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Background: Weakness in the muscles used to breathe and swallow can lead to difficulties with airway clearance for people with neurological disorders including neuromuscular disease and cerebral palsy. This can lead to aspiration and other respiratory problems which are the leading causes of death in patients with complex neurological disorders. The Vest™ system supports airway clearance through the use of High-Frequency Chest Wall Oscillation (HFCWO) to loosen secretions in the chest by reducing their viscosity. Objective: To assess the cost-effectiveness of the Vest™ system versus Manual Chest Wall Physiotherapy (MCWP) for airway clearance in patients with neurological disorders including neuromuscular disease and cerebral palsy. Methods: A decision-analytic Markov model was developed to estimate the cost-effectiveness of HFCWO and MCWP over 5- and 10-year time horizons. Costs were estimated from the perspective of the UK National Health Service and personal social services. The main input parameters in the model were: rates of respiratory infection, respiratory-related hospitalisation, antibiotic use for respiratory infection and cost of the Vest™ system. The input parameters were informed by existing clinical guidelines and literature. Sensitivity analyses were conducted to explore uncertainties around the input parameters. Results: Over 5- and 10-year time horizons, the Vest™ system results in more quality-adjusted life-years and lower costs per patient. The Vest™ system has a high probability of being cost-effective (>98%) at willingness-to-pay thresholds of £20,000 and £30,000. The estimated average cost saving per patient over a 5-year time horizon is £5,660 (SD = £2362). Our results show that the Vest™ system may result in approximately £6 million cost savings per 1,000 patients with complex neurological disorders in 5 years. Per 1,000 patients, 2,442 hospital admissions and 49,868 bed days could be averted with the use of the Vest™ system. Our results were generally robust to the sensitivity analyses performed. Conclusion: The Vest™ system results in fewer respiratory infection episodes and hospitalisations, and thus less National Health Service (NHS) resource use, than current practice. Therefore, it is highly likely to be a cost-saving strategy.

Many children seen under the umbrella of respiratory medicine benefit from physiotherapy. Physiotherapists bring a wide range of skills in the clinical management of this group of patients. These roles include secretion or airway clearance, breathing re-education, inhaled therapy, education for respiratory health, postural and musculoskeletal management, exercise prescription, support with weaning ventilation and admission prevention. Within this article we aim to explore some of the key roles physiotherapists undertake.

Background: In the medical complexity of a children with cerebral palsy, impaired airway clearance represents a major problem, leading to significative respiratory morbidity and mortality. Its management is difficult because of limited cooperation and poor tolerance to invasive treatments. Free Aspire(®) (FA) is a device designed to remove bronchial secretions noninvasively, without generating cough. Methods: The aim of our pilot prospective study is to assess the efficacy and acceptability of FA in removing airway obstruction in subjects with cerebral palsy and ineffective cough. We enrolled 11 subjects. At enrollment and after 3, 6, and 12 months, we collected data regarding health care resources use for respiratory exacerbations, perceived efficacy, and acceptability of treatment. Results: We observed a reduction in emergency room (ER) accesses, home pharmacological treatment, hospitalizations number, and hospital stay length. In particular after 12 months we observed a reduction of 74% in ER accesses and home pharmacological treatment, 38% in hospitalizations number, and 17% in hospital stay length for respiratory exacerbations. The 100% of caregivers considered the treatment effective and simple to use and noted an improvement in subjects' general condition. They also reported good treatment tolerance of subjects, with an overall good compliance. Conclusion: The study demonstrates that FA is an effective device for the removal of bronchial secretions, with a positive caregivers' perception, that favored a good long-term compliance.

Background: Airway clearance techniques (ACTs) are recommended for people with bronchiectasis both in stable state and during an acute exacerbation. Research has previously investigated ACTs for in...

BACKGROUND: Positive expiratory pressure (PEP) devices are widely used in clinical settings, yet the performance characteristics of these devices remain relatively unknown. This study compared the performance characteristics of 6 airway clearance devices by varying resistance and flow. METHODS: Mean PEP, peak PEP, oscillation frequency, and amplitude PEP of the Flutter, Pari PEP S, Acapella Choice, Acapella DM, Acapella DH, and Aerobika devices were obtained across flows of 5, 10, 15, 20, 25 and 30 L/min and at low, medium, and high resistance using an experimental apparatus custom-built for this bench study. RESULTS: Performance characteristics of the devices differed across flows and resistance settings (device × flow/resistance interaction; P < .001). At a fixed resistance, increasing flows increased mean PEP produced by the Acapella Choice, Acapella DH, Aerobika, and Pari PEP S. Increasing flow resulted in minimal change in mean PEP produced by the Flutter and Acapella DM. Increasing flow increased peak PEP and amplitude PEP produced by all devices except the Acapella DH and Acapella Choice. Increasing flow maintained or increased oscillation frequency for all devices except the Flutter. At a fixed flow, increasing resistance increased mean PEP produced by all devices except the Acapella Choice. Increasing resistance increased peak PEP produced by the Acapella DM, Aerobika, and Pari PEP S but resulted in minimal change in peak PEP for the Flutter and Acapella Choice. Increasing resistance either maintained or increased oscillation frequency for all devices. Amplitude PEP was either maintained or increased during oscillations when increasing resistance for all devices except the Flutter. CONCLUSIONS: PEP devices produced small but statistically significant variations in performance characteristics across a range of flows and resistance settings. There appear to be flow-dependent and non–flow-dependent devices. Varying flow or resistance typically maintained or increased the production of mean, peak, and amplitude PEP and oscillation frequency.

Background Airway clearance techniques (ACTs) are integral to cystic fibrosis (CF) management. However, there is no consensus as to which outcome measures (OMs) are best for assessing ACT efficacy. Objectives: To summarise OMs that have been assessed for their clinimetric properties (including validity, feasibility, reliability & reproducibility) within the context of ACT research. MethodsEligibility Criteria - Any parallel or cross-over randomised controlled trial (RCT) investigating outcome measures for ACT in the CF population. Information sources: Five medical databases; clinicaltrials.gov; abstracts from international CF conferences. Risk of Bias - The authors planned to independently assess study quality and risk of bias using the COSMIN risk of bias checklist with external validity assessment based upon study details (participants and study intervention).Synthesis of Results – Two review authors (GS and MJ) independently screened search results against inclusion criteria, further data extraction was planned but not required.ResultsIncluded studies - No completed RCTs from the 187 studies identified met inclusion criteria for the primary or post-hoc secondary objective. Two ongoing trials were identified.DiscussionLimitations of evidence: The search strategy may have missed some lesser-known terms for ACT or manuscripts reporting clinimetric properties solely within text. Studies validating outcome measures for use in other aspects of CF, which may be relevant to ACT, are not included.Interpretation - High-quality RCTs are urgently needed to investigate & validate the clinimetric properties of OMs used to assess ACT efficacy. With the changing demographics of CF combined with the introduction of CFTR modulator therapies, an accurate assessment of the current benefit of ACT or the effect of ACT withdrawal is a high priority for clinical practice and future research and OMs which have been validated for this purpose are essential.OtherFunding: NIHR/HEE Clinical Doctoral Fellowship grant for GS (reference CDRF-2014-05-055).Systematic review registration number - PROSPERO no.CRD42020206033

Background: Infants undergoing congenital cardiac surgery with cardiopulmonary bypass are at high risk for respiratory complications. As impaired airway mucociliary clearance (MCC) can potentially contribute to pulmonary morbidity, our study objective was to measure airway clearance in infants undergoing congenital cardiac surgery and examine correlation with clinical covariables that may impair airway clearance function.Materials and Methods: Airway clearance in infants was measured over 30 min using inhaled nebulized Technetium 99m sulfur colloid administered either via a nasal cannula or the endotracheal tube in intubated infants. This was conducted bedside with a portable gamma camera. No difficulty was encountered in positioning the gamma camera over the patient, and neither the camera nor the MCC scan interfered with routine medical care or caused any adverse events. Patient and perioperative variables were examined relative to the MCC measurements.Results: We prospectively enrolled 57 infants undergoing congenital cardiac surgery and conducted a single MCC scan per patient. MCC data from 42 patients were analyzable, including five pre-operative, 15 (40.5%) in the immediate post-operative period (days 1–2), and 22 (59.5%) were later post-operative (≥3 days). Pre-operative MCC was inversely proportional to days requiring post-operative mechanical ventilation (p = 0.006) and non-invasive positive pressure ventilation (p = 0.017). MCC was higher at later post-operative days (p = 0.002) with immediate post-operative MCC being lower (3%; 0–13%) than either pre-operative (21%; 4–25%) (p = 0.091) or later post-operative MCC (18%; 0–29%) (p = 0.054). Among the infants with low post-operative MCC, significantly more were pre-mature [5/19 (26%) vs. 0/18 (0%); p = 0.046], were intubated [14/19 (75%) vs. only 7/18 (39%); p = 0.033] and were receiving higher FiO2 (40%, 27–47% vs. 26%, 21–37%; p = 0.015).Conclusions: This is the first study to show that infants undergoing congenital cardiac surgery have impaired MCC. MCC appeared lowest in the immediate post-operative period. Worse MCC was associated with pre-maturity, mechanical ventilation, or receiving higher FiO2. These findings suggest MCC scans should be further explored for informing clinical decision making to improve post-surgical respiratory outcomes. The possible therapeutic benefit of airway clearance maneuvers for infants with poor MCC function should also be investigated.

The management of bronchial secretions is one of the main problems encountered in a wide spectrum of medical conditions ranging from respiratory disorders, neuromuscular disorders and patients undergoing either thoracic or abdominal surgery. The purpose of this review is illustrate to the reader the different ACTs currently available and the related evidence present in literature. Alongside methods with a strong background behind as postural drainage, manual techniques or PEP systems, the current orientation is increasingly aimed at devices that can mobilize and / or remove secretions. Cough Assist, Vacuum Techniques, systems that modulate airflow have more and more scientific evidence. Different principles combination is a new field of investigation that goes toward an increasing of clinical complexity that will facing us.

Introduction Medical errors can occur any time resident physicians transition between rotations, especially to unfamiliar areas such as subspecialty pediatrics. To combat this, we created and implemented the pediatric resident education in pulmonary (PREP) boot camp using Kern's six-step approach to curriculum development. Methods PREP was a 5-hour session with multiple high-yield components held on the first day of each new rotation, aimed to prepare residents to care for complex pulmonary inpatients, including those with tracheostomy and ventilator dependence, asthma, and cystic fibrosis. The curriculum was evaluated at multiple time points through surveys of residents and faculty and two formal resident focus group sessions. Results PREP was successfully implemented in July 2018 with continued monthly sessions held. Thirty-five residents participated in the first year. Resident perceived preparedness and confidence in taking call duties increased significantly following PREP. All residents rated PREP as extremely helpful or very helpful, the highest ratings possible. Overall, residents preferred active learning strategies. All qualitative data revealed positive effects of PREP. Clinical faculty in the pulmonology division found PREP similarly helpful and felt that PREP better prepared residents to provide care to pulmonary inpatients than our previous model. Discussion Our monthly preparatory boot camp on the first day of residents’ inpatient pulmonary rotation has improved resident experience, preparedness, and ability to care for complex pulmonary patients. The curriculum was adjusted in response to feedback to increase hands-on time and interactive sessions. Protected time for residents and active learning strategies were key to success of PREP.

The lung is protected by multiple mechanisms, but the primary defense is mucociliary clearance (MCC). MCC is responsible for removing noxious particulates that may reduce lung health, but it can also clear inhaled pharmaceuticals. Effective MCC relies on the correct ciliary structure and pattern of movement, combined with mucus rheology characteristics, that together facilitate particle capture and transport. Abnormalities in these result in muco-obstructive disease. The ability to accurately measure MCC is vital for understanding airway dysfunction, and for evaluating inhaled pharmaceutical performance. MCC measurements have been performed in humans for more than a century, and today most still rely on measuring the transit time of marker particles, with the gold standard technique utilizing radiolabeled technetium sulfur colloid. Similar assessment methods for tracking the mass-transit of particles have also been used in animal models. More recent methods designed to assess local individual particle clearance via computed tomography or synchrotron imaging have enabled the MCC behavior of individual particles to be better understood. These new methods have been augmented by airway clearance models and by micro-optical coherence tomography, which can assess MCC directly without the addition of marker particles. Although our understanding of non-absorptive clearance has improved, further technical advances are required to properly understand the key role these mechanisms play in drug design and delivery.

Objectives: to classify the degree of dependence on nursing care required by children with Congenital Zika Syndrome during hospitalization and to analyze their complexity. Methods: this is a descriptive, observational and quantitative study carried out in a pediatric ward of a public hospital in Rio de Janeiro. Data were collected from hospitalization records between June 2017 and April 2018. Results: 54% of the population studied showed a degree of dependence equivalent to semi-intensive care. On 37.5% of hospitalization days, patients required non-invasive or invasive mechanical ventilation; 31.5% had spontaneous breathing requiring airway clearance by aspiration and/or oxygen therapy. Conclusion: Congenital Zika Syndrome represents a challenge for health professionals due to its uniqueness. In this study, it is expressed by demands for complex and continuous care in hospitalization and in preparation for discharge, requiring semi-intensive nursing care. RESUMEN Objetivos: clasificar el grado de dependencia de los cuidados de enfermería que requieren los niños con Síndrome de Zika Congénito durante la hospitalización y analizar su complejidad. Métodos: estudio descriptivo, observacional y cuantitativo, realizado en una sala de pediatría de un hospital público de Rio de Janeiro. Los datos se obtuvieron de los registros de hospitalización entre junio de 2017 y abril de 2018. Resultados: el 54% de la población estudiada presenta un grado de dependencia equivalente a cuidados semi-intensivos. En el 37,5% de los días de hospitalización, los pacientes requirieron ventilación mecánica invasiva o no invasiva; el 31,5% presentaba respiración espontánea con necesidad de despejar las vías respiratorias por aspiración y/o necesidad de oxigenoterapia. Conclusión: el Síndrome de Zika Congénito representa un desafío para los profesionales de la salud debido a su singularidad. En este estudio, se expresa por demandas de cuidados complejos y continuos en la hospitalización y en la preparación para el alta, que requieren cuidados de enfermería semi-intensivos. RESUMO Objetivos: classificar o grau de dependência de cuidados de enfermagem requeridos por crianças com Síndrome de Zika Congênita durante a internação hospitalar e analisar a complexidade destes. Métodos: estudo descritivo, observacional e quantitativo, realizado em uma enfermaria pediátrica de um hospital público do Rio de Janeiro. Os dados foram coletados a partir dos registros de internação entre junho de 2017 e abril de 2018. Resultados: 54% da população estudada apresentou grau de dependência equivalente a cuidados semi-intensivos. Em 37,5% dos dias de internação, os pacientes necessitaram de ventilação mecânica não invasiva ou invasiva; 31,5% tinham respiração espontânea com necessidade de desobstrução de vias aéreas por aspiração e/ou necessidade de oxigenoterapia. Conclusão: a Síndrome de Zika Congênita representa um desafio aos profissionais de saúde devido à sua singularidade. Neste estudo, é expressa por demandas de cuidados complexos e contínuos na hospitalização e no preparo para alta, requerendo cuidados de enfermagem semi-intensivos.

BACKGROUND Depression and anxiety symptoms in patients with cystic fibrosis (CF) and their caregivers are 2-3 times higher than in the normal population. This study aims to evaluate the frequency and severity of depression and anxiety symptoms and to determine possible risk factors in CF patients and their mother and/or fathers at Marmara University CF center. METHODS The study included 132 CF patients who were followed up at our CF center. Patient Health Questionnaire (PHQ-9) and the Generalized Anxiety Disorder Questionnaire (GAD-7) were used to screen depression and anxiety. The questionnaires were completed by 50 CF patients (aged 12-17 years) and 132 parents of patients (aged 0-17 years). RESULTS While moderate to severe depressive symptoms were seen in 26% of patients, 33.7% of mothers and 14.6% of fathers; moderate to severe anxiety were present in 18%, 21.8% and 8.5%, respectively. None of the demographic characteristics was identified as a predictor of depression or anxiety. GAD-7 scores have shown a higher prevalence of anxiety in mothers of patients with chronic methicillin-resistant Staphylococcus aureus (p = .034). Additionally, hospitalization in the last 12 months was significantly correlated with higher PHQ-9 scores in fathers (p = .043). Analysis of patients' adherence to medical treatment and airway clearance showed higher depression and anxiety in mothers of the nonadherent group (p = .002). CONCLUSION Depression and anxiety were common in CF patients and their parents. These results illustrate the importance of depression/anxiety screening and psychosocial support for the CF patient and their parents.

Foreign Body Airway Obstruction (FBAO) is a medical emergency that can result in death, particularly if swift, appropriate action is not taken. It can be a frightening experience for all involved. DeChoker, an Airway Clearance Device (ACD), might provide an additional alternative in the management of choking; however, limited evidence around its safety and effectiveness makes adoption controversial.Objectives: An independent evaluation to explore the experiences of health and care professionals who used DeChoker in real-life adult choking emergencies, focusing on the product's safety, efficacy and ease of application.Design: Retrospective mixed methods case study, with multiple embedded units of analysis.Setting: UK adult care homes.Participants: Twenty seven incidents of adult choking emergencies self-reported by care home staff where DeChoker was used. This data was augmented by an in-depth exploration of four individual choking incidences.Results: The choking victim's ages range: 45 to 101 years (mean 79.8 years). The device was reported to have successfully removed the obstruction in 26 of 27 cases, with very few complications or adverse events reported. In 21 of 27 incidents (78%) the victim was not required to visit Accident and Emergency. Qualitative data indicated nursing home staff found the DeChoker easy to use and valued its presence as an adjunct to current guideline procedures.Conclusion: There is a dearth of evidence surrounding the management of choking and little innovation in this area for five decades. This retrospective evaluation contributes to discussion regarding the role ACDs might play in the management of choking, particularly in cases where current choking management guidance are ineffective, insufficient, inappropriate or impractical (e.g., frail or movement restricted people). The interview data presents a view from care home staff that the DeChoker, as an ACD, contributed to saving the life of choking victims.

This study was a clinical review of infant positive expiratory pressure (PEP) therapy in young children with cystic fibrosis (CF). The aim of this study was to determine whether pressures of 10–20 cm H2O PEP therapy (recommended by the CF trust) are being achieved with routine airway clearance therapy. This took place at the Royal Hospital for Children, Glasgow a specialist UK CF centre. Values were obtained from 21 young children. Pressures above 10 cm H2O during tidal volume breathing were not achieved within our cohort. Further investigation is required to determine efficacy of lower pressures in PEP therapy with young children.

Background: Chronic Obstructive Pulmonary Disease is the major leading cause of death. In COPD,mostly death occurred due to inappropriate airway clearance. So if these condition left untreated then thisinflammation leads to repeated cycles of injury and repair of the airway wall. Few studies have shown theeffect of postural drainage and forced expiratory technique on COPD patients for airway clearance. Inthis study postural drainage and forced expiratory technique along with segmental relaxation from LauraMitchell Relaxation Technique use for mucus clearance as soon as possible in COPD patientsAim: To study the effect of segmental relaxation followed by postural drainage and forced expiratorytechnique on airway clearance in COPD patients.Material and Method: In this pre-post intervention study 28 individuals with COPD were included. Theywere randomly divided into 2 groups with 14 individuals in each group. Group A were treated with segmentalrelaxation from Laura Mitchell Relaxation Technique along with postural drainage and forced expiratorytechnique and Group B were treated with postural drainage and forced expiratory technique. After pre-postassessment, data was analysed with the help of appropriate statistical methods.Conclusion: In that postural drainage and forced expiratory technique has less effect than these techniquesthat is postural drainage and forced expiratory technique along with segmental relaxation from LauraMitchell Relaxation Technique in COPD patients.

Cystic Fibrosis (CF) is the commonest life limiting inherited condition in the UK, affecting 3895 children. Children with CF undertake burdensome, time-consuming treatment, much of which is not evidence-based. Questions for clinical research should reflect patient and clinician priorities because both the number of potential participants and funding are limited. Aims We describe our work over a 4 year period to engage the CF community in prioritisation and co-production of clinical research. Methods In 2016–17 we undertook a James Lind Alliance (JLA) Priority Setting Partnership (PSP) to find the top 10 priorities for clinical research in CF. Through a series of surveys and workshops these were agreed in conjunction with the global CF community. In 2018–2019 we undertook further global surveys to explore 4 of the top 10 questions in more depth (treatment burden, gastrointestinal symptoms, adherence and exercise in place of some airway clearance). To avoid cross-infection and increase global reach, we adapted JLA methodology to use video conferencing and social media. Results During the past four years we have gathered opinions from 3729 respondents across six continents. Our youngest respondents were six years old and the median age of respondents with CF (answering directly or by proxy) was 15 years. On completion we disseminated the top 10 questions widely and worked to raise awareness with research funders such as the NIHR. This has resulted in two NIHR themed calls, featuring many of the JLA CF top 10 questions. Conclusions Encouraging patient participation, including children, in all stages of evidence-based medicine is vital to ensure clinical research is of good quality and relevant to patient needs.

Inhaled therapies are relatively simple and easy to be managed however ineffective use of aerosols when self-administered may occur. We described variation of the number of clinic visits, lung function and number of antibiotic courses performed over 12 months in participants with cystic fibrosis (CF), when supervised or not by physiotherapists (PTs) at home. Participants in 8 Italian CF centers with a prescription of dry-powder antibiotic choose whether to be supervised at home (PT-FU) or not (non-PT-FU), in adjunct to routine clinic visits. PTs assisted participants with their inhaled therapies regimen and reviewed the airway clearance program in use. Mixed-effect regression models were fitted to evaluate the variation of selected endpoints over time. A total of 163 participants were included. Lung function declined over time in both groups, at higher extent in the non-PT-FU group at 6 months (-1.8, 95%CI: -4.4 to 0.7 % predicted), without reaching statistical significance, whereas in the PT-FU group only, nearly one visit less was recorded (p=0.027). Regardless the type of supervision adopted, the number of antibiotic courses did not change compared to the previous year. We counted 19/90 (21.1%) drop-out in the PT-FU, double compared to the group followed up at the clinics (p=0.065). Participants under a course of an inhaled antibiotic therapy showed a 1-year decline in lung function, whereas only the group receiving home supervision counted nearly one visit less at the CF center, whose clinical relevance should be further discussed.

Introduction: Clinical guidelines recommend airway clearance techniques (ACTs) in adults with bronchiectasis. There is a paucity of evidence about their clinical implementation, particularly in different healthcare systems. Multicentre registries can facilitate studying patterns and differences across countries. Methods: Outpatients with bronchiectasis were prospectively recruited to the multicentre European Bronchiectasis Registry EMBARC. Patient-reported ACTs were registered in 31 countries. Demographic, baseline health status, exacerbations, radiology, and treatments were recorded. Results: Data were collected between 2015 and 2018. 13,512 patients participated, mean (SD) age 64.2 (14.6) years old, 8,121 females (60.1%). Only 48.3% of the participants reported performing airway clearance regularly. The most commonly used techniques were active cycle of breathing techniques (ACBT) (26.8%) and postural drainage (6.0%). 21.2% of patients used one or more airway clearance devices. Flutter (8.9%), fixed positive expiratory pressure (PEP) (6.5%) and Acapella (4.4%) were the most commonly used ones. The vast majority of patients perform regular ACTs in Denmark (91.7%) and Finland (88.7%), compared to less than 10% of participants in Bulgaria, North Macedonia, Moldova, Romania, and Sweden. The primary reason for not doing airway clearance was that it was not required in the opinion of the clinicians (67.9%). Conclusions: Most patients with bronchiectasis do not routinely perform ACTs. Clinicians’ opinion is often that bronchiectasis patients do not require ACTs. Acknowledgments: EMBARC has received support from the EU/EFPIA Innovative Medicines Initiative Joint Undertaking iABC grant agreement no 115721.

Background: The work wants to see if the Lung Sonography (LUS) can be helpful in the evaluation of a new device before and after a respiratory treatment. Aim: Simeox is a new device for airway clearway. The patient activates it using a button during the expiration phase that creates a negative vibratory suction of small volumes of air.The action is directed to the mucus rheology, improves the drainage from the periphery of the lung. Methods: 8 patients (4 female and 4 male), were examined by comparing LUS with traditional parameters such as SpO2 , FC, scales before and after a week’s use of the Simeox device and gym exercises. The ecography machine was set in B-mode with a convex probe oriented horizontally to have a greater view of the pleural line in the four Volpicelli’s zones. We took note on a map of number of the vertical artifacts B lines starting from the pleural line with a score from 0 to 4. Results: Lus and all parameters have improved but some patients, little compliant, were unable to tell if the amount of secretions had changed. The usual exams give the state of health but not the specific state of the lung such as LUS that represents a third eye, inner, in addition to the clinic exam. Conclusion: Our study suggests that LUS is a patient bedside exam modality, safe, reliable, fast to evaluate the alveolar drainage. Further studies are needed to understand the interaction of LUS with the respiratory treatments.

Introduction: Airway clearance devices (ACDs) assist in mobilizing retained secretions in lung diseases by increasing the velocity of expiratory flow. Aim: Aim of this study was to characterize oscillatory flow and negative expiratory pressure pulses generated by a new ACD in healthy subjects. Methods: 10 healthy adults activated a device (Simeox, PhysioAssist) generating intermittent pulses of intrapulmonary negative air pressure during relaxed exhalations. The procedure was repeated twice with 4 settings (25% or 100% power at 6 or 12 Hz frequency). Oscillatory flow and pressure pulses were measured at the mouth with a flow sensor (TSI, Certifier FA plus) to assess Maximal expiratory flow (MEF), maximal mid-expiratory flow (MMEF), Mean expiratory flow (EFmean), maximal expiratory flow amplitude (MEFamp), peak of negative expiratory pressure (NEPpeak) and maximal expiratory pressure amplitude (MEPamp). Results: 60% male, 34±12y, FEV1/FVC 90±14%. Data are presented in table 1. MEF (60 to 120 l/min) and MEFamp (70 to140 l/min) rates supported generation of high airflow velocity during exhalation over power range. Oscillatory flow was maintained at mid-exhalation. Low variability of data showed high reproducibility of flow and negative pressure pulses generated with Simeox during procedure. Range of pressure was safe (-10 to -60 mbar). Conclusions: These data suggest that Simeox may be an efficient and secure technology for airway clearance therapy.

Introduction: Bronchial drainage is a key component of chest physiotherapy performed in patients with cystic fibrosis (CF), to reduce recurrent pulmonary exacerbations and lung function decline. Evaluation of new airway clearance techniques (ACTs) is required to understand their physiological effects on respiratory function. Aim: Aim of this study was to assess the effects of Simeox technology on resting lung hyperinflation in clinically stable CF patients. Methods: Adult CF patients receiving prophylactic chest physiotherapy with Simeox device (Physio-Assist, France) assisted by respiratory physiotherapists were included consecutively in 2 centers. Patients performed under physiotherapist supervision 3 valid measurements (mean coefficient of variation Results: 21 CF patients were included in the study: 10 males (26.7±6.3y) and 11 females (26.9±8.1y). After device session, change in mean IC was increased by 110±140 ml and 4±5% pred. (p Conclusions: Inspiratory capacity at rest was improved in CF patients after one single drainage session with Simeox technology suggesting a direct effect on lung hyperinflation reduction. This physiological mechanism may have significant impact on the evolution of lung function in CF, and should be confirmed with long-term data.

Background: The Lung Clearance Index (LCI) measured by Multiple Breath Washout (MBW) may offer value in assessing airway clearance devices in COPD however the standardised 1/40th washout is time consuming. This study aims to assess the use of a shortened 1/20th washout in response to an airway clearance device. Methods: This is a sub-analysis of a randomised, double blind, sham controlled trial using High Frequency Airway Oscillations (HFAO) vs sham for eight weeks. The MBW adhered to ERS/ATS standards using an open circuit Innocor device using 0.2% SF6 and performed pre- and post intervention. Tests were analysed using a custom MatLab algorithm and accessed performance characteristics of an earlier 1/20th cut off. Results: 63 participants with COPD were recruited (mean[SD] age 70.02[7.62], FEV1 46.45%[18.03]). Post intervention the LCI1/40 increased in the HFAO and sham groups (0.757[1.233], 0.426[1.463] respectively) and in the LCI1/20 (0.343[0.173], 0.071[0.731] respectively) however this was not significant. The ratio of change between the LCI1/40 and LCI1/20 was 0.453 in the HFAO group and 0.167 in the sham (p=0.29). The average washout time was 204[93]secs (LCI1/40) and 140[61]secs (LCI1/20) per test with a time saving of 35%. Conclusion: The ratio of change following an intervention for the LCI1/20 and LCI1/40 differs between groups. The use of the LCI1/20 may overestimate between group differences.

Objectives To explore and describe current UK physiotherapy practice relating to airway clearance techniques and mucoactive agents in critically ill adult patients with acute respiratory failure in the intensive care unit. Design A descriptive, qualitative study using focus group interviews. Focus groups were audio-recorded, independently transcribed, and data analysed thematically. Participants Senior, experienced physiotherapists, clinically active in critical care. Results Fifteen physiotherapists participated in four interview sessions. Five themes emerged describing airway clearance techniques: 'Repertoire of airway clearance techniques', 'Staffing and skillset', 'Commencing respiratory physiotherapy', 'Technique selection', and 'Determining effectiveness' were themes related to airway clearance techniques. Five themes were also identified in relation to mucoactive agents: 'Use in clinical practice', 'Decision to commence', 'Selection of agent', 'Stopping mucoactive agents', and 'Determining effectiveness'. A summary of key features of standard practice was developed. Conclusions Standard UK physiotherapy practice of airway clearance techniques is variable, but patient-centred and targeted to individual need, with adjunctive use of mucoactive agents to enhance and optimise patient management if required. Based on this study, key features of airway clearance techniques have been summarised to help capture standard care, which could be used in future trials involving ACT as part of usual care.

Rationale: Sputum retention in chronic obstructive pulmonary disease (COPD) is a troubling symptom and can lead to reduced quality of life and increased exacerbations. Airway clearance devices are ...

Respiratory physiotherapy techniques for augmenting the normal mucociliary clearance, lung expansion and cough efficacy have been used for many years to treat patients with respiratory disorders. In recent years, new technologies and more advanced techniques have been developed to be more comfortable and effective for airway clearance and lung expansion. Airway clearance refers to two separate but connected mechanisms: mucociliary clearance and cough efficacy. The purpose of this chapter is to describe an updated review of devices and techniques for airway clearance that include the main clinical criteria to justify the application of each one as well as the evidence of efficacy in patients with respiratory dysfunction.

Objectives: This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To assess the effects of interventions to enhance adherence to airway clearance treatment and exercise therapy in people with CF and their effects on health outcomes, such as pulmonary exacerbations, exercise capacity, health-related QoL and healthcare costs. This systematic review was supported by the National Institute for Health Research, via Cochrane Infrastructure funding to the Cochrane Cystic Fibrosis and Genetic Disorders Group.

The evidence base for modulator therapies in cystic fibrosis (CF) has continued to expand, and it is likely that up to 90% of people with CF could benefit. Worldwide there are however marked inequalities of access to basic CF care and modulator therapies. For infants and young children there is now an evidence base for inhaled hypertonic saline. There is increasing evidence that structural lung disease in CF is not due purely to infection and that mucus retention and inflammation are also key, and further evidence of the value of azithromycin in those chronically infected with Pseudomonas aeruginosa. Finally, exercise is good for you, but airway clearance is better for mucus clearance.

Cough is an important mechanism of airway clearance. In patients who present weak and ineffective cough, augmentation techniques aim to assist or simulate the maneuver. These techniques target different phases of the cough cycle, mainly the inspiratory and expiratory phases, through assisted inspiration, assisted expiration and their combination. They include the manual hyperinflation, ventilator hyperinflation, glossopharyngeal breathing, manually assisted cough and mechanical insufflator-exsufflator, each applied individually or in different combinations. The aim of this review is to investigate the effectiveness and safety of cough augmentation techniques. Findings support that all commonly used techniques can theoretically improve airway clearance, as they generate higher cough peak flows compared to unassisted cough. Still, the studies assessing cough augmentation present considerable limitations and the direct comparison of different techniques is challenging. Current evidence indicate that cough peak flow shows higher increase with the combination of assisted inspiration and expiration, and improvement is greater in patients with lower unassisted values. Associated adverse events are infrequent.

BACKGROUND Autogenic drainage (AD) is used for airway clearance in individuals with cystic fibrosis (CF). The mechanical insufflator-exsufflator (MI-E) device is commonly used in patients with neuromuscular diseases for airway clearance by increasing inspiratory volume and expiratory flow. MI-E use has not been studied extensively in CF patients. OBJECTIVES To examine whether there are advantages to using the MI-E device in patients with CF. SUBJECTS Fourteen males and eight females from the national center for CF, with an average FEV1 of 54% were recruited DESIGN: Prospective cross-over trial (IRB 3009-16-SMC). INTERVENTION Subjects received either AD or MI-E in a random order. Sputum was collected and weighed immediately after treatment. Subjects performed lung function tests at baseline, 20 minutes after and 1 hour after treatment; additionally, a 2-minute walk test was performed at the end of all lung function tests. Saturation, dyspnea scores while resting and after a 2-minute walk and subjective fatigue were recorded. RESULTS Thirty-six percent more sputum was collected following MI-E than AD treatment (P

BACKGROUND: Despite the widespread use of sputum weight to assess the effect of airway clearance interventions, its psychometric properties have not been evaluated. The purpose of this ad hoc analysis was to determine the test-retest reliability of 24-h sputum weight in clinically stable individuals with bronchiectasis. This study also aimed to estimate the minimum important difference of 24-h sputum weight after an airway clearance session in subjects with bronchiectasis. METHODS: Sixty subjects were included in the 24-h test-retest cohort, 42 of whom were part of the airway clearance cohort. For the 24-h test-retest cohort, spontaneously expectorated sputum was collected over 24 h on 2 different days without any airway clearance interventions. For the airway clearance cohort, sputum expectoration was also collected during 3 airway clearance sessions and over the 24 h following these interventions. Intraclass correlation coefficient (ICC3,1) and Bland-Altman analysis were used to assess reliability. The minimum important difference was calculated using distribution-based and anchor-based methods, with cough impact as assessed with the Leicester Cough Questionnaire and the global rating of change as anchors. RESULTS: The reliability was acceptable (ICC3,1 = 0.75) for sputum weight over 24 h without any intervention. The agreement level was wide, particularly for high levels of sputum expectoration. The minimum important difference of the sputum collected in the 24 h after the intervention from baseline was −6.4 g (about −17%), determined using distribution-based methods. There was no correlation between sputum weight and the anchors, thus the anchor-based methodology could not be used. CONCLUSIONS: Multiple measurements should be considered to increase the agreement when sputum weight is used as an outcome measure for short periods in people with bronchiectasis. A reduction of 6.4 g (or 17% from baseline) in sputum collected during the 24 h after the airway clearance intervention may be considered the minimum important difference in people with bronchiectasis. (ClinicalTrials.gov registration NCT02392663; NCT01854788; NCT02614300.)

BACKGROUND: High-flow nasal cannula (HFNC) therapy may reduce the re-intubation rate compared with conventional oxygen therapy. However, HFNC has not been sufficiently compared with conventional oxygen therapy with a heated humidifier, even though heated humidification is beneficial for facilitating airway clearance. METHODS: This study was a single-center, open-label, randomized controlled trial. We randomized subjects with respiratory failure after extubation to either HFNC group or to a large-volume humidified nebulization-based nebulizer. The primary end point was the re-intubation rate within 7 d after extubation. RESULTS: We could not recruit enough subjects for the sample size we designed, therefore, we analyzed 69 subjects (HFNC group, 30 subjects; nebulizer group, 39 subjects). The re-intubation rate within 7 d was not significantly different between the HFNC and nebulizer groups (5/30 subjects [17%] and 6/39 subjects [15%], respectively; P > .99). P aO 2 /set F I O 2 at 24 h after extubation was also not significantly different between the respective groups (264 ± 105 mm Hg in the HFNC group vs 224 ± 53 mm Hg in the nebulizer group; P = .07). CONCLUSIONS: Compared with a large-volume nebulization-based humidifier, HFNC may not reduce the re-intubation rate within 7 d. However, because of insufficient statistical power, further studies are needed to reach a conclusion.

Airway clearance in patients under Invasive Mechanical Ventilation (IMV) or noninvasive mechanical ventilation (NIMV) is a key intervention that should be performed regularly, not only to prevent secretion accumulation, but also to prevent adverse effects that may result from this accumulation of secretions. One of the most relevant interventions in this type of patient is the use of the Mechanical Insufflator-Exsufflator device (MI-E), commonly known as Cough Assist®. On the other hand, Respiratory Functional Rehabilitation (RFR) involves a set of non-invasive procedures that ensure the release of secretions, namely the fluidization of secretions and the use of techniques that allow their mobilization, properly combined with directed and assisted cough teachings. The effectiveness of RFR associated with the use of MI-E yields gains from this conjugation, especially when the person does not collaborate, has decreased muscle strength, or cannot effectively cough. The study conducted in an Intensive Care Unit (ICU) in Portugal shows significant gains in the association of an RFR program with MI-E, with evident improvements in the level of dyspnea, which can be quantified with the implementation of the Modified Borg. At the beginning of the implementation of the RFR program the patients had mild to moderate level of dyspnea and at the end the patients did not have dyspnea. This study made clear the gains that exist for the ICU or NIMV intensive care admission person using MI-E in combination with airway cleaning techniques, in terms of ventilatory performance, airway permeability and decreased complications.