Evaluating the ease of secretion clearance with flutter device compared to lung FLute in patients with Bronchiectasis

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Bronchiectasis is pathological condition with diverse aetiologies, characterised by and abnormal dilation of conducting airways due to repeated cycles of airway infection and inflammation ultimately resulting in airway and lung parenchyma destruction. This leads to an alteration of the ciliated epithelial lining and compromises mucus clearance. In the affected areas there is excess production of mucus, where the impaired clearance of secretions causes colonisation and infections. Airway clearance techniques are regarded as an integral component in the management of Bronchiectasis, as it clears blockages of conducting airway and improves pulmonary ventilation. Some patients with Bronchiectasis only have scant secretions and it is unclear if airway clearance assists them. A systemic review on patients with chronic obstructive pulmonary disease, has reported airway clearance techniques to be useful only in patients who produce greater than 25 ml (one tablespoon) of sputum per day. Mechanical forms of airway clearance such as Flutter (Scandipharm Inc, Birmingham, Alabama, USA) has shown to assist with secretion clearance. Flutter is a simple hand held pipe like device which produces oscillating positive pressure on exhalation, through repeated displacement of the steel ball within a cone. Oscillation frequency within 3-17 Hz range has been shown to facilitate mucociliary clearance. On patients with cystic fibrosis (CF), the flutter demonstrated a mean oscillation frequency of 11.3 Hz 5. This was close to this optimal frequency range to facilitate mucociliary clearance. This study also demonstrated the Flutter to have a peak expiratory flow rate (PEFR) / peak inspiratory flow rate (PIFR) ratio > 1.1, which is critical level required for annular flow of secretions towards the oropharynx. In addition flutter has shown to alter physical properties of mucus in patients with Bronchiectasis which further assist secretion clearance. Lung Flute (Medical Acoustics, LLC, Buffalo, NY USA) is new device which has shown to assist secretion clearance. It is relatively cheaper than the Flutter. The current literature on the efficacy of the lung Flute is limited. The lung flute is a hand held device shaped like a flute with a mouth piece and a reed inside it. When the user blows into the lung flute, it creates a specific low frequency sound. The manufactures claim that this sound generates 18-22Hz with an output of 110 to 115 dB using 2.5 cmH2O pressure. This sound wave, when generated at the mouth with mild exhalation, is thought to travel retrograde down the tracheobronchial tress and vibrates the tracheobronchial secretions. The manufactures claim that this sound vibrates the airways and thins the lung secretions, which facilitate mucocilary clearance. Lung flute has demonstrated to expectorate similar quantity of sputum as active cycle breathing technique in patients with Bronchiectasis. No study has been done to evaluate the effectiveness lung flute compared to the Flutter. Therefore, the aim of the current study was to evaluate if the lung flue was as effective as the flutter in secretion clearance. Method. Study design: After ethics approval participants were recruited from the Bronchiestasis clinic at CRGH and any person with bronchiectasis referred for physiotherapy from other respiratory specialists. During the study patients were seen as outpatients. Inclusion criteria: patients with productive non – cystic fibrosis (CF) bronchiectasis (diagnosed on high resolution computerised tomography) who would produce greater than 25ml of sputum per day. Exclusion criteria: current pneumothorax, untreated cor pulmonale, haemoptysis, patients with an exacerbation in the 4 weeks prior or during the study and if they were hospitalised during the study. Information sheet about the study would be given to the participant and informed consent would be obtained. Patients would attend two visits over a two week period standardised to the same time of day, with advice to withhold usual airway clearance 24 hours prior to attendance. At each session one of the following airway clearance techniques (flutter, lung flute) will be performed in random order determined by computer generated randomisation with concealed allocation. Patients would receive comprehensive standardised practical instructions in each airway clearance technique. Participants would be supervised throughout by an experienced senior respiratory physiotherapist to ensure each technique was performed in a standardised and optimal manner. Duration of treatment would be recorded. Baseline medications were not altered. Treatment techniques Both treatment techniques would be performed in sitting. Patients would be instructed to clear secretions without to swallow the sputum. Flutter The patient would be instructed to inhale deeply and hold his/her breath for 2-3 seconds. Then the patient would be instructed to place the mouthpiece of the device into the mouth and exhale into expiratory reserve volume (ie, slightly further than one would exhale during normal breath but not to residual volume). During expiration through the flutter, the patient would be instructed to tilt the flutter upwards and downwards by a few degrees to induce maximum oscillations within the chest wall. This would be repeated for 10 breaths, with the patient inhaling through the nose and exhaling through the flutter. Then the patients would be performing one or two mid to low volumes huffs combined with periods of breathing control (normal tidal breathing). If the patients felt that they had cleared the secretions to the oropharynx then they would be instructed to do a high volume huff or cough to clear the secretions. Then the cycle was repeated after clearing secretions or if there was no secretions to clear from the oropharynx, after the low volume huff. The duration of periods of breathing control was varied depending on patients, the time required for patients to regain their normal breathing pattern and fatigue. The patients would be allowed to cough as required. The end point of the technique would be defined as two cycles and dry sounding huff. If the defined end point was not achieved within 30 minutes, the session was judged complete. Lung Flute The patients would be instructed to inhale slowly slightly deeper than normal and then place the mouthpiece of the device into the mouth. Then hold the lung flute pointing down at an angle and blow gently into the lung flute as if trying to blow out a candle. As they blow into the lung flute they would hear the reel inside the horn making a fluttering noise as it moves. Instruct the patient to concentrate on making more noise by blowing harder and faster into the lung flute. After blowing into the lung Flute twice, patients would be instructed to remove the mouth piece and wait for five seconds, taking several normal breaths. Then repeat this whole cycle of 20 sets with two blows each, unless the patient feels lightheaded or fatigued. If the patient was unable to tolerate the number of sets, the technique would be modified to do fewer sets. At the end of the session patients would be instructed to wait for 5 minutes and then do a low to mid volume huff , and when the secretions are in the oropharynx to to do a high volume huff or cough to clear the secretions. The average session would for 5 -10 minutes. This would be the end point of this technique.

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