Indian Journal of Physiotherapy and Occupational Therapy

Smibi Skaria¹, Arul Joseph Arun², Jasobanta Sethi³

¹M.P.T (cardiothoracic) student, ²Associate Professor, ³Professor & Principal, Goutham College of Physiotherapy, Bangalore

Abstract

Background and objectives: An understanding of the basis of findings reported in the studies of positive expiratory pressure technique assist physical therapists in planning and modifying mucus clearance program of their clients. This study was intended to ascertain the effectiveness of positive expiratory pressure technique over forced expiratory pressure technique in improving bronchial hygiene in moderate chronic bronchitis patients.

Methods: 30 chronic bronchitis patients were divided into two groups (Group A and Group B) in a randomized controlled trail study comparing positive expiratory pressure technique using Flutter device over forced expiratory pressure technique.(each of 2 sessions per day for 15 minutes for 5 days weekly for totally 2 weeks.) Improvement in bronchial hygiene was assessed using peak expiratory flow meter, pulse oxy meter and modified Borg’s scale.

Results: At the end of 2nd week of intervention, significant improvement in bronchial hygiene was found with independent’t’ test at p< 0.05 in Group A when compared with Group B. There were significant changes in peak expiratory flow rate (with peak expiratory flow meter), O2 saturation (with pulse oxy meter) and dyspnea level (with modified Borg’s scale) in Group A than Group B.

Conclusion: Positive expiratory pressure technique using flutter device eliminates mucus from the bronchial airway and thus improves bronchial hygiene in moderate chronic bronchitis patients. This study will be helpful for the physiotherapists to incorporate flutter device for improving bronchial hygiene in their patient care.

Key words: Moderate Chronic Bronchitis, positive expiratory pressure technique, Flutter device, forced expiratory pressure technique, Autogenic drainage, Bronchial hygiene.

Introduction

Diseases of respiratory system are the major causes of illness affecting a greater part of population worldwide.¹ Chronic obstructive pulmonary disease (COPD) is the internationally preferred term encompassing chronic bronchitis, emphysema and asthma.² Chronic obstructive pulmonary disease (COPD) is the most common chronic pulmonary disorder afflicting 10 to 15% of adults over the age of 45, COPD is a disorder characterized by the presence of airflow obstruction that is generally progressive, accompanied by airway hyper reactivity and may be partially reversible.³ A review of population studies from India, estimated that total number of COPD patients aged 40 years and above in 1996 were 8.15 million males and 4.21 millions females.⁴

Chronic Bronchitis is one of the common COPD disorder and is defined as chronic cough and expectoration which persists for at least 3 months period for at least 2 consecutive years. The cause of chronic bronchitis is related to long term irritation of the tracheobronchial tree.² The most common cause of irritation is cigarette smoking. Other causes are air pollution, bronchial infections and occupational diseases.⁵

Conventional methods like chest physical therapy, Active cycle of breathing technique, Airway clearance techniques like postural drainage, percussion, vibration, shaking and forced expiratory techniques are used for mucus clearance in chronic bronchitis patients.⁶ Recent methods like positive expiratory technique using flutter device and Autogenic drainage are also used for improving bronchial hygiene in chronic obstructive pulmonary disease patients.²

A form of PEP in combination with high frequency oscillation is available in a device (Flutter Device) developed in Switzerland, by Patrick Althaus, a Swiss physiotherapist who added a steel ball vibrating inside a cone to the PEP device which quickly gained popularity worldwide.⁷ The Flutter device is a handheld device that interrupts the expiratory flow and decreases the collapsibility of the airways. The functional principle of flutter device is based on oscillative positive expiratory pressure which is designed to improve the patients’ abilities to eliminate the excessive mucus from their airways independently. It also promotes correct breathing patterns with effective distribution of ventilation which improves gaseous exchange.⁸

In contrast to flutter therapy bronchial secretion during autogenic drainage are mobilized not only by high frequency oscillation, pressure changes and the air flow changes but by a special calm breathing technique. Autogenic Drainage was introduced by Chevaillier in Belgium in 1967 for the treatment of chronic obstructive pulmonary disease patients.⁹ Autogenic Drainage uses diaphragmatic breathing to mobilize secretions by varying expiratory airflow. It consists of three phases; Firstly, breathing at low-lung volumes to “unstuck” the peripheral secretions and secondly, breathing at low to mid lung volume to collect the mucus in the middle airways. Finally, breathing at mid to high lung volumes to evacuate the mucus from the central airways.¹⁰

All detectable rheologic differences in the sputum collected at the end of every autogenic drainage and flutter physiotherapy section may be caused by high frequency oscillation and pressure and air flow changes produced by the flutter device.⁸ Many studies have been conducted to show the individual effect of positive expiratory pressure technique and autogenic drainage to improve the bronchial hygiene in moderate chronic bronchitis patients. Hence this study aims to analyze the effectiveness of both the treatment techniques and prove the better effectiveness by comparing positive expiratory pressure technique and autogenic drainage in improving the bronchial hygiene in moderate chronic bronchitis patients.

Study design

This study was an experimental design involving the comparative analysis of the two groups treated with positive expiratory pressure technique and Autogenic drainage respectively and assessed by dependant variables namely Oxygen saturation (SaO2), Peak Expiratory Flow Rate (PEFR) and Rate of Perceived Exertion (RPE).

The Selection Criteria was as follows:

Inclusion criteria

• Clinically diagnosed moderate chronic bronchitis patients.
• Moderate Chronic bronchitis patients with dyspnoea grading above 3 (10-point modified Borg’s scale)
• Both males and females.
• Age group between 40-60 years.

Exclusion criteria

• Clinically diagnosed mild and severe chronic bronchitis patients.
• Age group below 40 and above 60 years.
• Associated unstable cardiovascular diseases and any other neurological deficits.
• Chronic bronchitis patients who has undergone recent thoracic and abdominal surgeries.
• Any other associated restrictive lung diseases.

Measurements tools

The following were the measurement tools used for the study.

• Pulse Oxymeter (Oxygen saturation level ,SaO2)
• Peak expiratory flow meter (Peak expiratory flow rate, PEFR)
• 10-point Modified Borg’s Scale (Rate of perceived exertion, RPE).

Procedure

30 subjects clinically diagnosed as moderate chronic bronchitis were selected according to inclusion and exclusion criteria and divided randomly into two experimental groups, as Group A and Group B, consisting of 15 subjects each. A brief explanation about the treatment session was explained to all the subjects.

The treatment duration for both the groups was given as listed below:

Duration per session: 15 -20 minutes / session
No. of sessions per day: Twice a day
No. of days per week: 5 Days
Duration of the study: 2 weeks

The pre- post test values of O2 saturation, peak expiratory flow rate and Rate of perceived exertion were noted before the test and at the end of 2nd week of treatment. Group A was treated with positive expiratory pressure technique using flutter device and Group B received Autogenic Drainage.

Group A: (Positive expiratory pressure technique) The subjects were asked to seat in a comfortable position leaning forward with elbows supported on a table and neck slightly extended in order to open up the airway. The flutter device was held horizontally and tilted slightly upwards in order to get maximal oscillatory effect and was placed in the mouth. Inspiration was done through the nose. A slow breath in, only slightly deeper than normal with a breath hold of 3-5 seconds followed by breath out through the flutter device at a slightly faster rate than normal. After 4-8 of these breaths, a deep breath with a ‘hold’ at full inspiration was followed by a forced expiration through the flutter device. This precipitated expectoration and was followed by a pause for breathing control, and then according to the subjects’ preference a cough or huff was done.¹⁴

The full effects of the vibrations induced by the flutter may be received by changing the angle of the device. Movement of the flutter upward increases the pressure and frequency while movement of the device downward results in lower pressure and frequency. While doing the procedure the patient must keep the cheeks flat and use the abdominal muscles effective exhalation. The vibration of the chest may be palpated by the patient to provide feedback as to the optimal angle of the device. A flutter session consists of 10 to 15 breaths followed by huffing, with session lasting about 15 to 20 minutes. To avoid dizziness due to hyper ventilation, a patient should refrain from forced exhalation. It may be necessary to pause every 5 to 10 exhalations before resuming the session.¹⁵

The flutter device should be cleaned regularly with hot and soapy water. In the hospital the equipment should be sterilized according to infection control recommendations¹⁴.

Group B: (Autogenic Drainage)

The patients were seated up straight in a chair with back support. The upper air ways were cleared of secretions by huffing or blowing the nose. The therapist was seated to the side and slightly behind the patient, close enough to hear the patient’s breathing. One hand was placed to feel the work of abdominal muscles and the other hand placed on the upper chest.¹⁴ In all phases, the inhalation was done slowly through the nose, using diaphragm; two to three breath holds allowing collateral ventilation to get air behind the secretions. Exhalation was done through the mouth.

The vibration of mucus is felt with hand placed on upper chest. The frequency of vibrations revealed their locations. High frequencies reveal secretions located in small airways. Low frequencies mean that secretions were moved to larger airways.⁹

1. The Unsticking Phase: Inspiration was followed by a deep expiration in to the expiratory reserve volume. It was done by contracting the abdominal muscles. This low lung volume breathing continued until the mucus was loosened and started to move in to the larger airways.⁹
2. The Collecting Phase: The tidal volume breathing was then changed gradually from expiratory reserve volume towards the inspiratory reserve volume range so that the lungs were expanded more with each inspiration. The patient increased both inspiration and expiration to move a greater volume of air. This low to middle lung volume breathing continued until the sound of mucus decreased, signaling its movement in to the central airways to be evacuated.⁹
3. The Evacuating Phase: In this Phase, the patient increased inspiration in to the inspiratory reserve volume range. This middle to high lung volume breathing continued until the secretions were in the trachea and ready to be expectorated. The collected mucus was evacuated by a stronger expiration or a high volume huff.⁹

The duration of each phase of autogenic drainage depended on the location of the secretions. The duration of a session depended on the amount and viscosity of the secretions.¹⁴

The post test values of Oxygen saturation, Peak expiratory flow rate and Rate of perceived exertion according to modified Borg’s Scale were noted at the end of second week of treatment. Then the pre and post test values were considered for data analysis to infer the results.

Data analysis

The statistical tool used in this analysis was independent’t’ test. The difference of values between pretest and post test were found. It was done for the values taken before and at the end of two weeks respectively. The mean differences of Oxygen Saturation, Peak Expiratory Flow Rate and Rate of Perceived Exertion of Group A were compared with Group B and the actual pattern of variation in all the categories was observed.

With the acquired’t’ value from the pretest and post test, the accurate level of significance was analyzed and interpreted. An alpha level of P<0.05 was the level of significance for the test.

A dependent ‘t’ test was performed to analyze the efficacy of treatment within the groups.

Results and interpretation

Thirty patients with Moderate Chronic Bronchitis with a mean age of 50.23 years were selected for the study. The mean, variance and standard deviation values of the age groups according to the distribution of the sex are shown in Table-1.1 and 1.2

Descriptive statistics

The following tables and graphs illustrates the mean, variance and SD values of the different parameters individually, thereby showing the improvement within the group by the respective training procedures.

Interpretation

The above table shows the value of t = 2.4076 for mean improvement in the values of Peak Expiratory Flow Rate (PEFR) at p<0.05 As the t’ value was greater than the table value (1.701) it was concluded that Positive Expiratory Pressure Technique had a more significant effect than Autogenic Drainage in improving the Bronchial Hygiene of patients with Moderate Chronic Bronchitis.

Table 1.1: Mean, Variance and Standard Deviation values of age group in Group A

GENDER	N	MEAN	VARIANCE	SD
Males	10	50.9	52.54	7.24
Females	5	49.2	16.7	4.08
Total	15	50.33	39.24	6.26

Table 1.2: Mean, Variance and Standard Deviation values of age group in Group B

GENDER	N	MEAN	VARIANCE	SD
Males	10	50.7	58.9	7.67
Females	5	49	29.5	5.43
Total	15	50.13	46.98	6.85

Table 3.1: Mean, Variance and SD values of pre and post tests for Oxygen saturation (SaO2) of Group A

Test	Mean	Variance	Standard Deviation
Pre Test	90.47	5.69	2.38
Post Test	92.73	4.92	2.21

Table 3.2: Mean, Variance and SD values of pre and post tests for Oxygen saturation (SaO2) of Group B

Test	Mean	Variance	Standard Deviation
Pre Test	90.86	4.98	2.23
Post Test	92.2	4.88	2.21

Interpretation

The above table shows the value for mean improvement for all the parameters such as Oxygen Saturation (SaO2), Peak Expiratory Flow Rate (PEFR) and Rate of Perceived Exertion (RPE) assessed using the Modified 10-point Borg’s Scale. All the parameters show a greater improvement with Positive Expiratory Pressure Technique done using Flutter Device than Autogenic Drainage in improving the Bronchial Hygiene of patients with Moderate Chronic Bronchitis.

Interpretation of statistical results

This study was done with 30 moderate chronic bronchitis subjects allotted into two experimental groups namely Group A and Group B consisting of 15 each, to know the effectiveness of Positive Expiratory Pressure Technique using Flutter Device over Autogenic Drainage in improving the Bronchial Hygiene of patients with Moderate Chronic Bronchitis.

The parameters used were Oxygen Saturation (SaO2), Peak Expiratory Flow Rate (PEFR) and Rate of Perceived Exertion (RPE) assessed using the Modified 10-point Borg’s Scale. It was taken before the treatment and at the end of second week post treatment. The data were analysed using dependent ‘t’ test to find the significance of the interventions used within the groups and then an independent ‘t’ test was used for the above mentioned parameter to find the significance between the groups. The dependent ‘t’ test showed significance for both the groups stating both the experimental Groups were improving the bronchial hygiene with their respective treatments done.

The results were found to be significant with independent ‘t’ test at p<0.05 with the calculated ‘t’ values as 3.8473, 2.4076 and 2.0371 for Oxygen Saturation (SaO2), Peak Expiratory Flow Rate (PEFR) and Rate of Perceived Exertion (RPE) respectively and being more than the table values. This stated that there is better effectiveness when Positive Expiratory Pressure Technique was given using Flutter Device than Autogenic Drainage in improving the Bronchial Hygiene of patients with Moderate Chronic Bronchitis.

Discussion

The chief objective of the study was to compare the efficacy of Positive expiratory pressure technique and Autogenic drainage. The study undertaken included patients who had moderate chronic bronchitis; hence this study can’t be generalized to whole of the population who are suffering from chronic bronchitis. Although many treatment methods are currently in vogue in order to deal these kinds of patients we are in emergent need of applying the correct technique which suits the patient’s need. The growing demand for meeting various problems associated with pulmonary complications are indeed worth considering.

Table 3.3: Mean, Variance and SD values of pre and post tests for PEFR of Group A

Test	Mean	Variance	Standard Deviation
Pre Test	217.33	3221	56.75
Post Test	396.67	8738	93.47

Table 3.4: Mean, Variance and SD values of pre and post tests for PEFR of

Test	Mean	Variance	;Standard Deviation
Pre Test	223.33	1738	41.69
Post Test	343.33	3523	59.36

Table 3.5: Mean, Variance and SD values of pre and post tests for Rate of perceived exertion (RPE) of Group A

Test	Mean	Variance	Standard Deviation
Pre Test	2.66	0.23	0.48
Post Test	0.83	0.2	0.44

Table 3.6: Mean, Variance and SD values of pre and post tests for rate of perceived exertion (RPE) of Group B

Test	Mean	Variance	Standard Deviation
Pre Test	2.6	0.25	0.5
Post Test	1.2	0.45	0.67

Table 6: Mean improvement in all the parameters between Group A and Group B

Parameters	Group A	Group B
Oxygen Saturation	2.26	1.33
PEFR	179.33	120
RPE	1.83	1.4

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Fig. 13:	Fig. 14:

The study was detailed and tailored to find the efficacy of which mode of treatment was better in the two groups using three different evaluating tools such as Oxygen saturation level, Peak expiratory flow rate and the Rate of perceived exertion. The analysis of variance between treatments of both the Groups using all the parameters exhibited significant improvement for Positive expiratory pressure technique than Autogenic drainage.

The results of this study show that Flutter therapy resulted in a significant reduction in sputum viscoelasticity and thus improves mucus clearance. This is in accordance with the study by Konstan et al, who found a large increase in expectorated sputum volume with Flutter therapy compared with cough or conventional chest physiotherapy.⁷ Flutter therapy improved cough clearance by keeping the airways open during lightly forced expiration, through the added positive airway pressure produced during expiration. The shear rates during such a cough maneuver, with the consequent flow and pressure changes, have to be high enough to move bronchial secretions, but not so high that airways collapse occurs.⁸

The results of this study is in accordance with Andreas Pfleger et al (1992) who suggested that airway clearance techniques are used to aid in mucus clearance in a variety of diseases such as COPD and new techniques like Positive expiratory pressure technique and autogenic drainage can be used to rely heavily on basic airway clearance.¹⁷ Also Bellone A et al (2000) who compared the effectiveness of oscillating positive expiratory pressure using flutter device with postural drainage and ELTGOL (expiration with the glottis open in the lateral posture) on oxygen saturation and sputum production; concluded that flutter techniques was more effective in prolonging secretion removal in chronic bronchitis.¹⁸

The results of the study also has got strong evidences from the study done by Eaton T et al (2007) who had suggested that flutter device was well accepted and tolerated airway clearance device and the patient’s preference was more for flutter device compared to active cycle of breathing and postural drainage.¹⁹

The statistical analysis done above correlated that the group taken for the study; both Group A treated by Positive expiratory pressure technique or Group B treated by Autogenic drainage, showed significance in improving the bronchial hygiene of moderate chronic bronchitis patients. It also showed that Group A had higher significance when compared to the Group B treated by Autogenic drainage. Based on this data, we accept the Experimental Hypothesis. In Contrast Van Hengstum M et al (1988), Olseni L et al (1994) had done separate studies on obstructive pulmonary disease patients using forced expiratory technique combined with either postural drainage or positive expiratory pressure breathing and concluded that mucus clearance was more effective with postural drainage and forced expiratory technique than positive expiratory pressure and forced expiratory technique.^20,21

Whereas this study implies that both Positive expiratory pressure technique and autogenic drainage can be used in the chest physiotherapy intervention of chronic bronchitis patients but the Positive expiratory pressure technique is more efficient than the former and it is also better to go for this advanced bronchial hygiene technique when there is a high risk of complications arising in chronic bronchitis patients.

Conclusion

This study can be concluded stating that Positive expiratory pressure technique is more effective when compared to autogenic drainage in improving the bronchial hygiene and the health status of moderate chronic bronchitis patients. In case of other types of chronic bronchitis who tend to fall under the low risk group of pulmonary complications; both the techniques are equally preferred. This study will be helpful for the physiotherapists to incorporate flutter device for improving bronchial hygiene in their patient care.

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Corresponding Author:
Smibi Skaria
MPT (Cardiothoracic) student, Gautham College of Physiotherapy #173,187 Main road, Kamalanagar, Bangalore.
Mobile No.9916159070,
Email: smibphysio(at)yahoo.co.in