High frequency chest compression for ambulatory pulmonary physical therapy in patients with cystic fibrosis

PICHON RIVIERE, A.; AUGUSTOVSKI, F.; GARCIA MARTI, S.; GLUJOVSKY, D.; ALCARAZ, A.; LOPEZ, A.; BARDACH, A.; CIAPPONI, A; REY-ARES, L.

Documento de Evaluación de Tecnologías Sanitarias

IECS

Año: 2012 p. 1 - 30

1668-2793

Cystic Fibrosis (CF) is a genetic, autosomal, recessive, disease which affects multiple organs and systems, but mainly the lungs. Its estimated incidence in Argentina is 1:6100 live-births.CF determines an increase in mucous viscosity, thus generating anomalous and thick secretions and consequently alterations in mucociliar clearance. The accumulation and infection of these secretions are responsible for the clinical manifestation, cause irreversible lung damage and lastly, respiratory failure and death.The Clinical Practice Guideline recommend periodic clearance of the secretions and this is consider one the most important treatment elements. Lung physical therapy includes techniques that make secretion elimination easier, such as conventional chest physiotherapy (CPT) and respiratory exercises. CPT comprises postural drainage, percussion, chest vibration, forced expirations and directed cough maneuvers. It requires the assistance of a qualified therapist or a trained relative and it is usually done once a day. It demands intense physical activity from the patient and the person performing the procedures, thus conditioning the frequency and the effectiveness of the technique.There are mechanical techniques for mucociliar clearance among which are those which apply oscillatory positive pressure (Flutter®, RC-Cornet®, Acapella® and Quake®) and those which mobilize small air volumes at high frequency, either by means of high flow mini- bursts of air to the airway (intrapulmonary percussive ventilation) or through chest compression.High frequency chest compression (HFCC) is proposed as an alternative to CPT which does not require a trained physical therapist and which involves less effort on the part of the patient.TechnologyHFCC is a system based on the principles of airflow oscillation; it has a vest connected with lines to a mechanical generator which generates an oscillatory airflow which contracts and relaxes the chest wall by inflating and deflating the vest between 5 and 20 cycles per second.This chest oscillation causes small expectorations which remove secretions from the bronchus walls towards the airways of greater diameter from which they are easy to eliminate through cough or suction.PurposeTo assess the available evidence on the efficacy, safety and issues related with use coverage policies of the high-frequency chest compressor for ambulatory lung physical therapy in patients with cystic fibrosis.MethodsA bibliographic search was carried out on the main databases: DARE, NHS EED, on Internet general search engines, in health technology evaluation agencies and health sponsors. Priority was given to the inclusion of systematic reviews; controlled, randomized clinical trials (RCTs); health technology assessments and economic evaluations; clinical practice guidelines and coverage policies of other health systems.Studies which included patient with stable CF who underwent techniques of home care secretion management were chosen.ResultsFour RCT, six clinical practice guidelines, two health technology assessments and three coverage policies were found.The RCT included patients between six and 50 years old. One compared HFCC with CCPT and Flutter® (n=166), the second one HFCC with CCPT (n=12), the third one HFCC with Flutter® (=29) and the fourth one HFCC with intrapulmonary percussive ventilation and CCPT (n=14). None of the studies found differences among the techniques regarding the pulmonary function tests, antibiotic use, quality, quality of life and amount of expectorated mucus.The clinical practice guidelines consulted, similar to the two technology assessments, found consider there is no airway clearance technique that has proved to be better than the other; HFCC being another option.The U.S. private health sponsors cover HFCC in patients with CF diagnosis and bronchiectasis.The estimate cost of the HFCC device is 20,000 U.S. dollars, whereas home respiratory physical therapy is around 18,000 Argentine pesos.ConclusionsThe available evidence, of moderate methodological quality, shows that HFCC would be as effective as CCPT and the remaining devices to achieve adequate secretion mobilization. The decision about which technique to use should take into account aspects such as accessibility, costs and patient preference. Studies with enough power are needed to assess the impact of the self-administered techniques on quality of life, as well as economic assessments which evaluate the cost of the intervention during the patients? life.