Airway Clearance Techniques: The Right Choice for the Right Patient.

The management of bronchial secretions is one of the main problems encountered in a wide spectrum of medical conditions ranging from respiratory disorders, neuromuscular disorders and patients undergoing either thoracic or abdominal surgery. The purpose of this review is illustrate to the reader the different ACTs currently available and the related evidence present in literature. Alongside methods with a strong background behind as postural drainage, manual techniques or PEP systems, the current orientation is increasingly aimed at devices that can mobilize and / or remove secretions. Cough Assist, Vacuum Techniques, systems that modulate airflow have more and more scientific evidence. Different principles combination is a new field of investigation that goes toward an increasing of clinical complexity that will facing us.

A pilot study on the non-invasive management of tracheobronchial secretions in tracheostomised patients.

INTRODUCTION/OBJECTIVES: The aim of our study was to assess the safety, efficacy and feasibility of an Expiratory Flow Accelerator (EFA) device, Free Aspire, in reducing the need for daily suctions in tracheostomised (TCS) patients. METHODS: Twenty-five patients (13 males, 12 females, aged 69.88 ± 9.06 years) were investigated. The number of superficial/deep suctions, shallows, arterial blood gas (ABG) analysis, perception of mucus encumbrance (Visual Numeric Scale, VNS) and adverse event were recorded for five days. On the first two days (T1-T2), suctioning was performed as usual, on the following three days (T3, T4, T5), patients were treated also with Free Aspire (20 min, 3 times a day). RESULTS/CONCLUSION: The use of the non-invasive device was associated with a decrease of total number of aspirations from T2 to T5 (8.48 ± 2.62 vs 4.48 ± 3.08, P = 0.0003). Total number of daily aspirations decreased over the five days (8.68 ± 3.64 vs 4.48 ± 3.08, P = 0.0009). Deep aspirations decreased from T1 to T5 (6.16 ± 3.53 vs 1.80 ± 1.50, P = 0.0001). ABG data confirmed that no significant side effects occurred. VNS score decreased from 7.03 ± 1.42 at T1 to 4.05 ± 1.80 at T5 (P < 0.0001). These data suggest that EFA may be useful for managing secretions in TCS patients, as it can reduce the number of daily suctions, particularly the deep ones, and may improve the perception of mucus encumbrance, without side effects. More studies are needed to confirm these data and to understand in which categories of TCS patients this device can be introduced.

Is Two Better Than One? The Impact of Doubling Training Volume in Severe COPD: A Randomized Controlled Study.

Patients with severe chronic obstructive pulmonary disease (COPD) are unable to exercise at high intensities for sufficiently long periods of time to obtain true physiological training effects. It therefore appears sensible to increase training duration at sub-maximal exercise intensities to optimize the benefit of exercise training. We compared the effects on exercise tolerance of two endurance cycloergometer submaximal exercise protocols with different cumulative training loads (one (G1) versus two (G2) daily 40 min training sessions) both implemented over 20 consecutive days in 149 patients with COPD (forced expiratory volume at first second (FEV1): 39% predicted) admitted to an inpatient pulmonary rehabilitation program. Patients in G2 exhibited greater improvement (p = 0.011) in submaximal endurance time (from 258 (197) to 741 (662) sec) compared to G1 (from 303 (237) to 530 (555) sec). Clinically meaningful improvements in health-related quality of life, 6MWT, and chronic dyspnea were not different between groups. Doubling the volume of endurance training is feasible and can lead to an additional benefit on exercise tolerance. Future studies may investigate the applicability and benefits of this training strategy in the outpatient or community-based pulmonary rehabilitation settings to amplify the benefits of exercise interventions.

Comparing airways clearance techniques in chronic obstructive pulmonary disease and bronchiectasis: positive expiratory pressure or temporary positive expiratory pressure? A retrospective study.

BACKGROUND: Airway clearance techniques include positive expiratory pressure, commonly used in our clinical practice, and a recently introduced temporary positive expiratory pressure device called UNIKO®. It is unclear which one provides the best benefit to patients. OBJECTIVES: The aim of this observational 4-year study was to retrospectively compare the efficacy of and specific indications for temporary positive expiratory pressure compared to positive expiratory pressure in a standard rehabilitation program. METHOD: We retrospectively collected data from 162 subjects (107 males, mean age 70±9 years, 97 with primary diagnosis of chronic obstructive pulmonary disease, 65 with bronchiectasis), 51 treated with temporary positive expiratory pressure and 111 with positive expiratory pressure. RESULTS: Subjects showed significant improvement in ratio of partial pressure arterial oxygen and fraction of inspired oxygen (p<0.001), forced vital capacity, forced expiratory volume in one second, peak expiratory flow, arterial oxygen saturation, and partial pressure arterial oxygen with no significant difference between positive expiratory pressure and temporary positive expiratory pressure groups apart from forced expiratory flow, which increased only in the positive expiratory pressure group. Evaluating specific subgroups, temporary positive expiratory pressure was more effective than positive expiratory pressure in improving gas transfer in subjects with emphysema and in those on oxygen therapy, as the effective supplement oxygen flow decreased significantly (p=0.034 and 0.046 respectively for temporary positive expiratory pressure vs. positive expiratory pressure). In subjects on mechanical ventilation, positive expiratory pressure was superior to temporary positive expiratory pressure in increasing forced expiratory flow (p=0.018). CONCLUSION: The physiological parameters of both groups improved significantly and similarly. Subgroup analysis suggests that temporary positive expiratory pressure could provide some advantage to subjects with emphysema and those on oxygen therapy, while positive expiratory pressure would benefit patients on mechanical ventilation. Randomized clinical trials are necessary to confirm our preliminary results indicating that different subgroups/phenotypes can benefit more from one type of treatment.