Evaluation of Bronchial Drainage in Patients with Cystic Fibrosis
Examined in this study are the results of six tests of pulmonary function immediately preceding and following bronchial drainage in twenty-six patients with cystic fibrosis. Highly significant increases averaging 5.67, 4.13, 13.47, and 6.98 percent occurred in peak expiratory flow rate, forced vital capacity, expiratory reserve volume, and inspiratory capacity respectively. Significant increases in peak expiratory flow rate, forced vital capacity, and inspiratory capacity were observed in a subgroup of six of the above patients who had evidence of bronchospasm. The authors conclude that bronchial drainage will produce significant increases in routine pulmonary function values. The results suggest that this treatment is most effective in clearing the larger, more proximal, airways and is of benefit even in the presence of clinical bronchospasm.
Bronchial drainage with percussion and vibration is almost universally used as a prophylactic and therapeutic tool in the man agement of patients with chronic suppurative pulmonary disease associated with cystic fibrosis (CF). 1 The excessive quantities of viscid bronchial secretions in patients with CF and the suggestion of altered ciliary activity, which may result from a humoral factor, are thought to be the major predisposing events which lead to the progressive airway obstruc tion characteristic of the disorder. 2,3 Bronchial drainage is employed in an effort to prevent the accumulation of pulmonary secretions, a medium in which microorganisms can flourish, and to maintain patent airways. Doyle was largely responsible for instituting Mr. Tecklin is a Pulmonary Physical Therapist at the Cystic Fibrosis and Pediatric Pulmonary Center, Department of Pediatrics, Hahnemann Medical College and Hospital, 230 N. Broad Street, Philadelphia, PA 19102. Dr. Holsclaw is Director, Cystic Fibrosis and Pediatric Pulmonary Center, Department of Pediatrics, Hahnemann Medical College and Hospital. This study was supported, in part, by grants from the Cystic Fibrosis Foundation and Philadelphia Regional Pediatric Pulmonary Disease Program, and by a Pulmonary Academic Award from the National Heart and Lung Institute (D.S.H.)
Volume 55 I Number 10, October 1975
chest physical therapy for patients with CF in this country, and the therapy has gradually become a standard portion of the comprehen sive treatment program for this condition. 4 Despite widespread use and acceptance, how ever, almost no objective data document the efficacy of bronchial drainage in CF. The present study attempts to provide quantitative evidence to support the hypothesis that bronchial drainage will improve pulmonary function in patients with CF. REVIEW OF LITERATURE
Several references to drainage appear in the early respiratory disease literature. The Jacksons were well aware of the necessity of "peroral pulmonary drainage" and the value of a cough. 5 Bushnell, in 1918, discussed the benefits to a patient assuming a position that would favor drainage into a bronchus. 6 The early physical therapy literature con cerning chest disorders is directed toward the postoperative care of the patient who has had thoracic surgery. The first mention of bronchial drainage was in 1938, when Knies observed that patients with nontuberculous conditions such as lung abscess, empyema, and bronchiectasis 1081
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JAN STEPHEN TECKLIN, B.S., and DOUGLAS S. HOLSCLAW, M.D.
1082
PHYSICAL THERAPY
Downloaded from https://academic.oup.com/ptj/article-abstract/55/10/1081/4567527 by University of Texas at Dallas user on 04 February 2019
Motoyama found significant changes in four might benefit from carefully graduated and supervised postural drainage. 7 After returning pulmonary functions forty-five minutes after from the Brompton Hospital in England in postural drainage in ten patients with CF, and 1952, May suggested that in treating lung concluded that postural drainage should be abscesses, collapsed lobes, and bronchiectasis considered an effective form of therapy in the aims of physical therapy should be to clear CF. 17 the bronchi of mucopurulent secretions using bronchial drainage and percussion. 8 She also METHOD recognized that involvement of specific bronchi Twenty-six patients with CF, aged nine to would indicate individualized drainage posi twenty-eight years and with various degrees of tions. Two widely accepted texts on pulmonary pulmonary involvement, were evaluated. Pul physical therapy offer no objective evidence monary disease in all was nonacute and tests that bronchial drainage improves ventila were performed during a routine clinic visit. tion. 9 ' 10 Zausmer, in this Journal, repeatedly First, two forced expiratory spirograms were notes that much of the treatment we provide obtained using the method of Polgar and for patients with pulmonary conditions is Promadhat. 18 The best effort of the two without supporting evidence and is based solely attempts was examined. Peak expiratory flow upon empirical observations. 11 Anthonisen and rate (PEFR) was obtained from the best of colleagues, studying chronic bronchitis, and eight attempts on a Wright peak flowmeter. March, using a group of patients with chronic Bronchial drainage for all lobes of the lung obstructive pulmonary disease, were unable to followed. In each of six positions, manual demonstrate any significant change in pulmo chest percussion was used for three minutes nary function when bronchial drainage was followed by five deep breaths accompanied by manual vibration during the expiratory phase. added to the treatment program. 12,1 3 Kang and his co-workers evaluated postural The subject was urged to cough up and drainage with percussion in patients with expectorate secretions after each position. chronic obstructive lung disease by comparing Following bronchial drainage, the subject rested such treatment with postural drainage alone. 14 for five minutes, then pulmonary function tests The methods of assessment were one-second were repeated. The values obtained from the forced expiratory volume (FEV t ) and spirogram were FEVj, maximal midexpiratory xenon 133 ventilatory lung scans. The FEV! flow rate (MMEFR), forced vital capacity increased by greater than 15 percent in eight of (FVC), expiratory reserve volume (ERV), and fifteen children treated with postural drainage inspiratory capacity (IC). The response to and percussion. The xenon! 3 3 lung scans treatment is expressed as mean percentage revealed uneven distribution of gas in different changes from pretreatment values. The three flow rates—PEFR, FEV l5 and areas of the lung following treatment, with the lower lobes showing the most consistent im MMEFR—were selected to determine the level in the tracheobronchial tree at which bronchial provement. Huber and his associates studied the effects drainage is most effective. The three volumes— of postural drainage with percussion and vibra FVC, ERV, and IC—were chosen to reflect the tion on two groups each of eleven asthmatic net effect of bronchial drainage upon ventila children thirty minutes after treatment. 15 The tory reserve. mean FEVi in the treated group showed an The data were analyzed using the one-tail t increase of 10.5 percent compared to a slight test for the significance of the difference reduction in mean FEVi in the control group. between two dependent means. 19 Lorin and Denning were able to demonstrate that in patients with CF more than twice the RESULTS amount of secretions were expectorated follow ing a period of bronchial drainage with percus The mean values of spirometric scores before sion, vibration, and coughing than with an and after bronchial drainage are shown in Table 1. Highly significant increases occurred in equal period of only coughing. 16
TABLE 1 Mean Pulmonary Function Scores before and after Bronchial Drainage (n = 26) Post
Percent Change
273.5 1436 52.63 2446 646 1791
289 1466 51.00 2547 733 1916
+5.67 +2.09 -3.10 +4.13 +13.47 +6.98
PEFR, FVC, ERV, and IC. Significant increases in FEVj and MMEFR were not observed. A subgroup of six patients had documented bronchospasm as evidenced by clinical wheez ing at the time of examination. The treatment results of this subgroup are shown in Table 2. Three of the tests—PEFR, FVC, and IC— showed significant increases. Significant in creases were not found for FEVj, MMEFR, or ERV. The results were quite similar in the two groups, the sole exception being the lack of significant change in the ERV for the broncho spasm subgroup. A 20 percent increase in ERV occurred in this latter group, but, because of the large variance and small number in the group, statistical significance was lacking. DISCUSSION Examination of flow rates can give an indication of the site at which the effects of bronchial drainage occur. Of the three measures of flow—PEFR, FEV X , and MMEFR—the only significant increase was found in PEFR, an indicator of large airway status. The FEVj and MMEFR, indicators of intermediate and small
P
Examined in this study are the results of six tests of pulmonary function immediately preceding and following bronchial drainage in twenty-six patients with cystic fibrosis. Highly significant increases averaging 5.67, 4.13, 13.47, and 6.98 percent occurred in peak expiratory flow rate, forced vital capacity, expiratory reserve volume, and inspiratory capacity respectively. Significant increases in peak expiratory flow rate, forced vital capacity, and inspiratory capacity were observed in a subgroup of six of the above patients who had evidence of bronchospasm. The authors conclude that bronchial drainage will produce significant increases in routine pulmonary function values. The results suggest that this treatment is most effective in clearing the larger, more proximal, airways and is of benefit even in the presence of clinical bronchospasm.
Bronchial drainage with percussion and vibration is almost universally used as a prophylactic and therapeutic tool in the man agement of patients with chronic suppurative pulmonary disease associated with cystic fibrosis (CF). 1 The excessive quantities of viscid bronchial secretions in patients with CF and the suggestion of altered ciliary activity, which may result from a humoral factor, are thought to be the major predisposing events which lead to the progressive airway obstruc tion characteristic of the disorder. 2,3 Bronchial drainage is employed in an effort to prevent the accumulation of pulmonary secretions, a medium in which microorganisms can flourish, and to maintain patent airways. Doyle was largely responsible for instituting Mr. Tecklin is a Pulmonary Physical Therapist at the Cystic Fibrosis and Pediatric Pulmonary Center, Department of Pediatrics, Hahnemann Medical College and Hospital, 230 N. Broad Street, Philadelphia, PA 19102. Dr. Holsclaw is Director, Cystic Fibrosis and Pediatric Pulmonary Center, Department of Pediatrics, Hahnemann Medical College and Hospital. This study was supported, in part, by grants from the Cystic Fibrosis Foundation and Philadelphia Regional Pediatric Pulmonary Disease Program, and by a Pulmonary Academic Award from the National Heart and Lung Institute (D.S.H.)
Volume 55 I Number 10, October 1975
chest physical therapy for patients with CF in this country, and the therapy has gradually become a standard portion of the comprehen sive treatment program for this condition. 4 Despite widespread use and acceptance, how ever, almost no objective data document the efficacy of bronchial drainage in CF. The present study attempts to provide quantitative evidence to support the hypothesis that bronchial drainage will improve pulmonary function in patients with CF. REVIEW OF LITERATURE
Several references to drainage appear in the early respiratory disease literature. The Jacksons were well aware of the necessity of "peroral pulmonary drainage" and the value of a cough. 5 Bushnell, in 1918, discussed the benefits to a patient assuming a position that would favor drainage into a bronchus. 6 The early physical therapy literature con cerning chest disorders is directed toward the postoperative care of the patient who has had thoracic surgery. The first mention of bronchial drainage was in 1938, when Knies observed that patients with nontuberculous conditions such as lung abscess, empyema, and bronchiectasis 1081
Downloaded from https://academic.oup.com/ptj/article-abstract/55/10/1081/4567527 by University of Texas at Dallas user on 04 February 2019
JAN STEPHEN TECKLIN, B.S., and DOUGLAS S. HOLSCLAW, M.D.
1082
PHYSICAL THERAPY
Downloaded from https://academic.oup.com/ptj/article-abstract/55/10/1081/4567527 by University of Texas at Dallas user on 04 February 2019
Motoyama found significant changes in four might benefit from carefully graduated and supervised postural drainage. 7 After returning pulmonary functions forty-five minutes after from the Brompton Hospital in England in postural drainage in ten patients with CF, and 1952, May suggested that in treating lung concluded that postural drainage should be abscesses, collapsed lobes, and bronchiectasis considered an effective form of therapy in the aims of physical therapy should be to clear CF. 17 the bronchi of mucopurulent secretions using bronchial drainage and percussion. 8 She also METHOD recognized that involvement of specific bronchi Twenty-six patients with CF, aged nine to would indicate individualized drainage posi twenty-eight years and with various degrees of tions. Two widely accepted texts on pulmonary pulmonary involvement, were evaluated. Pul physical therapy offer no objective evidence monary disease in all was nonacute and tests that bronchial drainage improves ventila were performed during a routine clinic visit. tion. 9 ' 10 Zausmer, in this Journal, repeatedly First, two forced expiratory spirograms were notes that much of the treatment we provide obtained using the method of Polgar and for patients with pulmonary conditions is Promadhat. 18 The best effort of the two without supporting evidence and is based solely attempts was examined. Peak expiratory flow upon empirical observations. 11 Anthonisen and rate (PEFR) was obtained from the best of colleagues, studying chronic bronchitis, and eight attempts on a Wright peak flowmeter. March, using a group of patients with chronic Bronchial drainage for all lobes of the lung obstructive pulmonary disease, were unable to followed. In each of six positions, manual demonstrate any significant change in pulmo chest percussion was used for three minutes nary function when bronchial drainage was followed by five deep breaths accompanied by manual vibration during the expiratory phase. added to the treatment program. 12,1 3 Kang and his co-workers evaluated postural The subject was urged to cough up and drainage with percussion in patients with expectorate secretions after each position. chronic obstructive lung disease by comparing Following bronchial drainage, the subject rested such treatment with postural drainage alone. 14 for five minutes, then pulmonary function tests The methods of assessment were one-second were repeated. The values obtained from the forced expiratory volume (FEV t ) and spirogram were FEVj, maximal midexpiratory xenon 133 ventilatory lung scans. The FEV! flow rate (MMEFR), forced vital capacity increased by greater than 15 percent in eight of (FVC), expiratory reserve volume (ERV), and fifteen children treated with postural drainage inspiratory capacity (IC). The response to and percussion. The xenon! 3 3 lung scans treatment is expressed as mean percentage revealed uneven distribution of gas in different changes from pretreatment values. The three flow rates—PEFR, FEV l5 and areas of the lung following treatment, with the lower lobes showing the most consistent im MMEFR—were selected to determine the level in the tracheobronchial tree at which bronchial provement. Huber and his associates studied the effects drainage is most effective. The three volumes— of postural drainage with percussion and vibra FVC, ERV, and IC—were chosen to reflect the tion on two groups each of eleven asthmatic net effect of bronchial drainage upon ventila children thirty minutes after treatment. 15 The tory reserve. mean FEVi in the treated group showed an The data were analyzed using the one-tail t increase of 10.5 percent compared to a slight test for the significance of the difference reduction in mean FEVi in the control group. between two dependent means. 19 Lorin and Denning were able to demonstrate that in patients with CF more than twice the RESULTS amount of secretions were expectorated follow ing a period of bronchial drainage with percus The mean values of spirometric scores before sion, vibration, and coughing than with an and after bronchial drainage are shown in Table 1. Highly significant increases occurred in equal period of only coughing. 16
TABLE 1 Mean Pulmonary Function Scores before and after Bronchial Drainage (n = 26) Post
Percent Change
273.5 1436 52.63 2446 646 1791
289 1466 51.00 2547 733 1916
+5.67 +2.09 -3.10 +4.13 +13.47 +6.98
PEFR, FVC, ERV, and IC. Significant increases in FEVj and MMEFR were not observed. A subgroup of six patients had documented bronchospasm as evidenced by clinical wheez ing at the time of examination. The treatment results of this subgroup are shown in Table 2. Three of the tests—PEFR, FVC, and IC— showed significant increases. Significant in creases were not found for FEVj, MMEFR, or ERV. The results were quite similar in the two groups, the sole exception being the lack of significant change in the ERV for the broncho spasm subgroup. A 20 percent increase in ERV occurred in this latter group, but, because of the large variance and small number in the group, statistical significance was lacking. DISCUSSION Examination of flow rates can give an indication of the site at which the effects of bronchial drainage occur. Of the three measures of flow—PEFR, FEV X , and MMEFR—the only significant increase was found in PEFR, an indicator of large airway status. The FEVj and MMEFR, indicators of intermediate and small
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