Airway Clearing Techniques

Airway Clearing Techniques can be considered in a number of distinct groups

  • Methods that must be MUST taught by an EXPERIENCED Respiratory Physiotherapist
  • Methods that be can be done without any Airway Clearance Aid (Breathing Techniques)
  • Methods that use devices to aid in clearing the lungs e.g
    • Positive pressure devices (PEP)
    • Oscillating Positive Expiratory Pressure  (OPEP)
    • High Frequency Chest Wall Oscillation (HFCWO)
  • Adjuncts to airway clearance that can help loosen mucus and so make the airway clearance easier e.g
    • Respiratory Humidification
    • Inhaled drugs such as saline or hyper tonic saline

Choosing the best method to clear your airways is a very daunting task.

There are some studies that have looked at comparing the different techniques but it seems that all the techniques can work to help clear mucus from the lungs. This is across many patient groups who have problems with chronic sputum production and not specifically NTM alone. Most airway clearance is done in some form of a cycle – first part of cycle is to dislodge the mucus and you shift it up to the main airways, where it can then be cleared easily. Airway clearance does take time, especially if you are working on dislodging the mucus that is stuck in the smaller and deeper airways. It should always be gentle. You shouldn’t be trying to do repeated exhaustive coughs etc.

For this reason the best method for you is best made by working with an EXPERIENCED Respiratory Physiotherapist who can work with you to find the best combination of techniques to help YOU clear YOUR lungs independently on a daily basis. The techniques below are the most commonly used techniques by patients in Australia and I’ve had some experience with or feedback from other NTM patients about them.

Methods that MUST be taught and initially supervised by an EXPERIENCED Respiratory Physiotherapist

Autogenic drainage

 a form of ‘self drainage’ based on breathing techniques. It can be beneficial if you have larger volumes of mucus. It takes some concentration to learn but can be very effective for some patients.

Postural Drainage

is the drainage of secretions, by the effect of gravity, from one or more lung segments to the central airways It can be combined with percussion and vibrations, which is accomplished by rhythmically striking the thorax with cupped hand and then vibrating the chest on the breath out. For some patients there may be benefits in using Postural Drainage in many different positions, most commonly lying on each side. Traditional postural drainage for the lower segments of the lung can involve lying with the head lower than the feet. There are many risks when your head is lower than your feet and should never be done without careful training and supervision

Methods that be can be done without any Airway Clearance Aid

Active Cycle of Breathing (ACBT)

This technique involves taking in deep breaths with holds followed by huffing. You do these in ‘cycles’. Like all airway clearance it does take time to master the technique, although this is a fairly simple option. To get the most out of the technique you need to pay close attention to detail and allow time for it to work. The huffing part of the cycle is used in many other airway clearance techniques. Once the mucus is dislodged, you use huffing to help bring the mucus up to the main airways, where it can be cleared.

Methods that be can be done with Airway Clearance devices and equipment

Bottle PEP, also called Bubble PEP

This method is commonly used by children with Cystic Fibrosis. It can be set up to become a game to encourage the child to use the method

For adults who do not have any particular problem in clearing the air ways, it is cheap and easy to use. You do need to buy the correct size tubing. For many people other methods will be more productive and it is often easier to buy a device that is easy to use and keep clean than replacing bottles, water and tubing. You need to use enough water (preferably boiled or distilled),  to get some pressure and vibration in the airways but not have the bottle too full so breathing out against it is hard work or tiring. Again a physiotherapist can guide you in the correct technique.

Click here to see how to use this method.

Positive Expiratory Pressure  (PEP)

These devices increase the air pressure in the lungs, to allow air to go behind the mucus, break the mucus away from the wall of the airways. The normal action of the lungs is to expel foreign objects from the lungs, then move the mucus into the larger airways. When using most devices the aim is for mucus to be dislodged and then move up to your main large airways where the mucus can be cleared. Read the topics Huffing and Productive Coughing to learn how to clear the mucus out of your main airways.

The most commonly used PEP device is the PARI PEP

Oscillating Positive Expiratory Pressure  (OPEP)

Various manufactures added an ability to oscillate (pulse) the higher pressure air when it is being exhaled. Each manufacturer developed a method to cause the air to pulse on exhalation.  The airways in the lungs have small hairs (called cilia) in the shape of something like a brush. They are moving continually brushing away anything that should not be in your lungs, such as dust, crumbs from a biscuit or loose mucus, towards your throat where you will feel a need to cough the debris and mucus out.

OPEP devices attempt to synchronize the air pulses they generate, to match the normal oscillation of the Cilia in your airways. In this way, helping the Cilia to move larger objects like the mucus through the airways’

Click here to learn more about Structure and Function of Cilia

The most commonly used OPEP devices are the Flutter (other brand names include the Turboforte and PARI-O-PEP) and also the Acapella Choice ( see the “Airway Clearance/Airway Clearance Aids” section). These devices need you to be able to breathe out with reasonable pressure. The Acapellas are gentler and so often NTM patients have found these to be a better choice.

The Acapella also works when you lie on your side or back and so may be better if you need to combine it with some postural drainage positioning (described above).In early 2014 another device called Aerobika was introduced to the market. It quickly became popular and is now the preferred OPEP device recommended by the gold standard NTM treatment institution “National Jewish Health” of the USA. You can attach a nebulizer to the Aerobika to inhale saline solution to make the mucus easier to remove. It also can work if you are sitting or using different side lying positions to clear your lungs.

The clinical studies to compare the benefits of all of the devices have NOT shown any significant statistical difference between the devices. It is important to follow the advice of an EXPERIENCED Respiratory Physiotherapist in choosing the device that best suits your individual need.

Adjuncts to airway clearance that can help loosen mucus and so make the airway clearance easier

Respiratory Humidification

 The “MyAirVo 2″ can supply warm, humid  air to your lungs. It is particularly useful for people who have very sticky secretions and so using airway clearance alone has not been working well.

You can adjust the settings of the “MyAirVo 2″ to suit your own needs. A good setting to start is, air output at 37 degrees, and 100 % humidity at the rate of 20 litres per minute. Again, it is best for a doctor or physiotherapist to recommend the correct settings for your home use.

The warm air softens the mucus , and the humidity prevents the mucus from drying out and make the softened mucus less viscous.

It is best used whilst you are asleep and also wearing it for 30 – 60 minutes BEFORE you do your airway clearance can be helpful. It can take 4 to 6 weeks before you will get a productive result and you will need support to get the most out of the “MyAirVo 2″.

See the “Respiratory Humidification” section below to learn more about the role of humidity in clearing your airways

Inhaled Drugs

There are many inhaled drugs that your doctor may prescribe that can help you with the management of your NTM.

Some drugs open the airways (bronchodilators) and can be helpful to use before your airway clearance . It makes sense if the airways are ‘open’ it will easier to move the mucus.

Some drugs are known as mucolytics. They help to moisten the mucus and also may help the cilia function better.   Normal saline (0.9%), or 3% or 6% hypertonic saline can be inhaled into your lungs through a nebuliser BEFORE or DURING airway clearance to make the mucus easier to shift. These drugs MAY also cause wheeze and close the airways down in some patients.

DO NOT inhale hypertonic saline unless recommended by an Experienced  Respiratory Physiotherapist. If you have a heart problem, before inhaling  hypertonic saline, also discuss it’s use with your Cardiologist.   Finally, before you use hypertonic saline seek advice from your Respiratory Physician. Often it will be necessary to do a trial with a physio to determine if they will work for you safely.

Some of the newer airway clearance devices and also the breathing techniques have the ability to combine the inhaling saline with your airway clearance technique. By doing so, airway clearance is quicker and is a very efficient way to clear sticky, thick secretions.

Other inhaled drugs may dampen the inflammation and irritability of the airways and some inhaled drugs are actually antibiotics. These drugs are usually taken AFTER you have cleared mucus from your lungs or certainly away from the time you are doing airway clearance. It makes sense not to inhale a drug that is a prevention/ treatment drug and then cough it all straight back up again.

With ALL inhaled drugs it is important to ask your Respiratory Physician and/or Physiotherapist for the best order in which to take these drugs, so you can maximize their benefits.