Abstract
Background
Cystic fibrosis is a life‐limiting genetic condition in which thick mucus builds up in the lungs, leading to infections, inflammation, and eventually, deterioration in lung function. To clear their lungs of mucus, people with cystic fibrosis perform airway clearance techniques daily. There are various airway clearance techniques, which differ in terms of the need for assistance or equipment, and cost.
Objectives
To summarise the evidence from Cochrane Reviews on the effectiveness and safety of various airway clearance techniques in people with cystic fibrosis.
Methods
For this overview, we included Cochrane Reviews of randomised or quasi‐randomised controlled trials (including cross‐over trials) that evaluated an airway clearance technique (conventional chest physiotherapy, positive expiratory pressure (PEP) therapy, high‐pressure PEP therapy, active cycle of breathing techniques, autogenic drainage, airway oscillating devices, external high frequency chest compression devices and exercise) in people with cystic fibrosis.
We searched the Cochrane Database of Systematic Reviews on 29 November 2018.
Two review authors independently evaluated reviews for eligibility. One review author extracted data from included reviews and a second author checked the data for accuracy. Two review authors independently graded the quality of reviews using the ROBIS tool. We used the GRADE approach for assessing the overall strength of the evidence for each primary outcome (forced expiratory volume in one second (FEV1), individual preference and quality of life).
Main results
We included six Cochrane Reviews, one of which compared any type of chest physiotherapy with no chest physiotherapy or coughing alone and the remaining five reviews included head‐to‐head comparisons of different airway clearance techniques. All the reviews were considered to have a low risk of bias. However, the individual trials included in the reviews often did not report sufficient information to adequately assess risk of bias. Many trials did not sufficiently report on outcome measures and had a high risk of reporting bias.
We are unable to draw definitive conclusions for comparisons of airway clearance techniques in terms of FEV1, except for reporting no difference between PEP therapy and oscillating devices after six months of treatment, mean difference ‐1.43% predicted (95% confidence interval ‐5.72 to 2.87); the quality of the body of evidence was graded as moderate. The quality of the body of evidence comparing different airway clearance techniques for other outcomes was either low or very low.
Authors' conclusions
There is little evidence to support the use of one airway clearance technique over another. People with cystic fibrosis should choose the airway clearance technique that best meets their needs, after considering comfort, convenience, flexibility, practicality, cost, or some other factor. More long‐term, high‐quality randomised controlled trials comparing airway clearance techniques among people with cystic fibrosis are needed.
Plain language summary
Airway clearance techniques for cystic fibrosis: an overview of Cochrane Reviews
We reviewed the evidence from Cochrane Reviews about the effect of airway clearance techniques in people with cystic fibrosis.
Background
Cystic fibrosis is a life‐limiting genetic condition that affects the respiratory and digestive systems. People with cystic fibrosis produce thick mucus that builds up in the lungs leading to infections and inflammation and eventually to a deterioration in lung function. People with cystic fibrosis perform airway clearance techniques at least daily to help keep their lungs clear of mucus. There are various airway clearance techniques, which differ in terms of the need for assistance or equipment, and cost. The airway clearance techniques included in this overview are conventional chest physiotherapy, various breathing techniques (active cycle of breathing technique, autogenic drainage), devices that create a positive pressure (positive expiratory pressure therapy (PEP) or high‐pressure PEP therapy) or a vibration (oscillating devices) to move mucus, and exercise.
The condition is progressive and as lung function worsens, airway clearance techniques may not be sufficient. It may be useful to consider other therapies, such as hypertonic saline or dornase alfa, in addition to airway clearance techniques. These additional therapies are not covered in this overview.
Search date
The evidence is current to: 29 November 2018.
Study characteristics
This overview included six Cochrane Reviews. One review compared any type of chest physiotherapy (conventional chest physiotherapy, PEP therapy, high‐pressure PEP therapy, active cycle of breathing technique, autogenic drainage, exercise, vibrating (oscillating) devices) with no chest physiotherapy or coughing alone. The remaining five reviews included head‐to‐head comparisons of different airway clearance techniques, thus these five reviews often overlapped with each other.
Key results
In this overview, we found moderate evidence that PEP therapy and vibrating (oscillating) devices have a similar effect on lung function (forced expiratory volume in one second (FEV1) after six months of treatment. We are unable to draw definitive conclusions for all other comparisons in terms of FEV1 because the quality of evidence is currently lacking. Likewise, we are unable to draw any definitive conclusions for other outcome measures such as individual preference and quality of life. Harms, such as acid reflux, collapsed lungs, coughing up blood, or decreased oxygen, were rarely mentioned in the original trials. There is a lack of evidence to determine if any particular airway clearance therapy is riskier than the other therapies.
Quality of the evidence
All of the reviews were considered to be well‐conducted. However, the individual trials included in the reviews often did not report enough detailed information to allow us to properly determine trial quality. Many trials did not report enough information on outcome measures; it is unclear how this missing information would influence the results. We graded the evidence for lung function when PEP was compared to vibrating (oscillating) devices as moderate, but the evidence comparing different airway clearance techniques for other outcomes, such as individual preference and quality of life was of low or very low quality. More long‐term, high‐quality trials (where participants are put into groups at random) which compare different airway clearance techniques among people with CF are needed.
Background
Description of the condition
Cystic fibrosis (CF) is a life‐limiting genetic condition that affects the respiratory and digestive systems. People with CF have a genetic mutation encoding the cystic fibrosis transmembrane conductance regulator (CFTR) protein, which regulates ion transport (Rowe 2005). People with abnormal CFTR activity produce thick mucus secretions that build up in the lungs, digestive system, and other organs, causing a wide range of challenging symptoms affecting the entire body. This build up of mucus in the lungs leads to infections and inflammation and eventually to deterioration in lung function (Cantin 1995; Konstan 1997).
While CF can affect people of any racial or ethnic background, it is most common among people of northern European descent (Farrell 2018). There were approximately 30,000 people living with CF in the USA in 2016 (CF Foundation 2016). In the European Union, the prevalence of CF is estimated to be 0.737 per 10,000 births (Farrell 2008).
Description of the interventions
The use of airway clearance therapies is recommended for all people with CF as this facilitates the movement of, and expectoration of, mucus to keep the lungs clear (ACPCF 2017; Flume 2009; IPG/CF 2009). People with CF usually start airway clearance therapies soon after diagnosis, and perform them at least daily for the rest of their lives.
There are a variety of airway clearance techniques, including conventional chest physiotherapy, positive expiratory pressure (PEP) therapy, high‐pressure PEP therapy, active cycle of breathing techniques, autogenic drainage, airway oscillating devices (e.g., Flutter®, Cornet®, Acapella®, Quake®, Aerobika®, and intrapulmonary percussive ventilation), external high frequency chest compression devices (e.g., The Vest™, ThAIRapy Vest®, SmartVest®, and Hayek Oscillator), and exercise. While these airway clearance techniques may differ in terms of the need for assistance or equipment, they all have the same goal of removing mucus secretions from the lungs. Selecting the most appropriate airway clearance technique is influenced by age, individual preference, adverse events, an individual's airway pathophysiology, and cost. Descriptions of each airway clearance therapy included in this review are provided in the 'Types of Interventions' section below (Criteria for considering reviews for inclusion).
CF is a progressive disease and as respiratory function deteriorates, airway clearance techniques may not be sufficient. It may be useful to consider an adjunctive therapy, such as hypertonic saline or dornase alfa, or a combination of adjunctive therapies in conjunction with airway clearance techniques (Dentice 2016; Elkins 2016). However, it is beyond the scope of this overview to evaluate the efficacy and safety of adjunctive therapies.
How the intervention might work
The goal of airway clearance techniques is to clear the airways of mucus, thus helping to prevent infection and improve lung function. Conventional chest physiotherapy uses manual techniques of percussion and vibration (and on occasion modified gravity‐assisted positioning) to loosen and move mucus through the airways. Active cycle of breathing techniques and autogenic drainage use a series of breathing manoeuvres to move mucus secretions. Techniques such as PEP therapy, high‐pressure PEP therapy, airway oscillation devices, and external high frequency chest compression can be used independently of an assistant or carer, thus affording the individual with CF independence and a more flexible approach to airway clearance management. In PEP and high‐pressure PEP therapy, the devices clear mucus by causing pressure to build up in the airways. High‐pressure PEP therapy is a modification of PEP which involves the full forced expiration against a fixed mechanical resistance usually between 40 cm H2O to 140 cm H2O (Prasad 1993). Airway oscillating devices and external high frequency chest compression devices use intra‐ or extra‐thoracic oscillation to help loosen mucus. Exercise improves physical health and strength, and exercise is proposed to improve mucus clearance by changes to airflow and mucus. Exercise increases ventilatory demand, which is met by increases in tidal volume and respiratory flow. In CF, the increase in ventilation and peak expiratory flow (PEF) with exercise could increase the propulsion or mechanical clearance of mucus (Dwyer 2011).
Why it is important to do this overview
In a 2006 publication, Bradley summarised five Cochrane Reviews of physical therapies, including airway clearance and physical training, for people with CF (Bradley 2006). They concluded that there was a lack of evidence of the long‐term efficacy of physical therapies and that no physical therapy was more or less efficacious than another. Since then, at least three more Cochrane Reviews on airway clearance therapies have been published (McKoy 2016; Morrison 2017; McCormack 2017) and other reviews have been updated. Some of the Cochrane Reviews overlap with each other in terms of the interventions and comparisons included and the results are organised in various ways.
An overview of reviews is needed to summarise the current evidence of the effectiveness of various airway clearance techniques and to identify research gaps. Furthermore, this overview can serve as a 'friendly front end' for policy makers, healthcare providers, and people with CF by reducing duplication of information and presenting the results of the Cochrane Reviews in a standard format.
Objectives
To summarise the evidence from Cochrane Reviews on the effectiveness and safety of airway clearance techniques in people with CF.
Methods
Criteria for considering reviews for inclusion
Types of reviews
For this overview, we included Cochrane Reviews of randomised controlled trials (RCTs) or quasi‐RCTs (including cross‐over trials) that evaluated an airway clearance technique in people with CF.
Types of participants
We included Cochrane Reviews of people with CF diagnosed on the basis of clinical criteria and sweat testing or genotype analysis. We did not have any restrictions based on age, disease severity, or exacerbation status.
Types of interventions
We included Cochrane Reviews that compared an airway clearance technique, either as a single technique or as a combination of techniques, with no intervention, with coughing, or with another airway clearance technique. The airway clearance techniques we included are:
Conventional chest physiotherapy
Conventional chest physiotherapy (or postural drainage with percussion and vibration) combines postural or modified postural drainage, percussion, or vibration or a combination of these. This technique requires assistance.
PEP therapy
In PEP mask, mouthpiece or 'bottle' therapy, the individual exhales against a positive pressure of 10 cm H2O to 25 cm H2O . Devices can be used to open up and recruit obstructed lung, allowing air to move behind secretions and assist in mobilising them. Breathing out against a slight resistance prevents the smaller bronchial tubes from collapsing down and thus permits the continuing upward movement of any secretions (McIlwaine 2015).
Following a series of exhalations through the device, the individual would be instructed to perform a forced expiration manoeuvre and follow up with a cough to expectorate any mucus cleared.
High‐pressure PEP therapy
In high‐pressure PEP therapy, the technique has been modified so the individual is exhaling against a pressure of 40 cm H2O to 140 cm H2O. Both PEP and high‐pressure PEP therapies can be self‐administered, but require the use of a device.
Active cycle of breathing techniques
Active cycle of breathing techniques include breathing control, thoracic expansion exercises, and the forced expiration technique. This technique can be self‐administered and does not require an assistant or device.
Autogenic drainage
Autogenic drainage involves a series of breathing techniques at different lung volumes to mobilise mucus secretions. There are three phases ‐ the Unstick, Collect, and Evacuate when breathing at low, mid, and high lung volumes to mobilise, collect, and expectorate secretions respectively. This technique can be self‐administered and does not require an assistant or device.
Airway oscillating devices
Exhalation through these devices generate both oscillation of positive pressure and repeated accelerations of expiratory airflow that have been shown to result in improved sputum clearance (Rogers 2005). Airway oscillating devices include Flutter®, Cornet®, Acapella®, Quake®, Aerobika®, and intrapulmonary percussive ventilation. These techniques are self‐administered, but require the use of a device.
Mechanical percussive devices and external high frequency chest compression devices
Mechanical percussive devices and external high frequency chest compression devices provide external chest wall compressions through the use of a device, such as a vest (e.g., The Vest™ and Hayek Oscillator). These devices or techniques can be self‐administered.
Exercise
Exercise includes both aerobic and strength training.
Other techniques
We may consider other techniques for inclusion as new Cochrane Reviews on airway clearance techniques are published.
Types of outcomes
Primary outcomes
Lung function as forced expiratory volume in one second (FEV1) (change from baseline in L or per cent (%) predicted; we reported final values if these were the only data reported)
Individual preference (either the nominated technique of choice by the participant at the conclusion of the trial or a comparison of technique acceptability or satisfaction)
Quality of life (total scores or domain scores from validated instruments such as Cystic Fibrosis Questionnaire‐Revised (Quittner 2009) or the Quality of Well‐Being Scale (Kaplan 1989))
Secondary outcomes
Adverse events (categorized by severity of the event)
-
Other measures of lung function (change from baseline in L or % predicted; we reported final values if these were the only data reported)
forced vital capacity (FVC)
forced expiratory flow between 25% and 75% (FEF25‐75)
Number or frequency of exacerbations (defined either by symptoms or changes in treatment)
-
Sputum clearance
weight (dry or wet)
volume (dry or wet)
Lung clearance index (LCI)
Search methods for identification of reviews
We searched the Cochrane Database of Systematic Reviews using the phrase "airway clearance" in the title, abstract, or keywords. We searched for any updates to the included reviews and for any full publications of any protocols.
Date of latest search: 29 November 2018.
Data collection and analysis
Selection of reviews
Two review authors independently evaluated all reviews retrieved through the search for eligibility using the criteria listed above (Criteria for considering reviews for inclusion). We resolved all conflicts through discussion to arrive at a consensus.
Data extraction and management
We extracted the data from each included review into a Microsoft Excel spreadsheet. One review author extracted the data, and a second review author checked the abstracted data for accuracy and completeness.
From each of the included reviews, we extracted data on the review characteristics (inclusion criteria (i.e., population, intervention, comparison, outcomes, trials), date of last search, number of included trials, and number of included participants) and statistical outcome data. We extracted the narrative text of the results, if statistical results were not available. We anticipated that most of these data would have already been entered into Review Manager (RevMan 2014). For the primary outcomes, we only included studies that followed participants for longer than one day. This is to allow time for the outcome to develop and for the participant to learn the airway clearance technique.
We noted the types of trials included in each of the reviews. Since data from cross‐over trials can be synthesised in a variety of ways in a systematic review (Elbourne 2002), we extracted information on how each review handled cross‐over trials. We also used data extracted by another review team who had previously evaluated how these reviews analysed data from cross‐over trials (Nolan 2016). Since participants in cross‐over trials receive each intervention, there should be a sufficient washout period between participants receiving the different interventions to reduce any carry‐over effect. To provide some consistency in analysing cross‐over trials, we required a washout period of at least one day for the outcomes of FEV1, FVC, FEF25‐75, and sputum. For the other outcomes, we did not have any limitations for the washout period and we presented results based on the most appropriate analysis (i.e., first‐ and second‐arm results if there is an adequate washout period; and only first‐arm results if there is an inadequate washout period).
Given that this is an overview of reviews, we had planned on relying on the data presented in the reviews and not repeating a review of the original trials for additional data. When needed for clarification, we confirmed data by reviewing the original trials.
We also extracted the quality and risk of bias assessments of the included trials within the included reviews; we did not re‐assess individual trial quality.
Assessment of methodological quality of included reviews
Quality of included reviews
Two review authors independently assessed the methodological quality of the included reviews and resolved differences through discussion. We had planned to use the Assessment of Multiple Systematic Reviews (AMSTAR) measurement tool (Shea 2007). However, we decided to use the risk of bias in systematic review (ROBIS) tool (Whiting 2016) because ROBIS assesses the risk of bias in systematic reviews whereas AMSTAR also includes assessment of reporting quality. The ROBIS tool assesses the risk of bias of systematic reviews in three phases: assessment of the relevance, identification of concerns with the review process, and judgements on the risk of bias. There are five domains: trial eligibility criteria; identification and selection of trials; data collection and trial appraisal; synthesis and findings; and interpretation of review findings. After answering signalling questions in each domain (Appendix 1), review authors assessed their level of concern (low, high, or no information) about bias.
Quality of evidence in included reviews
We used the GRADE approach for assessing the overall strength of the evidence for each primary outcome (Guyatt 2008). We had planned to extract the grading from each eligible Cochrane Review. Since only two of the reviews had conducted grading, we graded the body of evidence for each comparison in terms of short‐term trials (follow‐up duration of one week or shorter), medium‐term trials (follow‐up duration longer than one week and up to six months), and long‐term trials (follow‐up duration longer than six months). We based our assessments on the information provided in the review, but when needed, we confirmed the data by checking the original trial reports. Two review authors evaluated the quality of the body of evidence and resolved their differences through discussion. The quality of the body of evidence was based on trial design, directness of the evidence, consistency of results, precision of results, and probability of publication bias. We classified the strength of the evidence as:
high quality ‐ where we are very confident that the true effect lies close to that of the estimate of the effect;
moderate quality ‐ where we are moderately confident in the effect estimate, such that the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different;
low quality ‐ where our confidence in the effect estimate is limited and the true effect may be substantially different from the estimate of the effect;
very low quality ‐ where we have very little confidence in the effect estimate and the true effect is likely to be substantially different from the estimate of the effect (Balshem 2011).
Data synthesis
We had intended that our unit of analysis would be the included systematic reviews. We provided a narrative description of the summary statistics from the included reviews. We summarised the results that were reported in the included reviews in an 'Overview of Reviews' table. For the primary outcomes, we also generated a gap map, which shows the number of trials, a summary of the results, and the evidence grade for each comparison. We organised results by outcome and then by comparison. We anticipated that there would be some overlap in the trials included among the Cochrane Reviews. When this occurred, we abstracted the results from both reviews and compared and contrasted the findings. Because of the heterogeneity in how the reviews reported and analysed their results, we often had to present the results of the individual trials.
Since this is a Cochrane overview, we did not conduct any additional indirect comparisons or network meta‐analyses.
We discussed and presented the limitations in both the evidence base and in the systematic reviews. We used this information to identify research gaps and to make recommendations for future research.
Results
Our search of the Cochrane Database of Systematic Reviews retrieved 43 citations. We included six Cochrane Reviews (Main 2005; McCormack 2017; McIlwaine 2015; Morrison 2017; McKoy 2016; Warnock 2015). We excluded 37 reviews because they did not include people with CF, they did not evaluate an airway clearance therapy, or they were in the protocol stage (Appendix 2). This process is illustrated in a PRISMA diagram (Figure 1).
1.
Flow diagram.
Description of included reviews
We present the characteristics of the included reviews ‐ including the date the review was last assessed as up‐to‐date, the number of included trials and participants, the population, interventions, comparisons, and outcomes of interest, and the review limitations in the additional tables (Table 1). All of the reviews included people with CF, diagnosed on the basis of clinical criteria, sweat testing, or genotype analysis. None of the reviews excluded trials based on the participants' age or exacerbation status. One review excluded trials of people post lung transplant (McIlwaine 2015). One review compared any type of chest physiotherapy (conventional chest physiotherapy, PEP therapy, high‐pressure PEP therapy, active cycle of breathing technique, autogenic drainage, exercise, oscillating devices) with no chest physiotherapy or coughing alone (Warnock 2015). The other five reviews included head‐to‐head comparisons of different airway clearance techniques (Main 2005; McIlwaine 2015; McKoy 2016; McCormack 2017; Morrison 2017). Thus, the syntheses in these five reviews often overlapped with each other.
1. Characteristics of included reviews.
| Review | Date assessed as up to date | Number of included studies (participants) | Population | Interventions | Comparison interventions | Outcomes for which data were reported | Review limitations |
| Main 2005 | February 2009 | 15 (475) | people with CF, of any age, diagnosed on the basis of clinical criteria, sweat testing, or genotype analysis | conventional chest physiotherapy |
|
|
|
| McIlwaine 2015 | May 2015 | 26 (733) | people with CF, of any age, diagnosed on the basis of clinical criteria, sweat testing, or genotype analysis excluded people post‐lung transplant |
PEP therapy, high‐pressure PEP |
|
|
|
| McCormack 2017 | September 2017 | 7 (208) | people with CF, of any age, diagnosed on the basis of sweat testing or genetic testing | autogenic drainage |
|
|
|
| McKoy 2016 | June 2016 | 19 (440) | people with CF, of any age, diagnosed on the basis of clinical criteria, sweat testing, or genotype analysis | active cycle of breathing technique |
|
|
|
| Morrison 2017 | April 2017 | 35 (1138) | people with CF, of any age, diagnosed on the basis of clinical criteria, sweat testing, or genotype analysis | Oscillating devices, both oral and chest wall |
|
|
|
| Warnock 2015 | November 2015 | 8 (96) | people with CF, of any age, diagnosed on the basis of clinical criteria, sweat testing, or genotype analysis | chest physiotherapy |
|
|
|
CF: cystic fibrosis FEF25‐75: forced expiratory flow between 25% and 75% FEV1: forced expiratory volume in one second FVC: forced vital capacity PEP: positive expiratory pressure
Three reviews included trials of any duration (McIlwaine 2015; McKoy 2016; Warnock 2015). Two reviews excluded trials that evaluated airway clearance therapies after a single treatment (McCormack 2017; Morrison 2017) and one review excluded trials with less than seven days of follow‐up (Main 2005).
All reviews included RCTs and quasi‐RCTs, including those with a cross‐over design. However, the reviews differed in terms of how they handled cross‐over data. Some provided a narrative description of the cross‐over study (McIlwaine 2015; McKoy 2016; Morrison 2017; Warnock 2015), some analysed first‐period data only (McIlwaine 2015; McKoy 2016;McCormack 2017), or performed paired analyses (Main 2005; McKoy 2016; McCormack 2017).
Because we did not conduct a network meta‐analysis, we did not formally assess assumptions such as transitivity (i.e., the assumption that any participant in these trials could receive any of the included airway clearance techniques). Because many of the trials had similar eligibility criteria, we feel that the transitivity assumption would hold for older children and adults with CF. Certain techniques, such as autogenic drainage, cannot be performed by infants or younger children. For these individuals, we can assume transitivity for the interventions that are age appropriate.
Methodological quality of included reviews
Quality of included reviews
All of the reviews were considered to have a low risk of bias in terms of trial eligibility criteria, the identification and selection of trials, data collection and trial appraisal, synthesis and findings, and interpretation (Table 2). All of the reviews adhered to their pre‐defined eligibility criteria, which were appropriate and unambiguous. All of the reviews used a variety of sources to identify relevant trials and used methods to minimise error in trial selection. All of the reviews used methods to minimise errors in data collection, reported sufficient trial characteristics and all trial results, and used appropriate criteria for assessing risk of bias. All of the reviews reported on their pre‐defined analyses and used appropriate methods. None of the reviews conducted any sensitivity analyses, but this is likely because the data was sparse and heterogeneous. All of the reviews used appropriate methods for interpreting the results.
2. ROBIS assessment.
| Review | Trial eligibility criteria | Identification and selection of trials | Data collection and study appraisal | Synthesis and findings | Interpretation |
| Main 2005 | low risk of bias | low risk of bias | low risk of bias | low risk of bias | low risk of bias |
| McIlwaine 2015 | low risk of bias | low risk of bias | low risk of bias | low risk of bias | low risk of bias |
| McCormack 2017 | low risk of bias | low risk of bias | low risk of bias | low risk of bias | low risk of bias |
| McKoy 2016 | low risk of bias | low risk of bias | low risk of bias | low risk of bias | low risk of bias |
| Morrison 2017 | low risk of bias | low risk of bias | low risk of bias | low risk of bias | low risk of bias |
| Warnock 2015 | low risk of bias | low risk of bias | low risk of bias | low risk of bias | low risk of bias |
Quality of evidence in included reviews
Five reviews used the Cochrane tool for assessing the risk of bias (McIlwaine 2015; McKoy 2016; McCormack 2017; Morrison 2017; Warnock 2015) and one used the Jadad scale (Main 2005). All of the reviews expressed a frustration with the limited reporting in the included trials. In the reviews that used the Cochrane risk of bias tool, this frustration is reflected in the majority of the included trials being judged as having an unclear risk of bias for random sequence generation, allocation concealment, and blinding of outcome assessors. In the review that used the Jadad scale, most of the included trials were rated as having a quality score of two out of five or as insufficient information to generate a quality score. All of the reviews acknowledged that the quality of the included trials was limited because it is not possible to blind participants or trial personnel. Two reviews mentioned that many of the included cross‐over trials had issues with either the reporting of or the duration of the washout periods (McIlwaine 2015; McKoy 2016).
Effect of interventions
Primary outcomes
1. Lung function (FEV1)
The comparative effects of airway clearance techniques on FEV1 in terms of the change from baseline in L or % predicted are summarised in the additional tables (Table 3) and we present a gap map summarizing the results and the quality of the evidence (GRADE) for FEV1 as a figure (Figure 2).
3. Summary of results and quality of the evidence (GRADE): FEV1.
|
Comparison (intervention versus control) |
Follow‐up | Mean difference (95% CI) | No of participants (trials) | Quality of the evidence (GRADE) | Comments |
| Conventional chest physiotherapy versus PEP therapy | > 1 week ≤ 6 months | ‐0.65% predicted (95% CI ‐5.66% to 4.36% predicted) | 18 participants (1 cross‐over RCT) |
⊕⊝⊝⊝ very low |
|
| > 6 months | Range in MD ‐8.26% to 0.65% predicted | 102 participants (2 RCTs) |
⊕⊝⊝⊝ very low |
|
|
| Conventional chest physiotherapy versus active cycle of breathing technique | > 6 months | 2.8% predicted (95% CI ‐0.39% to 5.99% predicted) | 63 participants (1 RCT) |
⊕⊕⊝⊝ low |
|
| Conventional chest physiotherapy versus autogenic drainage | > 1 week ≤ 6 months | 1.29% predicted (95% CI ‐4.07 to 6.65 % predicted) | 18 participants (1 cross‐over RCT) |
⊕⊝⊝⊝ very low |
|
| > 6 months | 2.79% predicted (95% CI ‐4.54% to 10.12% predicted) | 36 participants (1 RCT) |
⊕⊝⊝⊝ very low |
|
|
| Conventional chest physiotherapy versus oscillating devices | > 1 day ≤ 1 week | ‐13% predicted (95% CI ‐34.91% to 8.91% predicted)a | 70 participants (2 RCTs) |
⊕⊕⊝⊝ low |
|
| > 1 week ≤ 6 months | Range in MD ‐18 to 0.70% predictedb | 353 participants (7 parallel RCTs and 1 cross‐over RCT) |
⊕⊝⊝⊝ very low |
|
|
| Conventional chest physiotherapy versus exercise | > 1 week ≤ 6 months | 7.05% predicted (95% CI 3.15% to 10.95% predicted) | 17 participants (1 RCT) |
⊕⊕⊝⊝ low |
|
| PEP therapy versus active cycle of breathing technique | > 6 months | ‐0.08 L (95% CI ‐0.85 L to 0.69 L) | 26 participants (1 RCT) |
⊕⊕⊝⊝ low |
|
| PEP therapy versus autogenic drainage | > 1 week ≤ 6 months | No quantitative results provided | 18 participants (1 cross‐over RCT) |
⊕⊝⊝⊝ very low |
|
| > 6 months | ‐0.62 L (95% CI ‐1.54 to 0.30 L) | 30 participants (1 RCT) |
⊕⊕⊝⊝ low |
|
|
| PEP therapy versus oscillating devices | > 1 day to 1 week | 0% predicted (95% CI ‐10.98% to 10.98% predicted)c | 53 participants (2 RCTs) |
⊕⊝⊝⊝ very low |
|
| > 1 week ≤ 6 months | Range in MD 0.49 to 9.37% predictedd | 88 participants (2 parallel RCTs and 2 cross‐over RCTs) |
⊕⊝⊝⊝ very low |
|
|
| > 6 months | Range in MD ‐9.71 to 3.59e | 249 participants (5 RCTs) |
⊕⊕⊕⊝ moderate |
|
|
| Active cycle of breathing technique versus autogenic drainage | > 1 day ≤ 1 week | No quantitative results provided | 18 participants (1 cross‐over RCT) |
⊕⊝⊝⊝ very low |
|
| > 6 months | ‐0.7 L (95% CI ‐1.49 to 0.09 L) | 30 participants (1 RCT) |
⊕⊕⊝⊝ low |
|
|
| Active cycle of breathing technique versus oscillating devices | > 6 months | versus Cornet: 0.04 L (95% CI ‐0.60 L to 0.68 L) versus Flutter: ‐0.49 L (95% CI ‐1.18 L to 0.20 L) |
45 participants (1 RCT) |
⊕⊕⊝⊝ low |
|
| Autogenic drainage versus oscillating devices | > 1 week ≤ 6 months | ‐0.1 L (95% CI ‐1.96 L to 1.76 L) | 14 participants (1 cross‐over RCT) |
⊕⊝⊝⊝ very low |
|
| > 6 months | versus Cornet: ‐0.1 L (95% CI ‐1.44 L to 1.42 L) versus Flutter: ‐0.01 L (95% CI ‐1.51 L to 1.49 L) |
45 participants (1 RCT) |
⊕⊕⊝⊝ low |
|
|
| Airway oscillating devices versus external high frequency chest compression devices | > 1 week ≤ 6 months | ‐2.3% predicted (95% CI ‐5.44% to 0.84% predicted)c | 190 participants (1 parallel RCT and 1 cross‐over RCT) |
⊕⊝⊝⊝ very low |
|
| Airway oscillating devices (Flutter) versus airway oscillating devices (Cornet) | > 6 months | 0 L (95% CI ‐1.22 L to 1.22 L) | 30 participants (1 RCT) |
⊕⊕⊝⊝ low |
|
| Airway oscillating devices versus intrapulmonary percussive ventilation | > 1 week ≤ 6 months | No quantitative results provided | 16 participants (1 RCT) |
⊕⊝⊝⊝ very low |
|
| Chest physiotherapy versus no chest physiotherapy | > 1 day ≤ 1 week | ‐0.02 L (95% CI ‐0.77 L to 0.73 L) | 19 participants (1 cross‐over RCT) |
⊕⊝⊝⊝ very low |
|
Abbreviations: CI: confidence interval; MD: mean difference; PEP: positive expiratory pressure; RCT: randomised controlled study.
a. Results are based on a single RCT. A second RCT reported no significant difference in the % change from baseline in FEV1 for conventional chest physiotherapy (14% change) and oscillating devices (21% change).
b. Range of results from 5 trials ‐ 2 trials were not included in the range; one reported no significant difference in the % change from baseline in FEV1 for conventional chest physiotherapy (24% change) and oscillating devices (31% change) and the second did not report sufficient information to include in the analysis.
c. Results from 1 trial; the second trial did not provide sufficient information to provide an estimate of effect.
d. Range of results from 2 trials; the other trials did not provide sufficient quantitative data, but reported no significant difference between PEP mask therapy and oscillating devices in FEV1.
e. Range of results from 4 trials. An additional trial reported FEV1 L; there were no statistically significant differences between PEP mask therapy and Cornet (MD ‐0.12 L (95% CI ‐1.47 L to 1.23 L)) and Flutter® (MD ‐0.12 L (95% CI ‐1.55 L to 1.31 L)).
2.
Gap map summarizing the results and quality of the evidence (GRADE) for FEV1.
Conventional chest physiotherapy versus PEP therapy
This comparison was addressed in two reviews which included a total of seven trials with 181 participants; both reviews evaluated FEV1 (Main 2005; McIlwaine 2015). Four of the trials were included in both reviews (Darbee 1990; Gaskin 1998; McIlwaine 1997; van Asperen 1987). The Main review excluded one trial (Braggion 1995) because the follow‐up duration was less than one week (Main 2005). The two reviews classified one trial into different comparisons (McIlwaine 1991); a second trial reported FEV0.75 instead of FEV1 (Tyrrell 1986) and the FEV0.75 results were included in the one review (McIlwaine 2015), but not the second review (Main 2005).
Short‐term trials with a follow‐up of one week or less
One cross‐over trial (16 participants) followed participants for two days and reported on FEV1 but did not have a sufficient washout period, and is therefore excluded from our analysis (Braggion 1995).
Medium‐term trials with a follow‐up longer than one week and up to six months
Four cross‐over trials (63 participants) with follow‐up ranging from four weeks to three months compared conventional chest physiotherapy with PEP therapy (Darbee 1990; McIlwaine 1991; Tyrrell 1986; van Asperen 1987). We excluded three trials from the overview due to an insufficient washout period (Darbee 1990; Tyrrell 1986; van Asperen 1987). The only cross‐over trial with a sufficient washout period found no significant difference in FEV1 % predicted between the two groups, mean difference (MD) ‐0.65% (95% CI ‐5.66 to 4.36), but the strength of evidence was graded as very low and we are unable to draw conclusions (McIlwaine 1991). We considered this trial to have an unclear risk of bias because it did not report on random sequence generation, allocation concealment, or blinding of the outcome assessors. The results were imprecise and may be subject to reporting bias.
Long‐term trials with a follow‐up longer than six months
Two trials (102 participants) with follow‐up ranging from one to two years compared conventional chest physiotherapy to PEP therapy and reported on FEV1 (Gaskin 1998; McIlwaine 1997). One of the trials was conducted in children and showed a significant difference favouring PEP therapy, MD ‐8.26% predicted (95% CI ‐15.76 to ‐0.76% predicted) (McIlwaine 1997). The second trial was conducted in adults and showed no significant difference between treatment groups, MD 0.65% predicted (95% CI ‐1.95 to 3.35% predicted) (Gaskin 1998).
Both trials had unclear to low risk of bias. One of the trials blinded the outcome assessors, had a low rate of withdrawals, and specified the randomisation sequence generation (McIlwaine 1997). The second trial was published only as an abstract and did not provide sufficient details about the methodology to adequately assess trial quality (Gaskin 1998). Due to the inconsistency and imprecision of the results, we are unable to draw a conclusion about the long‐term effects of conventional chest physiotherapy compared with PEP therapy on FEV1 (very low strength of evidence).
Conventional chest physiotherapy versus active cycle of breathing technique
This comparison was addressed in two reviews which included a total of four trials (102 participants) which evaluated FEV1 (Main 2005; McKoy 2016). One trial was included in both reviews (Reismann 1988). A further trial (Osman 2008) was included in one review (McKoy 2016) and is being considered for inclusion in the second review (Main 2005). Main excluded two trials because the duration of follow‐up was less than one week (Pryor 1979; Webber 1985).
Short‐term trials with a follow‐up of one week or less
Three cross‐over trials (39 participants) with two to four days of follow‐up compared conventional chest physiotherapy with active cycle of breathing technique (Osman 2008; Pryor 1979; Webber 1985). Two trials were excluded due to an insufficient washout period (Pryor 1979; Webber 1985). The third trial also had an insufficient washout period, but was considered because first‐arm data were obtained. However, there was only one participant who received the active cycle of breathing technique during that period (Osman 2008). No conclusions can be drawn about the short‐term effects of conventional chest physiotherapy versus active cycle of breathing technique on FEV1 due to the lack of data.
Medium‐term trials with a follow‐up longer than one week and up to six months
Neither review included any medium‐term trial for this comparison.
Long‐term trials with a follow up longer than six months
One trial (63 participants) with 2.4 years of follow‐up compared conventional chest physiotherapy with active cycle of breathing technique and reported on FEV1 (Reismann 1988). The change in FEV1 % predicted between interventions was not statistically significant, MD 2.8% predicted (95% CI ‐0.39 to 5.99). This trial had an unclear risk of bias because it did not report on several methodological details, such as sequence generation, allocation concealment or blinding of outcome assessors. We graded the strength of evidence as low due to the unclear risk of bias and the imprecise results. Both airway clearance techniques had a similar effect on FEV1.
Conventional chest physiotherapy versus autogenic drainage
This comparison was addressed in two reviews (Main 2005; McCormack 2017) which included two trials (54 participants) evaluating FEV1 (Davidson 1992;McIlwaine 1991). The McCormack review considered the evidence from both of these trials and graded the evidence comparing conventional chest physiotherapy and autogenic drainage for FEV1 % predicted as very low (McCormack 2017).
Short‐term trials with a follow‐up of one week or less
The review did not include any short‐term trials comparing conventional chest physiotherapy with autogenic drainage.
Medium‐term trials with a follow‐up longer than one week and up to six months
One cross‐over trial (18 participants) with a two‐month follow‐up and a sufficient washout period compared conventional chest physiotherapy with autogenic drainage (McIlwaine 1991). The trial reported that the difference between treatments in FEV1 % predicted was not statistically significant, MD 1.29% predicted (95% CI ‐4.07 to 6.65). This trial was only published as an abstract and did not provide sufficient information to assess trial quality. The strength of evidence was graded as very low because of the unclear risk of bias, the imprecise results, and the strong suspicion of reporting bias. No conclusions can be drawn based on this evidence.
Long‐term trials with a follow‐up longer than six months
One trial lasting one year (36 participants) compared conventional chest physiotherapy with autogenic drainage and reported on FEV1 % predicted (Davidson 1992). Results showed no difference between treatments, MD 2.79% predicted (95% CI ‐4.54 to 10.12). This trial was only published as an abstract and did not provide sufficient information to assess trial quality. The strength of evidence was graded as very low because of the unclear risk of bias, the imprecise results, and the strong suspicion of publication bias.
Conventional chest physiotherapy versus oscillating devices
This comparison was addressed by two reviews including a total of 11 trials (389 participants) (Main 2005; Morrison 2017). Three trials were included in both reviews (Arens 1994; Homnick 1995; Homnick 1998). There were differences between the reviews; Morrison excluded one trial because the authors did not consider acoustic percussion as an oscillating device (Kirkpatrick 1995) and did not mention a further trial (Bauer 1994); while Main excluded one trial because the duration of follow‐up was less than one week (Braggion 1995) and listed five trials for consideration for inclusion in a future update (Giles 1996; Gondor 1999; Hare 2002; Modi 2006; Padman 1999). The Morrison review graded the evidence comparing conventional chest physiotherapy and oscillating devices for FEV1 % predicted as very low (Morrison 2017).
Short‐term trials with a follow‐up of one week or less
Three trials (86 participants), one of which was of cross‐over design, compared conventional chest physiotherapy with an oscillating device and evaluated FEV1 between two days to one week (Arens 1994; Braggion 1995; Gondor 1999). The cross‐over trial was not included in the analysis due to an insufficient washout period (Braggion 1995). One trial reported no significant differences in the % change from baseline in FEV1 % predicted between groups (Arens 1994). The third trial showed no significant differences between groups in the change in FEV1 % predicted, MD ‐13.00% predicted (95% CI ‐34.91 to 8.91% predicted) (Gondor 1999). Based on these two trials, we conclude that the two airway clearance techniques had a similarly positive effect on FEV1 % predicted.
Both trials were considered to have an unclear risk of bias since, with a few exceptions, they did not report sufficient details about methodology to assess trial quality. One of the trials blinded the outcome assessors, but it also had a high loss to follow‐up (Gondor 1999). We graded the strength of evidence as low because of the unclear risk of bias and the imprecise results.
Medium‐term trials with a follow‐up longer than one week and up to six months
There were 10 trials (373 participants) with a follow‐up ranging from two weeks to six months which compared conventional chest physiotherapy with an oscillating device and reported on FEV1 (Arens 1994; Bauer 1994; Giles 1996; Gondor 1999; Hare 2002; Homnick 1995; Homnick 1998; Kirkpatrick 1995; Modi 2006; Padman 1999). Three trials were of cross‐over design (Giles 1996; Kirkpatrick 1995; Padman 1999), two of which were excluded because they did not have a sufficient washout period between treatment groups (Kirkpatrick 1995; Padman 1999). The mean between‐group difference from five trials for FEV1 % predicted ranged from ‐18% to 0.70% predicted (Bauer 1994, Giles 1996, Gondor 1999, Homnick 1995, Homnick 1998). Two further trials reported no between‐group differences in FEV1 % predicted, but reported the results as % change (Arens 1994) and longitudinal change (Modi 2006). A final trial did not provide sufficient data to include in the analysis (Hare 2002).
The trials were considered to have an unclear to high risk of bias since, with a few exceptions, they did not report sufficient details about methodology to assess trial quality. One of the trials blinded the outcome assessors (Gondor 1999). Three trials had a high loss to follow‐up (Gondor 1999; Homnick 1995; Modi 2006). Four trials had a high risk of reporting bias (Giles 1996; Hare 2002; Homnick 1998; Modi 2006), and two trials were published only as conference abstracts (Giles 1996;Hare 2002). We graded the evidence as very low because of the high risk of bias and the strong suspicion of publication bias.
Long‐term trials with a follow‐up longer than six months
Neither review included any trials that evaluated this comparison after six months of follow‐up.
Conventional chest physiotherapy versus exercise
This comparison was addressed in one review (Main 2005), which included one medium‐term trial (17 participants) which reported on FEV1 (Cerny 1989).
Short‐term trials with a follow‐up of one week or less
The review did not include any short‐term trials comparing conventional chest physiotherapy to exercise.
Medium‐term trials with a follow‐up longer than one week and up to six months
One trial (17 participants) with a two‐week follow‐up compared conventional chest physiotherapy with exercise among people with CF who had been hospitalised for an acute exacerbation (Cerny 1989). Participants in the conventional chest physiotherapy group improved significantly more than those in the exercise group (low strength of evidence). The difference in the change in FEV1 % predicted was significant, MD 7.05% predicted (95% CI 3.15% to 10.95% predicted). However, these results should be interpreted with caution because the conventional chest physiotherapy group had a worse respiratory function at baseline. This trial was considered to have an unclear risk of bias and imprecise results.
Long‐term trials with a follow‐up longer than six months
The review did not include any long‐term trials that compared conventional chest physiotherapy with exercise.
PEP therapy versus active cycle of breathing technique
This comparison was addressed by two reviews (McIlwaine 2015; McKoy 2016). The two reviews included two trials which followed a total of 46 participants for longer than one day and reported on FEV1 (Kofler 1994; Pryor 2010). One trial was included in both reviews (Pryor 2010); but one review did not include the comparison for PEP therapy and active cycle of breathing technique and lists the Kofler trial as awaiting classification (McIlwaine 2015).
Short‐term trials with a follow‐up of one week or less
Neither review included any short‐term trials that evaluated this comparison.
Medium‐term trials with a follow‐up longer than one week and up to six months
One trial (20 participants) with a four‐month follow‐up compared PEP therapy with active cycle of breathing technique and reported on FEV1 (Kofler 1994). This trial did not report on the duration of the washout period and could therefore be subject to a carry‐over effect. This trial was excluded from the analysis.
Long‐term trials with a follow up longer than six months
One trial recruited 75 participants and randomised them to one of five treatment groups (two of which were active cycle of breathing technique and PEP therapy with 26 participants randomised to these treatment groups) and reported on FEV1 L at 12 months (Pryor 2010). There was no significant difference in FEV1 L between the two treatments at the end of the 12 months, MD ‐0.08 L (95% CI ‐0.85 to 0.69 L) (low strength of evidence). This trial had an adequate randomisation scheme and it blinded the outcome assessors, but it lost a high proportion of participants during follow‐up. The results were imprecise.
PEP therapy versus autogenic drainage
This comparison was addressed in two reviews (McCormack 2017; McIlwaine 2015), which included two trials (48 participants) which reported on FEV1 (McIlwaine 1991; Pryor 2010). One trial (McIlwaine 1991) was included in both reviews, but the second trial (Pryor 2010) was included only in the McCormack review. The McCormack review graded the evidence comparing PEP therapy with autogenic drainage as low for FEV1 L (McCormack 2017).
Short‐term trials with a follow‐up of one week or less
The review did not include any short‐term trials comparing PEP therapy with autogenic drainage.
Medium‐term trials with a follow‐up longer than one week and up to six months
One trial (18 participants) with a cross‐over design and with an adequate washout period compared PEP therapy with autogenic drainage and reported on FEV1 (McIlwaine 1991). There was no significant difference in FEV1 after two months of treatment (very low strength of evidence). We considered this trial to have an unclear risk of bias because it did not provide adequate details on the trial methodology. We were unable to assess precision because no quantitative results were presented. We suspected publication bias because the trial was only published as an abstract.
Long‐term trials with a follow‐up longer than six months
One RCT recruited 75 participants and randomised them to one of five treatment groups (two of which were PEP therapy and autogenic drainage with 30 participants randomised to these groups) and reported on FEV1 L at 12 months (Pryor 2010). There was no significant difference in FEV1 L between the two treatments at the end of the 12 months, MD ‐0.62 L (95% CI ‐1.54 to 0.30 L) (low strength of evidence). This trial had an adequate randomisation scheme and it blinded the outcome assessors, but it lost a high proportion of participants during follow‐up. The results were imprecise.
PEP therapy versus oscillating devices
This comparison was addressed by two reviews which between them included 13 trials (421 participants) with a duration of follow‐up longer than one day and which reported on FEV1 (McIlwaine 2015; Morrison 2017). Seven trials were included in both reviews (Braggion 1995; McIlwaine 2001; McIlwaine 2013; Newbold 2005; Prasad 2005; Pryor 2010; van Winden 1998). The earlier review lists five trials to be considered in a future update of the review (Davies 2012; Gotz 1995; Grzincich 2008; Khan 2014; West 2010) and excludes one trial (Padman 1999) which is included in the Morrison review since the intervention did not meet their criteria for PEP therapy (McIlwaine 2015). Morrison graded the evidence comparing PEP therapy with oscillating devices as very low for FEV1 (Morrison 2017).
Short‐term trials with a follow‐up of one week or less
Three trials (69 participants) with two to seven days of follow‐up compared PEP therapy with oscillating devices and reported on FEV1 (Braggion 1995,Grzincich 2008, Khan 2014). We excluded one of these trials from our analysis of FEV1 because it was a cross‐over trial with an insufficient washout period (Braggion 1995). The remaining two trials reported no significant differences between PEP therapy and oscillating devices in FEV1 % predicted (very low strength of evidence) (Grzincich 2008; Khan 2014). In one trial, the final between‐group difference was MD 0% predicted (95% CI ‐10.98 to 10.98% predicted) (Grzincich 2008). Both trials were judged to have an unclear risk of bias because neither reported sufficient detail about the methodology to assess trial quality. The results were imprecise and could be subject to publication bias.
Medium‐term trials with a follow‐up longer than one week and up to six months
Five trials (103 participants), three of which were cross‐over trials, with two to four weeks of follow‐up compared PEP therapy with oscillating devices (Davies 2012; Gotz 1995; Padman 1999; van Winden 1998; West 2010). We excluded one trial from the analysis because it was a cross‐over trial and did not specify the duration of the washout period (Padman 1999). The remaining two cross‐over trials had washout periods of one to two weeks (Gotz 1995, van Winden 1998). The four trials reported no significant differences between treatments for FEV1 % predicted (very low strength of evidence). The mean between‐group differences from the two trials that reported sufficient quantitative data ranged from 0.49% to 9.37% predicted (van Winden 1998; West 2010). The four trials had a low to unclear risk of bias; the results were imprecise, and there were concerns about publication bias (Davies 2012; Gotz 1995; van Winden 1998; West 2010).
Long‐term trials with a follow‐up longer than six months
Five trials (249 participants) with 12 to 13 months of follow‐up compared PEP therapy with oscillating devices and reported on FEV1 (McIlwaine 2001; McIlwaine 2013; Newbold 2005; Prasad 2005; Pryor 2010). All of the trials reported there were no statistically significant between‐group differences. The between‐group difference in FEV1 % predicted from four of these trials ranged from ‐9.71% to 3.59% predicted (McIlwaine 2001; McIlwaine 2013; Newbold 2005; Prasad 2005). The fifth trial, which reported results in FEV1 L, randomised participants to one of five treatment groups, three of which were PEP therapy (13 participants), Cornet® oscillating device (14 participants), and Flutter® oscillating device (12 participants). There were no statistically significant differences in the between‐group difference in FEV1 L between PEP therapy and Cornet, MD ‐0.12 L (95% CI ‐1.47 to 1.23 L) and between PEP and Flutter, MD ‐0.12 L (95% CI ‐1.55 to 1.31 L) (Pryor 2010).
We graded the strength of the evidence as moderate. These five trials had a low to unclear risk of bias because many of the included trials had an adequate randomisation scheme, blinded the outcome assessors, and had a low loss to follow‐up ratio, but the results were imprecise (Davies 2012; Gotz 1995; Padman 1999; van Winden 1998; West 2010).
PEP therapy versus exercise
This comparison was eligible for inclusion in one review, but it did not include any trials (McIlwaine 2015).
Active cycle of breathing technique versus autogenic drainage
This comparison was addressed in two reviews (McCormack 2017; McKoy 2016). Both reviews included two trials (48 participants) which had a duration of follow‐up longer than one day (Miller 1995; Pryor 2010). The later review graded the evidence comparing active cycle of breathing technique with autogenic drainage as low (McCormack 2017).
Short‐term trials with a follow‐up of one week or less
One cross‐over trial (18 participants) with a sufficient washout period compared active cycle of breathing technique with autogenic drainage and followed participants for two days (Miller 1995). The trial reported no significant differences in pulmonary function tests between the two airway clearance techniques, but did not provide any data to support this statement. This trial did not provide sufficient information to assess trial quality or to determine the precision of the results. We graded the strength of evidence as very low because of the unclear risk of bias, the imprecise results, and the strong suspicion of reporting bias (Miller 1995).
Medium‐term trials with a follow‐up longer than one week and up to six months
The review did not include any medium‐term trials that compared active cycle of breathing technique with autogenic drainage.
Long‐term trials with a follow‐up longer than six months
One trial recruited 75 participants and randomised them to one of five treatment groups, two of which were the active cycle of breathing technique (15 participants) and autogenic drainage (15 participants) (Pryor 2010). The between‐group difference in final values for FEV1 L was not statistically significant, MD ‐0.7 L (95% CI ‐1.49 L to 0.09 L) (low strength of evidence). This trial had an adequate randomisation scheme and it blinded the outcome assessors; however, it also lost a high percentage of participants to follow‐up and the results were imprecise (Pryor 2010).
Active cycle of breathing technique versus oscillating devices
This comparison was addressed by two reviews (McKoy 2016; Morrison 2017), which included one long‐term trial with 45 participants (Pryor 2010). The Morrison review graded the evidence comparing breathing techniques, including active cycle of breathing technique, with oscillating devices as low (Morrison 2017).
Short‐term trials with a follow‐up of one week or less
The review did not include any short‐term trials that compared active cycle of breathing technique with an oscillating device.
Medium‐term trials with a follow‐up longer than one week and up to six months
The review did not include any medium‐term trials that compared active cycle of breathing technique with an oscillating device.
Long‐term trials with a follow‐up longer than six months
One trial recruited 75 participants and randomised them to one of five treatment groups (three of which were active cycle of breathing technique, and the Cornet® and Flutter® oscillating devices with 45 participants randomised to these groups); it reported FEV1 L at 12 months (Pryor 2010). There was no significant difference in FEV1 L between the active cycle of breathing technique and Cornet®, MD 0.04 L (95% CI ‐0.60 L to 0.68 L) and Flutter®, MD ‐0.49 L (95% CI ‐1.18 L to 0.20 L) at the end of the 12 months (low strength of evidence). This trial had an adequate randomisation scheme and it blinded the outcome assessors; however, it also lost a high percentage of participants to follow‐up and the results for both comparisons were imprecise (Pryor 2010).
Active cycle of breathing technique versus exercise
One review addressed this comparison, but did not include any eligible trials (McKoy 2016).
Autogenic drainage versus oscillating devices
Two reviews addressed this comparison (McCormack 2017; Morrison 2017). Both reviews included two trials that followed 59 participants for longer than one day and reported on FEV1 (App 1998; Pryor 2010). One review graded the evidence comparing autogenic drainage with Cornet® as moderate and the evidence comparing autogenic drainage with Flutter® as low (McCormack 2017). The second review graded the evidence comparing breathing techniques, including autogenic drainage, with oscillating devices as low (Morrison 2017).
Short‐term trials with a follow‐up of one week or less
This review did not include any short‐term trials that compared autogenic drainage with oscillating devices.
Medium‐term trials with a follow‐up longer than one week and up to six months
One cross‐over trial (14 participants) with four weeks of follow‐up and an adequate washout period compared autogenic drainage with an oscillating device and reported on FEV1 (App 1998). The between‐group difference for the change in FEV1 L was not significant, MD ‐0.1 L (95% CI ‐1.96 L to 1.76 L) (very low strength of evidence). We considered the trial to have an unclear risk of bias because it did not report sufficient details about its methodology to assess trial quality and the results were imprecise (App 1998).
Long‐term trials with a follow‐up longer than six months
One trial recruited 75 participants and randomised them to one of five treatment groups (three of which were autogenic drainage, and the Cornet® and Flutter® oscillating devices with 45 participants randomised to these groups) and reported on FEV1 L at 12 months (Pryor 2010). At the end of the 12 months, there was no significant difference in FEV1 L between the autogenic drainage and Cornet® groups, MD ‐0.01 L (95% CI ‐1.44 L to 1.42 L) or the autogenic drainage and Flutter® groups, MD ‐0.01 L (95% CI ‐1.51 L to 1.49 L) (low strength of evidence). The trial had an adequate randomisation scheme and it blinded the outcome assessors; but it also lost a high percentage of participants to follow‐up and the results for both comparisons were imprecise (Pryor 2010).
Autogenic drainage versus exercise
One review addressed this comparison, but did not include any eligible trials (McCormack 2017).
Oscillating devices versus exercise
One review addressed this comparison, but it did not include any eligible trials (Morrison 2017).
Airway oscillating devices versus external high frequency chest compression devices
One review addressed this comparison (Morrison 2017); it included two medium‐term trials with 190 participants and reported on FEV1 (Modi 2006; Oermann 2001). The review graded the evidence comparing an oscillating device with any other oscillating device as very low.
Short‐term trials with a follow‐up of one week or less
This review did not include any short‐term trials comparing an airway oscillating device with an external high frequency chest compression device.
Medium‐term trials with a follow‐up longer than one week and up to six months
Two trials (190 participants) compared an airway oscillating device with an external high frequency chest compression device and reported on FEV1 (Modi 2006; Oermann 2001). One of these trials was a three‐arm trial of parallel design lasting two months (Modi 2006) and the second was a cross‐over trial with a two‐week washout period and a four‐week follow‐up period (Oermann 2001). In the cross‐over trial, the between‐group difference in the change in FEV1 % predicted was not significant, MD ‐2.3% predicted (95% CI ‐5.44% to 0.84% predicted) (Oermann 2001). The three‐arm trial reported no significant differences between the treatment groups (Modi 2006). Both trials had an unclear risk of bias because neither reported sufficient detail about trial methodology and the results were imprecise and subject to reporting bias.
Long‐term trials with a follow‐up longer than six months
This review did not include any long‐term trials for this comparison.
Airway oscillating devices (Flutter®) versus airway oscillating devices (Cornet®)
One review addressed this comparison (Morrison 2017); it included one long‐term trial with 30 participants reporting on FEV1 (Pryor 2010). The review graded the evidence comparing an oscillating device with any other oscillating device as very low (Morrison 2017).
Short‐term trials with a follow‐up of one week or less
This review did not include any short‐term trials that compared Flutter® with Cornet®.
Medium‐term trials with a follow‐up longer than one week and up to six months
This review did not include any medium‐term trials comparing Flutter® with Cornet®.
Long‐term trials with a follow‐up longer than six months
One trial recruited 75 participants and randomised them to one of five treatment groups (two of which were the Cornet® and Flutter® oscillating devices with 30 participants randomised to these groups) and reported on FEV1 L at 12 months (Pryor 2010). There was no significant difference in FEV1 L between the Flutter® and Cornet® at the end of the 12 months, MD 0 L (95% CI ‐1.22 L to 1.22 L) (low strength of evidence). This trial had an adequate randomisation scheme and it blinded the outcome assessors, but it also lost a high percentage of participants to follow‐up and the results for were imprecise (Pryor 2010).
Airway oscillating devices versus intrapulmonary percussive ventilation
One review addressed this comparison (Morrison 2017); it included one medium‐term trial with 16 participants (Marks 2001). The review graded the evidence comparing an oscillating device with any other oscillating device as very low.
Short‐term trials with a follow‐up of one week or less
This review did not include any short‐term trials that compared an airway oscillating device with intrapulmonary percussive ventilation.
Medium‐term trials with a follow‐up longer than one week and up to six months
One trial (16 participants) with a six‐month follow‐up compared an airway oscillating device with intrapulmonary percussive ventilation (Marks 2001). The between‐group differences in FEV1 were not significant (P = 0.217). We are unable to draw a conclusion (very low strength of evidence). The trial had an unclear risk of bias because it did not report sufficient detail about its methodology. We were unable to assess precision because the trial did not report sufficient data on their results (Marks 2001).
Long‐term trials with a follow‐up longer than six months
This review did not include any long‐term trials that compared an airway oscillating device with intrapulmonary percussive ventilation.
Chest physiotherapy versus no chest physiotherapy
One review addressed this comparison (Warnock 2015); it included two short‐term trials with 35 participants (Braggion 1995; Jarad 2010).
Short‐term trials with a follow‐up of one week or less
Two cross‐over trials (35 participants) followed participants for two days and reported on FEV1 (Braggion 1995; Jarad 2010). One trial did not have a sufficient washout period and is therefore excluded from our analysis (Braggion 1995). We included the second cross‐over trial which had a one‐week washout period between therapies (Jarad 2010). The between‐group difference in the change in FEV1 L was not significant, MD ‐0.02 L (95% CI ‐0.77 L to 0.73 L) (low strength of evidence). The trial had an unclear risk of bias because it did not report sufficient detail about its methodology and the results were imprecise.
Medium‐term trials with a follow‐up longer than one week and up to six months
This review did not include any medium‐term trials that compared chest physiotherapy with no chest physiotherapy.
Long‐term trials with a follow‐up longer than six months
This review did not include any long‐term trials that compared chest physiotherapy with no chest physiotherapy.
2. Participant preference
The results for participant preference for airway clearance techniques are summarised in the additional tables (Table 4) and we present a gap map summarizing the results and the quality of the evidence (GRADE) for participant preference as a figure (Figure 3).
4. Summary of results and quality of the evidence (GRADE): participant preference.
|
Comparison (intervention versus control) |
Follow‐up | Summary of results | No of participants (trials) | Quality of the evidence (GRADE) | Comments |
| Conventional chest physiotherapy versus PEP therapy | > 1 day to 1 week | we are unable to draw a conclusion | 7 participants (1 cross‐over RCT) |
⊕⊝⊝⊝ very low |
|
| > 1 week to 6 months | we are unable to draw a conclusion | 32 participants (2 cross‐over RCTs) |
⊕⊝⊝⊝ very low |
|
|
| > 6 months | we are unable to draw a conclusion | 48 participants (2 RCTs) |
⊕⊝⊝⊝ very low |
|
|
| Conventional chest physiotherapy versus autogenic drainage | > 6 months | we are unable to draw a conclusion | 36 participants (1 RCT) |
⊕⊝⊝⊝ very low |
|
| Conventional chest physiotherapy versus oscillating devices | > 1 day to 1 week | we are unable to draw a conclusion | 40 participants (2 cross‐over RCTs) |
⊕⊝⊝⊝ very low |
|
| > 1 week to 6 months | we are unable to draw a conclusion | 326 participants (5 parallel RCTs and 2 cross‐over RCTs) |
⊕⊝⊝⊝ very low |
|
|
| PEP therapy versus active cycle of breathing technique | > 1 week to 6 months | we are unable to draw a conclusion | 20 participants (1 cross‐over RCT) |
⊕⊝⊝⊝ very low |
|
| PEP therapy versus autogenic drainage | > 1 week to 6 months | we are unable to draw a conclusion | 18 participants (1 cross‐over RCT) |
⊕⊝⊝⊝ very low |
|
| > 6 months | we are unable to draw a conclusion. | 30 participants (1 RCT) |
⊕⊝⊝⊝ very low |
|
|
| PEP therapy versus oscillating devices | > 1 day to 1 week | we are unable to draw a conclusion | 16 participants (1 cross‐over RCT) |
⊕⊝⊝⊝ very low |
|
| > 1 week to 6 months | we are unable to draw a conclusion | 60 participants (1 parallel RCT and 2 cross‐over RCTs) |
⊕⊝⊝⊝ very low |
|
|
| > 6 months | participants may have a similar preference for PEP mask therapy and oscillating devices | 177 participants (3 RCTs) |
⊕⊕⊝⊝ low |
|
|
| Active cycle of breathing technique versus autogenic drainage | >1 day to 1 week | participant preference was split between the 2 airway clearance techniques | 18 participants (1 cross‐over RCT) |
⊕⊕⊝⊝ low |
|
| Autogenic drainage versus oscillating devices | > 6 months | we are unable to draw a conclusion. | 45 participants (1 RCT) |
⊕⊝⊝⊝ very low |
|
| Airway oscillating devices versus external high frequency chest compression devices | > 1 week to 6 months | we are unable to draw a conclusion | 190 participants (1 parallel RCT and 1 cross‐over RCT) |
⊕⊝⊝⊝ very low |
|
| Airway oscillating devices versus intrapulmonary percussive ventilation | > 1 week to 6 months | we are unable to draw a conclusion | 16 participants (1 RCT) |
⊕⊝⊝⊝ very low |
|
| Chest physiotherapy versus no chest physiotherapy | > 1 day to 1 week | we are unable to draw a conclusion. | 19 participants (1 cross‐over RCT) |
⊕⊝⊝⊝ very low |
|
Abbreviations: CI: confidence interval; PEP: positive expiratory pressure; RCT: randomised controlled trial.
3.
Gap map summarizing the results and quality of the evidence (GRADE) for participant preference.
Conventional chest physiotherapy versus PEP therapy
This comparison was addressed in two reviews (Main 2005; McIlwaine 2015) including a total of five trials (87 participants) that evaluated participant preference. Three trials were included in both reviews (Costantini 2001; Darbee 1990; McIlwaine 1997). Main excluded one trial because the follow‐up duration was shorter than one week (Braggion 1995). One trial reported the airway clearance technique used by participants six months after the trial (Tyrrell 1986); one review captured this as preference (Main 2005), but the second review did not (McIlwaine 2015).
Short‐term trials with a follow‐up of one week or less
Participant preference was assessed by one cross‐over trial that followed seven participants for two days (Braggion 1995). Preference was measured indirectly using a three‐point rating scale of tolerance. The trial reported no significant differences between conventional chest physiotherapy and PEP therapy, but did not provide sufficient details about their methodology to assess trial quality, nor did it provide sufficient information about the results to assess precision. Due to the unclear risk of bias, the indirect measurement of precision, and the unclear precision of results, we cannot draw a conclusion about the short‐term preference for conventional chest physiotherapy compared with PEP therapy (very low strength of evidence).
Medium‐term trials with a follow‐up longer than one week and up to six months
Two cross‐over trials (32 participants) with two to three months of follow‐up evaluated participant preference for conventional chest physiotherapy compared with PEP therapy (Darbee 1990; Tyrrell 1986). Both trials reported that participants preferred PEP therapy over conventional chest physiotherapy (very low strength of evidence). However, we are unable to draw a conclusion based on this evidence. Firstly, both trials had an unclear risk of bias as neither provided sufficient detail to assess quality. Secondly, there were serious limitations to how participant preference was assessed; one of the trials did not directly assess preference, but rather reported the number of participants using each therapy six months after the trial (Tyrrell 1986), and the second trial did not describe how preference was measured (Darbee 1990). Furthermore, neither trial provided sufficient detail to assess precision; and finally, the results are subject to reporting bias. One trial was published only as an abstract (Darbee 1990) and both trials failed to report sufficient outcome data (Darbee 1990; Tyrrell 1986).
Long‐term trials with a follow‐up longer than six months
Two trials (48 participants) with one year of follow‐up compared participant preference for conventional chest physiotherapy and PEP therapy (Costantini 2001;McIlwaine 1997). Both trials were conducted in children, so participant preference was answered by the caregivers. Both trials reported that caregivers preferred PEP therapy over conventional chest physiotherapy (very low strength of evidence); the trials had an unclear to low risk of bias. One of the trials blinded the outcome assessors, had a low rate of withdrawals, and specified the randomisation sequence generation (McIlwaine 1997). The second trial was published only as an abstract and did not provide sufficient details about their methodology to adequately assess trial quality (Costantini 2001). There are some serious limitations to the body of evidence that prevents us from drawing a conclusion. Firstly, it is unclear if either trial directly measured participant preference; one trial assessed preference only in participants who received PEP therapy and the second trial did not specify how preference was assessed. Secondly, neither trial reported sufficient information for the results to assess their precision. Lastly, publication bias is strongly suspected because one of the trials is published only as an abstract.
Conventional chest physiotherapy versus active cycle of breathing technique
This comparison was addressed in two reviews, but neither included any trials that reported on participant preference (Main 2005; McKoy 2016).
Conventional chest physiotherapy versus autogenic drainage
This comparison was addressed in two reviews (Main 2005; McCormack 2017); both reviews included one long‐term trial (36 participants) that evaluated participant preference (Davidson 1992). The McCormack review considered the evidence from this trial and graded the evidence comparing conventional chest physiotherapy and autogenic drainage for participant preference as very low (McCormack 2017).
Short‐term trials with a follow‐up of one week or less
The reviews did not include any short‐term trials that compared conventional chest physiotherapy with autogenic drainage.
Medium‐term trials with a follow‐up longer than one week and up to six months
The reviews did not include any medium‐term trials that compared conventional chest physiotherapy with autogenic drainage.
Long‐term trials with a follow‐up longer than six months
Participant preference was assessed in one trial that followed 36 participants for one year (Davidson 1992). Participants preferred autogenic drainage over conventional chest physiotherapy, but there are several limitations that prevent us from drawing a conclusion (very low strength of evidence). The trial did not provide sufficient information about methodology to assess quality, so it was considered to have an unclear risk of bias. Participant preference was not formally assessed; rather, it was observed that participants who received autogenic drainage first refused to switch treatments during the second period. Since preference was not assessed in both groups, there is insufficient information to assess precision. Publication bias is strongly suspected because results were reported only as conference abstracts.
Conventional chest physiotherapy versus oscillating devices
This comparison was addressed in two reviews (Main 2005; Morrison 2017), which included a total of nine trials (366 participants) which evaluated participant preference (Arens 1994; Bauer 1994; Braggion 1995; Giles 1996; Hare 2002; Homnick 1995; Modi 2006; Padman 1999; Varekojis 2003). Two trials were included in both reviews (Arens 1994; Homnick 1995), but the Morrison review did not mention one trial (Bauer 1994). One trial had a follow‐up duration of less than one week and was therefore excluded from the Main review (Braggion 1995); the same review listed five trials (Giles 1996; Hare 2002; Modi 2006; Padman 1999; Varekojis 2003) as being considered for inclusion in future updates (Main 2005). The Morrison review graded the evidence comparing conventional chest physiotherapy and oscillating devices for participant preference as very low (Morrison 2017).
Short‐term trials with a follow‐up of one week or less
Two cross‐over trials (40 participants) with a two‐day follow‐up evaluated participant preference for conventional chest physiotherapy compared to oscillating devices (Braggion 1995; Varekojis 2003). Both trials had a high risk of bias; one had a high loss to follow‐up and was subject to reporting bias, and the second had recruitment issues where participants may have been double‐counted. We are unable to draw a conclusion about participant preference (very low strength of evidence).
Medium‐term trials with a follow‐up longer than one week and up to six months
Seven trials (two of cross‐over design) (326 participants), with between two weeks and six months of follow‐up, evaluated participant preference for conventional chest physiotherapy or an oscillating device (Arens 1994; Bauer 1994; Giles 1996; Hare 2002; Homnick 1995; Modi 2006; Padman 1999). These trials had an unclear to high risk of bias; none of them were blinded or described their randomisation scheme. One trial had a high risk of selection bias (Hare 2002), three trials had a high risk of attrition bias (Homnick 1995; Modi 2006; Padman 1999) and four trials had a high risk of reporting bias (Giles 1996; Hare 2002; Modi 2006; Padman 1999). Most of the seven trials reported a preference for or a satisfaction with oscillating devices, but two trials only assessed preference among the participants assigned to the oscillating device group (Arens 1994; Bauer 1994; Giles 1996; Hare 2002; Homnick 1995; Modi 2006). The strength of evidence was graded as very low, and we are unable to draw a conclusion.
Long‐term trials with a follow‐up longer than six months
Neither review included any long‐term trials that evaluated this comparison.
Conventional chest physiotherapy versus exercise
The review which addressed this comparison did not include any eligible trials (Main 2005).
PEP therapy versus active cycle of breathing technique
This comparison was addressed by two reviews (McIlwaine 2015; McKoy 2016). There was a single relevant medium‐term trial (20 participants) (Kofler 1994); this trial is included in one review (McKoy 2016) and listed as awaiting classification in the second review (McIlwaine 2015).
Short‐term trials with a follow‐up of one week or less
Neither review included any short‐term trials that evaluated this comparison.
Medium‐term trials with a follow up longer than one week and up to six months
One cross‐over trial (20 participants) with a four‐month follow‐up compared PEP therapy with active cycle of breathing technique and reported on participant preference (Kofler 1994). This trial, with an unclear risk of bias and imprecise results, suggested that individuals may prefer PEP therapy over active cycle of breathing technique (very low strength of evidence). However, we are unable to draw a conclusion.
Long‐term trials with a follow‐up longer than six months
Neither review included any long‐term trials evaluating this comparison.
PEP therapy versus autogenic drainage
This comparison was addressed in two reviews (McIlwaine 2015; McCormack 2017), which included a total of two trials (48 participants) (McIlwaine 1991; Pryor 2010). Each review evaluated a different trial for participant preference; we suspect the discrepancy in inclusion is due to different interpretations of preference, such as participant satisfaction. The McCormack review graded the evidence for participant preference for PEP therapy versus autogenic drainage as low (McCormack 2017).
Short‐term trials with a follow‐up of one week or less
The review did not include any short‐term trials that compared PEP therapy with autogenic drainage.
Medium‐term trials with a follow‐up longer than one week and up to six months
One two‐month cross‐over trial (18 participants) compared PEP therapy with autogenic drainage and reported on participant preference (McIlwaine 1991). Preference was indirectly assessed by rating five measures that may influence preference. Participants considered PEP therapy to have a shorter treatment time than autogenic drainage, but the two treatments were rated similarly on comfort, flexibility of treatment times, control in performing their own treatment, and interruptions to daily living. However, we are unable to draw a conclusion because of the very low strength of evidence. We considered this trial to have an unclear risk of bias because it did not provide adequate details on the methodology. We were unable to assess precision because there were no standard deviations reported and we suspect publication bias because the trial was only published as an abstract and the outcomes were not fully reported (McIlwaine 1991).
Long‐term trials with a follow‐up longer than six months
One trial recruited 75 participants and randomised them to one of five treatment groups (two of which were PEP therapy and autogenic drainage with 30 participants randomised to these groups) (Pryor 2010). This trial reported on the total number of participants who withdrew from the trial because they did not like their assigned treatment, but did not report this by treatment group. We graded the strength of evidence as very low because of the risk of bias, the indirect measure of participant preference, the lack of data to determine precision, and the suspicion of publication bias (Pryor 2010).
PEP therapy versus oscillating devices
This comparison was addressed by two reviews (McIlwaine 2015; Morrison 2017); however, one review included only participant satisfaction as an outcome (Morrison 2017) while the second considered either participant preference or satisfaction (McIlwaine 2015). The two reviews included a total of seven trials (253 participants) of sufficient duration and reporting on participant preference (Braggion 1995; McIlwaine 2001; McIlwaine 2013; Padman 1999; Prasad 2005; van Winden 1998; West 2010). Although five of the trials were included in both reviews, not all five were included in the analysis for participant preference (Braggion 1995; McIlwaine 2001; McIlwaine 2013; Prasad 2005; van Winden 1998); we suspect that the differences between reviews are related to the differences in outcome definition. Morrison reported that there were no consistent differences across seven trials in terms of participant satisfaction and graded the evidence as very low (Morrison 2017).
Short‐term trials with a follow‐up of one week or less
One cross‐over RCT (16 participants) with two days of follow‐up compared PEP therapy with oscillating devices and reported on participant preference using a three‐point scale of effectiveness and tolerance (Braggion 1995). No significant differences between treatments were reported (data not provided). We graded the strength of evidence as very low. The trial had an unclear risk of bias because it did not provide sufficient detail about its methodology. We could not assess the directness and precision of the results because the trial did not provide sufficient information. We suspect publication bias because the trial was only published as an abstract and the outcomes were not fully reported (Braggion 1995).
Medium‐term trials with a follow‐up longer than one week and up to six months
Three trials, two of which were cross‐over in design, (60 participants) with two to four weeks of follow‐up compared PEP therapy with oscillating devices and reported on participant preference (Padman 1999; van Winden 1998; West 2010). One trial rated preference on a five‐point scale (West 2010), another trial asked participants their device preference (van Winden 1998), but the third trial did not adequately describe how preference was measured and did not provide quantitative results (Padman 1999). One trial had a low risk of bias, but the other two trials had an unclear to high risk of bias because they did not report sufficient details about their methodology and one trial had a high loss to follow‐up. In the three trials, there were no significant differences in participant preference for either device, but we are unable to draw a conclusion. We graded the evidence as very low because of the serious limitations to the risk of bias, directness, and precision of the results.
Long‐term trials with a follow‐up longer than six months
Three trials (177 participants) with one year of follow‐up compared PEP therapy to oscillating devices and reported on participant preference, but each measured this outcome differently (McIlwaine 2001; McIlwaine 2013; Prasad 2005). One reported the number of participants who withdrew from the trial due to perceived ineffectiveness of the treatment (McIlwaine 2001) and a second trial reported the number who decided to continue with their assigned treatment after the trial (Prasad 2005). In the third trial, participants rated the comfort, independence, and flexibility of the device using a visual analogue scale (McIlwaine 2013). All three trials report no statistically significant differences between PEP therapy and oscillating devices; although participants in one trial rated PEP therapy as more flexible (McIlwaine 2013). The trials had a low to unclear risk of bias. However, none of the trials directly measures preference and the results were imprecise. We, therefore, graded the strength of evidence as low.
PEP therapy versus exercise
The only review presenting this comparison did not include any trials reporting on participant preference (McIlwaine 2015).
Active cycle of breathing technique versus autogenic drainage
One review assessed this comparison (McKoy 2016), which included one short‐term cross‐over trial (18 participants) which reported on participant preference (Miller 1995).
Short‐term trials with a follow‐up of one week or less
The included trial compared active cycle of breathing technique with autogenic drainage with a two‐day follow‐up and reported that participant preference was split similarly between the two airway clearance techniques. There was not sufficient information to assess trial quality and we graded the strength of evidence as low because of the unclear risk of bias and the imprecise results (Miller 1995).
Medium‐term trials with a follow‐up longer than one week and up to six months
The review did not include any medium‐term trials comparing the active cycle of breathing technique with autogenic drainage.
Long‐term trials with a follow‐up longer than six months
The review did not include any long‐term trials comparing the active cycle of breathing technique with autogenic drainage.
Active cycle of breathing technique versus oscillating devices
This comparison was reported by two reviews, neither of which included any eligible trials (McKoy 2016; Morrison 2017).
Active cycle of breathing technique versus exercise
The only review which compared the active cycle of breathing technique to exercise did not include any eligible trials (McKoy 2016).
Autogenic drainage versus oscillating devices
This comparison was addressed by two reviews (McCormack 2017; Morrison 2017), but only one of these reviews (McCormack 2017) included any eligible trials for patient preference. The McCormack review (McCormack 2017) graded the evidence comparing autogenic drainage with oscillating devices (Flutter® or Cornet®) as low.
Short‐term trials with a follow‐up of one week or less
Neither review included any short‐term trials comparing autogenic drainage with oscillating devices.
Medium‐term trials with a follow‐up longer than one week and up to six months
Neither review included any medium‐term trials comparing autogenic drainage with oscillating devices.
Long‐term trials with a follow‐up longer than six months
One trial recruited 75 participants and randomised them to one of five treatment groups (three of which were autogenic drainage, Flutter®, and Cornet® with 45 participants randomised to these groups) (Pryor 2010). This trial reported on the total number of participants who withdrew from the trial because they did not like their assigned treatment, but not by treatment group. We graded the strength of evidence as very low because of the risk of bias, the indirect measure of participant preference, the lack of data to determine precision, and the suspicion of publication bias (Pryor 2010).
Autogenic drainage versus exercise
One review addressed this comparison, but did not include any eligible trials (McCormack 2017).
Oscillating devices versus exercise
Only one review compared oscillating devices to exercise, but it did not include any eligible trials (Morrison 2017).
Airway oscillating devices versus external high frequency chest compression devices
One review compared airway oscillating devices to external high frequency chest compression devices (Morrison 2017). It included two medium‐term trials which followed 190 participants and reported on participant preference (Modi 2006; Oermann 2001). The review graded the evidence comparing an oscillating device with any other oscillating device as very low.
Short‐term trials with a follow‐up of one week or less
No short‐term trials reporting this comparison were included in the review (Morrison 2017).
Medium‐term trials with a follow‐up longer than one week and up to six months
Two trials (190) with one to three months of follow‐up compared an airway oscillating device with an external high frequency chest compression device and reported on participant preference (Modi 2006; Oermann 2001); one of these had a cross‐over design (Oermann 2001). In this trial, participants rated the airway oscillating device as significantly more convenient and the external high frequency chest compression device as significantly more efficacious, but neither was favoured for comfort (Oermann 2001). In the second trial, there were no significant differences in participant satisfaction measured in terms of overall preference, comfort, convenience, and efficacy (Modi 2006). We are unable to draw any conclusion about participant preference for airway oscillating devices or external high frequency chest compression devices. Both trials had an unclear risk of bias because neither reported sufficient detail about methodology and the results were imprecise and subject to reporting bias (Modi 2006; Oermann 2001).
Long‐term trials with a follow‐up longer than six months
The review did not include any long‐term trials comparing an airway oscillating device with an external high frequency chest compression device.
Airway oscillating devices (Flutter®) versus airway oscillating devices (Cornet®)
The only review that addressed this comparison did not include any eligible trials (Morrison 2017).
Airway oscillating devices versus intrapulmonary percussive ventilation
One review addressed this comparison (Morrison 2017) and included one medium‐term trial with 16 participants and reported on their preference (Marks 2001). The review graded the evidence comparing an oscillating device with any other oscillating device as very low.
Short‐term trials with a follow‐up of one week or less
This review did not include any short‐term trials with this comparison of devices (Morrison 2017).
Medium‐term trials with a follow‐up longer than one week and up to six months
One trial (16 participants) compared an airway oscillating device with intrapulmonary percussive ventilation and followed participants for six months (Marks 2001). Participant satisfaction was only assessed in the intrapulmonary percussive ventilation group and most (67%) of those participants stated they were willing to continue with that device. We are unable to draw a conclusion about participant preference for the two devices because the trial had an unclear risk of bias, preference was only indirectly assessed, precision could not be assessed, and the results are subject to reporting bias (Marks 2001).
Long‐term trials with a follow‐up longer than six months
This review did not include any eligible long‐term trials (Morrison 2017).
Chest physiotherapy versus no chest physiotherapy
The only review presenting this comparison included one short‐term trial (Warnock 2015); the included trial followed 18 participants and reported on participant preference (Jarad 2010).
Short‐term trials with a follow up of one week or less
One cross‐over trial (19 participants) reported on participant preference for hydro‐acoustic therapy (intervention not included in this review), an oscillating device (Flutter®), and placebo (Jarad 2010). Interventions were given in a random sequence for two days with a one‐week washout period between treatments and participants were asked at the end of the trial which of the three treatment options they preferred. More participants preferred placebo over the oscillating device. However, we are unable to draw a conclusion about preference because the trial had an unclear risk of bias, preference was only indirectly assessed, and precision could not be assessed (Jarad 2010).
Medium‐term trials with a follow‐up longer than one week and up to six months
The review did not include any medium‐term trials for this comparison (Warnock 2015).
Long‐term trials with a follow‐up longer than six months
The review did not include any long‐term trials for this comparison (Warnock 2015).
3. Quality of life
Results for quality of life (total scores or domain scores from validated instruments) are summarised in the additional tables (Table 5) and we present a gap map summarising the results and the quality of the evidence (GRADE) for quality of life as a figure (Figure 4).
5. Summary of results and quality of the evidence (GRADE): quality of life.
|
Comparison (intervention versus control) |
Follow‐up | Summary of results | No of participants (trials) | Quality of the evidence (GRADE) | Comments |
| Conventional chest physiotherapy versus PEP therapy | > 6 months | the trial reported no statistically significant difference between treatments | 66 participants (1 RCT) |
⊕⊝⊝⊝ very low |
|
| Conventional chest physiotherapy versus oscillating devices | > 1 week ≤ 6 months | there was no evidence of a difference in quality of life between conventional chest physiotherapy and oscillating devices | 166 participants (1 RCT) |
⊕⊕⊝⊝ low |
|
| PEP therapy versus active cycle of breathing technique | > 6 months | we are unable to draw a conclusion due to the serious risk of bias, lack of information to determine precision, and the suspected reporting bias | 26 participants (1 RCT) |
⊕⊝⊝⊝ very low |
|
| PEP therapy versus autogenic drainage | > 6 months | we are unable to draw a conclusion due to the serious risk of bias, lack of information to determine precision, and the suspected reporting bias | 26 participants (1 RCT) |
⊕⊝⊝⊝ very low |
|
| PEP therapy versus oscillating devices | > 6 months | there was no evidence of a difference in quality of life between PEP mask therapy and oscillating devices | 209 participants (4 RCTs) |
⊕⊕⊝⊝ low |
|
| Active cycle of breathing technique versus autogenic drainage | > 6 months | we are unable to draw a conclusion due to the serious risk of bias, lack of information to determine precision, and the suspected reporting bias | 26 participants (1 RCT) |
⊕⊝⊝⊝ very low |
|
| Active cycle of breathing technique versus oscillating devices | > 6 months | we are unable to draw a conclusion due to the serious risk of bias, lack of information to determine precision, and the suspected reporting bias | 39 participants (1 RCT) |
⊕⊝⊝⊝ very low |
|
| Autogenic drainage versus oscillating devices | > 6 months | we are unable to draw a conclusion due to the serious risk of bias, lack of information to determine precision, and the suspected reporting bias | 39 participants (1 RCT) |
⊕⊝⊝⊝ very low |
|
| Airway oscillating devices (Flutter) versus airway oscillating devices (Cornet) | > 6 months | we are unable to draw a conclusion due to the serious risk of bias, lack of information to determine precision, and the suspected reporting bias | 26 participants (1 RCT) |
⊕⊝⊝⊝ very low |
|
Abbreviations: PEP: positive expiratory pressure; RCT: randomised controlled trial.
4.
Gap map summarizing the results and quality of the evidence (GRADE) for quality of life.
Conventional chest physiotherapy versus PEP therapy
Two reviews compared conventional chest physiotherapy to PEP therapy (Main 2005; McIlwaine 2015). They included the same two‐year trial (66 participants) which evaluated quality of life (Gaskin 1998).
Short‐term trials with a follow‐up of one week or less
Neither review included a short‐term trial reporting on quality of life (Main 2005; McIlwaine 2015).
Medium‐term trials with a follow‐up longer than one week and up to six months
Neither review included a medium‐term trial reporting on quality of life (Main 2005; McIlwaine 2015).
Long‐term trials with a follow‐up longer than six months
One trial (66 participants) with two years of follow‐up evaluated quality of life using the Quality of Well‐Being scale and reported no significant differences between the treatments in their ability to affect quality of life (very low strength of evidence) (Gaskin 1998). The trial had an unclear risk of bias because it was published only as an abstract and did not provide sufficient information to assess quality. There was also insufficient detail on the results to allow an assessment of precision and the results may be susceptible to reporting bias.
Conventional chest physiotherapy versus active cycle of breathing technique
This comparison was addressed in two reviews, but neither included any trials that evaluated quality of life (Main 2005; McKoy 2016).
Conventional chest physiotherapy versus autogenic drainage
Two reviews compared conventional chest physiotherapy with autogenic drainage (Main 2005; McCormack 2017). One review (McCormack 2017) included two cross‐over trials (Davidson 1992; McIlwaine 1991) which evaluated quality of life, but the second review did not present any trials (Main 2005). McCormack graded the evidence for this comparison on quality of life as very low (McCormack 2017).
Short‐term trials with a follow‐up of one week or less
Neither review included a short‐term trial that reported on quality of life (Main 2005; McCormack 2017).
Medium‐term trials with a follow‐up longer than one week and up to six months
One cross‐over trial (18 participants) with two months of follow‐up reported on quality of life (McIlwaine 1991). However, they did not use a validated instrument to assess quality of life and therefore, this trial was excluded from our analysis.
Long‐term trials with a follow‐up longer than six months
One cross‐over trial (36 participants) with one year of follow‐up reported on quality of life (Davidson 1992). However, they did not use a validated instrument to assess quality of life and therefore, this trial was excluded from our analysis.
Conventional chest physiotherapy versus oscillating devices
Two reviews compared conventional chest physiotherapy with oscillating devices (Main 2005; Morrison 2017). One review included one medium‐term trial (166 participants) (Morrison 2017), but the second review did not present any trials (Main 2005).
Short‐term trials with a follow‐up of one week or less
Neither review included a short‐term trial reporting on quality of life (Main 2005; Morrison 2017).
Medium‐term trials with a follow‐up longer than one week and up to six months
One trial (166 participants) with two months of follow‐up evaluated quality of life using the CFQ (Modi 2006). This trial reported no significant differences between treatments for all of the CFQ domains after adjusting for multiple comparisons. We graded the evidence as low because of the high risk of bias and the imprecise results.
Long‐term trials with a follow‐up longer than six months
Neither review included a short‐term trial that reported on quality of life (Main 2005; Morrison 2017).
Conventional chest physiotherapy versus exercise
One review presented this comparison but did not include any trials that reported on quality of life (Main 2005).
PEP therapy versus active cycle of breathing technique
Two reviews compared PEP therapy to active cycle of breathing technique (McIlwaine 2015; McKoy 2016). One multi‐arm trial with sufficient follow‐up was included in both reviews (Pryor 2010), but one review did not include this trial in the comparison of PEP therapy and active cycle of breathing technique (McIlwaine 2015).
Short‐term trials with a follow‐up of one week or less
Neither review included a short‐term trial comparing PEP therapy with active cycle of breathing technique (McIlwaine 2015; McKoy 2016).
Medium‐term trials with a follow‐up longer than one week and up to six months
Neither review included a medium‐term trial comparing PEP therapy with active cycle of breathing technique (McIlwaine 2015; McKoy 2016).
Long‐term trials with a follow‐up longer than six months
One 12‐month trial randomised 75 participants to one of five treatment groups, two of which were PEP therapy (13 participants) and active cycle of breathing technique (13 participants) (Pryor 2010). The trial evaluated quality of life using two validated measures, the Short Form‐36 and the Chronic Respiratory Questionnaire, but found no significant differences between groups for the physical and mental domains of the Short Form‐36 and for the dyspnoea, fatigue, emotion and mastery domains of the Chronic Respiratory Questionnaire. This trial had an adequate randomisation scheme and it blinded the outcome assessors, but it also lost a high percentage of participants to follow‐up. We are unable to evaluate precision because the trial only reported P values for comparisons across the five treatment groups. We are unable to draw a conclusion and graded the strength of the evidence as very low because of the serious risk of bias, the lack of information to determine precision, and the suspected reporting bias.
PEP therapy versus autogenic drainage
Two reviews compared PEP therapy to active cycle of breathing technique (McIlwaine 2015; McCormack 2017). One multi‐arm trial with sufficient follow‐up was included in both reviews (Pryor 2010), but one review did not include this trial in the comparison of PEP therapy and autogenic drainage (McIlwaine 2015). The McCormack review graded the strength of evidence as low (McCormack 2017).
Short‐term trials with a follow‐up of one week or less
Neither review included a short‐term trial comparing PEP therapy with autogenic drainage (McIlwaine 2015; McCormack 2017).
Medium‐term trials with a follow‐up longer than one week and up to six months
Neither review included a medium‐term trial comparing PEP therapy with autogenic drainage (McIlwaine 2015; McCormack 2017).
Long‐term trials with a follow‐up longer than six months
One 12‐month trial randomised 75 participants to one of five treatment groups, two of which were PEP therapy (13 participants) and autogenic drainage (13 participants) (Pryor 2010). The trial evaluated quality of life using two validated measures, the Short Form‐36 and the Chronic Respiratory Questionnaire, but found no significant differences between groups for the physical and mental domains of the Short Form‐36 and for the dyspnoea, fatigue, emotion and mastery domains of the Chronic Respiratory Questionnaire. This trial had an adequate randomisation scheme and it blinded the outcome assessors, but it also lost a high proportion of participants to follow‐up. We were unable to evaluate precision because the trial only reported P values for comparisons across the five treatment groups. We are unable to draw a conclusion and graded the strength of the evidence as very low because of the serious risk of bias, the lack of information to determine precision, and the suspected reporting bias (Pryor 2010).
PEP therapy versus oscillating devices
Two reviews compared PEP therapy to oscillating devices and included a total of four long‐term trials (209 participants) that reported on quality of life (McIlwaine 2015; Morrison 2017). Two trials were included in both reviews (Prasad 2005; Pryor 2010), but it is unclear why the McIlwaine review did not include the quality of life outcomes for the remaining two trials (McIlwaine 2013; Newbold 2005).
Short‐term trials with a follow‐up of one week or less
Neither review included a short‐term trial for this comparison that reported on quality of life (McIlwaine 2015; Morrison 2017).
Medium‐term trials with a follow‐up longer than one week and up to six months
Neither review included a medium‐term trial for this comparison that reported on quality of life (McIlwaine 2015; Morrison 2017).
Long‐term trials with a follow‐up longer than six months
Four trials (209 participants) with a follow‐up of 12 to 13 months compared PEP therapy with an oscillating device and reported on quality of life using different scales (McIlwaine 2013; Newbold 2005; Prasad 2005; Pryor 2010). One trial used the Cystic Fibrosis Questionnaire‐Revised (McIlwaine 2013), two trials used the Chronic Respiratory Questionnaire (Newbold 2005; Pryor 2010), two trials also used the Quality of Well‐Being Scale (Newbold 2005; Prasad 2005) and one trial used the Short Form‐36 (Pryor 2010). None of the trials reported any significant differences between PEP therapy and an oscillating device for any of the quality of life domains or total scores. We considered the trials to have a low to unclear risk of bias; three trials described their randomisation scheme (McIlwaine 2013; Newbold 2005; Pryor 2010) and three had a low loss to follow‐up (McIlwaine 2013; Newbold 2005; Prasad 2005). We graded the strength of evidence as low because of the imprecise results and suspicions of reporting bias.
PEP therapy versus exercise
The only review comparing PEP therapy to exercise did not include any trials that reported on quality of life (McIlwaine 2015).
Active cycle of breathing technique versus autogenic drainage
Two reviews compared active cycle of breathing technique to autogenic drainage (McKoy 2016; McCormack 2017) and both included one trial (26 participants) with 12‐month follow‐up which reported on quality of life (Pryor 2010). The McCormack review graded the strength of evidence as low (McCormack 2017).
Short‐term trials with a follow‐up of one week or less
Neither review included any short‐term trials comparing active cycle of breathing technique with autogenic drainage and reporting on quality of life (McKoy 2016; McCormack 2017).
Medium‐term trials with a follow‐up longer than one week and up to six months
The review did not include any medium‐term trials comparing active cycle of breathing technique with autogenic drainage and reporting on quality of life (McKoy 2016).
Long‐term trials with a follow‐up longer than six months
As already described, one 12‐month trial recruited 75 participants and randomised them to one of five treatment groups, two of which were active cycle of breathing technique (13 participants) and autogenic drainage (13 participants) (Pryor 2010). The trial evaluated quality of life using two validated measures, the Short Form‐36 and the Chronic Respiratory Questionnaire. There were no significant differences between groups for the physical and mental domains of the Short Form‐36 or for the dyspnoea, fatigue, emotion and mastery domains of the Chronic Respiratory Questionnaire. This trial had an adequate randomisation scheme and it blinded the outcome assessors, but it also lost a high proportion of participants to follow‐up. We are unable to evaluate precision because the trial only reported P values for comparisons across the five treatment groups. We suspected publication bias because of the poor outcome reporting. We are unable to draw a conclusion and graded the strength of the evidence as very low because of the serious risk of bias, the lack of information to determine precision, and the suspected reporting bias.
Active cycle of breathing technique versus oscillating devices
Two reviews compared the active cycle of breathing technique to oscillating devices (McKoy 2016; Morrison 2017). Both reviews included only one long‐term trial (45 participants) which reported on quality of life (Pryor 2010).
Short‐term trials with a follow‐up of one week or less
The reviews did not include any short‐term trials for this comparison (McKoy 2016; Morrison 2017).
Medium‐term trials with a follow‐up longer than one week and up to six months
The reviews did not include any medium‐term trials for this comparison (McKoy 2016; Morrison 2017).
Long‐term trials with a follow‐up longer than six months
As described previously, one 12‐month trial randomised 75 participants to one of five treatment groups, three of which were active cycle of breathing technique (13 participants) and the different oscillating devices Cornet® (14 participants) and Flutter® (12 participants) (Pryor 2010). The trial evaluated quality of life using two validated measures, the Short Form‐36 and the Chronic Respiratory Questionnaire, and found no significant differences between groups for the physical and mental domains of the Short Form‐36 or for the dyspnoea, fatigue, emotion and mastery domains of the Chronic Respiratory Questionnaire. This trial had an adequate randomisation scheme and it blinded the outcome assessors, but it also lost a high percentage of participants to follow‐up. We are unable to evaluate precision because the trial only reported P values for comparisons across the five treatment groups. We suspected publication bias because of the poor outcomes reporting. We are unable to draw a conclusion and graded the strength of the evidence as very low because of the serious risk of bias, the lack of information to determine precision, and the suspected reporting bias.
Active cycle of breathing technique versus exercise
The one review addressed this comparison but did not include any trials with our pre‐specified follow‐up period which reported on quality of life (McKoy 2016).
Autogenic drainage versus oscillating devices
Two reviews compared autogenic drainage to oscillating devices (Morrison 2017; McCormack 2017) and included one long‐term trial which randomised 75 participants to one of five treatment groups (45 participants in this comparison) that reported on quality of life (Pryor 2010). The McCormack review graded the evidence as low (McCormack 2017).
Short‐term trials with a follow‐up of one week or less
Neither review included any short‐term trials for this comparison (Morrison 2017; McCormack 2017).
Medium‐term trials with a follow‐up longer than one week and up to six months
Neither review included any medium‐term trials for this comparison (Morrison 2017; McCormack 2017).
Long‐term trials with a follow‐up longer than six months
As described above one 12‐month trial randomised 75 participants to one of five treatment groups (three of which were autogenic drainage and the different oscillating devices Cornet® and Flutter®) (Pryor 2010). The trial evaluated quality of life using two validated measures, the Short Form‐36 and the Chronic Respiratory Questionnaire, and found no significant differences between groups for the physical and mental domains of the Short Form‐36 and for the dyspnoea, fatigue, emotion and mastery domains of the Chronic Respiratory Questionnaire. This trial had an adequate randomisation scheme and it blinded the outcome assessors, but it also lost a high percentage of participants to follow‐up. We are unable to evaluate precision because the trial only reported P values for comparisons across the five treatment groups. We suspected publication bias because of the poor outcome reporting. We are unable to draw a conclusion and graded the strength of the evidence as very low because of the serious risk of bias, the lack of information to determine precision, and the suspected reporting bias (Pryor 2010).
Autogenic drainage versus exercise
One review addressed this comparison, but did not include any eligible trials (McCormack 2017).
Oscillating devices versus exercise
One review addressed this comparison but did not include any trials with our pre‐specified intervention period which reported on quality of life (Morrison 2017).
Airway oscillating devices versus external high frequency chest compression devices
One review addressed this comparison but did not include any trials with our pre‐specified intervention period which reported on quality of life (Morrison 2017).
Airway oscillating devices (Flutter®) versus airway oscillating devices (Cornet®)
This comparison was evaluated by one review (Morrison 2017), which included one long‐term trial (n = 30) reporting on quality of life (Pryor 2010).
Short‐term trials with a follow‐up of one week or less
The review did not include any short‐term trials for this comparison (Morrison 2017).
Medium‐term trials with a follow‐up longer than one week and up to six months
The review did not include any medium‐term trials for this comparison (Morrison 2017).
Long‐term trials with a follow‐up longer than six months
As already described, one 12‐month trial randomised 75 participants to one of five treatment groups (two of which were the oscillating devices Cornet® and Flutter®) (Pryor 2010). The trial evaluated quality of life using two validated measures, the Short Form‐36 and the Chronic Respiratory Questionnaire and found no significant differences between groups for the physical and mental domains of the Short Form‐36 or for the dyspnoea, fatigue, emotion and mastery domains of the Chronic Respiratory Questionnaire. This trial had an adequate randomisation scheme and it blinded the outcome assessors, but it also lost a high percentage of participants to follow‐up. We are unable to evaluate precision because the trial only reported P values for comparisons across the five treatment groups. We suspected publication bias because of the poor outcome reporting. We are unable to draw a conclusion and graded the strength of the evidence as very low because of the serious risk of bias, the lack of information to determine precision, and the suspected reporting bias (Pryor 2010).
Airway oscillating devices versus intrapulmonary percussive ventilation
One review addressed this comparison but did not include any trials with our pre‐specified intervention period which reported on quality of life (Morrison 2017).
Chest physiotherapy versus no chest physiotherapy
One review addressed this comparison but did not include any trials with our pre‐specified intervention period which reported on quality of life (Warnock 2015).
Secondary outcomes
1. Adverse events
Four reviews evaluated adverse events (Main 2005; McIlwaine 2015; McKoy 2016; McCormack 2017). Adverse events were rarely reported in the trials included in these reviews but the available information is summarised in the additional tables (Table 6). We were unable to present the results by the severity of the event because we did not have sufficient information to do this. There is little evidence to suggest that any particular airway clearance therapy is more strongly associated with adverse events.
6. Summary of results: adverse events.
| Comparison | Cochrane Review |
Number of trials (participants) reporting adverse events |
Number of participants experiencing an adverse event | Comments | |
| Intervention group | Comparison group | ||||
| Conventional chest physiotherapy versus PEP therapy | Main 2005 | 2 (48) | 0 | 2 | 1 trial reported that 2 adverse events (gastro‐oesophageal reflux and transient episode of atelectasis (complete or partial collapse of the lung)) occurred in the PEP mask group both trials reported there were no adverse events in the conventional chest physiotherapy groups |
| McIlwaine 2015 | 2 (48) | 0 | 2 | 1 trial reported that 2 adverse events (gastro‐oesophageal reflux and transient episode of atelectasis (complete or partial collapse of the lung)) occurred in the PEP mask group both trials reported there were no adverse events adverse events in the conventional chest physiotherapy groups |
|
| Conventional chest physiotherapy versus active cycle of breathing technique | Main 2005 | 0 | 0 | 0 | none of the included trials addressed this outcome |
| McKoy 2016 | 0 | 0 | 0 | none of the included trials addressed this outcome | |
| Conventional chest physiotherapy versus autogenic drainage | Main 2005 | 0 | 0 | 0 | none of the included trials addressed this outcome |
| McCormack 2017 | 0 | 0 | 0 | none of the included trials addressed this outcome | |
| Conventional chest physiotherapy versus oscillating devices | Main 2005 | 2 (66) | 2 | 2 | 2 participants receiving conventional chest physiotherapy and 2 participants using an oscillating device experienced an adverse event (minor or mild haemoptysis) |
| Morrison 2017 | NA | NA | NA | this review did not evaluate adverse events | |
| Conventional chest physiotherapy versus exercise | Main 2005 | 0 | 0 | 0 | none of the included trials addressed this outcome |
| PEP therapy versus active cycle of breathing technique | McIlwaine 2015 | 0 | 0 | 0 | none of the included trials addressed this outcome |
| McKoy 2016 | 0 | 0 | 0 | none of the included trials addressed this outcome | |
| PEP therapy versus autogenic drainage | McIlwaine 2015 | 0 | 0 | 0 | none of the included trials addressed this outcome |
| McCormack 2017 | 0 | 0 | 0 | none of the included trials addressed this outcome | |
| PEP therapy versus oscillating devices | McIlwaine 2015 | 0 | 0 | 0 | none of the included trials addressed this outcome |
| Morrison 2017 | NA | NA | NA | this review did not evaluate adverse events | |
| PEP therapy versus exercise | McIlwaine 2015 | 0 | 0 | 0 | none of the included trials addressed this outcome |
| Active cycle of breathing technique versus autogenic drainage | McKoy 2016 | 0 | 0 | 0 | none of the included trials addressed this outcome |
| McCormack 2017 | 1 (18) | 4 | 0 | 4 participants experienced 5 episodes of a decrease in oxygen saturation while performing active cycle of breathing technique. No episodes occurred during autogenic drainage | |
| Active cycle of breathing technique versus oscillating devices | McKoy 2016 | 0 | 0 | 0 | none of the included trials addressed this outcome |
| Morrison 2017 | NA | NA | NA | this review did not evaluate adverse events | |
| Active cycle of breathing technique versus exercise | McKoy 2016 | 0 | 0 | 0 | the review did not include any trials that addressed this comparison |
| Autogenic drainage versus oscillating devices | McCormack 2017 | 0 | 0 | 0 | none of the included trials addressed this outcome |
| Morrison 2017 | NA | NA | NA | this review did not evaluate adverse events | |
| Autogenic drainage versus exercise | McCormack 2017 | 0 | 0 | 0 | the review did not include any trials that addressed this comparison |
| Oscillating devices versus exercise | Morrison 2017 | NA | NA | NA | this review did not evaluate adverse events |
| Airway oscillating devices versus external high frequency chest compression devices | Morrison 2017 | NA | NA | NA | this review did not evaluate adverse events |
| Airway oscillating devices (Flutter®) versus airway oscillating devices (Cornet®) | Morrison 2017 | NA | NA | NA | this review did not evaluate adverse events |
| Airway oscillating devices versus intrapulmonary percussive ventilation | Morrison 2017 | NA | NA | NA | this review did not evaluate adverse events |
| Chest physiotherapy versus no chest physiotherapy | Warnock 2015 | NA | NA | NA | this review did not evaluate adverse events |
Abbreviations: NA: not applicable; PEP: positive expiratory pressure.
2. Other measures of lung function (change from baseline in L or % predicted values)
a. FVC
All of the included reviews reported on FVC. The comparative effects of airway clearance techniques on FVC are summarised in the additional tables (Table 7). None of the airway clearance therapies demonstrated any superiority in terms of FVC.
7. Summary of results: FVC.
| Comparison | Cochrane Review | Number of trials (participants) reporting on FVC | Mean FVC in intervention group | Mean FVC in the comparison group | Absolute effect (95% CI)* | Comment |
| Conventional chest physiotherapy versus PEP therapy | Main 2005 | 6 (164) | NR | NR | MD 0.38% predicted (95% CI ‐1.56 to 2.33) |
|
| McIlwaine 2015 | 1 (14) | significantly decreased | significantly increased | NA |
|
|
| 2 (26) | range ‐2.33% to 0.58% predicted | range ‐11.43% to 2.78% predicted | MD 4.18% predicted (95% CI ‐4.56 to 12.92) |
|
||
| 1 (20) | mean (SD) ‐1 (7.25)% predicted | mean (SD) 1.09 (9.95)% predicted | MD ‐2.09% predicted (95% CI ‐9.64 to 5.46) |
|
||
| 1 (36) | mean (SD) ‐2.17 (13.58)% predicted | mean (SD) 6.57 (8.06)% predicted | MD ‐8.74% predicted (95% CI ‐16.04 to 1.44) |
|
||
| 1 (66) | mean (SD) ‐0.97 (4.84)% predicted (4.84) | mean (SD) ‐2.54 (6.48)% predicted | MD 1.57% predicted (95% CI ‐1.19 to 4.33) |
|
||
| Conventional chest physiotherapy versus active cycle of breathing technique | Main 2005 | 1 (63) | NR | NR | MD 1.8% predicted (‐0.83 to 4.43) |
|
| McKoy 2016 | 1 (63) | NR | NR | MD 1.8% predicted (95% CI ‐0.83 to 4.43) |
|
|
| Conventional chest physiotherapy versus autogenic drainage | Main 2005 | 2 (54) | NR | NR | MD 0.39% predicted (95% CI ‐3.62 to 4.40) |
|
| McCormack 2017 | 1 (36) | NR | NR | MD 1.88% predicted (95% CI 0.68 to 3.08) |
|
|
| Conventional chest physiotherapy versus oscillating devices | Main 2005 | 2 (38) | NR | NR | MD 6.06% predicted (95% CI ‐2.42 to 14.55) |
|
| 3 (145) | NR | NR | MD ‐1.45% predicted (95% CI ‐5.17 to 2.33) |
|
||
| Morrison 2017 | 2 (36) | range 81% to 81.5% predicted | range 81.8% to 89% predicted | MD ‐2.6% predicted (95% CI ‐13.84 to 8.63) |
|
|
| 1 (20) | mean (SD) 80 (31)% predicted | mean (SD) 93 (17)% predicted | MD ‐13% predicted (95% CI ‐36.54 to 10.54) |
|
||
| 1 (14) | mean (SD) 92 (4)% predicted | mean (SD) 95 (6)% predicted | MD ‐3% (95% CI ‐6.78 to 0.78) |
|
||
| 1 (16) | mean (SD) 79% predicted (SD 16) | mean (SD) 90% predicted (SD 12) | MD ‐11% (95% CI ‐24.86 to 2.86) |
|
||
| Conventional chest physiotherapy versus exercise | Main 2005 | 1 (17) | NR | NR | MD 7.83% predicted (95% CI 2.48 to 13.18) |
|
| PEP therapy versus active cycle of breathing technique | McIlwaine 2015 | 0 | NA | NA | NA |
|
| McKoy 2016 | 0 | NA | NA | NA |
|
|
| PEP therapy versus autogenic drainage | McIlwaine 2015 | 1 (18) | NR | NR | no significant differences |
|
| McCormack 2017 | 2 (48) | NR | NR | no significant differences |
|
|
| PEP therapy versus oscillating devices | McIlwaine 2015 | 1 (22) | NR | NR | no significant differences |
|
| 2 (118) | range 0.06% to 6.39% predicted | range ‐8.62% to 11.39% predicted | range in MD ‐5 to 8.68% predicted |
|
||
| 1 (42) | mean (SD) ‐4.7 (8)% predicted | mean (SD) ‐3 (7.1)% predicted | MD ‐1.7% predicted (95% CI ‐6.27 to 2.87) |
|
||
| Morrison 2017 | 2 (39) | range in final values 83.6% to 91% predicted | range in final values 81.8% to 91% predicted | MD 0.66% predicted (95% CI ‐7.40 to 8.71) |
|
|
| 1 (22) | mean (SD) 97 (3)% predicted | mean (SD) 99 (4)% predicted | MD 2% predicted (95% CI ‐0.09 to 4.09) |
|
||
| 1 (23) | mean (SD) 5.03 (10.03)% predicted | mean (SD) 10.43 (21.73)% predicted | MD 5.40% predicted (95% CI ‐9,21 to 20.01) |
|
||
| 3 (162) | % change from baseline (range) ‐8.62 to 11.39 | % change from baseline (range) ‐4.7 to 6.39 |
MD 0.25 (95% CI ‐6.14 to 6.65) |
|
||
| PEP therapy versus exercise | McIlwaine 2015 | 0 | NA | NA | NA |
|
| Active cycle of breathing technique versus autogenic drainage | McKoy 2016 | 2 (48) | NR | NR | no significant differences |
|
| McCormack 2017 | 2 (48) | NR | NR | no significant differences |
|
|
| Active cycle of breathing technique versus oscillating devices | McKoy 2016 | 1 (45) | NR | NR | no significant differences |
|
| Morrison 2017 | 1 (45) | NR | NR | no significant differences |
|
|
| Active cycle of breathing technique versus exercise | McKoy 2016 | 0 | NA | NA | NA |
|
| Autogenic drainage versus oscillating devices | McCormack 2017 | 1 (14) | mean (SD) 2.9 (1.5) L | mean (SD) 3.2 (0.6) L | MD ‐0.30 L (95% CI ‐1.50 to 0.90) |
|
| Morrison 2017 | 1 (14) | mean (SD) 2.9 (1.4)% predicted | mean (SD) 3.2 (0.6)% predicted | MD ‐0.3% predicted (95% CI ‐1.43 to 0.83) |
|
|
| Autogenic drainage versus exercise | McCormack 2017 | 0 | NA | NA | NA |
|
| Oscillating devices versus exercise | Morrison 2017 | 0 | NA | NA | NA |
|
| Airway oscillating devices versus external high frequency chest compression devices | Morrison 2017 | 1 (24) | mean (SD) 72.6 (2.9)% predicted | mean (SD) 74 (3)% predicted | MD ‐1.4% predicted (95% CI ‐3.07 to 0.27) |
|
| Airway oscillating devices (Flutter®) versus airway oscillating devices (Cornet®) | Morrison 2017 | 1 (30) | NR | NR | no significant differences |
|
| Airway oscillating devices versus intrapulmonary percussive ventilation | Morrison 2017 | 1 (16) | NR | NR | no significant differences |
|
| Chest physiotherapy versus no chest physiotherapy | Warnock 2015 | 2 (35) | NR | NR | no significant differences |
|
* Positive numbers favour the intervention groups
Abbreviations: CI: confidence interval; FVC: forced vital capacity; MD: mean difference; NA: not applicable; NR: not reported; PEP: positive expiratory pressure; RCT: randomised controlled trial; SD: standard deviation.
b. FEF25‐75
Five reviews evaluated FEF25‐75 (Main 2005; McCormack 2017; McIlwaine 2015; Morrison 2017; Warnock 2015). The comparative effects of airway clearance techniques on FEF25‐75 are summarised in the additional tables (Table 8). All of the airway clearance therapies had a similar effect on FEF25‐75.
8. Summary of results: FEF 25‐75.
| Comparison | Cochrane Review | Number of trials (participants) reporting on FVC | Mean FVC | Absolute effect (95% CI)* | Comment | |
| Intervention group | Comparison group | |||||
| Conventional chest physiotherapy versus PEP therapy | Main 2005 | 4 (84) | NR | NR | MD ‐0.44% predicted (95% CI ‐3.38 to 2.5) |
|
| McIlwaine 2015 | 1 (10) | mean (SD) 1 (1.41) % predicted | mean (SD) ‐5.2 (9.26)% predicted | MD 6.2% predicted (95% CI ‐2.01 to 14.41) |
|
|
| 1 (20) | mean (SD) 0.25 (5.29)% predicted | mean (SD) ‐2.83 (5.46)% predicted | MD 3.08% predicted (‐95% CI 1.71 to 7.87) |
|
||
| 1 (36) | mean (SD) ‐0.24 (13.58)% predicted | mean (SD) 3.32 (16.12)% predicted | MD ‐3.56% predicted (95% CI ‐13.3 to 6.18) |
|
||
| Conventional chest physiotherapy versus active cycle of breathing technique | Main 2005 | 1 (63) | NR | NR | MD 6% predicted (95% CI 0.55 to 11.45) |
|
| McKoy 2016 | NA | NA | NA | NA |
|
|
| Conventional chest physiotherapy versus autogenic drainage | Main 2005 | 2 (36) | NR | NR | MD ‐0.42% predicted (95% CI ‐5.38 to 4.54) |
|
| McCormack 2017 | 1 (36) | mean (SD) 0.47 (1.65)% predicted | mean (SD) 2.35 (1.87)% predicted | MD 1.88% predicted (95% CI 0.68 to 3.08) |
|
|
| Conventional chest physiotherapy versus oscillating devices | Main 2005 | 2 (38) | NR | NR | MD 1.26% predicted (95% CI ‐7.56 to 10.09) |
|
| 2 (101) | NR | NR | MD 0.49% predicted (‐95% CI 2.53 to 3.52) |
|
||
| Morrison 2017 | 2 (36) | final value (range) 28.4% to 29 % predicted |
final value (range) 28.5% to 47% predicted |
MD ‐0.24% predicted (95% CI ‐0.83 to 0.35) |
|
|
| 1 (20) | final mean (SD) 34 (31) % predicted |
final mean (SD) 56 (33) % predicted |
MD ‐0.65% predicted (95% CI ‐1.58 to 0.27) |
|
||
| 1 (16) | final mean (SD) 40 (19) |
final mean (SD) 34 (20) % predicted |
MD ‐0.29% predicted (95% CI ‐1.28 to 0.7) |
|
||
| Conventional chest physiotherapy versus exercise | Main 2005 | 1 (17) | NR | NR | MD 4.74% predicted (95% CI 1.94 to 7.54) |
|
| PEP therapy versus active cycle of breathing technique | McIlwaine 2015 | 0 | NA | NA | NA |
|
| McKoy 2016 | NA | NA | NA | NA |
|
|
| PEP therapy versus autogenic drainage | McIlwaine 2015 | 1 (18) | NR | NR | No significant differences |
|
| McCormack 2017 | 1 (18) | NR | NR | No significant differences |
|
|
| PEP therapy versus oscillating devices | McIlwaine 2015 | 1 (22) | NR | NR | No significant differences |
|
| 1 (30) | mean (SD) ‐3.58 (15.49)% predicted | mean (SD) ‐8.87 (20)% predicted | MD 5.29% predicted (95% CI ‐7.84 to 18.42) |
|
||
| 1 (42) | mean (SD) ‐3.1 (6.2)% predicted | mean (SD) ‐2 (11)% predicted | MD ‐1.1% predicted (95% CI ‐6.5 to 4.3) |
|
||
| 1 (88) | mean (SD) 6.22 (29.25)% predicted | mean (SD) 6.56 (29.05)% predicted | MD ‐0.34% predicted (95% CI ‐12.54 to 11.86) |
|
||
| Morrison 2017 | 2 (39) | final value (range) 29.4% to 36% predicted |
final value (range) 28.5% to 37% predicted |
MD 0.09% predicted (95% CI ‐9.33 to 9.52) |
|
|
| 1 (15) | final mean (SD) 48 (38)% predicted |
final mean (SD) 47 (37)% predicted | MD 1% predicted (95% CI ‐25.85 to 27.84) |
|
||
| 1 (22) | final mean (SD) 55 (5)% predicted | final mean (SD) 54 (5)% predicted | MD 1% predicted (95% CI ‐1.95 to 3.95) |
|
||
| 1 (22) | mean (SD) 3.8 (27.47)% predicted | mean (SD) 19.06 (32.37)% predicted | MD ‐15.26% predicted (95% CI ‐40.64 to 10.12) |
|
||
| 1 (12) | mean (SD) 31.68 (23.1)% predicted | mean (SD) 11.61 (20.9)% predicted | MD 20.07% predicted (95% CI ‐4.86 to 45) |
|
||
| 3 (162) | range ‐3.58 to 6.22 | range ‐8.87 to 6.56 | MD ‐0.13% predicted (95% CI ‐4.72 to 4.46) |
|
||
| PEP therapy versus exercise | McIlwaine 2015 | 0 | NA | NA | NA |
|
| Active cycle of breathing technique versus autogenic drainage | McKoy 2016 | NA | NA | NA | NA |
|
| McCormack 2017 | 1 (18) | NR | NR | greater improvement with autogenic drainage |
|
|
| Active cycle of breathing technique versus oscillating devices | McKoy 2016 | NA | NA | NA | NA |
|
| Morrison 2017 | 0 | NA | NA | NA |
|
|
| Active cycle of breathing technique versus exercise | McKoy 2016 | NA | NA | NA | NA |
|
| Autogenic drainage versus oscillating devices | McCormack 2017 | 0 | NA | NA | NA |
|
| Morrison 2017 | 0 | NA | NA | NA |
|
|
| Autogenic drainage versus exercise | McCormack 2017 | 0 | NA | NA | NA |
|
| Oscillating devices versus exercise | Morrison 2017 | 0 | NA | NA | NA |
|
| Airway oscillating devices versus external high frequency chest compression devices | Morrison 2017 | 1 (24) | mean (SD) 31.5% (4.3)% predicted | mean (SD) 33.3% (4.6)% predicted | MD ‐1.8% predicted (95% CI ‐4.32 to 0.72) |
|
| Airway oscillating devices (Flutter®) versus airway oscillating devices (Cornet®) | Morrison 2017 | 0 | NA | NA | NA |
|
| Airway oscillating devices versus intrapulmonary percussive ventilation | Morrison 2017 | 1 (16) | NR | NR | no significant difference |
|
| Chest physiotherapy versus no chest physiotherapy | Warnock 2015 | 2 (35) | NR | NR | not enough information |
|
Abbreviations: CI: confidence interval; FEF 25‐75: mid‐expiratory flow; MD: mean difference; NA: not applicable; NR: not reported; PEP: positive expiratory pressure; RCT: randomised controlled trial; SD: standard deviation.
3. Number or frequency of exacerbations
All of the reviews sought to evaluate the number or frequency of respiratory exacerbations, but most trials did not report on respiratory exacerbations. The available results for respiratory exacerbations are summarised in the additional tables (Table 9). There is little evidence to suggest that any particular airway clearance therapy is more effective at reducing the number or frequency of exacerbations.
9. Summary of results: number or frequency of exacerbations.
| Intervention and comparison intervention | Cochrane Review | Number of trials (participants) reporting exacerbations | Risk of exacerbations | Relative effect (95% CI) | Comment | |
| Intervention group | Comparison group | |||||
| Conventional chest physiotherapy versus PEP therapy | Main 2005 | 0 | NA | NA | NA |
|
| McIlwaine 2015 | 0 | NA | NA | NA |
|
|
| Conventional chest physiotherapy versus active cycle of breathing technique | Main 2005 | 0 | NA | NA | NA |
|
| McKoy 2016 | 1 (63) | 5/30 participants experienced at least 1 exacerbation | 3/33 participants experienced at least 1 exacerbation | RR 1.64 (95% CI 0.62 to 4.34) |
|
|
| Conventional chest physiotherapy versus autogenic drainage | Main 2005 | 0 | NA | NA | NA |
|
| McCormack 2017 | 1 (36) | 16 hospitalisations | 13 hospitalisations | NA |
|
|
| Conventional chest physiotherapy versus oscillating devices | Main 2005 | 0 | NA | NA | NA |
|
| Morrison 2017 | 2 (70) | number of days hospitalised (range) 16.2 to 16.6 days | number of days hospitalised (range) 16 to 17.9 days |
MD ‐0.01 (95% CI ‐1.99 to 1.97) |
|
|
| 1 (16) | 5.6 hospital days | 3.9 hospital days | MD ‐1.70 (‐6.95, 3.55) |
|
||
| 1 (166) | NR | NR | NR |
|
||
| Conventional chest physiotherapy versus exercise | Main 2005 | 0 | NA | NA | NA |
|
| PEP therapy versus active cycle of breathing technique | McIlwaine 2015 | 0 | NA | NA | NA |
|
| McKoy 2016 | 0 | NA | NA | NA |
|
|
| PEP therapy versus autogenic drainage | McIlwaine 2015 | 1 (15) | NA | NA | NA |
|
| McCormack 2017 | 1 (30) | NR | NR | NR |
|
|
| PEP therapy versus oscillating devices | McIlwaine 2015 | 4 (197) | unable to summarize due to heterogeneity in reporting of outcomes |
|
||
| Morrison 2017 | 4 (197) | unable to summarize due to heterogeneity in reporting of outcomes |
|
|||
| PEP therapy versus exercise | McIlwaine 2015 | 0 | NA | NA | NA |
|
| Active cycle of breathing technique versus autogenic drainage | McKoy 2016 | 0 | NA | NA | NA |
|
| McCormack 2017 | 1 (30) | NR | NR | NR |
|
|
| Active cycle of breathing technique versus oscillating devices | McKoy 2016 | 0 | NA | NA | NA |
|
| Morrison 2017 | 0 | NA | NA | NA |
|
|
| Active cycle of breathing technique versus exercise | McKoy 2016 | 0 | NA | NA | NA |
|
| Autogenic drainage versus oscillating devices | McCormack 2017 | 2 (59) | NR | NR | NR |
|
| Morrison 2017 | 0 | NA | NA | NA |
|
|
| Autogenic drainage versus exercise | McCormack 2017 | 0 | NA | NA | NA |
|
| Oscillating devices versus exercise | Morrison 2017 | 0 | NA | NA | NA |
|
| Airway oscillating devices versus external high frequency chest compression devices | Morrison 2017 | 0 | NA | NA | NA |
|
| Airway oscillating devices (Flutter®) versus airway oscillating devices (Cornet®) | Morrison 2017 | 0 | NA | NA | NA |
|
| Airway oscillating devices versus intrapulmonary percussive ventilation | Morrison 2017 | 1 (16) | NA | NA | no significant difference (no quantitative results available) |
|
| Chest physiotherapy versus no chest physiotherapy | Warnock 2015 | 0 | NA | NA | NA |
|
Abbreviations: CI: confidence interval; MD: mean difference; NA: not applicable; PEP: positive expiratory pressure; RCT: randomised controlled trial; RR: relative risk; SD: standard deviation.
4. Sputum clearance
All of the reviews planned to evaluate sputum weight or volume. However, most included trials did not report on sputum clearance outcomes; those which did generally reported sputum weight (wet, dry, or both), while a few reported sputum volume. The results are summarised in the additional tables (Table 10). There was generally not enough information to draw any conclusion about the effectiveness of airway clearance techniques on removing sputum. None of the airway clearance therapies demonstrated any consistent superiority in sputum production.
10. Summary of results: sputum clearance.
| Intervention and comparison intervention | Cochrane Review | Outcome definition | Number of trials (participants) reporting sputum | Mean sputum weight/volume group | Absolute effect (95% CI) | Comment | |
| Intervention group | Comparison group | ||||||
| Conventional chest physiotherapy versus PEP therapy | Main 2005 | sputum weight (g) and volume (mL) | 2 (32) | NA | NA | no differences (no quantitative results available) |
|
| McIlwaine 2015 | sputum weight (g) and volume (mL) | 3 (43) | NA | NA | no differences (no quantitative results available) |
|
|
| Conventional chest physiotherapy versus active cycle of breathing technique | Main 2005 | unspecified | 0 | NA | NA | NA |
|
| McKoy 2016 | sputum weight (g) | 0 | NA | NA | NA |
|
|
| Conventional chest physiotherapy versus autogenic drainage | Main 2005 | unspecified | 0 | NA | NA | NA |
|
| McCormack 2017 | sputum weight (g) | 1 (18) | NR | NR | significantly greater for autogenic drainage |
|
|
| Conventional chest physiotherapy versus oscillating devices | Main 2005 | unspecified | 2 (55) | NA | NA | no differences (no quantitative results available) |
|
| Morrison 2017 | sputum volume | 2 (17) | NA | NA | inconclusive results (no quantitative results available) |
|
|
| dry sputum weight (g) < 1 week of follow‐up | 4 (115) | range 0.26 g to 5.3 g | range 0.26 g to 3.4 g | range in MD: ‐0.09 g to 1.90 g |
|
||
| wet sputum weight (g) < 1 week of follow‐up | 4 (115) | range 4.77 g to 51.3 g | range 2.86 g to 30.6 g | range in MD: ‐0.76 g to 20.7 g |
|
||
| dry sputum weight (g) with follow‐up > 1 week and < 6 months | 2 (26) | range 0.57 g to 1.3 g | range 0.44 g to 1.2 g | range in MD: 0.10 g to 0.13 g |
|
||
| wet sputum weight (g) with follow‐up > 1 week and < 6 months | 2 (26) | range 7.5 g to 13.56 g | range 6.5 g to 9.52 g | range in MD: 1.00 g to 4.04 g |
|
||
| Conventional chest physiotherapy versus exercise | Main 2005 | unspecified | 0 | NA | NA | NA |
|
| PEP therapy versus active cycle of breathing technique | McIlwaine 2015 | unspecified | 0 | NA | NA | NA |
|
| McKoy 2016 | unspecified | 0 | NA | NA | NA |
|
|
| PEP therapy versus autogenic drainage | McIlwaine 2015 | unspecified | 0 | NA | NA | NA |
|
| McCormack 2017 | sputum weight (g) | 1 (18) | NA | NA | significantly greater for autogenic drainage |
|
|
| PEP therapy versus oscillating devices | McIlwaine 2015 | wet sputum weight (g) | 1 (16) | NA | NA | no differences (no quantitative results available) |
|
| dry sputum weight (g) | 1 (16) | NA | NA | no differences (no quantitative results available) |
|
||
| Morrison 2017 | sputum volume (mL) | 1 (23) | mean (SD) 6.7 (8.2) mL | mean (SD) 8.5 (8.4) mL | MD ‐1.80 mL (95% CI ‐6.60 to 3.00) |
|
|
| wet sputum weight (g) | 1 (22) | mean (SD) 50.35 (52.21) g | mean (SD) 52.29 (56.38) g | MD ‐1.94 g (95% CI ‐47.70 to 43.82) |
|
||
| PEP therapy versus exercise | McIlwaine 2015 | unspecified | 0 | NA | NA | NA |
|
| Active cycle of breathing technique versus autogenic drainage | McKoy 2016 | sputum weight (g) | 1 (18) | NA | NA | MD ‐0.4 g (95% CI ‐3.93, 3.13) |
|
| McCormack 2017 | sputum weight (g) | 1 (18) | NA | NA | no significant differences (no quantitative results available) |
|
|
| Active cycle of breathing technique versus oscillating devices | McKoy 2016 | NA | 0 | NA | NA | NA |
|
| Morrison 2017 | NA | 0 | NA | NA | NA |
|
|
| Active cycle of breathing technique versus exercise | McKoy 2016 | NA | 0 | NA | NA | NA |
|
| Autogenic drainage versus oscillating devices | McCormack 2017 | wet sputum weight (g) | 1 (14) | mean (SD) 3.6 (2.5) g | mean (SD) 4.5 (2.5) g | MD ‐0.90 (95% CI ‐3.52 to 1.72) |
|
| Morrison 2017 | sputum volume | 1 (14) | mean (SD) 3.6 (2.5) | mean (SD) 4.5 (2.5) | MD ‐0.9 (95% CI ‐3.52 to 1.72) |
|
|
| Autogenic drainage versus exercise | McCormack 2017 | NA | 0 | NA | NA | NA |
|
| Oscillating devices versus exercise | Morrison 2017 | NA | 0 | NA | NA | NA |
|
| Airway oscillating devices versus external high frequency chest compression devices | Morrison 2017 | NA | 0 | NA | NA | NA |
|
| Airway oscillating devices (Flutter®) versus airway oscillating devices (Cornet®) | Morrison 2017 | NA | 0 | NA | NA | NA |
|
| Airway oscillating devices versus intrapulmonary percussive ventilation | Morrison 2017 | wet sputum weight (g) | 1 (24) | mean (SD) 6.84 (5.41) g |
mean (SD) 4.77 (3.29) g |
MD 2.07 g (95% CI 1.03 to 3.11) |
|
| dry sputum weight (g) | 1 (24) | mean (SD) 0.34 (SD 0.25) | mean (SD) 0.26 (0.19) | MD 0.08 (95% CI 0.03 to 0.13) |
|
||
| Chest physiotherapy versus no chest physiotherapy | Warnock 2015 | wet sputum weight | 2 (35) | NA | NA | inconsistent results (no quantitative results available) |
|
| dry sputum weight | 2 (35) | NA | NA | inconsistent results (no quantitative results available) |
|
||
Abbreviations: CI: confidence interval; MD: mean difference; NA: not applicable; PEP: positive expiratory pressure; RCT: randomised controlled trial; SD: standard deviation.
5. LCI
Two reviews evaluated LCI as an outcome; however, most of the included trials did not report LCI. The results for LCI are summarised in the additional tables (Table 11). There is little evidence to suggest that any particular airway clearance therapy affects the LCI more than any other therapy.
11. Summary of results: LCI.
| Intervention and comparison intervention | Cochrane Review | Number of trials (participants) reporting on LCI | Mean LCI | Absolute effect (95% CI) | Comment | |
| Intervention group | Comparison group | |||||
| Conventional chest physiotherapy versus PEP therapy | Main 2005 | NA | NA | NA | NA |
|
| McIlwaine 2015 | 0 | NA | NA | NA |
|
|
| Conventional chest physiotherapy versus active cycle of breathing technique | Main 2005 | NA | NA | NA | NA |
|
| McKoy 2016 | NA | NA | NA | NA |
|
|
| Conventional chest physiotherapy versus autogenic drainage | Main 2005 | NA | NA | NA | NA |
|
| McCormack 2017 | 0 | NA | NA | NA |
|
|
| Conventional chest physiotherapy versus oscillating devices | Main 2005 | NA | NA | NA | NA |
|
| Morrison 2017 | 0 | NA | NA | NA |
|
|
| Conventional chest physiotherapy versus exercise | Main 2005 | NA | NA | NA | NA |
|
| PEP therapy versus active cycle of breathing technique | McIlwaine 2015 | 0 | NA | NA | NA |
|
| McKoy 2016 | NA | NA | NA | NA |
|
|
| PEP therapy versus autogenic drainage | McIlwaine 2015 | 0 | NA | NA | NA |
|
| McCormack 2017 | 0 | NA | NA | NA |
|
|
| PEP therapy versus oscillating devices | McIlwaine 2015 | 1 (30) | mean (SD) 1.0 (3.47) | mean (SD) 0.2 (2.47) | MD 0.80 (95% CI ‐1.36 to 2.96) |
|
| Morrison 2017 | 1 (30) | NA | NA | no statistical differences (no quantitative results available) |
|
|
| PEP therapy versus exercise | McIlwaine 2015 | 0 | NA | NA | NA |
|
| Active cycle of breathing technique versus autogenic drainage | McKoy 2016 | NA | NA | NA | NA |
|
| Active cycle of breathing technique versus oscillating devices | McKoy 2016 | NA | NA | NA | NA |
|
| Morrison 2017 | 0 | NA | NA | NA |
|
|
| Active cycle of breathing technique versus exercise | McKoy 2016 | NA | NA | NA | NA |
|
| Autogenic drainage versus oscillating devices | McCormack 2017 | 0 | NA | NA | NA |
|
| Morrison 2017 | 0 | NA | NA | NA |
|
|
| Autogenic drainage versus exercise | McCormack 2017 | 0 | NA | NA | NA |
|
| Oscillating devices versus exercise | Morrison 2017 | 0 | NA | NA | NA |
|
| Airway oscillating devices versus external high frequency chest compression devices | Morrison 2017 | 0 | NA | NA | NA |
|
| Airway oscillating devices (Flutter®) versus airway oscillating devices (Cornet®) | Morrison 2017 | 0 | NA | NA | NA |
|
| Airway oscillating devices versus intrapulmonary percussive ventilation | Morrison 2017 | 0 | NA | NA | NA |
|
| Chest physiotherapy versus no chest physiotherapy | Warnock 2015 | NA | NA | NA | NA |
|
Abbreviations: CI: confidence interval; LCI: lung clearance index; MD: mean difference; NA: not applicable; PEP: positive expiratory pressure; RCT: randomised controlled trial; SD: standard deviation.
Discussion
Summary of main results
Six Cochrane Reviews evaluated airway clearance techniques for people with CF. Five of these reviews compared conventional chest physiotherapy, PEP therapy, active cycle of breathing technique, and oscillating devices with other airway clearance techniques. A sixth review compared chest physiotherapy with no chest physiotherapy or with coughing alone. There was considerable overlap in terms of what the reviews covered, but there were some differences in how the reviews were conducted and carried out, particularly in terms of their inclusion criteria and in their methods for handling cross‐over trials.
In this overview, we concluded that there is no evidence of a difference of effect on FEV1 between PEP therapy and oscillating devices after six months of treatment. The relative effects of these devices at earlier time‐points, however, are not as clear.
We are unable to draw any definitive conclusions for all other comparisons in terms of FEV1. Most of the evidence comparing different airway clearance techniques is of low or very low grade. Many trials did not report sufficient detail of their trial methodology to adequately assess their risk of bias. The results were often imprecise because of the few number of trials and the small sample sizes in those trials. Additionally, the results were sometimes subject to publication bias. We excluded several cross‐over trials from the analysis of FEV1 because the cross‐over trials did not have a sufficient washout period or did not report first‐period results.
Likewise, the evidence grade comparing different airway clearance techniques in terms of participant preference and quality of life was either low or very low. Most of the trials evaluating these measures did not sufficiently describe their methodology. Preference was often not directly assessed, or the trials did not describe how preference was assessed. In many cases, there was not sufficient quantitative information to assess the precision of these outcomes.
Evidence for the secondary outcomes was limited. Not all of the systematic reviews included adverse events or LCI as outcomes and those reviews that did include these outcomes found few trials that reported on them. There were no clear differences between the different airway clearance techniques in terms of FVC, FEF25‐75, sputum clearance, or adverse events. There was considerable heterogeneity in how exacerbations were reported.
Overall completeness and applicability of evidence
As of January 2019, the Cochrane Reviews included in this overview were reasonably up‐to‐date, with most having been updated within the last two years. The one exception is the Main 2005 review, which was last assessed as up to date in 2009 (Main 2005). All of the reviews included participants with CF, regardless of age, sex, or disease severity. The reviews were also reasonably comprehensive in their inclusion of outcomes. All of the reviews included all of our primary outcomes and most of the reviews included the secondary outcomes.
All of the comparisons that we sought were included in at least one Cochrane Review. One third of the comparisons were addressed in two Cochrane Reviews. An airway clearance technique that has not been covered in a Cochrane review is exercise in conjunction with another airway clearance technique. None of the reviews addressed the potential effects of co‐interventions.
The overall completeness and applicability of the evidence was limited by the individual trials included in the reviews. In particular, many trials had incomplete outcome reporting, which limited our ability to assess the relative effects of the airway clearance techniques.
Quality of the evidence
The Cochrane Reviews included in this overview appeared to follow the Cochrane guidance and were considered to have a low risk of bias (Table 2).
However, the individual trials included in the reviews often did not report sufficient information to adequately assess their risk of bias. Nearly two thirds of the trials were considered to have an unclear risk of bias. Additionally, many trials did not sufficiently report on outcome measures and had a high risk of reporting bias.
Over half of the trials were conducted as randomised cross‐over trials and just over half of the cross‐over trials did not have a sufficient washout period (i.e., at least one day) to reduce any potential carryover effect. Due to the possible bias, we excluded these cross‐over trials from the FEV1 analyses. Carryover effects are less relevant for assessing participant preference and quality of life.
Potential biases in the overview process
Since only two of the included Cochrane Reviews had graded the strength of evidence, we retroactively graded the strength of the evidence for each comparison for the primary outcomes. The process of grading the strength of evidence was complicated by the overlapping comparisons in the reviews, and the heterogeneity in the trials. We relied on information reported in the individual Cochrane Reviews and, if necessary, checked the individual trials for clarification or additional information. To grade the strength of evidence, we often combined trials that were reported separately in the Cochrane Reviews. Many of the trials were included in more than one review. When there were discrepancies in the inclusion status of an individual trial, we noted this in the text and alerted the Cochrane Review Group Managing Editor. These discrepancies are likely to be resolved in future updates of the overview. For our FEV1 analysis, we excluded cross‐over trials that did not have a sufficient washout period (i.e., at least one day). We excluded these trials to avoid any potential carryover effect. Additionally, another study had noted how some reviews have been inconsistent in their analysis and reporting of cross‐over trials (Nolan 2016). Although it is unconventional for an overview to exclude individual trials, we provide consistency in how cross‐over trials are analysed by limiting our analysis to those trials with a sufficient washout period.
We did not evaluate how the efficacy and safety of the airway clearance devices may have differed by the type of device. For instance, the efficacy of the PEP mask therapy may be different than the PEP mouthpiece therapy.
We did not update the searches for the individual Cochrane Reviews. It is possible that our overview missed more recent trials. However, the majority of the Cochrane Reviews were reasonably up‐to‐date.
There may be other considerations for selecting one airway clearance technique over another that were not measured in this overview. For instance, we could have used a finer measure (e.g., time to complete airway clearance session, availability of help, comfort) for evaluating participant preference. There may be clearer differences between the airway clearance techniques on these finer measures. However, participant preference was often difficult to assess because of the heterogeneity in how it was measured, incomplete descriptions on how it was assessed, and incomplete outcome reporting.
Agreements and disagreements with other studies or reviews
Similar to the Bradley 2006 review (Bradley 2006), we found little evidence to support one airway clearance technique over another. Our overview adds to this review by including three new reviews (McCormack 2017; McKoy 2016; Morrison 2017), and updates of the other reviews.
Authors' conclusions
Implications for practice.
No single airway clearance technique appears to be superior. There is little evidence to support the use of one airway clearance technique over another in terms of respiratory function, participant preference, and quality of life. People with cystic fibrosis (CF) should choose the airway clearance technique that best meets their needs, in relation to comfort, convenience, flexibility, practicality, cost, or some other factor.
Implications for research.
There are a few areas that future Cochrane Reviews on airway clearance techniques for people with CF should consider. Firstly, review authors should consider how best to analyse cross‐over trials. The analysis plan for cross‐over trials should consider the minimum duration for the washout period that is needed for each outcome.
Secondly, review authors should consider how best to report on their outcome measures. The reviews differed on how they reported the lung function outcomes, with some reporting final values, absolute change from baseline, or percentage change from baseline. Some of these differences are due to the heterogeneity of how outcomes are reported in the included trials, but some of these differences represent heterogeneity in the reviews. Review authors need to clearly label the specific metrics that are being used. Review authors should also consider how to best report on participant preference and satisfaction. Trials use a myriad of methods for evaluating these outcomes. Reviewers may want to consider finer measures of evaluating preference and satisfaction, such as time to complete airway clearance session, availability of help, comfort.
Additionally, review authors should consider how best to combine studies, such as by length of follow‐up. They may also want to consider the possible influence of adjunctive therapies on the effectiveness of airway clearance techniques. Lastly, review authors should consider grading the strength of evidence.
Review authors may consider including non‐randomised trials. These airway clearance techniques are commonly used and non‐randomised trials could potentially provide additional information regarding effectiveness and safety. However, review authors would need to consider potential bias when assessing these trials, such as selection bias, confounding by indication, use of co‐interventions, time‐varying exposure to therapies, and confounding.
More long‐term, high‐quality randomised controlled trials (RCTs) comparing airway clearance techniques among people with CF are needed. Investigators should be encouraged to publish their results within full manuscripts, and not just as conference abstracts. They should provide sufficient detail about their methodology and fully report on all outcomes. Trial authors should consider following a reporting standard, such as the Consolidated Standards of Reporting Trials (CONSORT), when publishing their trials (Schulz 2010). Multi‐centered trials may be needed to provide sufficient power to detect any meaningful differences in airway clearance techniques. Cross‐over trials, designed with a sufficient washout period, can also be considered because of their increased power. Both parallel and cross‐over RCTs should try to minimise the number of drop‐outs. Trial authors may also want to consider how an individual's airway pathophysiology may impact the effectiveness of a particular airway clearance technique. Trial authors could consider either limiting their trials to individuals with a similar pathophysiology or conducting subgroup analyses based on pathophysiology. By targeting the patient population, we may be better able to understand who could benefit from specific airway clearance techniques.
Finally, both trial authors and review authors should consider evaluating and reporting on outcomes that are most important to people with CF.
Acknowledgements
We would like to thank Oluwaseun Akinyede and Jennifer Agnew for their help in developing the protocol.
This project was supported by the National Institute for Health Research, via Cochrane Infrastructure funding to the Cochrane Cystic Fibrosis and Genetic Disorders Group. The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the Systematic Reviews Programme, NIHR, NHS or the Department of Health.
Appendices
Appendix 1. ROBIS Signalling Questions
| Domain 1: trial eligibility criteria | |
| 1.1 Did the review adhere to pre‐defined objectives and eligibility criteria? 1.2 Were the eligibility criteria appropriate for the review question? 1.3 Were eligibility criteria unambiguous? 1.4 Were any restrictions in eligibility criteria based on trial characteristics appropriate (e.g., data, sample size, study quality, outcomes measured)? 1.5 Were any restrictions in eligibility criteria based on sources of information appropriate (e.g., publication status or format, language, availability of data)? |
Yes Probably yes Probably no No No information |
| Risk of bias introduced by specification of study eligibility criteria | Low High Unclear |
| Domain 2: identification and selection of trials | |
| 2.1 Did the search include an appropriate range of databases or electronic sources for published and unpublished reports? 2.2 Were the methods additional to database searching used to identify relevant reports? 2.3 Were the terms and structure of the search strategy likely to retrieve as many eligible trials as possible? 2.4 Were restrictions based on date, publication format, or language appropriate? 2.5 Were efforts made to minimise error is selection of studies? |
Yes Probably yes Probably no No No information |
| Risk of bias introduced by methods used to identify or select trials, or both | Low High Unclear |
| Domain 3: data collection and trial appraisal | |
| 3.1 Were efforts made to minimise error in data collection? 3.2 Were sufficient trial characteristics available for both review authors and readers to be able to interpret the results? 3.3 Were all relevant trials' results collected for use in the synthesis? 3.4 Was risk of bias (or methodological quality) formally assessed using appropriate criteria? |
Yes Probably yes Probably no No No information |
| Risk of bias introduced by methods used to collect data and appraise trials | Low High Unclear |
| Domain 4: synthesis and findings | |
| 4.1 Did the synthesis include all trials that it should, or use techniques to account for missing trials?
4.2 Were all pre‐defined analyses reported or their absence explained?
4.3 Was the synthesis appropriate given th degree of similarity in the research questions, trial designs, and outcomes across the included trials? 4.4 Was robustness of the finding(s) assessed (e.g., through sensitivity analyses)? 4.5 Were biases in primary trials minimal or addressed in the synthesis? 4.6 Was a complete account provided of results including heterogeneity and uncertainty? |
Yes Probably yes Probably no No No information |
| Risk of bias introduced by the synthesis | Low High Unclear |
| Domain 5: interpretation | |
| 5.1 Was the quality of the evidence considered when interpreting the results and drawing conclusions? 5.2 Was the relevance of identified trials to the review's research question appropriately considered? 5.3 Did the reviewers avoid emphasising results on the basis of their statistical significance? |
Yes Probably yes Probably no No No information |
| Risk of bias introduced by the interpretation of results | Low High Unclear |
Appendix 2. Characteristics of excluded reviews
| Review | Reason for exclusion |
| Aslam 2017 | Does not evaluate an airway clearance therapy |
| Burrows 2014 | Does not evaluate an airway clearance therapy |
| Chang 2014 | Does not evaluate an airway clearance therapy, does not include people with cystic fibrosis |
| Corley 2017 | Does not evaluate an airway clearance therapy |
| Dentice 2016 | Does not evaluate an airway clearance therapy |
| Elkins 2016 | Does not evaluate an airway clearance therapy |
| Enriquez 2012 | Does not evaluate an airway clearance therapy, does not include people with cystic fibrosis |
| Gillies 2011 | Does not evaluate an airway clearance therapy |
| Goyal 2012 | Does not evaluate an airway clearance therapy |
| Hart 2014 | Does not evaluate an airway clearance therapy, does not include people with cystic fibrosis |
| Hnin 2015 | Does not evaluate an airway clearance therapy, does not include people with cystic fibrosis |
| Hough 2008 | Does not include people with cystic fibrosis |
| Irons 2016 | Does not evaluate an airway clearance therapy |
| Jones 2011 | Does not include people with cystic fibrosis |
| Kassab 2015 | Does not evaluate an airway clearance therapy |
| Kelly 2018 | Does not include people with cystic fibrosis |
| King 2015 | Does not evaluate an airway clearance therapy, does not include people with cystic fibrosis |
| Lee 2015 | Does not include people with cystic fibrosis |
| Lee 2017 | Does not include people with cystic fibrosis |
| Leonardi‐Bee 2011 | Does not evaluate an airway clearance therapy, does not include people with cystic fibrosis |
| McCullough 2015 | Does not evaluate an airway clearance therapy |
| Moran 2017 | Does not evaluate an airway clearance therapy |
| Moresco 2016a | Does not evaluate an airway clearance therapy |
| Moresco 2016b | Does not evaluate an airway clearance therapy |
| Morrow 2013 | Does not evaluate an airway clearance therapy |
| Nevitt 2018 | Does not evaluate an airway clearance therapy |
| Osadnik 2012 | Does not include people with cystic fibrosis |
| Patel 2015 | Does not evaluate an airway clearance therapy |
| Roqué 2016 | Does not include people with cystic fibrosis |
| Savage 2014 | Does not evaluate an airway clearance therapy |
| Tam 2013 | Does not evaluate an airway clearance therapy |
| Wark 2018 | Does not evaluate an airway clearance therapy |
| Welsh 2015 | Does not include people with cystic fibrosis |
| Wilkinson 2014 | Does not evaluate an airway clearance therapy, does not include people with cystic fibrosis |
| Wilson 2014 | Protocol for this review |
| Winfield 2014 | Does not include people with cystic fibrosis |
| Yang 2016 | Does not evaluate an airway clearance therapy |
Contributions of authors
| Roles and responsibilities | |
| TASK | WHO WILL UNDERTAKE THE TASK? |
| Protocol stage: draft the protocol | All authors |
| Review stage: select which reviews to include (2 + 1 arbiter) | Karen Robinson, Lisa Wilson |
| Review stage: extract data from reviews (2 people) | Karen Robinson, Lisa Wilson |
| Review stage: enter data into RevMan | Lisa Wilson |
| Review stage: carry out the analysis | Karen Robinson, Lisa Wilson |
| Review stage: interpret the analysis | All authors |
| Review stage: draft the final review | All authors |
| Update stage: update the review | All authors |
Sources of support
Internal sources
No sources of support supplied
External sources
-
National Institute for Health Research, UK.
This systematic review was supported by the National Institute for Health Research, via Cochrane Infrastructure funding to the Cochrane Cystic Fibrosis and Genetic Disorders Group.
Declarations of interest
Two of the authors of this overview (LMW, KAR) have contributed to the review on the active cycle of breathing technique. One author (LM) has contributed to the review on oscillating devices.
New
References
References to included reviews
Main 2005
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Aslam 2017
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