Airway Clearance & Exercise

Within this section you will find information about various airway clearance techniques, the role of exercise in CF, tips to save energy and fight fatigue, how we measure functional status using a 6-minute walk test and how to cope with shortness of breath.

Physiotherapy

There are several physiotherapists on the CF team and they cover both the inpatient ward and outpatient clinic.

Physiotherapy is a healthcare profession which aims to promote, improve and maintain mobility and physical functioning ultimately optimizing quality of life. Physiotherapists can help people with a wide range of conditions ranging from a sprained ankle to patients that have had stroke or are managing chronic conditions like diabetes or CF. All physiotherapists are registered to practice in Canada and have met national entry-level education and practice standards. They have also successfully passed a standardized physiotherapy competence examination prior to being registered with the College of Physiotherapists in their province/territory. Physiotherapists combine their in-depth knowledge of the body and how it works with specialized hands-on clinical skills to assess, diagnose and treat symptoms of illness, injury or disability. To learn more about physiotherapy, visit the Canadian Physiotherapy Association.

Saving Energy & Fighting Fatigue

Feeling tired and as though you are unable to do things can sometimes happen in CF. While this can be frustrating, it is important to know that asking for help is more than okay. In addition, there are many tips and tricks you can do in your daily life to help reduce feelings of tiredness, and be able to perform routine tasks a little easier.

For more information on energy conservation, explore this handout from our clinic physiotherapists.

Coping With Shortness of Breath

Shortness of breath can occur due to the airways being plugged with mucous. If you feel short of breath, try the following steps from the Lung Association.
Remember: Breathlessness on effort is uncomfortable but not in itself harmful or dangerous.

  1. STOP and REST in a comfortable position.
  2. Get your head down.
  3. Get your shoulders down.
  4. Breathe IN through your MOUTH.
  5. Blow OUT through your MOUTH.
  6. Breathe in and out as fast as necessary.
  7. Begin to BLOW OUT LONGER, but not forcibly, and use pursed lips if you find it effective.
  8. Begin to SLOW your breathing.
  9. Begin to use your nose.
  10. Begin diaphragmatic breathing.
  11. STAY IN POSITION for 5 minutes longer.

Source: The Lung Association

For more infomation, read this handout on coping with breathlessness.

Chest Physiotherapy (also called ‘Airway Clearance’)

Chest physiotherapy is a broad term used to describe a variety of manual and breathing techniques that help your body to clear mucous from your lungs. Chest physiotherapy can also improve the movement of air into and out of your lungs, as well as decrease shortness of breath and fatigue associated with the increased work of breathing often experienced by people with CF. Daily airway clearance is standard of care for people with CF.

We all have mucous in our lungs. Mucous is part of our immune system and helps our body to trap and eliminate dust, bacteria and other microscopic pathogens. Our lungs are equipped with a system known as the mucociliary escalator that works to move the lung mucous, along with the dirt and bacteria, out of our smaller airways. Once this mucous is moved out of the smaller airways into the larger airways, we can cough, or even clear our throat to remove it from our lungs. With CF, this mucous can be thicker, stickier, dehydrated and more difficult to move. As a result, people with CF typically need Airway Clearance Techniques (ACT), to help mucous move more effectively. This also explains why simply coughing is not a great way to clear your airways. Coughing can clear mucous once it is in the higher airways but is not a good way to move mucous from the deeper airways. Trapped mucous can cause bacteria to thrive and grow causing infection and inflammation. Research has shown that people with CF have better lung function if they do ACT, compared to those who do not.

There are many different techniques that have been developed and shown to be effective ways to perform airway clearance. Below is a list of current airway clearance techniques in order of their development:

  • Percussions and Modified Postural Drainage
  • Autogenic Drainage (AD)
  • Active Cycle of Breathing Technique (ACBT)
  • Positive Expiratory Pressure devices (PEP)
  • Oscillating PEP
  • High frequency chest wall oscillation (HFCWO), commonly referred to as the “VEST”

There are other options for ACT but the research supporting their use is not currently as strong as the above.

Some people find it challenging to fit daily ACT into their lifestyle. Some airway clearance techniques involve multiple steps, or need help from others. The recommendation of an airway clearance technique for an individual is based on many factors, i.e. your health status, lifestyle, your previous experience with different techniques, your preference, your funding availability, and scientific evidence. Your physiotherapist can design an airway clearance program that best suits your needs. They can also assess and modify your program regularly as changes occur in your life circumstance and/or disease process.

Percussions may also be known as “chest physiotherapy” or “clapping”. Individuals are placed in specific positions to clear mucous from different parts of the lungs. This is known as postural drainage. Lying with your head below the level of your stomach is no longer recommended due to the increased risk for reflux (acid moving from the stomach into the esophagus). Specific areas of the lung are clapped or percussed in these positions to unstick mucous from the airways. Mucous can then move towards the upper airways where it can be cleared by coughing or huffing.

Individuals can perform their own percussions using their hands on the front and sides of their chest. Usually assistance is needed to percuss the segments of the lungs on the back. Individuals may also choose to use a mechanical percussor to help facilitate the technique.

Percussion and modified postural drainage is very specific to the lung segments that receive treatment. It is important to have a regimen that treats all the necessary parts of the lung and uses positioning appropriately to optimize the treatment. Proper technique is also critical to ensure that the treatment is effective and comfortable. Your physiotherapist can help to evaluate your technique and create a specific program that meets your needs.

In certain situations, it may not be appropriate to continue with percussion therapy. Percussions can sometimes increase wheezing and chest tightness and therefore may not be as effective for someone with a lot of asthmatic symptoms. Percussions may need to be temporarily stopped or changed in instances where an individual has had a pneumothorax, hemoptysis, rib fracture or a port-a-cath that is accessed. It is important to talk to your physiotherapist in these situations for a safe and effective treatment alternative.

Autogenic drainage (AD) is an airway clearance technique aimed at moving mucous in the airways through breathing in a controlled manner. It stemmed from observations that suggest mucous can be cleared during breathing exercises, playing, laughing, huffs, or even sleep.

The AD technique involves breathing in different lung volumes with a high airflow during expiration (breathing out). Coughing is discouraged during the AD technique. AD is best suited to people that have good intuitive knowledge of their body and their lungs.

AD is initiated with a slow breath in through the nose, followed by two to three seconds of breath hold. The three phases of the technique, referring to the depth of the airways being targeted and the volume of air breathing in and out, are:

Phase 1: “Unsticking” of mucous in smaller airways
Phase 2: Collection of secretions from the smaller airways
Phase 3: Evacuation of mucous

This is a complicated airway clearance technique to learn and perform. It should be carefully taught and reviewed by one of the physiotherapists on the CF team.

Active Cycle of Breathing Technique (ACBT) is an airway clearance technique, developed by a physician and a physiotherapist in New Zealand. The aim was to help people with asthma clear secretions from their lungs. ACBT involves three different breathing exercises to help move mucous from the lungs. This is also one of the most gentle airway clearance techniques, and thus can be used when different common CF related complications arise such as hemoptysis or pneumothorax. It is, however, important to confirm the appropriateness with our physiotherapist on the CF team.

  1. Breathing control (BC) – gentle, relaxed breathing at a normal pace, to assist in relaxing the airways and muscles used for breathing.
  2. Thoracic expansion exercise (TEE) – deep, slow, relaxed breath in, with or without breath-holds, followed by quiet, relaxed breathing out. This allows air to go deep into the lungs and behind mucous.
  3. Forced expiratory technique (FET) – a series of huffs, possibly the most important part of ACT. This looks like fogging up a mirror or warming your hands in winter by breathing on them. This part helps move mucous towards the upper airways where it can be cleared by coughing

This is a relatively flexible and easy technique to learn and perform. The three breathing exercises are performed in a specific order, which is tailored specifically for each individual person by our physiotherapist on the CF team.


Abbreviations: BC, breathing control; TEE, thoracic expansion exercise; FET, Forced expiratory technique.

Positive expiratory pressure (or commonly known as PEP) was developed in Denmark in the late 1970s as another great airway clearance technique. As you breathe in and out of the PEP mask, slight pressure builds up inside your airways to help to keep them open. With this extra support, your body is better able to use the air you breathe out to move mucous towards your bigger airways so you can huff or cough them out of your lungs. This pressure is not a lot; it’s approximately 10-20cm of water pressure, similar to the pressure you experience when you breathe out under water when swimming. The PEP device is available with either a face mask or mouthpiece option. Breathing out should take three to four times as long as breathing in. It will also help equalize the air going into different portions of the lung and thus improve the amount of air getting into the body.
Currently, there are two PEP devices available on the market:

  1. TheraPEP
  2. PariPEP-S

PEP has been found to be as effective as other airway clearance techniques. However, in situations where an individual feels very short of breath, is diagnosed with pneumothorax, or is coughing up large amount of blood (hemoptysis), it may not be appropriate to use the PEP device. You should contact the physiotherapist on the CF team for an assessment and advice. Note that proper cleaning of the PEP device after each use and disinfecting the device regularly are vital. Please read and follow the recommended cleaning instructions.

Oscillating positive expiratory pressure (PEP) combines the techniques of PEP with high-frequency oscillations at the airway opening. Flutter valve device is the original oscillating PEP, developed in Switzerland in the late 1980s, however, it is no longer available for sale in Canada. Oscillating PEP generates oscillations of about 15Hz, which are transmitted through the airways. The interruption in the airflow with the oscillation helps to loosen the mucous and move it to the upper airways. By gently breathing out through an oscillating PEP device, a positive pressure of 18-22cm of water back pressure is created, which helps mobilize the mucous in the airways. Holding one’s breath for about 3 seconds after breathing in is recommended to allow air to be pushed behind the mucous and promote movement of the secretions.

There is currently one oscillating PEP device for sale in Canada that has been shown to be an effective form of ACT for people with CF which is the Acapella Choice.

Oscillating PEP has been shown to be as effective as other airway clearance techniques. However, in situations where an individual feels very short of breath, is diagnosed with pneumothorax, or is coughing up large amount of blood (hemoptysis) it may not be appropriate to use the oscillating PEP device. You should contact the physiotherapist on the CF team for an assessment and advice. Note that proper cleaning of the oscillating PEP device after each use and disinfecting the device regularly are vital.

Many people with and other medical conditions use high-frequency chest wall oscillation (HFCWO) vests, otherwise known as airway clearance systems, as part of their daily airway clearance routine. The goals of HFCWO treatment are the same as with any other airway clearance technique—to break up mucus and help bring it to the upper airways, where it can be coughed out or removed by suction. The machine connected to the vest is an air compressor that delivers bursts of air to rapidly inflate and deflate the vest. This creates gentle pressure and vibration on the chest, which does three things:

  1. Breaks up mucus, making it thinner
  2. Creates “mini-coughs” in the lungs, which help push the mucus out
  3. Makes the cilia move faster, helping them carry the loosened mucus to the upper airways

These systems can be expensive or hard to find. New models of the vest can cost between $15,000 and $20,000, and may not always be covered by insurance. For example, most insurance companies require certain criteria to be met before they agree to pay for the vest. For example, some insurers may want documentation of frequent respiratory infections or evidence that other airway clearance techniques have been attempted with limited or no success. For some, the vest offers a great alternative or addition to manual chest physiotherapy (CPT), but it’s not necessarily the best option for everyone. The decision to use HFCWO therapy or not is a choice based on personal preference and healthcare provider recommendations.

HFCWO vests are only available by prescription. If you are considering using the vest, talk to your healthcare provider or CF centre.

Other newer techniques available on the market are Frequencer™ and Aerobika® although there is limited published literature on the efficacy of these devices.

Exercise

It’s unlikely to surprise anyone to hear that exercise is good for you. Our bodies have adapted over thousands of years to make us really good at moving around, jumping, running and carrying. Unfortunately, due to our modern lifestyles, the vast majority of people in the developed world are underactive. This includes people living with CF. Living with CF can make finding time for exercise even more challenging given the daily grind of treatments and therapies. Not to mention that for someone with a lung condition, being short of breath can be even more distressing than being short of breath to someone without any lung issues. Research demonstrates that exercise can help with improving bone density and muscle mass, managing a range of mental health issues such as anxiety, depression and sleeping issues. Exercise may be used by many people living with CF to help control blood glucose levels. Exercise can also be an adjunct to airway clearance (ACT) but research to date has not indicated that exercise can replace ACT (more on this later).

Exercise can be broken down into three main categories: Cardiovascular, strength and flexibility. Each of these are important and you might find that you can do all three types in any workout.

Cardiovascular exercise is exercise that will increase your heart rate and respiratory rate. Some examples of cardio exercise are walking, jogging, biking, dance or aerobics classes. It is important to make sure that the intensity is just right for this type of exercise. We like to use the “talk test” to gauge intensity: If you can have a full conversation without having to stop for a breath, the intensity of exercise is likely too low, on the other hand, if you need to gasp after every word, the intensity is likely too high. Aim for somewhere in the middle.

Cardiovascular exercise is typically performed for 15-20 mins or longer, in which case would be considered endurance training. This type of exercise makes your body better at exercising for a longer period of time without getting tired. This will make typical tasks that you do daily: walking to the store, doing housework or walking up stairs, easier to do over time. This is because you train your heart, lungs, muscles and nervous system to be more efficient at these activities and they tend to not get tired when you then perform them as part of your daily activities.

Strength training, also called resistance training or conditioning, is often done for shorter periods of time but involves lifting heavier weight for a prescribed number of repetitions (reps). You then typically repeat that set of reps 2-4 times (or more depending on your fitness goals). Strength training can be used to recover from or prevent injury, to decrease pain, to improve body composition eg increase muscle mass and to improve bone density; this is especially relevant for people with osteopenia or osteoporosis. Depending on the amount of weight lifted and reps/sets performed, strength training can be used to improve speed, power, strength or endurance. Strength training can be performed in a small space with limited exercise equipment; even a backpack with bottles of water in it can be used as a cheap alternative to more expensive weight equipment. Remember: one litre weighs the same as one kilogram so it is easy to track and progress your workouts. Strength training does not usually require the same amount of heavy breathing as cardio exercises; therefore, it could be a really good place to start if you find getting short of breath is distressing for you.

Flexibility training, sometimes called stretching, is a way of moving your body or a part of your body through full range of movement. Flexibility training may look like movement ‘flows’ or may follow more structured patterns such as yoga postures and holds. You may prefer to work on static stretching to improve flexibility. This involves bringing a muscle to its end range and holding it there for at least 30 seconds. Whatever way you choose to improve or maintain your flexibility, the goal is usually to ensure that your body can move in all the ways that it needs to in order to feel good and work optimally. Just remember: if you want to maintain your new found flexibility, you need to strengthen this position and repeat it regularly.

One of the most common questions I get asked about exercise is “what is the best exercise to do?”. My answer to this is “it depends”. The exercise that will help you achieve your fitness goals is the exercise that you enjoy doing and do regularly (4-6 times per week). It is important that you start slowly and gradually increase the time or intensity of exercises. This may look like doing 5 mins of walking every other day. If you have stuck to this after a month then increase the time spent walking or the amount of days walking. Gradually, over time, you will get better and better at this and it will feel easier. When it feels easier, you can progress. The one caveat is that you really do need to stay consistent. Intermittent bouts of exercise likely won’t create real change and will probably just leave you sore, frustrated and disliking exercise. The real magic happens when exercise just becomes part of your daily routine.

Now for the part that you’re all interested in: “can I do exercise instead of official airway clearance?”. Unfortunately, the evidence we have to date does not support using exercise as a stand-alone treatment for airway clearance. Some studies do show that exercise can be used as an adjunct to airway clearance. This means that as long as you are huffing and coughing during and after exercise, your lung function is stable and relatively good, you may be able to use exercise as one of your “twice per day” airway clearance routines. You still need to be taking all of your treatments and performing a standard form of airway clearance daily on top of the exercise and huffing/coughing mentioned above. If you would like to learn more about your options for airway clearance, reach out to your CF Physiotherapist and we will be more than happy to discuss the options with you.

When starting an exercise program, there are many factors to consider to ensure your safety and optimize your results. Your physiotherapist can assist you in tailoring the goals, frequency and intensity of your program to suit your needs!

Six Minute Walk Test

Six minute walk test (6MWT) is a standardized functional test designed to assess an individual’s functional capacity. Functional capacity refers to how able someone is to perform tasks and activities that they find necessary or desirable in their lives. When an individual is sick, their ability to function may be affected; but as one gets better, they may regain their ability to function. The only way we can accurately tell your level of functional capacity is to perform a functional test, like the 6MWT.

During a 6MWT, you are asked to walk as far as possible in six minutes on a set route. If necessary, you will be asked to use adequate supplemental oxygen as recommended by the respiratory therapist during the walk. We will measure your oxygen saturation, heart rate, your perceived breathlessness and fatigue before and after the test, and the amount of rest you need during the test. The distance you covered over the six minutes will be recorded. Studies have shown that the distance walked in the 6MWT significantly increases in the first two trials but reaches a plateau by the third trial. Thus, the third trial result will give the most accurate indication of level of functional capacity.

Research studies have shown that the distance you walk during the 6MWT is directly proportional to:

  • Your exercise tolerance
  • Your maximal oxygen consumption (VO2max – the amount of oxygen delivered to your active body tissues, indicating your fitness level)
  • Your lung function
  • Your feeling of breathlessness

Six minute walk test can provide information about your level of daily activity, your well-being, and functional exercise tolerance that you need to perform your daily activities.