Respiratory Medicine ( 1991 ) 85, 45-51

Evaluation of chest percussion in the treatment of patients with copious sputum production A . GALLON

Norfolk and Norwich Hospital, Brunswick Road, Norwich, Norfolk NRI 3SR

The effect of manual chest percussion was studied in nine patients with copious sputum production. Treatment consisting ofpostural drainage (PD) and the forced expiration technique (FET) produced sputum at the rate of 0.831 g min -~. When percussion was included in the treatment regimen, the rate of sputum production was significantly greater (P < 0.05), being 1.231 g min- ~for fast percussion and 1.040 g min- ~for slow percussion. Pulmonary function and oxygen saturation were unaffected by any of the treatment regimens. This study demonstrates that manual chest percussion is a useful adjunct to PD and FET in the treatment of patients with copious sputum production. Introduction

Chest physiotherapy is not an entity in itself, but a variety of techniques which can be used individually or in various combinations, depending on the condition of the patient being treated. One of the aims of chest physiotherapy is the removal of excessive bronchial secretions. Cochrane et al. (1) demonstrated the detrimental effect that excessive secretions have on pulmonary function and that their removal significantly improves specific conductance of the airways. Techniques designed to remove excessive secretions are, naturally, only beneficial to those patients who have excessive secretions (1). In recent years, several studies have attempted to evaluate the various different components of chest physiotherapy (2-8). Postural drainage (PD) and the forced expiration technique (FET) have been shown to be effective at clearing secretions (2,3) and more effective than directed coughing alone (4) in patients with copious sputum production. Percussion, on the other hand, has been reported to be less effective (5-8), although the evidence is far from conclusive. Many of the patients in the above studies did not have copious secretions. Wollmer (5) and Van der Schans (6) studied patients with chronic bronchitis rather than bronchiectasis. Murphy (7) studied cystic fibrosis patients but only included two subjects in his study. Sutton (8) looked at too many different components (i.e. percussion, vibratory-shaking and deep breathing) to be clear exactly which elements were effective. It is important to know exactly which of the various components is effective in clearing excessive bronchial Received27 September 1989and accepted25 September 1990. 0954-6111/91/010045+07 $03.00/0

secretions. This study, therefore, was designed specifically to evaluate manual chest percussion (MCP) in patients with copious sputum production by (a) comparing two regimens of treatment (i.e. PD and FET with PD, FET and MCP) and (b) comparing two types of MCP (fast and slow).

Patients and methods PATIENTS

Ten out-patients, aged between 22 and 58 years, with known bronchiectasis were entered into the study. All were in a stable condition and produced a minimum of 25 g sputum per day. They were not receiving regular physiotherapy but consented to treatment for the purposes of the study. Patiefits were excluded from the study if they had insufficient sputum production, any change in medication immediately prior to recruitment or any contra-indication to either postural drainage or percussion (9). If, during the course of the study, a patient developed a pneumothorax, haemoptysis or required hospital admission, they were withdrawn from the study.

STUDY DESIGN

Each patient underwent three different treatment modalities, which were performed at the same time of the day and on the same day of the week for 3 consecutive weeks. The order of treatments was randomized for each patient. All three treatments included postural drainage (PD), deep breathing exercises (DBE) and the forced expiration technique (FET), with the addition of fast manual chest percussion (FMCP) for treatment (B) © 1991 BaiUi6reTindall

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A. Gallon

and slow manual chest percussion (SMCP) for treatment (C). Treatment (A) comprised PD, DBE, and FET only and acted as the control. PD is positioning the patient in such a way as to allow gravity to assist the drainage of secretions from the affected areas of the lungs. (For positions see The Brompton Hospital guide to chest physiotherapy (9)). FET consists of huffing and breathing control. A huff is a forced expiratory manoeuvre with an open glottis. In order to clear secretions from more distal airways, a huff should start at mid-lung volume and continue to low-lung volume. One or two huffs are followed by a period of relaxation (i.e. relaxing the upper chest and accessory muscles) and controlled diaphragmatic breathing (breathing control). Deep breathing exercises consist of maximal inspirations followed by relaxed expirations. Manual chest percussion is clapping the chest wall over the affected area to produce an energy wave which is transmitted to the airways. For the purposes of this study, 'fast' MCP is two-handed clapping at a rate of approximately 240 cycles/minute and of sufficient magnitude to produce quivering of the voice or the 'Dalek' effect (10). 'Slow', one-handed percussion is clapping the chest wall once at the beginning of a relaxed expiration following a maximal inspiration (i.e. 6-12 cyles/minute). During treatment, the patient adopted the appropriate PD position(s). (One patient had one lower lobe affected and the rest had bilateral lower lobe disease). Thirty-second periods of DBE were alternated with 30-s periods of FET. For (B) and (C), the percussion was included in 30-s cycles to coincide with the periods of DBE. Coughing and expectoration occurred spontaneously and as required. Treatment was continued until the patient felt that his/her chest was clear and then had a 5-min period free from expectoration. Bronchodilators were withheld for at least one hour prior to a treatment session. All treatments were carried out by the same physiotherapist, who also instructed the patients in the various techniques. MEASUREMENTS

All sputum expectorated during the treatment session was collected and the weight recorded. Any sputum expectorated during the 60-min period after treatment was added to that produced during the treatment period (to allow for any carry-over effect) and the joint weight was recorded. The length of time taken for each treatment was recorded. Using that, and the weight of sputum produced, the rate at which sputum was expectorated was calculated. Using a computerized spirometer (VitalographCompact), respiratory function tests were performed

before the start of each treatment session and repeated 20, 40 and 60 min after treatment had ended. The tests included: peak expiratory flow rate (PEFR); forced expiratory volume in one second (FEV~); forced vital capacity (FVC); forced mid-expiratory flow between 25 and 75% of FVC (FEF25_75o/.); and forced midexpiratory flow between 75 and 85% of FVC (FEF75_85,/.). Oxygen saturation was monitored continously with a pulse oximeter (Life Stat 1600, Physio Control) before, during and for 60min after treatment. Throughout the treatment, readings were taken for every phase of the treatment, i.e. during DBE, MCP and FET, on a cyclical basis. After completion of all three treatment sessions, the patients were asked to complete a simple questionnaire, anonymously, stating a preference, if any, for one of the three treatments. ANALYSIS OF DATA

Statistical analysis of the results was by analysis of variance (ANOVA) and for the rates of sputum production, Duncan's Multiple Range Test was carried out. CONSENT

The study was approved by the District Ethical Research Committee and informed consent was obtained from each patient. Results

One patient was withdrawn from the trial following an episode of haemoptysis which occurred 2 days prior to the start of the study. The characteristics of the remaining nine patients, on entering the trial, are given in Table 1. The mean weights of sputum produced during treatment (and the 60-min period after treatment) were: (A) 21 g, range 0-42 g (24.5 g, range 0 - 4 9 g); (B) 23 g, range 10-39g (27g, range 12-51 g); (C) 26g, range 10-57 g (29 g, range 10-68 g). The mean times taken for each treatment session were: (A) 25.4 min, range 14-35; (B) 19.7 min, range 13-25; (C) 24.8 min, range 14-35. The mean rates of sputum production ( _ standard error) were: (A) 0-831 g min-i ( _ 0.146); (B) 1-231 g min- z ( __+0.177); (C) 1.040 g min- J ( __+0" 158). These results show a statistically significant difference in the rate of sputum production between treatments (P

Evaluation of chest percussion in the treatment of patients with copious sputum production.

The effect of manual chest percussion was studied in nine patients with copious sputum production. Treatment consisting of postural drainage (PD) and ...
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