Airway Clearance Therapy With Devices and Mechanism of Action in People With Cystic Fibrosis Lisa Monchil, RRT-NPS, CCRC, AE-C New York Medical College/ Armond V. Mascia MD CF Center Valhalla, New York

Lisa Monchil, RRT-NPS, CCRC Presenter Disclosure Lisa Monchil, RRT-NPS, CCRC No Relationships to Disclose Related to this Presentation

Why add devices???? Maintaining pulmonary health in Cystic Fibrosis is a crucial component to care and quality of life. An airway clearance plan is an active and ongoing process throughout all life stages. One size definitely does not fit all. Enhancing the efficacy of airway clearance therapy with these devices has advantages. Giving independence and control over treatments improves adherence to therapy Hristara-Papdopoulou A,Tsanakas J, Diomou G, Papadopoulou O Current Devices of Respiratory Physiotherapy. Hippokratia 2008 Oct-Dec 12(4): 211-220

Devices and Mechanism of Action 1) Positive Expiratory Pressure (PEP) 2) Oscillating PEP 3) High Frequency Chest Wall Oscillation (HFCWO) 4) Percussion / Vibration 5) Intrapulmonary Percussive Ventilation (IPV), Percussive Neb, Metaneb, Cough Assist with upgraded software 6) Acoustic Percussor

Positive Expiratory Pressure (PEP) Exhaling through a fixed resistance Stents the airways open and allows air to enter peripheral airways via collateral ventilation channels Air is then able to move behind secretions

Oscillating PEP Combines PEP therapy with oscillations on exhalation Oscillations reduce vicosity and small bursts of air move secretions cephalad – HZ 11.6-18 Main E, Rand S, Grillo L Airway Clearance Strategies in Cystic Fibrosis and non-Cystic Fibrosis Bronchiectasis. Seminars in respiratory and critical care medicine. 2015;36(2)251-266 Pursley, D Analysis of three oscillating positive expiratory pressure devices during simulated breathing. Respiratory Therapy vol 12 No.1 Winter 2017

High Frequency Chest Wall Oscillation Creates an oscillatory airflow bias – greater airflow out than with normal breathing – 300 to 1500 staccato coughs (11) Both central and peripheral airways have enhanced clearance (12) Physical nature of the mucus is changed, breaking down, thinning, coughing clearability index – twofold reduction in sputum viscosity, acting as a physical mucolytic (9) Airflow patterns shear mucus from bronchial walls Mucus is moved to the central airways to be removed – cough or swallowed Tracheal mucus clearance was most pronounced in the range of 11-15 HZ –reaching 340% at 13HZ (12) Vest fit, inflation pressures, frequencies, patient comfort are crucial to effectiveness and adherence 11- Warwick WJ High-frequency chest compression moves mucusby means of sustained staccato coughs Pediatr Pulmonolo 1998 283(supl 6) pA219 12 – King et al Enhanced tracheal mucus clearance eith high-frequency chest wall compression Am Rev Respir J 1983 128(3):p511-5 9-Majaesic CMMontgomery M, Jones R, King M. Reduction in sputum viscosityusing high-frequency chest wall compression compared to conventional CPT Pediatr Pulmonol 1996(suppl 13) A358

Percussion / Vibration Both the Afflo and Monarch provide therapy via discs or pods that vibrate/percuss the lungs – able to thin mucus can create cough-like airflow Flimm-fighter – directional stroking and percussion to help move secretions and stimulate a cough

Oral High Frequency Percussive/Vibratory/ Oscillatory Devices Intrapulmonary Percussive Vibration/Ventilation – can be administered via mouthpiece, mask, tracheostomy, or inline with ventilator Devices include IPV, Metaneb, Percussive neb, Cough Assist T-70Lung expansion, vibrate and enlarge airways and deliver gas into distal lung units beyond retained secretions Provide internal percussion of the lungs to loosen mucus With the exception of the Cough Assist – devices deliver high density aerosol to hydrate mucus with positive expiratory pressure Brenda Button and Brian Button Structure and Function of the mucus clearance system of the lung Cold Springs Harbor Perspectives in Medicine 20133:3:a009720 Respironics/ Phillips T70 training 2017 Sancho j, Nures E, de la asuncion S, Severa E. Effect of High Frequency Oscillations on Cough Peak Flows Generated by Mechanical cough insufflation/exsufflation im Medically Stable patients with ALS Respir Care 2016; 61(8):1051-1058

Acoustic Percussors Lung Flute uses vibrating reeds to generate 16-25 HZ Vibralung therapy requires regular breathing on the mouthpiece Vibralung generates sound energy sending it ti the column of gas in the airways on both exhalation and inhalation – frequencies range 5-1200HZ Energy transferred to airways through “sympathetic resonance” Aerosol treatments can be added to Vibralung therapy Frequencer delivers acoustic waveforms generated at a lower frequency, but over a larger area Frequencer requires no patient cooperation and can be placed to targeted areas in the lungs – avoiding chest tubes and other painful areas Vibrlung Acoustical Percussor- Accessed 07/03/2017 http://westmedinc.com/vibralung/principles/ Dymedso accessed 07/03/2017 www.dymedso .com