Airway clearance and exercise are an important part of the treatment for people with CF. Getting rid of the excess mucous that builds up in your lungs must be regularly scheduled into each day. A build up of mucous can lead to increased lung infections, decreased lung function, shortness of breath, decreased activity level, and more frequent hospitalizations.
Methods and Procedures
There are a number of ways to clear mucous from your lungs. Many of these are performed right after you have used your bronchodilator or other respiratory medicine. Which one is right for you? That depends on several factors, such as how you respond to therapies, your lifestyle, your physical condition, what devices are available to you, and your preferences. This section will review some airway clearance options that you may consider.
The methods described here are intended only as general information
The "best" therapy differs from person to person, and your treatments should be customized to meet your specific needs as determined by your physiotherapist. If you use any mechanical device or apparatus, look to the manufacturer's instructions for general treatment options and advice on how to maintain your equipment.
Conventional Postural Drainage with Percussion
Conventional postural drainage with percussion (PD&P), sometimes called clapping, is the original method of lung clearance. Postural drainage involves placing the patient in a downward position that allows gravity to help move the mucous from the small airways to the larger airways (six to twelve positions are usually used, depending on the area of the lung you are draining). While the patient is in a postural drainage position, percussion is done on the chest wall anywhere from three to ten minutes to aid in dislodging the mucous. Vibrating the hands on the chest while the person is breathing out is also incorporated into the treatment, which helps to move mucous further into the larger airways. Finally, the person sits up and performs huffing exercises and effective coughing to help clear the loosened mucous. The treatment is divided into two or three daily sessions. It usually requires the help of another person, but some adult patients can do it alone by using a mechanical percussor.
Autogenic (self) drainage (AD) is a method that uses controlled breathing to move the mucous out of your lungs. It does not need any equipment and you can do it by yourself. With this method, you are taught to breathe at three specific lung volumes. The first begins with low lung volume to "unstick" the mucous deep in your lungs. From there, you move to mid lung volume to "collect" the mucous that loosened in the first stage. In the last stage, you use high lung volume to "expel" (remove) the mucous.
With AD, it's important to adjust how fast you breathe out at each level so that you reduce airway compression (tightening) when exhaling. The goal is to achieve a mucous "rattle" rather than a whistling "wheeze," which would mean your airways are getting tight. Perfecting an AD technique needs training and frequent review. It can be a good method for people who can concentrate well and are healthy enough not to become overly tired while performing it. This method can also be adjusted somewhat for people with poor lung function.
Positive Expiratory Pressure
Positive expiratory pressure (PEP) is a form of chest physical therapy that
uses a device consisting of a mask or a mouthpiece, and a one-way valve with a
resistor attached to the expiratory outlet. When performing PEP Therapy, you
breathe in and out through the device approximately 15 times/cycle. Breathing
out creates a positive pressure (back pressure) in your airways, which helps
open small airways and air sacs deep in the lungs. These small airways and air
sacs might otherwise remain closed because of mucous blockage.
When learning PEP Therapy, you first learn relaxed abdominal breathing.
Breathing through the PEP device should be slightly active, meaning you will
have to use some force. However, you don't have to use the same amount of force
as you do with your Pulmonary Function tests. Form a good seal with the mask or
mouthpiece (using nose plugs) and breathe out through the flow resistor so that
you maintain the correct pressure (which is shown by a meter). This is repeated
15 times. Then learn the "huff" maneuver (an exercise that is similar to
forcefully fogging a window with your breath), using your breath to move and
then cough up the mucous that had been blocking your airways. These steps are
then repeated approximately five to six times.
Active Cycle of Breathing
Active cycle of breathing therapy (ACBT) combines three breathing methods to move mucous out of your lungs:
breathing control (gentle relaxed breathing)
thoracic expansion exercises (deep breaths, often with a three-second-breath hold and a quiet unforced breath out)
the forced expiration method (breathing out one or two huffs)
These three steps are done in
sequence to loosen and expel the mucous, then repeated for a time period
designated by your physiotherapist or until you feel you can no longer cough up
any more mucous. Some people may need to use gravity-assisted positions with
this method. One advantage of this method is that you can do it on your own with
no equipment. People with CF can also perform it even if they have poor lung function.
Oscillating PEP (Flutter®)
The Flutter is a small handheld
pipe-shaped device that has a hard plastic mouthpiece at one end, a perforated
plastic cover at the other, and a stainless-steel ball resting in a plastic cone
on the inside. It is portable and relatively inexpensive and can be used on your
own. The Flutter helps airway clearance by:
vibrating the airways to loosen mucous
keeping the airways open during exhalation (breathing out)
creating "mini-coughs" to promote mucous removal
The Flutter is used in a sitting
position. You hold it horizontally, take a deep breath in and hold it for two to
three seconds before breathing out actively into the device. You can adjust the
degree you hold the device at to feel the maximum amount of vibrations in your
airways. You repeat this step for ten to twelve breaths, and then perform one to
two huffs through the device, followed by coughing. This whole cycle is then
repeated for a time period designated by your physiotherapist or until you feel
that you can no longer cough up any more mucous.
The Flutter can be combined with
other methods of airway clearance and is often very effective in stimulating a
cough in those patients who are having difficulty coughing.
The Acapella is also a small
handheld plastic device that comes in two colours - blue and green. Which model
you should use depends on your expiratory flow (ask your physiotherapist). This
device uses a counterweighted plug and magnet rather than a steel ball. It
combines the features of the PEP device and the vibratory features of a flutter
valve to move mucous out of the airways. Because it's not dependent on gravity,
it can also be held at different angles. Unlike the other techniques listed
above, this airway clearance method has not been as well researched with patient
studies. Therefore, further research is needed to assess its effectiveness for
people with CF.
High Frequency Chest Wall Oscillation (vibration) (HFCWO)
HFCWO uses a mechanical chest wall oscillator (vibrator). It consists of two parts, an inflatable vest and an air pulse generator. Pulses are created by the generator to inflate and deflate the vest, creating high-frequency chest wall oscillations (vibrations). You can use this device without the help of another person. However, it's not easy to carry around, is expensive, and its price may not be covered by your insurance. The vest can be used with other methods of airway clearance as well as during activities such as reading, watching TV, or surfing the Internet.
Inhalation therapy is an important part of the treatment in CF. When doing
your inhalation treatment, you should sit upright with good posture and use
relaxed abdominal breathing. The compressor and nebulizers recommended by your
physiotherapist or respiratory therapist, should be used following the
Most people should be able to use a mouthpiece rather than a facemask with
their nebulizer. This will help deliver more medication into the lungs rather
than filtering it through the nose and losing some of the medication into the
air. Strict cleaning guidelines should always be followed.
Inhalers may also be prescribed which require you to take a deep inspiration
(breathing in) and hold your breath for ten seconds. A device called a "spacer"
should be used with inhalers when possible, to insure the medication gets into
Exercise is very important for people with CF. It can help improve mucous clearance
in some people, maintain or even improve lung function, and give you a sense of well
being. Try to make it a part of your daily routine as much as possible. Aim for a
routine that combines endurance training with strengthening and flexibility, and that
is in harmony with your ability and interests.
Postural exercises and education should also be a part of your program to try
and prevent back pain that can be associated with CF. Do keep in mind however,
that exercise does not replace airway clearance treatments.
Airway clearance and exercise are an important part of the daily regimen for people with CF. Remember — all the methods listed above need proper instruction from a qualified person and motivation on your part to be effective. In many cases, breathing exercises and a device can be combined. For example, you could use a Flutter in the morning, and clapping in the afternoon. Not all methods are right for everybody. Talk to your physiotherapist to see what's best for you. You may want to try a few methods until you find one or more that you feel comfortable with and that seem to offer you the most benefit. No matter what methods you use, you should always have regular check ups with your physiotherapist to review your technique and equipment. Your treatment may change in the hospital.
The information in this article was adapted from an article by Jim Bolek, RRT
CF Care Path Manager, Rainbow Babies' and Children's Hospital, Cleveland, Ohio
(Genentech's CF Toolbox)