Current knowledge of airway clearance techniques… Scott Alleshunas RT

1. Current knowledge of airway clearance techniques…Scott Alleshunas RT EXPECTORATION EXPECTATIONS This Photo by Unknown Author is licensed under CC BY-SA

2. Objectives: - Review current medications - Discuss new/experimental medications - Assess different airway clearance modalities in various patient populations - Discuss current literature / guidelines regarding the use of these medications and therapies

3. “…a systematic review with the purpose of determining whether the use of these medications to promote airway clearance improves oxygenation and respiratory mechanics, reduces ventilator time and ICU stay, and/or resolves atelectasis/consolidation compared with usual care.” “There is no high-level evidence related to the use of bronchodilators, mucolytics, mucokinetics, and novel therapy to promote airway clearance in these populations.”AARC Clinical Practice Guideline: Effectiveness of Pharmacological Airway Clearance Therapies in Hospitalized Patients“These populations”: - Hospitalized adult and pediatric patients without CF (trauma, inhalation injury, viral infections, asthma, bronchitis, COPD, etc.) - Adult and pediatric patients with neuromuscular disease, respiratory muscle weakness, or impaired cough - Post-operative adult or pediatric patients

4. “…these medications” - N-acetylcysteine - Sodium bicarbonate - Guaifenesin - Mannitol - Hypertonic saline - Normal saline - Inhaled heparin - Inhaled heparin + N-acetylcysteine - Albuterol + N-acetylcysteine - Inhaled tissue plasminogen activator - Dornase alfa

5. N-Acetylcysteine: “Despite excellent in vitro mucolytic activity and a long history of use, no data clearly demonstrate that oral or aerosolized NAC is effective therapy for treating any lung disease.” Egan’s Fundamentals of Respiratory Care 11th Ed. P 725Results: There was no difference between the groups in the rate of change of FEV1, VC, SaO2 or breathlessness. Nor did the groups differ in the median length of stay in hospital.Conclusions: Addition of NAC to treatment with corticosteroids and bronchodilators does not modify the outcome in acute exacerbations of COPD. BMC Pulmonary Medicine: 2004Mucolytics that depolymerize mucin, such as N-acetylcysteine, have no proven benefit and carry a risk of epithelial damage when administered via aerosol. Respir Care Jul 2007. Rubin, BK

6. Sodium bicarbonate: “Sodium bicarbonate has not been clinically demonstrated to improve airway mucus clearance. There is little to recommend its use.” Mucolytics, Expectorants, and Mucokinetic Medications Respir Care 2007 Bruce K Rubin MD Tyloxapol withdrawn by the FDA as ineffective.

7. Guaifenesin:Finiguerra (1982) – Decrease in sputum viscosity and ease of expectoration.Parvez (1996) – 37% increase in sputum volume and ease of expectoration at day 10 and 14Kuhn (1982) – Decrease in sputum viscosity and decrease in sputum volume.Albrecht (2012) – Subjective improvement in cough intensity and ease of expectoration.Hoffer-Schaefer et al – No effect on sputum volume or properties.

8. Mannitol: Bronchitol DPI, Aridol DPI

9. Hypertonic Saline: “Although hypertonic saline is recommended for patients with CF, there are no studies demonstrating effectiveness in other hospitalized patient populations. Research indicates that a single treatment with hypertonic saline (most studies used 3%) can induce bronchospasm; significantly decrease FEV1 (>20%) and SpO2; and increase vascular permeability, neutrophil adhesion, and gland secretion (neurogenic inflammation) in normal lung tissue and with pulmonary disease. These effects can occur despite pretreatment with Beta agonists.” AARC Clinical Practice Guideline: Effectiveness of Pharmacological Airway Clearance Therapies in Hospitalized Patients

10. Normal Saline: Ummm, what ?

11. Inhaled Heparin:No good studies yet. Safe but ineffective in CF patients. Little information in non-CF patients.

12. Inhaled tissue plasminogen activator (tPA):Used in pediatrics for Plastic Bronchitis

13. Iodinated Glycerol:Rubin (1996) – “There were no significant changes in pulmonary function, clinical scores, or sputum properties related to therapy with IG.”

14. Dornase Alfa:“Recombinant human dornase alfa should not be used in adults with non-CF bronchiectasis.” AARC Clinical Practice Guideline: Effectiveness of Pharmacological Airway Clearance Therapies in Hospitalized Patients“Limited and anecdotal data suggest that dornase alfa may be effective in treating some persons with non-CF bronchiectasis…” “However, in patients with chronic bronchitis, dornase alfa does not appear to improve pulmonary function or reduce morbidity.” Mucolytics, Expectorants, and Mucokinetic Medications Bruce K Rubin: Respir Care 2007“rhDNase was ineffective and potentially harmful in this group of adult outpatients in stable condition with idiopathic bronchiectasis. This contrasts with previously published results that demonstrated efficacy of rhDNase in patients with cystic fibrosis bronchiectasis.” O'Donnell AE, et al. Chest 1998

15. Anything else ?

16. Anything else ?- P2Y2 agonists (Denufosol) - Nacystelyn - Erdosteine - Thymosin - Surfactants (Tyloxapol) - Ambroxol - Bromhexine - Carbocisteine - Domiodol - Eprazinone - Letosteine - Mesna - Neltenexine - Sobrerol - Stepronin - Tiopronin - Levoverbenone - Ammonium chloride

17. Nonpharmacological airway clearance…

18. Nonpharmacological airway clearance… - CPT

19. Nonpharmacological airway clearance… - CPT - HFCWO / HFCWC

20. Nonpharmacological airway clearance… - CPT - HFCWO / HFCWC - OPEP

21. Nonpharmacological airway clearance… - CPT - HFCWO / HFCWC - OPEP - PEP

22. Nonpharmacological airway clearance… - CPT - HFCWO / HFCWC - OPEP - PEP - IPV

23. Nonpharmacological airway clearance… - CPT - HFCWO / HFCWC - OPEP - PEP - IPV - The Frequencer

24. Nonpharmacological airway clearance… - CPT - HFCWO / HFCWC - OPEP - PEP - IPV - The Frequencer - Vibralung

25. Vibralung

26. Nonpharmacological airway clearance… - CPT - HFCWO / HFCWC - OPEP - PEP - IPV - The Frequencer - Vibralung - Mechanical insufflation-exsufflation

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

28. AARC Clinical Practice Guideline: Effectiveness of Nonpharmacologic Airway Clearance Therapies in Hospitalized PatientsHospitalized adult and pediatric patients without CF

29. AARC Clinical Practice Guideline: Effectiveness of Nonpharmacologic Airway Clearance Therapies in Hospitalized PatientsHospitalized adult and pediatric patients without CF1. CPT is not recommended for the routine treatment of uncomplicated pneumonia.

30. AARC Clinical Practice Guideline: Effectiveness of Nonpharmacologic Airway Clearance Therapies in Hospitalized PatientsHospitalized adult and pediatric patients without CF1. CPT is not recommended for the routine treatment of uncomplicated pneumonia.2. Airway Clearance Therapy (ACT) is not recommended for routine use in patients with COPD.

31. AARC Clinical Practice Guideline: Effectiveness of Nonpharmacologic Airway Clearance Therapies in Hospitalized PatientsHospitalized adult and pediatric patients without CF1. CPT is not recommended for the routine treatment of uncomplicated pneumonia.2. Airway Clearance Therapy (ACT) is not recommended for routine use in patients with COPD.3. ACT may be considered in patients with COPD with symptomatic secretion retention.

32. AARC Clinical Practice Guideline: Effectiveness of Nonpharmacologic Airway Clearance Therapies in Hospitalized PatientsHospitalized adult and pediatric patients without CF1. CPT is not recommended for the routine treatment of uncomplicated pneumonia.2. Airway Clearance Therapy (ACT) is not recommended for routine use in patients with COPD.3. ACT may be considered in patients with COPD with symptomatic secretion retention.4. ACT is not recommended if the patient is able to mobilize secretions with cough…

33. AARC Clinical Practice Guideline: Effectiveness of Nonpharmacologic Airway Clearance Therapies in Hospitalized PatientsAdult and pediatric patients with neuromuscular disease, respiratory muscle weakness, or impaired cough.

34. AARC Clinical Practice Guideline: Effectiveness of Nonpharmacologic Airway Clearance Therapies in Hospitalized PatientsAdult and pediatric patients with neuromuscular disease, respiratory muscle weakness, or impaired cough.1. Cough assist techniques should be used in patients with neuromuscular disease, particularly when peak cough flow is < 270 L/min. CPT, PEP, IPV, and HFCWC cannot be recommended due to insufficient evidence.

36. AARC Clinical Practice Guideline: Effectiveness of Nonpharmacologic Airway Clearance Therapies in Hospitalized PatientsPostoperative adult and pediatric patients

37. AARC Clinical Practice Guideline: Effectiveness of Nonpharmacologic Airway Clearance Therapies in Hospitalized PatientsPostoperative adult and pediatric patients 1. Incentive spirometry is not recommended for routine, prophylactic use in postoperative patients.

38. AARC Clinical Practice Guideline: Effectiveness of Nonpharmacologic Airway Clearance Therapies in Hospitalized PatientsPostoperative adult and pediatric patients 1. Incentive spirometry is not recommended for routine, prophylactic use in postoperative patients.2. Early mobility and ambulation is recommended to reduce postoperative complications and promote airway clearance.

39. AARC Clinical Practice Guideline: Effectiveness of Nonpharmacologic Airway Clearance Therapies in Hospitalized PatientsPostoperative adult and pediatric patients 1. Incentive spirometry is not recommended for routine, prophylactic use in postoperative patients.2. Early mobility and ambulation is recommended to reduce postoperative complications and promote airway clearance.3. ACT is not recommended for routine postoperative care.

40. “Cochrane systematic reviews found no evidence of benefit for the routine use of incentive spirometry in patients following coronary artery bypass graft or upper abdominal surgery.”AARC Clinical Practice Guideline: Effectiveness of Nonpharmacologic Airway Clearance Therapies in Hospitalized Patients

41. CPT:Chest. 1985 Sep;88(3):436-44.Does chest physical therapy work?Kirilloff LH, et al.Postural drainage has usually been shown to be an effective component of chest physical therapy; there is currently no data showing a beneficial effect of percussion or vibration; directed coughing may be as efficacious as postural drainage. The forced expiration technique may increase sputum clearance with or without postural drainage.

42. “…patients with chronic airway obstruction who produced copious volumes of sputum and found cough alone and chest physical therapy equally effective in removing secretions from central lung regions. However, CPT but not cough alone significantly increased clearance of peripheral secretions. Also, sputum yield was greater during CPT than during cough.” Bateman, J., et. al. Thorax: 1981, 36: 683-687“In patients with chronic bronchitis who produced 10-120ml of sputum per day, coughing alone produced the most sputum from total lung and peripheral lung regions.” Oldenberg, et. al. Am Rev Respir Dis.1979 Oct;120(4):739-45

43. “255 children ages 29 days to 12 years with pneumonia treated with conventional CPT, breathing exercises, and PEP therapy. There was improvement is some parameters, such as respiratory rate and SpO2, there was no difference in hospital length of stay, chest x-ray, fever, antibiotic use. Overall, there is insufficient evidence to justify the use of CPT in children with pneumonia.” Lisy, Karolina The American Journal of Nursing May 2014

44. Is there any hope ??

45. Is there any hope ?Mannitolshowed to improve cough clearability, improved the hydration of mucus and significantly improved the health over 12 days in patients with bronchiectasis. Daviskas et al. 2005We found that 14 days of aerosolized surfactant increased in vitro sputum transportability, improved FEV1 and FVC by more than 10% in patients with stable chronic bronchitis. Anzueto, et al. JAMA 1997“Published evidence suggests that oral acetylcysteine may improve pulmonary function in selected patients with COPD but the clinical benefit observed is likely due to antioxidant properties.” Rubin, BK Mucolytics, Expectorants, and Mucokinetic Medications

48. “Four trials assessing P+PD to no therapy… All trials demonstrated more sputum production with P+PD.” “17 hospitalized patients demonstrated greater sputum production using PEP compared with no therapy.” “In general, there is no ACT that has been demonstrated to be superior to others.” Cystic Fibrosis Pulmonary Guidelines: Airway Clearance Therapies Respir Care 2009

49. “For patients having abdominal surgery, the evidence suggests that any type of lung expansion intervention is better than no prophylaxis. No modality seems superior, and combined modalities do not seem to provide additional risk reduction. Incentive spirometry may be the least labor-intensive, while continuous positive airway pressure may be particularly beneficial for patients who cannot participate in incentive spirometry or deep breathing exercises.” Lawrence, Valerie, et. al. Strategies To Reduce Postoperative Pulmonary Complications after Noncardiothoracic Surgery: Systematic Review for the American College of Physicians Apr 2006

50. “The lack of high-level evidence has a significant impact on the respiratory therapist’s ability to recommend for or against using inhaled medications to improve mucus clearance. Clinical decision making should be based on individual patient need, response to therapy, and potential for harm.” AARC Clinical Practice Guideline: Effectiveness of Pharmacological Airway Clearance Therapies in Hospitalized Patients “Respiratory Therapists and others on the healthcare team must face the reality that the ACTs commonly provided for hospitalized patients lack support from high-level studies. In this time of cost-containment, we are obliged to provide therapy for which there is sufficient evidence for benefit.” AARC Clinical Practice Guideline: Effectiveness of Nonpharmacologic Airway Clearance Therapies in Hospitalized Patients