PAEDIATRIC RESPIRATORY REVIEWS (2006) 7S, S220–S222

Physiotherapy and airway clearance techniques

and devices
Maggie McIlwaine*

BC Children’s Hospital, Vancouver, Canada

The focus of this talk is on the use of airway clearance siotherapy consisting of postural drainage, percussion
techniques to assist in the removal of secretions from the and vibration for a mean of 57 minutes. He suggested that
lungs with particular emphasizes on their use in the NICU chest physiotherapy needs to be of 1-hour duration to be
and PICU setting. Until the early 1990’s the term, ‘‘Chest effective.
Physiotherapy’’ was synonymous with the terms, ‘‘airway Thomas et al.4 attempted to review the use of vibration
clearance techniques, or postural drainage and percussion’’ in airway clearance. The physiological literature suggests a
with the latter being the traditional method of airway rationale to support the use of vibrations with a frequency
clearance used by Physiotherapists. Over the past 15 years, of <60 Hz., by improving mucociliary transport and altering
it has been recognized that we must be more compre- the thixotropic property of mucus.5 However, there are
hensive in our approach to the cardiopulmonary system few clinical trials examining the effect of vibration as an
Modalities now used by Physiotherapists to treat cardio- adjunct to PD.
pulmonary pathology include airway clearance techniques,
exercise, positioning, re-education of breathing, thoracic
mobility exercises and inhalation therapy. DETRIMENTAL EFFECTS OF
There are currently a number of airway clearance POSTURAL DRAINAGE AND
techniques available for use, although not all of them have PERCUSSION
been validated by scientific data. Postural drainage and
percussion was first described by William Ewart in Until recently, it was thought, there were no detrimental
19011 who referred to it as ‘‘empty bronchus treatment effects to performing PD&P. As a result PD&P was often
by posture in the bronchiectasis of children’’. To enhance over prescribed with the rationale, ‘‘lets try it, as it can only
clearance of secretions chest wall clapping or percussion help’’. However, recent studies have suggested that PD&P
was added to postural drainage. Flower2 showed mechan- may have a detrimental effect on patients. Button et al.6
ical percussion increases intra-thoracic pressure, but no demonstrated that PD&P performed in head down posi-
studies have been performed to examine the effects of tions may aggravate gastro esophageal reflux in infants with
manual percussion. Physiological rationale for the use of CF. As a result of this study, Button et al.7 modified PD
postural drainage to assist in the clearance of secretions is positions to no tipping and recently published the results of
based on the use of gravity to assist with the mucociliary using these modified non tip positions over a five year
action. However, for gravity to be effective, the patient period in patients with CF, showing improved outcomes.
would have to be placed in head down positions for In the NICU, PD&P has been associated with neurolo-
between 60–100 minutes. MacKenzie et al.3 in a study gical sequalae. Three studies have reported conflicting
on 42 ventilated patients, were able to demonstrate an results on neurological outcomes following neonatal chest
increase in total lung compliance following chest phy- physiotherapy. One study from New Zealand reported
neurological sequelae following the use of chest physiother-
* Tel.: +1 6048752123. apy.8 Two other studies could not find any correlation
E-mail address: mmcilwaine@cw.bc.ca. between chest physiotherapy and negative neurological
1526-0542/$ – see front matter ß 2006 Elsevier Ltd. All rights reserved.
doi:10.1016/j.prrv.2006.04.197
PHYSIOTHERAPY AND AIRWAY CLEARANCE TECHNIQUES AND DEVICES S221

outcomes. In the New Zealand paper, vigorous percussion Necessary oxygenation is required during chest physiother-
was performed by nurses in the low birth weight infant apy and suctioning to prevent hypoxemia.
<1000 grams. In the other 2 papers only gentle physiother-
apy using vibrations was performed in the LBW infant and
no neurological sequelae was reported.9,10
CURRENT AIRWAY CLEARANCE
Rib fractures are another complication to be aware of in TECHNIQUES
the very young paediatric patient with the incidence being Over the past 20 years, other airway clearance techniques
reported as 1:1000 infants median age 3 months treated for have been developed which utilize ventilation to get the air
bronchiolitis and Pneumonia.11 Other adverse reactions to behind the secretions and then the expiratory airflow to
PD&P include bronchospasm, changes in cardiac rhythm,12 mobilize the secretions up the airways. These newer
and raised intracranial pressures in head-down positions. techniques have been scientifically validated.21

NEW EVIDENCE TO SUPPORT THE VENTILATION

USE OF PERCUSSION AND Ventilation may be altered by a variety of methods. The
VIBRATION IN NON-TIPPED method chosen will depend upon the patient, lung pathol-
POSITIONS ogy and the level of co-operation from the patient.
Simple positioning in side lying will alter ventilation to a
As a result of the research concerning the detrimental specific lung. Prone positioning will increase PaO2 by as
effects of PD&P, the practice of Physiotherapy in relation to much as 10%, due to enhanced ventilation, although prone
PD&P in Canada has changed. No longer are head-down positioning is not very practical in the PICU setting. Ventila-
positions used to assist in secretion removal, rather patients tion will be improved by an inspiratory vital capacity
are placed in positions to optimize ventilation to specific maneuver with a three second breath hold. This maneuver
lung regions. It has been speculated that the redistribution allows air to get behind secretions and avoids ventilator
of ventilation, as occurs with a change in body position, asynchronism. It utilizes the principles of interdependence
might alter the local airway patency and gas/liquid and collateral ventilation.
pump.13,14 Consequently, it can be hypothesized that Several airway clearance techniques incorporate these
the physiological basis on which the concept of PD was breathing manoeuvres. The Active Cycle of Breathin-
originally developed, may not be the only mechanism for g(ACBT) utilizes both a deep inspiration with or without
the improvement seen with changes in position as used in a 3 second breath hold, while Autogenic drainage uses only
PD positions. This hypothesizes is partly supported by the 3 second breath hold. The three second breath hold is
Lannefors and Wollmer15 who noted that more secretions very useful in post-operative patients or patients who have
were cleared from the dependant lung rather than from the restrictive lung disease.
uppermost lung during postural drainage. Breath stacking performed with a one way valve and
Ambu mask is another method used to increase ventilation
AIRWAY CLEARANCE TECHNIQUES and get air behind secretions in patients with restrictive lung
disease who are unable to take a full inspiratory effort
IN NICU
independently, i.e. neuromuscular patients and spinal cord
For this Paper, eighteen studies were reviewed and sum- patients.
marized. Three systematic reviews could find no evidence The Positive Expiratory Pressure Mask (PEP) increases
to support the routine use of prophylactic airway clearance ventilation by applying a positive pressure of 10–20 cms H2O
techniques for neonates. There was some evidence to at the mouth. FRC is increased during breathing through the
indicate the need for physiotherapy in neonates with device and air moves behind secretions by use of collateral
CXR changes and/or mucus plugging.16,10,17 ventilation. The Flutter and Acapella devices both utilize
There was substantial evidence to support the use of positive expiratory pressure but the Flutter is based on
physiotherapy to prevent post-extubation atelectasis and different physiological principles which decreases FRC during
reintubation18,19 however, physiotherapy needs to be given use. This has been shown to have detrimental effects.22
2 hourly to obtain this effect. NIPPV and Nasal CPAP are High Frequency Chest Wall Oscillation (HFCWO) or
both effective evidence based treatments to facilitate wean- the ‘‘Vest’’ does not allow for increasing ventilation to a
ing and extubation of preterm infants.20 As physiotherapy particular lung region.
may have deleterious consequences, it should only be
initiated by a physiotherapist after careful assessment and
an initial treatment to assess the effects of the treatment and
EXPIRATORY AIRFLOW
modifications necessary to accommodate the fragile state of The use of the expiratory airflow to mobilize the secretions
the patient. Only gentle physiotherapy with vibrations should up the airway has proven to be very effective. Lung
be performed in the low birth weight infant <1000 grams. volumes, intra-bronchial pressures and pleural pressures
S222 M. McILWAINE

are all adjusted to create optimum airflow to mobilize the 4. Thomas J, DeHueck A, Kleiner M, Newton J, Crowe J, Mahler S. To
vibrate or not to vibrate: Usefulness of the mechanical vibrator for
secretions.
clearing bronchial secretions. Physiotherapy Canada 1995; 47: 120–
Huffing uses a strong expiratory airflow which com- 125.
presses the airways and squeezes the mucus up the airways. 5. King M, Phillips DM, Gross D. Enhanced tracheal mucus clearance with
It is based on the equal pressure point theory. ACBT and PEP high frequency chest wall compression. Am Rev Respir Dis 1983; 128:
both use huffing to mobilize secretions up the airways. Care 511–515.
needs to be taken to avoid too strong a compression leading 6. Button BM, Heine RG, Catto-Smith AG, Phelan PD, Olinsky A.
Postural drainage and gastro-oesophageal reflux in infants with cystic
to bronchospasm. AD works well when hyperinflation is fibrosis. Arch of Dis in Child 1997; 76: 148–150.
present such as in Asthma, bronchiolitis, and cystic fibrosis. It 7. Button BM, Heine RG, Catto-Smith AG, Olinsky A, Phelan PD,
utilizes lower expiratory flow rates, avoiding airway com- Ditchfield MR. Chest physiotherapy in infants with cystic fibrosis.
pression, and exhaling into expiratory reserve volume. In Pediatr Pulmonol 2003; 35: 208.
8. Harding JE, Miles FKI, Becroft DMO, Allen BC, Knight DB. Chest
infants or when a patient is on a ventilator it can be
physiotherapy may be associated with brain damage in extremely
performed passively on the patient by the Physiotherapist. premature infants. The Journal of Pediatrics 1998; 132: 440–444.
Oscillating devices such as the Flutter and HFCWO 9. Beeby PJ, Henderson-Smart DJ, Lacey JL, Rieger I. Short- and long-
have a twofold effect on secretion clearance. Oscillation has term neurological outcomes following neonatal chest physiotherapy. J
been shown to decrease the viscoelastic properties of Paediatr Child Health 1998; 34: 60–62.
mucus hence making it easier to mobilize up the airways. 10. Lacey JL. Chest physiotherapy. Department of Neonatal Protocol
Book 2000; Royal Prince Alfred Hospital.
The second effect of the oscillations is to cause short bursts 11. Chalumeau M, Foix-L’Helias L, Scheinmann P, Zuani P. Rib fractures
of increased acceleration of the expiratory airflow which after chest physiotherapy for bronchiolitis or pneumonia in infants.
assist in mobilizing the secretions up the airways. Pediatric Radiology 2002; 32: 644–647.
In patients with a neuromuscular disorder or a spinal 12. Naylor JM, Chow CM, McLean AS. Cardiovascular responses to short-
cord injury, assisted coughing may be helpful to assisting in term headdown positioning in healthy young and older adults. Phy-
siotherapy Research International 2005; 10: 32–47.
mobilizing secretions up the airways. 13. Menkes H, Britt J. Rationale for physical therapy. Am Rev Respir Dis
1980; 122(suppl 2): 127–213.
14. Oberwaldner B. Physiotherapy for airway clearance in paediatrics. Eur
UPPER AIRWAY SECRETION Respir J 2000; 15: 196–204.
CLEARANCE 15. Lannefors L, Wollmer P. Mucus clearance with three chest physiother-
apy regimes in cystic fibrosis. A comparison between postural drai-
When secretions are mobilized to the upper airways, a nage, positive expiratory pressure and physical exercise. Eur Resp J
strong cough will clear the secretions. If the patient is unable 1992; 5: 748–753.
to cough, suctioning may be required in the very ill patient. 16. Flenady VJ, Gray PH. Chest Physiotherapy for preventing morbidity in
In patients with a neuromuscular disorder or a spinal cord babies being extubated from mechanical ventilation. (Cochrane
Review). In: The Cochrane Library 2006; 1: Oxford Update Software.
injury, a coughalator is very effective in clearing secretions
17. Lewis JA, Lacey JL, Henderson-Smart DJ. A review of chest phy-
from the larger airways.23 siotherapy in neonatal intensive care units in Australia. J Paediatr Child
Health 1992; 28: 297.
18. Bloomfield FH, Teele RL, Voss M, Knight DB, Harding JE. The role of
CONCLUSION neonatal chest physiotherapy in preventing postextubation atelectasis.
Physiotherapists now have a variety of airway clearance J Pediatr 1998; 133: 269–271.
19. Al-Alaiyan S, Dyer D, Khan B. Chest physiotherapy and post-extuba-
techniques and devices available for use. Applying them to
tion atelectasis in infants. Pediatr Pulmonol 1996; 21: 227–230.
the patient takes expertise not only in knowing the tech- 20. Halliday H. What interventions facilitate weaning from the ventilator?
niques but in understanding the physiology behind the A review of the evidence from systematic reviews Paediatric Respir Rev
techniques and being able to adapt and apply the techni- 2004; 5(suppl A): S347–S352.
ques to the individual patient. The Physiotherapist also 21. Langenderfer B. Alternatives to percussion and postural drainage. A
review of mucus clearance therapies: percussion and postural drai-
needs to know when airway clearance will be helpful to
nage, autogenic drainage, positive expiratory pressure, flutter valve,
the patient and when it will have no effect. intrapulmonary percussive ventilation and high frequency chest com-
pression with the ThAIRapy vest. J Cardiac and Pul Rehab 1998; 18:
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