we do when we "huff" on a mirror to fog it up.

Chest Physical Therapy (CPT)
Chest physical therapy (CPT) is the standard way to clear the airways. CPT is also called chest PT or PD & P (postural drainage and percussion). All people with CF can benefit from CPT. CPT most often calls for the help of some other person. Some adults can do it alone with the help of a percussion tool.

CPT clears the airways by mixing five techniques:

• Postural drainage uses gravity to pull mucus from smaller airways to larger ones where it can be coughed out. During CPT, a person lies or sits in different positions that let gravity drain the mucus as tapping and vibration break it loose. Up to 12 different positions may be used.
• Percussion is done by some other person. He or she uses a cupped hand to pound the front, back, and sides of the chest in a steady way. This does not hurt because the cupped hand keeps a cushion of air under it. Percussion loosens mucus.
• Vibration is done with a flat hand. The caregiver uses a vibrating motion on the chest. This shakes mucus from the walls of the lungs.
• Deep breathing comes next. The person breathes deep enough to move the belly in and out. This deep breathing moves the loose mucus. It may cause coughing.
• Coughing is the final step. It removes the mucus and clears the airway. This is called a "productive" cough.

If a drug to open airways has been prescribed, it should be used before CPT. If an aerosol antibiotic has been prescribed, it should be used after CPT to treat the opened airways.>>

CPT takes about 20 to 40 minutes. It should be done before meals or an hour and a half to two hours after a meal. Many people find that the best times to do this ACT are in the early morning and again before bed. During illness, CPT may need to be done more than twice a day.

Devices
Some ACTs use special devices. These ACTs can be done as well as, or instead of, CPT. They work as well as CPT and do not call for the help of some other person.

• PEP (positive expiratory pressure). PEP gets air into the lungs and behind the mucus. A person breathes into a mask or mouthpiece that is hooked up to a resistor. The resistor creates pressure that holds the airways open. This lets air get behind the mucus. The person breathes in normally and breathes out harder against the resistance. After doing this many times, the person coughs or huffs. A PEP tool does not cost very much and it is portable.
• Oscillating PEP (oscillating positive expiratory pressure). This ACT uses a hand-held tool that vibrates the small and large airways. The person blows all the way out through the device. He or she then coughs or huffs, and repeats the cycle many times. Some oscillating PEP devices are: Flutter^®, Comet^™, Acapella,^™ and IPV (Intrapulmonary Percussive Ventilation).
  These devices are portable and do not cost much.
• High-frequency Chest Compression (HFCC). In HFCC, a person wears an inflatable vest that is attached to a machine. The machine sends air pulses through the vest to make it vibrate. This loosens and thins the mucus in the airways. This ACT takes about 15-20 minutes. Every five minutes, the person stops the machine and coughs or huffs. Before doing HFCC, people often breath in medicine to open the airways. Most people do HFCC twice a day. It can be done while watching TV or using a computer. A vest costs more than other ACTs and it is not portable. Some HFCCs are: The Vest™, inCourage™, and MedPulse®.

Breathing Techniques
Two types of breathing techniques are used to clear the airways:

• Active Cycle of Breathing Therapy (ACBT)
  ACBT moves mucus by getting air behind it. The breathing can be done in ways that meet each person's needs. There are three parts:
  • Controlled breathing. (Breathing gently with the lower chest while the upper chest is relaxed.)
  • Thoracic expansion exercises. (Deep breathing to open up the chest. This can include self-percussion on the chest. Some other person could also help with this.)
  • Forced expiration. (Huffing with breathing control.)
• Autogenic Drainage (AD)
  Autogenic means self-drainage. AD is a way to control airflow so that the air moves mucus. With AD, a person breathes three different ways. This works to move mucus from small to large airways. The three parts of are AD are:
  • Light breathing to loosen mucus
  • Medium breathing to collect mucus
  • Heavy breathing to clear mucus

People must be trained to do AD. It can be hard to learn. It is best for those over age 8 who focus well. If you want to try AD, your doctor may suggest using PEP or oscillating PEP along with it.

References

Cystic Fibrosis Foundation Web site. Accessed September 1, 2007. 

Cystic Fibrosis Foundation Web site.  Accessed May 13, 2008.

Consumer Fact Sheet: An Introduction to Postural Drainage and Percussion. Cystic Fibrosis Foundation Web site. Accessed May 13, 2008.

Lannefors L, Button BM, Mcllwaine M. Physiotherapy in infants and young children with cystic fibrosis: current practice and future developments. J R Soc Med. 2004;97(44):8-25.

Accordant Drug and Technology Guideline Cystic Fibrosis: High Frequency Chest Compression (HFCC) ("The Vest"). Updated March 18, 2008.

Cystic Fibrosis Foundation Web site . Accessed May 13, 2008.

Cunningham JC, Taussig LM, An Introduction to Cystic Fibrosis for Patients and Families. Fifth edition. Cystic Fibrosis Foundation; 2003.

Accordant Drug and Technology Guideline Cystic Fibrosis: Chest Physiotherapy (CPT). Updated March 18, 2008.

Cystic Fibrosis Education Web site. Accessed June 6, 2008.

Yankaskas JR, Marshall BC, Sufian B, Simon RH, Rodman D. Cystic fibrosis adult care: consensus conference report. Chest. 2004;125(1)(suppl 1):1S-39S.

Gumery L, Dodd M, Parker A, Prasad A, Pryor J, Kennedy N, eds. Clinical Guidelines for the Physiotherapy Management of Cystic Fibrosis. Bromley, United Kingdom: Cystic Fibrosis Trust; 2002.

Last Modified Date: March 19, 2009 © Accordant Health Services, a CVS/Caremark company. All rights reserved.
This article has been reviewed for accuracy by a member of the Accordant Health Services Medical Advisory Team.
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