Nonpharmacologic Airway Clearance Techniques in Hospitalized Patients: A Systematic Review

Abstract

SummaryNonpharmacologic airway clearance techniques are used to reduce the sequelae of obstructive secretions. We systematically reviewed comparative studies of nonpharmacologic interventions that health professionals can employ to achieve mucus clearance in hospitalized or postoperative patients without cystic fibrosis, over the age of 12 months. We searched MEDLINE and other databases from 1990 to 2012 to identify relevant literature. Two reviewers independently assessed each study against predetermined inclusion/exclusion criteria. Two reviewers also independently extracted data regarding subject and intervention characteristics and outcomes, and assigned overall quality ratings. The 32 studies meeting the review criteria included 24 randomized controlled trials, 7 crossover randomized controlled trials, and one prospective cohort study. Studies were typically small and together included a total of 2,453 subjects (mean 76/study). Studies generally examined chest physical therapy/physiotherapy modalities in postoperative or critically ill subjects or those with COPD. Interventions, comparators, and populations varied considerably across studies, hampering our ability to draw firm conclusions. Interventions, including conventional chest physical 2160RESPIRATORY CARE • DECEMBER 2013 VOL 58 NO 12 therapy/physiotherapy, intrapulmonary percussive ventilation, and positive expiratory pressure, typically provided small benefits in pulmonary function, gas exchange, oxygenation, and need for/duration of ventilation, among other outcomes, but differences between groups were generally small and not significant. Harms of the techniques were not consistently reported, though airway clearance techniques were generally considered safe in studies that did comment on adverse effects. Further research with clearly characterized populations and interventions is needed to understand the potential benefits and harms of these techniques.

Pharmacologic Agents That Promote Airway Clearance in Hospitalized Subjects: A Systematic Review

“…This team previously reviewed the benefits and harmful effects of nonpharmacologic airway clearance techniques in hospitalized subjects. 8 …”

Early warning and prevention of pneumonia in acute leukemia by patient education, spirometry, and positive expiratory pressure: A randomized controlled trial

“…Non‐pharmacological prevention of pulmonary diseases has included invasive (endotracheal intubation) and noninvasive (mask, helmet) mechanical ventilatory support for respiratory deficient hypoxic patients 37. Effects are documented on morbidity and survival compared with endotracheal mechanical ventilation 38 and conventional oxygen delivery 39, 40; however conflicting results exist 41, 42, 43, 44. An RCT among hematological patients admitted to the ICU, showed that comprehensive 45‐minute noninvasive ventilation every 3 hr with face mask connected to a ventilator (CPAP/PEEP), in addition to oxygen therapy, can reduce the number of intubation cases and increase survival compared to initial oxygen therapy alone 45.…”

AARC Clinical Practice Guideline: Effectiveness of Nonpharmacologic Airway Clearance Therapies in Hospitalized Patients

“…The ACTs considered are listed in the Table. Because no high-level evidence was available and the recommendations are based on low-level evidence, we have not used a formal guideline development process such as the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. 15 Rather, the recommendations are based on a consensus of the committee, informed by a systematic review of the literature 14 and clinical experience. The systematic review helped frame the issues and allowed for an identification of potential harms.…”

“…35 Incentive spirometry is one of the most common therapies ordered for postoperative patients at risk for postoperative pulmonary complications and in those who develop pneumonia and atelectasis. The systematic review 14 did not include incentive spirometry, but several recent meta-analyses have been published on this topic. Cochrane systematic reviews found no evidence of benefit for the routine use of incentive spirometry in patients following coronary artery bypass graft 31 or upper abdominal surgery.…”

“…Clinicians prescribing this therapy and those implementing the therapy must be familiar with the evidence supporting ACT techniques and devices, which is often limited. 12,13 The purpose of this guideline, developed in conjunction with the systematic review by Andrews et al, 14 is to provide guidance to clinicians in the identification, selection, and application of ACT techniques. These guidelines do not include the use of ACT in patients with cystic fibrosis (CF), as this has already been addressed.…”