Active cycle of breathing techniques in non-invasive ventilation for acute hypercapnic respiratory failure. [Influence of an oscillating physiotherapy device (RC-Cornet trade mark) on the regional distribution of the pulmonary aerosol deposition in patients with COPD]. Effect of physiotherapy on pulmonary function. A laboratory study. Influence of oscillating positive expiratory pressure and the forced expiratory technique on sputum cell counts and quantity of induced sputum in patients with asthma or chronic obstructive pulmonary disease. Physiotherapy and intermittent positive-pressure ventilation of chronic bronchitis. Use of a mucus clearance device enhances the bronchodilator response in patients with stable COPD. A preliminary study of the effect of a vibrating pad on bronchial clearance. [Course of Severe COPD with and without Physiotherapy with the RC-Cornet(R)]. Effect of positive expiratory pressure mask physiotherapy (PEP) versus forced expiration technique (FET/PD) on regional lung clearance in chronic bronchitics. Physiologic effects of chest percussion and postural drainage in patients with stable chronic bronchitis. THE VALUE OF LUNG PHYSIOTHERAPY IN THE TREATMENT OF ACUTE EXACERBATIONS IN CHRONIC BRONCHITIS. Effects of postural drainage, exercise, and cough on mucus clearance in chronic bronchitis. [Physical therapy in patients with COPD and tracheobronchial instability--comparison of 2 oscillating PEP systems (RC-Cornet, VRP1 Desitin). Results of a randommized prospective study of 90 patients]. [Physiotherapy in chronic obstructive pulmonary disease: oscillatory breathing with flutter VRP1]. PEEP-masks in patients with severe obstructive pulmonary disease: a negative report. Treatment of chronic bronchitis with terbutaline inhaled from a cone spacer with and without positive expiratory pressure. Nebulized terbutaline and positive expiratory pressure in chronic obstructive pulmonary disease. Effect of chest wall vibrations on pulmonary function in chronic bronchitis. Intrapulmonary percussive ventilation in acute exacerbations of COPD patients with mild respiratory acidosis: a randomized controlled trial [ISRCTN17802078].
We hypothesised that applying the active cycle of breathing techniques (ACBT) in patients with acute hypercapnic respiratory failure undergoing non-invasive ventilation would improve patient outcome. Thirty-four patients were randomised so that 17 patients with acute hypercapnic respiratory failure received the ACBT and non-invasive ventilation (ACBT group), and 17 patients received non-invasive ventilation alone (control group). The primary outcome measure was length of time requiring non-invasive ventilation, and secondary outcome measures were change in acute physiology score, change in arterial blood gas values, total duration of non-invasive ventilation, and length of stay in the intensive care unit. Although not significant, there was a greater decrease in arterial carbon dioxide pressure in the ACBT group compared to the control group (-21.41 mmHg vs -17.45 mmHg, p = 0.27). Total duration of ventilation tended to be shorter in the ACBT group than in the control group (64.9 hours vs 84.1 hours, p = 0.15). Length of time in need of non-invasive ventilation was significantly lower in the ACBT group than in the control group (5.0 days vs 6.7 days, p = 0.03). There was no significant difference in length of stay in the intensive care unit between the two groups (8.0 vs 9.4 days, p = 0.31). The use of ACBT may have positive effects in the treatment of patients with acute hypercapnic respiratory failure, resulting in a shorter length of time requiring non-invasive ventilation. The inhalation of ipratropium bromide via a jet nebulizer obtained a significantly higher bronchodilation, if the oscillating physiotherapy device RC-Cornet trade mark was integrated into the exaspiratory limb of the nebulizer. Therefore we investigated the influence of the RC-Cornet trade mark on the central pulmonary radioaerosol deposition as well as the relationship between central and peripheral lung deposition in patients with chronic obstructive lung disease in a controlled study.
                Lung ventilation scintigraphy was performed routinely in 14 pat. with COPD (Nebulizer: PARI VECTOR trade mark, radioaerosol 500 MBq tin-colloid). At first all pat. inhaled a single breath from the nebulizer, afterwards the lungs were scanned with a planar gamma camera. Both groups (biometric and lung function data were identical) then inhaled another 5 breaths. In group A the RC-Cornet trade mark was inserted into the exaspiratory limb, in group B a normal exaspiratory valve. Once more lung scans were collected. Evaluation of the scans by means of a "region of interest" technique, dividing the lungs in a central and a peripheral area. Measuring of the radioactivity (impulse) per pixel and determination of the penetration index (PI).
                The following 5 breaths led to a significant increase of the central aerosol deposition (i. e. decrease of PI) in comparison with the measuring after the first breath in both groups (A 0,41 +/- 0,07 to 0,38 +/- 0,08, p = 0,04; B 0,38 +/- 0,08 to 0,34 +/- 0,11, p = 0,02). However, no difference could be recognized between the groups. No significant difference was seen with respect to the impulses per pixel.
                Neither the aerosol deposition in the central region of the lung nor the relation between central and peripheral deposition (PI) differs between the both groups. The effect of the RC-Cornet trade mark mentioned in the introduction seems to be caused by physiotherapeutic induced changes of the mucus transport and not by an enhanced central drug deposition. 33 patients with acute exacerbations of chronic bronchitis were studied within 4 days of admission to hospital. Physiotherapy produced an acute rise in lung volume and conductance, without altering specific conductance. There was no consistent change in arterial-blood gases. To evaluate whether respiratory therapy techniques influence the number of cells within and quantity of induced sputum in patients with asthma or chronic obstructive pulmonary disease (COPD).
                Randomized clinical trial, in which patients with asthma or COPD under intervention (n = 16 and 10, respectively) were compared with control groups (n = 16 and 10). Patients in the asthma/intervention (A/I) and COPD/intervention (C/I) groups were submitted to oscillating positive expiratory pressure maneuvers for 5 min, followed by 10 forced expiratory technique sequences. These patients were also submitted to an induced sputum protocol with inhaled hypertonic saline (3%, 4% or 5%; A/I group) or inhaled isotonic saline (C/I group). The asthma/control (A/C) and COPD/control (C/C) groups were submitted only to the standard induced sputum protocol.
                The final mean weight of the sputum samples was significantly greater in the A/I group than in the A/C group (2,767.25 +/- 998.08 mg vs. 1,689.17 +/- 1,189.96 mg; p = 0.03). The mean/median total cell counts (x10(6)/mL) were higher in the A/I and C/I groups than in the A/C and C/C groups (4.06/0.95 and 0.63/0.39, p = 0.05, vs. 5.08/1.77 and 0.64/0.40, p = 0.02). There were no statistically significant differences among the groups in terms of cell viability.
                The use of respiratory therapy techniques can increase sputum sample weight in asthma patients, as well as increasing total cell counts in patients with asthma or COPD. Patients aged over 45 admitted to hospital with exacerbations of chronic bronchitis alone or in association with cor pulmonale, pneumonia, or respiratory failure were placed in one of three groups (men with hypoxia, men without hypoxia, and women). Patients within these groups were then randomly allocated to receive either standard drug treatment alone or standard drug treatment plus intermittent positive-pressure ventilation (IPPV). No significant differences occurred between the controls and patients receiving physiotherapy and IPPV in any group. We conclude that when a patient with chronic bronchitis and respiratory failure is deteriorating emphasis should be on correct diagnosis, fluid electrolyte balance, and nutrition together with oxygen treatment when necessary, rather than on additional physiotherapy. To determine whether the use of a mucus clearance device (MCD) [Flutter; Axcan Scandipharm; Birmingham, AL] could improve the bronchodilator response to inhaled ipratropium and salbutamol delivered by a metered-dose inhaler in patients with stable, severe COPD.
                Twenty-three patients with severe COPD were studied. Mean +/- SD age was 71.7 +/- 6.3 years. Mean FEV(1) was 0.74 +/- 0.28 L or 34.5 +/- 12.7% predicted.
                Patients were tested in random order on 2 subsequent days after using an MCD or a sham MCD. A bronchodilator (four puffs; each puff delivering 20 microg of ipratropium bromide and 120 microg of salbutamol sulfate) was administered by metered-dose inhaler with a holding chamber after use of the MCD or sham MCD. Spirometry was performed before and after use of the MCD or sham MCD, and at 30 min, 60 min, and 120 min after the bronchodilator. Six-minute walk distance was tested between 30 min and 60 min; oxygen saturation, pulse, and a dyspnea score were recorded before and after walking.
                Immediately after use of the MCD, but not the sham MCD, there was a statistically significant (p < 0.05) improvement in FEV(1) and FVC (11 +/- 24% vs 1 +/- 7% and 18 +/- 33% vs 6 +/- 18%, respectively). Whether patients were pretreated with the MCD or sham MCD, there was a significant improvement in FEV(1) and FVC compared to baseline with combined bronchodilator therapy. At 120 min, the change in FEV(1) after treatment with the MCD was greater than with the sham MCD (186 +/- 110 mL vs 130 +/- 120 mL; p < 0.05). When comparing the MCD to the sham MCD, 6-min walk distance was greater (174 +/- 92 m vs 162 +/- 86 m; p < 0.05), with less dyspnea before and at the end of walking.
                Patients with severe COPD may demonstrate a significant bronchodilator response to combined ipratropium and salbutamol delivered by metered-dose inhaler. This response may be enhanced and additional functional improvement obtained with the prior use of a bronchial MCD. The effect of vibration (41.0 +/- 5.4 Hz; 2 mm amplitude) on the clearance of lung secretions was ascertained in 10 patients with chronic bronchitis who complained of difficulty in raising sputum. Vibration was applied to the back for one hour by an electrically driven pad while the patients reclined on a couch with the trunk at 45 degrees to the vertical. Each patient had randomized control and experimental runs of 5 hours' duration that were identical in all respects except for vibration. The rate of clearance of secretions from the lung was assessed by serial whole lung counts after inhaling monodispersed tracer particles tagged with a gamma-emitting radioisotope (technetium-99m) and by sputum production. The mean rates of clearance and of sputum production were slightly higher during the vibration runs than the control runs but the differences were not significant. The efficacy of respiratory physiotherapy by combined-PEP (RC-Cornet(R) in combined-PEP-position) was evaluated in a long-term study with the following set up.
                Randomized prospective clinical trial over 2 years in 50 patients with severe COPD (12 f, 38 m, 63,1 y, FEV 1 41 %, DLCO 51 % of the normal). Patients were without infection and exsmokers at begin of the trial. One group was treated only by drug therapy (theophylline, salmeterol, ipratropiumbromide, systemic steroids 5 mg prednisolone equivalent). The second group received the same drug therapy plus physical therapy with the RC-Cornet(R) (oscillating PEP; in combined PEP-position) 3 times daily at least for 5 minutes or whenever needed. Lung function data were controlled every 3 month during first year and every 4 month in the second year. The compliance was checked by theophylline and cortisol blood levels, inspection of the functionality of the RC-Cornet(R) and by questioning the patient about compliance with the therapy.
                TGV (% of normal) and airway resistance (measured by bodyplethysmography) decreased significantly in contrast to the "mere" drug therapy (p < 0.0177, p < 0.0179). VC (% of normal) increased significant p < 0.0179 in the RC-Cornet(R) therapy group. In this group significantly less patients (13/24) needed antibiotics in comparison to the "mere" drug group (Chi-Quadrat p < 0.0004). Also the need for hospital care was significantly less in the RC-Cornet(R) group (5/12) in comparison to the drug therapy group (Chi-Quadrat < 0.000765). The length of hospital stay in the two groups was not significantly different: 16.2 +/- 6.3 days in the RC-Cornet(R)-group and 18.3 +/- 4.7 days in the drug therapy-group.
                This study proves the efficacy of respiratory physiotherapy with combined-PEP in addition to drug therapy in the management of COPD-patients. On theoretical grounds it is assumed that positive expiratory pressure mask physiotherapy (PEP) as a means of promoting mucus clearance is especially effective in the more distal airways. In a randomized cross-over trial including a control measurement the effect of PEP and of the forced expiration technique combined with postural drainage (FET/PD) on regional lung clearance was evaluated in seven patients with chronic bronchitis and abundant sputum production (mean 32 g.day-1). PEP consisted of positive expiratory pressure mask breathing interspersed with breathing exercises, forced expiration manoeuvres (huffing) and, if necessary, coughing. FET consisted of breathing exercises, huffing and also, if necessary, coughing. FET was combined with PD. Following inhalation of a radio-aerosol regional lung clearance was estimated by means of gamma camera imaging. The results after PEP appeared to be not significantly different from control. The mean clearance in all three lung zones (peripheral, intermediate and inner) was largest after FET/PD as compared with PEP and control. Statistical significance (p less than 0.02) was reached only for clearance in the inner region. It is concluded that PEP has no demonstrable effect on regional lung clearance in these patients. The effects of a 30-minute period of chest percussion and postural drainage were compared to a sham treatment (infrared lamp) in 35 patients with stable chronic bronchitis and to a period of directed coughing in 11 of these same patients. There were no differences in subjective responses or arterial blood gas levels following therapy. Spirometric studies showed small improvements over baseline values following either treatment but no difference between active and sham treatments. The volume of sputum expectorated during percussion and drainage was significantly greater than during the infrared warming (5.5 vs 1.4 ml) or during the directed coughing (9.0 vs 3.5 ml). Although chest percussion and postural drainage are effective in augmenting the volume of expectorated sputum, no significant alternations in air flow or gas exchange after two hours were demonstrated. nan The effects of postural drainage, exercise, and cough on mucus clearance were compared in 8 patients with chronic bronchitis. A bolus of 99mTc albumin aerosol was inhaled at a high inspiratory flow rate to enhance proximal deposition. Retention of deposited aerosol in the lung, as a function of time, was quantified using a gamma camera and subsequent computer analysis. Coughing greatly accelerated total lung (P less than 0.005) and peripheral (P less than 0.005) mucus clearance. Exercise resulted in much smaller changes than did cough, but significantly increased total lung clearance (P less than 0.005). Postural drainage in which coughing was prohibited did not alter clearance. These results have therapeutic implications and stress the importance of controlling cough when evaluating therapeutic interventions by these techniques. In a randomized prospective study in 90 patients with COAD and tracheo-bronchial instability 3 groups were formed. Group 1: Therapy as group 3+ Physiotherapy with VRP1 Desitin, Group 2: Therapy as group 3+ Physiotherapy with RC-Cornet, Group 3: Control group: daily 40 mg prednisolon i.v., 2 x theophylline i.v. in relation to serum levels and 3 x inhalation of beta 2+ parasympathicolytic with a compressor inhaler. Therapy group 1 and 2 received the same drug and inhalation therapy as the controls. Controls of lung function before and after physiotherapy and visual analog scales for dyspnoea, cough, sputum and acceptance of the physiotherapy were performed at days 1, 4 and 7. With RC-Cornet the residual volume decreases statistically significant in comparison to VRP1 Desitin. Hyperventilation is also statistically significant smaller in RC-Cornet compared to VRP1 Desitin. The subjective improvement of sputum, dyspnoea and acceptance of the method of physiotherapy was statistically significant better for RC-Cornet. Regarding cough the significance was just failed by p < 0.055. RC-Cornet is a comfortable, effective, small accepted tool for the long term physiotherapy of patients with COAD and tracheobronchial instability. Chronic obstructive pulmonary disease (COPD) is characterized by sputum production and cough. It has been shown that mucus hypersecretion predisposes to recurrent bronchial infection and that reduction in airway secretions is associated with clinical improvement. Recently a new pipe-shaped device for chest physiotherapy, the flutter VRP1 ("VarioRaw:" Aubonne, Switzerland), was introduced in order to help clear bronchial hypersecretion. We determined the long-term efficacy of daily chest physiotherapy with the VRP1 in COPD and bronchial hypersecretion. 13 men and 7 women with COPD and sputum hypersecretion were studied; 10 were assigned to the physiotherapy group, and 10 to the control group getting sham therapy. After 3 months of physiotherapy, FVC, FEV1 and distance walked in 12 minutes increased in the treated group, but were almost unchanged in the sham-treated group. Arterial blood gases, the maximum voluntary ventilation, and respiratory rate at rest were unchanged in both groups. There was also an overall significant improvement in COPD symptoms in the physiotherapy group compared to baseline (p < 0.05). We conclude that long-term home physiotherapy with the flutter VRP1 is effective in COPD in improving airflow, functional ability and symptoms. Positive pressure during expiration by face masks applied by the patient has gained wide acceptance in the treatment of chronic bronchitis, but the efficacy is still unproven. The effect of 6 months of treatment with PEEP-masks (positive end-expiratory pressure) was therefore studied in 47 patients with severe irreversible obstructive pulmonary disease (forced expiratory volume in one second (FEV1) about 1 l), and mucus hypersecretion. Patients were double-blindly randomized to at least 45 min daily treatment with PEEP-masks with either 10 or 0 cm water pressure. After 6 months of treatment, no statistical difference was found between the two groups in change of median values (month 6 - month 0) of FEV1, forced vital capacity (FVC), arterial oxygen tension (PaO2), amount of sputum or dyspnoea. Median values of arterial carbon dioxide tension (PaCO2) decreased significantly (0.03 kPa) in the placebo group. Cough intensity and dyspnoea during walking on staircases improved significantly in the placebo group. No difference among groups was found in number of days bedridden, hospitalized, number of exacerbations or antibiotic consumption. We conclude, that the use of PEEP-masks in these patients is without clinical documentation and cannot be recommended. Patients with chronic bronchitis were randomly allocated to 4 weeks treatment with terbutaline 0.5 mg inhaled through a cone spacer with an expiratory resistance creating a positive expiratory pressure (+PEP group) or without (-PEP group). The patients recorded their symptoms in a diary and peak expiratory flow (PEFR) was measured before and after each inhalation. PEFR increased significantly after inhaled terbutaline both with and without PEP. The mean increase in PEFR after terbutaline inhalations was significantly greater (p less than 0.0001) in the +PEP group (24 L/min) compared to the -PEP group (17 L/min). The +PEP group had less sputum and less difficulty with coughing up sputum compared to the -PEP group. This study showed a small but significant enhancement of the bronchodilation and a beneficial effect on symptoms when inhalation of beta-2-agonist was combined with PEP in patients with chronic bronchitis. The effect of positive expiratory pressure (PEP) and inhaled terbutaline was evaluated in ten patients with chronic obstructive pulmonary disease in a randomized cross-over study with three 2 weeks periods. In one period 5 mg terbutaline was inhaled 3 times daily from a nebulizer combined with PEP. In a second period 5 mg terbutaline was inhaled similarly but without PEP and in a third period placebo inhalations were combined with PEP. Symptom score and peak expiratory flow (PEF) measured before and after each inhalation was noted in a diary. The treatment with nebulized terbutaline combined with PEP gave the best relief in symptoms. All treatments increased PEF significantly. PEP alone gave the least increase in PEF (25 1/min), and there was no difference between the increase in PEF after terbutaline inhaled with PEP (28 1/min) compared to terbutaline alone (29 1/min). Manual chest wall vibration is one physiotherapeutic technique frequently employed in the management of respiratory disease. A clinical study was undertaken to examine the effects of manual chest wall vibrations on pulmonary function and arterial oxygen saturation in patients with chronic bronchitis. Twelve patients participated in a three-day experimental design where the factors of three different days and three different treatments were randomized and balanced. On one day, deep-breathing exercises were given; on another, deep-breathing exercises with vibrations; and on the remaining day, no treatment was given. Lung volumes were measured before and after each maneuver, and arterial oxygen saturation was monitored continuously. There was a significant decrease in the expiratory reserve volume (ERV) immediately following the deep-breathing exercises alone, which remained constant after the 15-minute rest period (p = 0.032). The remaining outcome parameters do not appear to be significantly affected. Chest wall vibrations do not decrease the ERV in patients with chronic bronchitis. We hypothesized that the use of intrapulmonary percussive ventilation (IPV), a technique designed to improve mucus clearance, could prove effective in avoiding further deterioration in patients with acute exacerbations of chronic obstructive pulmonary disease (COPD) with mild respiratory acidosis.
                The study was performed in a medical intensive care unit of a university hospital. Thirty-three patients with exacerbations of COPD with a respiratory frequency >or= 25/min, a PaCO2 > 45 Torr and 7.35 <or= pH <or= 7.38 were included in the study. Patients were randomly assigned to receive either standard treatment (control group) or standard treatment plus IPV (IPV group). The IPV group underwent two daily sessions of 30 minutes performed by a chest physiotherapist through a full face mask. The therapy was considered successful when both worsening of the exacerbation and a decrease in pH to under 7.35, which would have required non-invasive ventilation, were avoided.
                Thirty minutes of IPV led to a significant decrease in respiratory rate, an increase in PaO2 and a decrease in PaCO2 (p < 0.05). Exacerbation worsened in 6 out of 17 patients in the control group versus 0 out of 16 in the IPV group (p < 0.05). The hospital stay was significantly shorter in the IPV group than in the control group (6.8 +/- 1.0 vs. 7.9 +/- 1.3 days, p < 0.05).
                IPV is a safe technique and may prevent further deterioration in patients with acute exacerbations of COPD with mild respiratory acidosis.
Evidence from this review indicates that airway clearance techniques are safe for individuals with COPD and confer small beneficial effects on some clinical outcomes. Consideration may be given to the use of airway clearance techniques for patients with COPD in both acute and stable disease, however current studies suggest that the benefits achieved may be small.