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Introduction to Treatment Options

Airway clearance is very important in cystic fibrosis care. Performing regular airway clearance helps to prevent a build-up of thick mucus in the lungs. This allows the lungs to work at their highest capacity. It may also reduce chest infections and improve lung function in people with cystic fibrosis.

There are many different airway clearance techniques (many are listed below). The physiotherapist will work with patients and their caregivers to choose the technique or a combination of techniques that work best for that individual. They will also recommend how often patients should perform their airway clearance therapy and work with other team members to determine the timing of airway clearance with certain medications. For more information about airway clearance options, please contact your local CF clinic.

Please see below for available airway clearance techniques. Techniques are recognized by the International Physiotherapy Group for Cystic Fibrosis (IPG/CF) as being evidence based.

Active Cycle of Breathing Techniques (ACBT)

This is a cycle of breathing control, chest expansion exercises, and the forced expiratory technique or huffing. Breathing control and chest expansion exercises allow air to travel deep into the lungs and get behind thick mucus, which can then be expelled by huffing.

Autogenic Drainage (AD)
Autogenic Drainage (AD)

This technique uses one’s airflow while they breathe out to move mucus from the small to larger airways where it can be cleared. To achieve this, the level of breathing is adjusted, from low lung volume breathing, progressing to mid lung volume breathing and then high lung volume breathing.

Positive Expiratory Pressure (PEP)
Positive Expiratory Pressure (PEP)

Individuals breathe through a face mask or mouthpiece attached to a piece of equipment called a resistor, which causes pressure to build up in the lungs. The pressure keeps the airways open, allowing air to get behind the mucus. Mucus can then be moved to the main airway and be cleared.

Oscillating PEP using the Flutter®
Oscillating PEP using the Flutter®

This technique involves breathing repeatedly through a device which causes pressure and vibrations in the airways to help loosen and move mucus out. The Flutter can only be used in an upright position such as sitting or standing.

Oscillating PEP using the Acapella®, RC Cornet® Quake®
Oscillating PEP using the Acapella®, RC Cornet® Quake®

This technique involves breathing repeatedly through a device which causes pressure and vibrations in the airways to help loosen and move mucus. The Acapella and RC Cornet can be used while the individual is placed in any position.

Postural drainage and percussion (PD&P), also commonly known as chest physiotherapy
Postural drainage and percussion (PD&P), also commonly known as chest physiotherapy

An individual is placed in a variety of positions to drain mucus from different parts of the lung. Chest clapping, or percussion, is often added, along with deep breathing exercises, huffing (actively exhaling but less forceful than coughing) and coughing to help clear mucus from the airway. Modified non-head down positions are now used as the standard of care.

These techniques are listed in the IPG/CF booklet Physiotherapy for people with Cystic Fibrosis: from infant to adult. For more detailed information, download the Blue Booklet on Physiotherapy Techniques.

Thanks to the Physiotherapy Advisory Group, Cystic Fibrosis Canada now has a document on Cleaning Nebulizer and Airway Clearance Equipment at Home. This document reviews all Physiotherapy equipment and appropriate techniques of how to clean your various Physiotherapy equipment. The Cleaning Nebulizer and Airway Clearance Equipment at Home document was written by the Physiotherapy Advisory Group.

The following techniques are newer and require further research/studies.

High Frequency Chest Wall Oscillation (HFCWO), also known as a vest airway clearance system
High Frequency Chest Wall Oscillation

An inflatable vest is attached to a machine that makes it vibrate, which loosens the mucus in the lungs. After using the vibrating vest for several minutes, the individual stops the machine and coughs or huffs to clear the airway. This procedure is repeated 5 or 6 times.

Frequencer™
Frequencer

This machine provides pressure through both mechanical and sound waves to the chest, causing airways within the chest to vibrate, loosening the mucus, and allowing it to move into larger airways and be cleared.

Exercise

The positive benefits of exercise with cystic fibrosis have been well recognized and are now an important part of the care plan for people with cystic fibrosis. Regular physical activity and exercises can slow the rate of decline of pulmonary function, improve physical fitness, and enhance quality of life. Greater exercise capacity, regardless of lung function, is associated with a lower rate of mortality in individuals with cystic fibrosis.

Cardiovascular, strengthening and stretching exercises form the three major components of a balanced exercise program. Cardiovascular exercise (also known as aerobic exercise or endurance training) involves moving the larger muscle groups to increase a person’s heart rate for a prolonged period of time. This form of training is generally performed at a lower intensity. Some examples of cardiovascular exercise include fast-paced walking, jogging, running, swimming, cycling and aerobic classes.

Strengthening exercises (also known as resistance or weight training) involve applying load to the muscles to make them stronger. This involves using some kind of weight or resistance, e.g. dumbbells, resistance bands or even a person’s body weight.

Both cardiovascular and strengthening exercises have the added benefit of increasing ventilation and opening clogged or collapsed airways, allowing mucus to be loosened. If this is combined with airway clearance therapy, then the mucus can be transported up the airways to be cleared.

Stretching exercises (also known as flexibility training) help to increase the range of motion of the muscles and joints. They are commonly performed after exercise to help minimize the chance of soreness and muscle injury. They may also be useful as part of a postural program to correct muscle imbalances that are common in people with cystic fibrosis.

Contributions from: Erika Szego and the Canadian Physiotherapy Group

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