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Active cycle of breathing technique for cystic fibrosis (Review)
Mckoy NA, Wilson LM, Saldanha IJ, Odelola OA, Robinson KA
Mckoy NA, Wilson LM, Saldanha IJ, Odelola OA, Robinson KA.

Active cycle of breathing technique for cystic fibrosis.
Cochrane Database of Systematic Reviews 2016, Issue 7. Art. No.: CD007862.
DOI: 10.1002/14651858.CD007862.pub4.
www.cochranelibrary.com

Active cycle of breathing technique for cystic fibrosis (Review)
Copyright © 2016 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Cochrane Trusted evidence.
Informed decisions.

Library Better health. Cochrane Database of Systematic Reviews
TABLE OF CONTENTS
HEADER......................................................................................................................................................................................................... 1
ABSTRACT..................................................................................................................................................................................................... 1
PLAIN LANGUAGE SUMMARY....................................................................................................................................................................... 2
BACKGROUND.............................................................................................................................................................................................. 4
OBJECTIVES.................................................................................................................................................................................................. 4
METHODS..................................................................................................................................................................................................... 5
RESULTS........................................................................................................................................................................................................ 7
Figure 1.................................................................................................................................................................................................. 9
Figure 2.................................................................................................................................................................................................. 11
DISCUSSION.................................................................................................................................................................................................. 17
AUTHORS' CONCLUSIONS........................................................................................................................................................................... 18
ACKNOWLEDGEMENTS................................................................................................................................................................................ 18
REFERENCES................................................................................................................................................................................................ 19
CHARACTERISTICS OF STUDIES.................................................................................................................................................................. 24
DATA AND ANALYSES.................................................................................................................................................................................... 51
Analysis 1.1. Comparison 1 ACBT versus ACBT+CCPT, Outcome 1 FEV1%........................................................................................ 52
Analysis 1.2. Comparison 1 ACBT versus ACBT+CCPT, Outcome 2 FVC %......................................................................................... 52
Analysis 1.3. Comparison 1 ACBT versus ACBT+CCPT, Outcome 3 Pulmonary exacerbation........................................................... 52
Analysis 2.1. Comparison 2 ACBT versus PEP, Outcome 1 FEV1........................................................................................................ 53
Analysis 3.1. Comparison 3 ACBT versus AOD (Cornet), Outcome 1 FEV1......................................................................................... 53
Analysis 4.1. Comparison 4 ACBT versus AOD (Flutter), Outcome 1 FEV1......................................................................................... 54
Analysis 4.2. Comparison 4 ACBT versus AOD (Flutter), Outcome 2 Sputum weight........................................................................ 54
Analysis 5.1. Comparison 5 ACBT+CCPT versus AOD (Flutter), Outcome 1 FEV1.............................................................................. 55
Analysis 5.2. Comparison 5 ACBT+CCPT versus AOD (Flutter), Outcome 2 FEV1%........................................................................... 55
Analysis 5.3. Comparison 5 ACBT+CCPT versus AOD (Flutter), Outcome 3 FVC................................................................................ 56
Analysis 5.4. Comparison 5 ACBT+CCPT versus AOD (Flutter), Outcome 4 FVC %............................................................................ 56
Analysis 5.5. Comparison 5 ACBT+CCPT versus AOD (Flutter), Outcome 5 Sputum weight............................................................. 56
Analysis 5.6. Comparison 5 ACBT+CCPT versus AOD (Flutter), Outcome 6 Oxygen saturation........................................................ 57
Analysis 6.1. Comparison 6 ACBT+CCPT versus HFCC (HFCWO), Outcome 1 FEV1........................................................................... 57
Analysis 6.2. Comparison 6 ACBT+CCPT versus HFCC (HFCWO), Outcome 2 FEV1%........................................................................ 58
Analysis 6.3. Comparison 6 ACBT+CCPT versus HFCC (HFCWO), Outcome 3 FVC............................................................................. 58
Analysis 6.4. Comparison 6 ACBT+CCPT versus HFCC (HFCWO), Outcome 4 FVC %......................................................................... 58
Analysis 6.5. Comparison 6 ACBT+CCPT versus HFCC (HFCWO), Outcome 5 Sputum weight.......................................................... 59
Analysis 6.6. Comparison 6 ACBT+CCPT versus HFCC (HFCWO), Outcome 6 Oxygen saturation..................................................... 59
Analysis 7.1. Comparison 7 ACBT versus AD, Outcome 1 FEV1.......................................................................................................... 59
Analysis 7.2. Comparison 7 ACBT versus AD, Outcome 2 Sputum weight......................................................................................... 60
Analysis 8.1. Comparison 8 ACBT+CCPT versus AD, Outcome 1 FEV1............................................................................................... 60
Analysis 8.2. Comparison 8 ACBT+CCPT versus AD, Outcome 2 FEV1%............................................................................................ 61
Analysis 8.3. Comparison 8 ACBT+CCPT versus AD, Outcome 3 FVC................................................................................................. 61
Analysis 8.4. Comparison 8 ACBT+CCPT versus AD, Outcome 4 FVC %............................................................................................. 61
Analysis 8.5. Comparison 8 ACBT+CCPT versus AD, Outcome 5 Sputum weight.............................................................................. 62
Analysis 8.6. Comparison 8 ACBT+CCPT versus AD, Outcome 6 Oxygen saturation......................................................................... 62
WHAT'S NEW................................................................................................................................................................................................. 62
HISTORY........................................................................................................................................................................................................ 62
CONTRIBUTIONS OF AUTHORS................................................................................................................................................................... 63
DECLARATIONS OF INTEREST..................................................................................................................................................................... 63
SOURCES OF SUPPORT............................................................................................................................................................................... 63
DIFFERENCES BETWEEN PROTOCOL AND REVIEW.................................................................................................................................... 63
INDEX TERMS............................................................................................................................................................................................... 63
Active cycle of breathing technique for cystic fibrosis (Review) i

Informed decisions.

[Intervention Review]
Active cycle of breathing technique for cystic fibrosis
Naomi A Mckoy1, Lisa M Wilson2, Ian J Saldanha3, Olaide A Odelola4, Karen A Robinson5
1SSM Microbial Upstream Common Use Production, GlaxoSmithKline, Rockville, Maryland, USA. 2Evidence-based Practice Center, Johns
Hopkins University, Baltimore, MD, USA. 3Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore,
MD, USA. 4Department of Internal Medicine, Albert Einstein Medical Center, Philedelphia, PA, USA. 5Department of Medicine, Johns
Hopkins University, Baltimore, MD, USA
Contact address: Karen A Robinson, Department of Medicine, Johns Hopkins University, 1830 E. Monument St., Suite 8068, Baltimore,
MD, 21287, USA. krobin@jhmi.edu.
Editorial group: Cochrane Cystic Fibrosis and Genetic Disorders Group

Publication status and date: New search for studies and content updated (no change to conclusions), published in Issue 7, 2016.
Citation: Mckoy NA, Wilson LM, Saldanha IJ, Odelola OA, Robinson KA. Active cycle of breathing technique for cystic fibrosis. Cochrane
Database of Systematic Reviews 2016, Issue 7. Art. No.: CD007862. DOI: 10.1002/14651858.CD007862.pub4.
ABSTRACT
Background
People with cystic fibrosis experience chronic airway infections as a result of mucus build up within the lungs. Repeated infections often
cause lung damage and disease. Airway clearance therapies aim to improve mucus clearance, increase sputum production, and improve
airway function. The active cycle of breathing technique (also known as ACBT) is an airway clearance method that uses a cycle of techniques
to loosen airway secretions including breathing control, thoracic expansion exercises, and the forced expiration technique. This is an
update of a previously published review.
Objectives
To compare the clinical effectiveness of the active cycle of breathing technique with other airway clearance therapies in cystic fibrosis.
Search methods
We searched the Cochrane Cystic Fibrosis Trials Register, compiled from electronic database searches and handsearching of journals and
conference abstract books. We also searched the reference lists of relevant articles and reviews.
Date of last search: 25 April 2016.
Selection criteria
Randomised or quasi-randomised controlled clinical studies, including cross-over studies, comparing the active cycle of breathing
technique with other airway clearance therapies in cystic fibrosis.
Data collection and analysis

Two review authors independently screened each article, abstracted data and assessed the risk of bias of each study.
Main results
Our search identified 62 studies, of which 19 (440 participants) met the inclusion criteria. Five randomised controlled studies (192
participants) were included in the meta-analysis; three were of cross-over design. The 14 remaining studies were cross-over studies with
inadequate reports for complete assessment. The study size ranged from seven to 65 participants. The age of the participants ranged
from six to 63 years (mean age 22.33 years). In 13 studies, follow up lasted a single day. However, there were two long-term randomised
controlled studies with follow up of one to three years. Most of the studies did not report on key quality items, and therefore, have an
unclear risk of bias in terms of random sequence generation, allocation concealment, and outcome assessor blinding. Due to the nature
Active cycle of breathing technique for cystic fibrosis (Review) 1
Informed decisions.

of the intervention, none of the studies blinded participants or the personnel applying the interventions. However, most of the studies
reported on all planned outcomes, had adequate follow up, assessed compliance, and used an intention-to-treat analysis.
Included studies compared the active cycle of breathing technique with autogenic drainage, airway oscillating devices, high frequency
chest compression devices, conventional chest physiotherapy, and positive expiratory pressure. Preference of technique varied: more
participants preferred autogenic drainage over the active cycle of breathing technique; more preferred the active cycle of breathing
technique over airway oscillating devices; and more were comfortable with the active cycle of breathing technique versus high frequency
chest compression. No significant difference was seen in quality of life, sputum weight, exercise tolerance, lung function, or oxygen
saturation between the active cycle of breathing technique and autogenic drainage or between the active cycle of breathing technique
and airway oscillating devices. There was no significant difference in lung function and the number of pulmonary exacerbations between
the active cycle of breathing technique alone or in conjunction with conventional chest physiotherapy. All other outcomes were either not
measured or had insufficient data for analysis.
Authors' conclusions
There is insufficient evidence to support or reject the use of the active cycle of breathing technique over any other airway clearance therapy.
Five studies, with data from eight different comparators, found that the active cycle of breathing technique was comparable with other
therapies in outcomes such as participant preference, quality of life, exercise tolerance, lung function, sputum weight, oxygen saturation,
and number of pulmonary exacerbations. Longer-term studies are needed to more adequately assess the effects of the active cycle of
breathing technique on outcomes important for people with cystic fibrosis such as quality of life and preference.
PLAIN LANGUAGE SUMMARY
A comparison of active cycle of breathing technique (ACBT) with other methods of airway clearance therapies in people with cystic
fibrosis
Review question
We reviewed the evidence about the effect of active cycle of breathing technique (ACBT) compared with other methods of airway clearance
in people with cystic fibrosis.
Background
Chronic infections are common in cystic fibrosis, and repeated infections can cause lung damage and disease. People with cystic fibrosis
use airway clearance therapies to clear mucus and improve lung function. The active cycle of breathing technique uses a combination of
three breathing methods to loosen and clear mucus. This is an update of a previously published review.
Search date
The evidence is current to: 25 April 2016.
Study characteristics
While 19 studies comparing the active cycle of breathing technique with other airway clearance therapies are included in the review,
only five studies (192 participants) reported data that we could include in the analysis. Each of the five studies compared different
techniques: the active cycle of breathing technique was compared with autogenic drainage, airway oscillating devices, high-frequency
chest compression devices, positive expiratory pressure, and conventional chest physiotherapy. Most studies lasted a single day, but there
were two studies that lasted between one and three years. Participants ranged in age from six to 63 years and most (63%) were male.
Key results
We found that the active cycle of breathing technique was comparable with other treatments in outcomes such as quality of life, personal
preference, exercise tolerance, lung function, sputum weight, oxygen saturation, and the number of pulmonary exacerbations. We were
not able to show that any single technique was better than another. Longer studies are needed to better assess the effects of the active
cycle of breathing technique on outcomes important for people with cystic fibrosis such as quality of life and personal preference.
Quality of the evidence
Many of the studies did not provide enough details of their methods to determine if there were any biases that might have affected the
results. Many studies did not report how they decided who would get which treatment and how they made sure that the people who were
putting people into the different treatment groups and those who were assessing the results did not know which group each individual
was in. Most of the included studies had a cross-over design (where people have one treatment and then switch to the second), and many
of these did not report the length of time in between different treatments. As it is possible that the first treatment might affect the results
of the next treatment, we only included results from the first treatment period. Many of the studies did not report separate results for just
the first treatment period, so we did not include their results in our review.

Informed decisions.

All participants knew which treatment group they were in (it is not possible to disguise different physiotherapy techniques). This could
have affected the results for some of the self-reported outcomes, such as quality of life, personal preference, or exercise tolerance, but is
unlikely to have affected the more objective outcomes, such as lung function.
Most of the studies followed those taking part for less than one month and did this for most of the participants for the entire study period.
In two out of the three longer studies more than 10% of the people taking part dropped out. The study results could be affected if the
people who dropped out of the studies were not evenly spread across the different treatment groups.
Over half of the studies checked that participants were using the airway clearance therapy they were supposed to. Most of the studies
reported on all their planned outcomes.
The findings of the review were limited as not many studies made the same comparisons; also, there were not many long-term studies and
the studies we included did not report enough data.

Informed decisions.

BACKGROUND hPEP, AOD, and HFCC. The techniques in this review which require
assistance include CCPT and RIM. Descriptions of all interventions
Description of the condition can be found in the Types of interventions section.
Cystic fibrosis (CF) is a hereditary multisystem disorder. It is How the intervention might work
a relatively common autosomal recessive disease, occurring in
approximately 1 in 2500 live births (Ratjen 2003). It predominately In ACBT, a cycle of techniques is used to loosen airway secretions.
affects the lungs, liver, and the exocrine glands of the pancreas and The techniques include breathing control, thoracic expansion
intestines. Individuals with CF have a defect in the gene responsible exercises, and the forced expiration technique (FET). In breathing
for the chloride channel that co-ordinates salt transport across cells control, the individual performs tidal breathing (gentle relaxed
(Rowe 2005). Abnormal sodium transport results in the production breathing) using the lower chest, at his or her own rate and depth
of viscous mucus and an environment susceptible to chronic airway (International Physiotherapy Group for CF 2009). Individuals are
obstruction. This leads to pulmonary colonisation by pathogenic encouraged to relax their shoulders and upper chest. Breathing
bacteria. Pulmonary disease is the leading cause of morbidity and control is the resting period between the active parts of ACBT.
mortality in people with CF, accounting for 90% of deaths (Ramsey Thoracic expansion exercises consist of deep breathing with
1996). inspiration and passive relaxed expiration. In FET, huffing and
breathing control are combined so that one or two forced
Currently there is no cure for CF, but treatment has been developed expirations (huffs) are interspersed with periods of breathing
to increase the life span and quality of life of individuals with control (International Physiotherapy Group for CF 2009). Huffing
CF. The United States of America (USA) Cystic Fibrosis Patient is a type of cough which includes inhaling and active exhaling
Registry compared data of individuals with CF between 1986 and (Cystic Fibrosis Foundation 2009). The length of the huff is altered to
2010; the median age of survival in 2010 was 38.3 years compared optimise clearance. Huffing helps mobilise and clear peripherally-
to approximately 27 years in 1986 (Cystic Fibrosis Foundation situated secretions (Pryor 1999). One of the benefits of this
2010). Importance has been placed on early diagnosis as well as technique is that it can be self-administered by the person with CF.
effective disease management. Advances in the areas of airway
infection control, secretion mobilisation, and reduction of airway Why it is important to do this review
inflammation have greatly decreased disease-related morbidity
People with CF experience chronic airway infections as a result
and mortality over the past 20 years (Rubin 1999).
of mucus build up within the lungs. Repeated infections cause
Description of the intervention lung damage and disease which are the main causes of death in
individuals with CF. For this reason, airway clearance therapies play
There are a number of methods used to remove airway secretions an important role in the treatment of CF. Scientists have not agreed
in individuals with CF. These include a variety of medications and upon a definitive method of treatment, thus both conventional
inhalation therapies, as well as breathing exercises and devices. and alternative treatments are in widespread use. Many treatment
The goals of chest physiotherapy (usually initiated soon after centres apply those methods that are most familiar to them and
diagnosis) are to improve mucus clearance, increase sputum neglect others. Globally, it has been observed that CCPT is widely
production, and improve airway function. A Cochrane review used in the USA; ACBT is most commonly used in the United
concluded that chest physiotherapy was beneficial for mucus Kingdom (UK); PEP, flutter (AOD) and AD are commonly used in
transport in people with CF (Warnock 2015). There is a significant the rest of Europe; and exercise is the favoured treatment in the
increase in the volume of sputum produced when performing chest Scandinavian countries (Prasad 1998b). Other Cochrane reviews
physiotherapy compared with cough alone (Lorin 1971). have explored the effectiveness of airway clearance therapies in
CF including CCPT (Main 2005; Warnock 2015), PEP (McIlwaine
Conventional chest physiotherapy (CCPT) has been the standard 2015), and AOD (Morrison 2014). Only two of the reviews included
treatment used to treat excessive mucus secretions in CF in results on comparisons involving ACBT versus other therapies.
North America since the 1950s (McIlwaine 1997). Other airway One review compared ACBT with CCPT (Main 2005), while another
clearance therapies became popular in the 1990s (McIlwaine 2007). compared ACBT with AOD (including flutter, acapella, cornet,
These include the active cycle of breathing technique (ACBT), intrapulmonary percussive ventilation (IPV), and extra-thoracic
positive expiratory pressure (PEP) mask therapy, high-pressure PEP oscillations) (Morrison 2014). A review comparing ACBT with all
(hPEP) mask therapy, airway oscillating devices (AOD), autogenic therapies is needed.
drainage (AD), high frequency chest compression devices (HFCC),
and the resistive inspiratory manoeuvre (RIM). In the early 1990s, This is an updated version of a previously published review (McKoy
concern about oxygen desaturation during chest physiotherapy 2012; Robinson 2010).
was addressed with the use of sufficient pauses for relaxation
and breathing control during ACBT (Pryor 1990b). In the late OBJECTIVES
1990s, the use of AOD was shown to enhance mucus expectoration
during exacerbations of CF lung disease (Gondor 1999). A number To compare the clinical effectiveness of ACBT with other airway
of these therapies can be self-administered by the individual, clearance therapies in CF.
while others require the assistance of a trained physiotherapist,
parent, or caregiver. The self-administered techniques can be
performed anywhere once the individual is properly trained. The
self-administered techniques included in this review are ACBT,
AD, and exercise. The techniques in this review which can be
self-administered but require the use of a device include PEP,

Informed decisions.

METHODS Oscillatory Devices

Airway oscillating devices (AOD)
Criteria for considering studies for this review
Includes flutter, cornet, acapella, and intrapulmonary percussive
Types of studies ventilation (IPV). This technique can be self-administered but
Randomised or quasi-randomised controlled clinical studies, requires a device.
including cross-over studies.
High frequency chest compression devices (HFCC)
Types of participants The VestTM (formerly known as ThAIRapy Vest and manufactured
Individuals with CF diagnosed based on clinical criteria, sweat by Hill-Rom) and the Hayek Oscillator (manufactured by Breasy
testing or genotype analysis. Medical Equipment Ltd) provide external chest wall compression.
This also includes high frequency chest wall oscillations (HFCWO)
Types of interventions which utilizes The VestTM with interim periods of huffs or coughs.
This technique can be self-administered but requires a device.
We compared ACBT with other airway clearance therapies. This
includes comparisons as a single technique (e.g. ACBT versus AD or Breathing Techniques (excluding ACBT)
ACBT versus AD and AOD) or in conjunction with other techniques
(e.g. ACBT versus ACBT and CCPT). Autogenic drainage (AD)
A self-administered breathing technique that uses optimal

Airway clearance therapies include: expiratory flow rates at varying lung volumes to mobilise mucus
while avoiding airway closure.
Intervention
Active Cycle of Breathing Technique (ACBT) Exercise
This self-administered technique combines breathing control with A combination of endurance and strength training for the upper and
thoracic expansion and the forced expiration technique (FET). It lower body. This technique is self-administered.
may also include postural drainage and chest clapping.
Other Therapy
The ACBT were initially described as FET. In 1990, the term ACBT Resistive inspiratory manoeuvre (RIM)
was developed to emphasise the importance of breathing control
and thoracic expansion, in addition to FET, within the technique Includes inspiration against resistance after forced expiration.
(Webber 1998). As a result of this reclassification, we included all Repeated inspirations at 80% of the maximum sustained
studies which described FET interventions that contained all of inspiratory pressure are completed in groups of six efforts with
the components of ACBT outlined above. We used the definitions rest intervals in between (Chatham 2004). This technique requires
of the ACBT components as described by the Cystic Fibrosis assistance and the use of a device.
Foundation and the Cystic Fibrosis Trust in the process (Cystic
Types of outcome measures
Fibrosis Foundation 2009; Cystic Fibrosis Trust 2002).
Primary outcomes
Comparators
1. Quality of life - all instruments that measure the ability of
Conventional chest physiotherapy (CCPT) participants to perform activities of daily living (including but
Combines a collection of techniques which include postural not limited to the Cystic Fibrosis Questionnaire (CFQ), Health
drainage, percussion, chest shaking, huffing, and coughing. Assessment Questionnaire (HAQ), Quality of Well Being (QWB)
Excludes the use of exercise, FET, PEP, or other mechanical devices. scale, and Nottingham Health Profile (NHP))
This technique requires assistance. 2. Personal preference - the nominated technique of choice by the
participant at the conclusion of the study, or by comparison of
PEP technique acceptability
Positive expiratory pressure (PEP) mask therapy 3. Mortality
Breathing with a positive expiratory pressure of 10 cm to 25 cm Secondary outcomes
of water. This technique can be self-administered but requires a
device. 1. Adverse events
2. Exercise tolerance - subjective exercise tolerance or objective
High pressure PEP (hPEP) mask therapy measures such as the six-minute walk test or treadmill test
A modification of PEP that includes a full forced expiration against 3. Lung function
a fixed mechanical resistance which usually generates pressures a. forced expiratory volume in one second (FEV1) in litres or per
ranging from 40 cm to 100 cm of water (McIlwaine 2015). This cent (%) predicted
technique can be self-administered but requires a device. b. forced vital capacity (FVC) in litres or % predicted
4. Sputum weight (g)
a. dry weight
b. wet weight

Informed decisions.

5. Oxygen saturation assessors; compliance assessment; washout reporting; intention-

a. arterial blood gas to-treat analysis; adequate follow up; and selective reporting. Two
b. pulse oximetry review authors independently applied the methods for evaluating
c. transcutaneous oximetry the risk of bias as described in the Cochrane Handbook for
Systematic Reviews of Interventions (Higgins 2011). A third author
6. Number of pulmonary exacerbations
resolved any disagreements.
Search methods for identification of studies Measures of treatment effect
Electronic searches We analysed continuous outcomes by mean difference (MD) (or
We identified relevant studies from the Group's Cystic Fibrosis Trials we calculated standardised mean difference (SMD) if study reports
Register using the terms: active cycle breathing technique (ACB) OR used different scales of measurement). We analysed dichotomous
forced expiration technique (FET or Huff). outcomes using risk ratios (RR). We have presented all outcomes
with the associated 95% confidence intervals (CIs).
The Cystic Fibrosis Trials Register is compiled from electronic
searches of the Cochrane Central Register of Controlled Trials Unit of analysis issues
(CENTRAL) (updated each new issue of The Cochrane Library), When conducting analyses we took into consideration the level
weekly searches of MEDLINE, a search of Embase to 1995 and the at which randomisation occurred (Deeks 2011). Randomised
prospective handsearching of two journals - Pediatric Pulmonology controlled studies with parallel group designs are studies
and the Journal of Cystic Fibrosis. Unpublished work is identified where individuals are independently randomised to intervention
by searching the abstract books of three major cystic fibrosis groups. In randomised cross-over studies, individuals receive each
conferences: the International Cystic Fibrosis Conference; the intervention sequentially in a random order. Cross-over studies
European Cystic Fibrosis Conference and the North American Cystic usually contain a washout period, which is a stage after the first
Fibrosis Conference. For full details of all searching activities for treatment but before the second treatment, where time is given for
the register, please see the relevant sections of the Cochrane Cystic the active effects of the first treatment to wear off before the new
Fibrosis and Genetic Disorders Group Module. treatment begins (i.e. to reduce the carry-over effect). A concern
with the cross-over design is the risk of a carry-over effect when the
Date of most recent search: 25 April 2016. first treatment affects the second. If the carry-over effect exceeds
the washout period, the washout is inadequate. For this review, we
Searching other resources
considered an adequate washout period for cross-over studies to
We searched the reference lists of relevant articles and reviews for be a minimum of one day.
additional studies.
When including both parallel and cross-over studies with an
Data collection and analysis adequate washout period, we used the inverse variance method,
as recommended by Elbourne (Elbourne 2002). In this method,
Selection of studies we used the results from paired analyses (including an estimate
We used a two-tier screening process to identify relevant articles. of treatment effect and its standard error) of the cross-over
Initially, we screened the titles and abstracts of articles identified studies. In the meta-analysis, the weight of each study is inversely
through searching and obtained the full text versions of those proportional to the variance (one over the square of the standard
considered potentially relevant. We then screened the full text error) (Deeks 2011). When including cross-over studies with an
articles to identify those studies which were eligible for data inadequate washout period we used only the first-arm data. Even
abstraction and should be included in the review. Two review though all information is not considered in this method, this avoids
authors independently screened each article. We resolved any inappropriate consideration of multiple arms.
disagreements by consensus or by consulting a third review author.
Dealing with missing data
Data extraction and management We contacted the original investigators of studies when we
We imported the search results into a reference management encountered missing, incomplete, or unclear data. If we could not
software (Procite, Thomson Reuters, Stamford, CT). We used this locate the investigators or they did not send the requested data, we
software to track the results of the two-tier screening process. categorised these studies as 'Studies awaiting classification', to be
We then abstracted information from eligible review articles and included in future updates of the review, if data are made available.
entered data into RevMan 5.3 (RevMan 2014).
Assessment of heterogeneity
We grouped studies together based on the time of assessment of If we are able to include sufficient data in future updates,
outcomes. We considered outcomes as immediate if less than one we will assess heterogeneity within each outcome between the
day duration; short term if up to one week duration; medium term
comparisons using the Chi2 test and I2 statistic (Deeks 2011).
if up to one month duration; and long term if beyond one month
duration. Under the null hypothesis of homogeneity, we will consider a P
value less than 0.10 to indicate the presence of heterogeneity in the
Assessment of risk of bias in included studies
Chi2 test (Deeks 2011). We will interpret the results with care since
We assessed the risk of bias in included studies through the test could have low or high power. Low power is common when
assessment of sequence generation; allocation concealment; studies have a small sample size or there are a small number of
blinding of the study participants, personnel, and outcome studies, which may result in the lack of detection of heterogeneity
Informed decisions.

when it is present. High power is common when there are many RESULTS
studies being analysed, resulting in the detection of heterogeneity
that might be insignificant. Description of studies
The I2 statistic measures the proportion of inconsistency in Results of the search

individual studies that cannot be explained by sampling error. In The electronic searches identified 72 citations representing 42
this test the degree of heterogeneity is quantified. The values of studies. We identified an additional 20 citations, representing 20
I2 lie between 0% and 100%. We will consider results for I2 which studies, by searching the reference lists of relevant articles. In
are less than 40% to indicate that heterogeneity might not be total, there were 92 citations representing 62 studies. Of these,
important, between 30% and 60% to indicate that heterogeneity we included 35 citations representing 19 studies and excluded 45
may be moderate, between 50% and 90% to indicate that citations representing 36 studies (see below). We have listed 12
heterogeneity may be substantial, and between 75% and 100% to citations representing seven studies as awaiting classification.
indicate considerable heterogeneity (Deeks 2011).
Studies Awaiting Classification
Assessment of reporting biases
We have listed seven studies (12 citations) as awaiting
We assessed outcome reporting bias. Study authors may record classification. Six of the studies were associated with abstracts
more outcome measures than they choose to publish, which that provided insufficient information (Castle 1994; Chatham 1999;
can lead to misleading results (Sterne 2011). We compared the Falk 1993; Lannefors 1992; Parker 1984; Petrone 2009). No full-text
'Methods' section of each included paper to the 'Results' section to publications were found that were associated with the abstracts.
ensure all outcomes were reported. The study authors have been contacted for additional data.
If we are able to include sufficient data in future updates, we One study compares CCPT with FET (van Hengstum 1988). Results
will assess reporting bias among the studies using the funnel were presented for the eight participants involved in the study (six
plot method discussed in the Cochrane Handbook for Systematic with CF and two with agammaglobulinaemia). The study authors
Reviews of Interventions (Sterne 2011). If asymmetry is present, have been contacted to obtain data for CF participants separately.
we will explore possible causes including publication bias, poor
methodological quality, and true heterogeneity. Included studies
Data synthesis We included 35 citations representing 19 studies. Full text articles

were available for 16 studies (Bilton 1992; Chatham 2004; Fauroux
We entered data abstracted from included studies into RevMan 5.3 1999; Hofmeyr 1986; Holland 2003; Miller 1995; Milne 2004;
(RevMan 2014). We analysed each comparator separately. Mortensen 1991; Osman 2008; Phillips 2004; Pryor 1979; Pryor 1994;
Reisman 1988; Steven 1992; Webber 1985; Pryor 2010), while only
If we are able to include sufficient data in future updates, we abstracts were available for three studies (Howard 2000; Kofler
will assess heterogeneity. If we determine that heterogeneity may 1994; Pike 1999). When multiple citations were available for a
be moderate, substantial, or considerable, as indicated by an I2 study, data were extracted from full text articles. All citations were
result greater than 30%, we will use the random-effects model to reviewed, and when applicable, additional outcomes not included
synthesise the results. Otherwise, we will synthesise the results in the full-text articles were also abstracted.
using a fixed-effects model.
Of the 19 included studies, five studies were included in the
Subgroup analysis and investigation of heterogeneity meta-analysis: two randomised controlled parallel studies, two
If we are able to include sufficient data in future updates, we will randomised cross-over studies with adequate washout periods,
investigate heterogeneity by performing the following subgroup and one randomised cross-over study with an inadequate washout
analyses: period for which there is first-arm data before the first cross-
over period. The remaining studies were randomised cross-over
• treatment setting (home versus hospital); studies with inadequate washout periods, and we have attempted
• treatment length (one day on and one day off, once daily, twice to obtain first-arm data collected before the first cross-over. We
daily, three times daily, three times per week); have contacted the study authors and are awaiting their responses.
We have included information on all 19 included studies in the
• age (paediatric, adolescent, adult);
sections Included studies and Risk of bias in included studies. We
• gender; have included results on the five studies included in the analysis in
• disease severity (FEV1 % predicted above 90%, 70% to 89%, 40% the Effects of interventions section.
to 69%, under 40%).
Trial design
Sensitivity analysis
In 13 studies the intervention duration was less than one day
If we are able to include sufficient data in future updates, we will (Bilton 1992; Fauroux 1999; Hofmeyr 1986; Holland 2003; Howard
perform sensitivity analyses to identify the effects on the results of 2000; Miller 1995; Milne 2004; Mortensen 1991; Osman 2008; Phillips
study size (stratify by sample size), study design (cross-over versus 2004; Pike 1999; Pryor 1994; Steven 1992). Three studies had an
parallel studies), allocation concealment (high risk of bias versus intervention duration between two days and one week (Chatham
low risk of bias), assessor blinding (high risk of bias versus low risk 2004; Pryor 1979; Webber 1985). Three studies had an intervention
of bias), and loss to follow up (high risk of bias versus low risk of duration of greater than one month (Kofler 1994; Pryor 2010;
bias). Reisman 1988). The intervention durations of the randomised

Informed decisions.

controlled trials with a parallel design were one and three years Pike 1999; Pryor 2010). Six studies included FET as an intervention,
(Pryor 2010; Reisman 1988). but reported FET to contain all of the components of ACBT as
described in the Methods section of this review (Fauroux 1999;
We defined adequate washout for cross-over studies to be a Hofmeyr 1986; Mortensen 1991; Pryor 1979; Reisman 1988; Webber
minimum of one day. A total of 17 of the 19 studies were randomised 1985). We considered these six studies as including ACBT as an
cross-over studies (Bilton 1992; Chatham 2004; Fauroux 1999; intervention.
Hofmeyr 1986; Holland 2003; Howard 2000; Kofler 1994; Miller 1995;
Milne 2004; Mortensen 1991; Osman 2008; Phillips 2004; Pike 1999; In eight studies, ACBT was compared as a single technique (Howard
Pryor 1979; Pryor 1994; Steven 1992; Webber 1985); two had a 2000; Kofler 1994; Miller 1995; Milne 2004; Phillips 2004; Pike 1999;
parallel design (Pryor 2010; Reisman 1988). Of these, only three Pryor 2010; Steven 1992) and in conjunction with other techniques
studies had adequate washout periods (Miller 1995; Milne 2004; in 11 studies (Bilton 1992; Chatham 2004; Fauroux 1999; Hofmeyr
Phillips 2004). For studies with adequate washout periods, we have 1986; Holland 2003; Mortensen 1991; Osman 2008; Pryor 1979;
included all data. For studies with inadequate washout periods, Pryor 1994; Reisman 1988; Webber 1985). Postural drainage was
we planned to include only first-arm data collected before the included as a component of ACBT in four studies (Miller 1995;
first cross-over. In one study which had no washout period, we Mortensen 1991; Steven 1992; Webber 1985).
contacted the authors and we were able to obtain first-arm data
which we have included (Osman 2008). We have contacted the Outcomes
corresponding authors of the remaining studies with inadequate Of the nine outcomes of this review, only seven were assessed
or not reported washout periods, and are awaiting their responses in the eligible studies. These included quality of life, personal
(Bilton 1992; Chatham 2004; Fauroux 1999; Hofmeyr 1986; Holland preference, exercise tolerance, lung function, sputum weight,
2003; Howard 2000; Kofler 1994; Mortensen 1991; Pike 1999; Pryor oxygen saturation, and number of pulmonary exacerbations.
1979; Pryor 1994; Steven 1992; Webber 1985). Sputum weight was the most often reported outcome, discussed
in 17 of the 19 studies (Bilton 1992; Chatham 2004; Fauroux 1999;
Participants
Hofmeyr 1986; Holland 2003; Howard 2000; Miller 1995; Milne 2004;
There were a total of 440 participants across the 19 studies. The Mortensen 1991; Osman 2008; Phillips 2004; Pike 1999; Pryor 1979;
smallest study had seven participants (Milne 2004), while the Pryor 1994; Pryor 2010; Steven 1992; Webber 1985). The least
largest had 65 participants (Pryor 2010). Age ranged from six years reported outcomes, which were each discussed in only one study,
to 63 years across all studies, and the mean age was 22.33 years. was quality of life (Pryor 2010), exercise tolerance (Pryor 2010), and
Of the 407 participants in the 17 studies which reported gender number of pulmonary exacerbations (Reisman 1988).
distribution, 256 (63%) were male. Two studies, only available in
abstract form, did not report age or gender distributions (Howard Excluded studies
2000; Kofler 1994). We excluded 45 citations representing 36 studies. Nine studies
were excluded because they did not address ACBT (Asher 1982;
The participants in a number of the included studies were
Bain 1988; Baldwin 1994, Chatham 1998; Desmond 1983; Kofler
identified as being infected or colonised with bacteria. In four
1998, McDonnell 1986; Rossman 1982; Sutton 1985). Nine studies
studies, all analysed participants were infected or colonised with
were excluded because they were non-randomised (Klig 1989;
Pseudomonas aeruginosa (Bilton 1992; Chatham 2004; Hofmeyr
Oberwaldner 1986; Orlik 2000; Orlik 2001 Pryor 1990a; Rogers 1984;
1986; Mortensen 1991). In another study, approximately half of
Salh 1989; Webber 1986; Wilson 1995). Five studies were excluded
the participants were infected or colonised with Pseudomonas
because they were review articles with no original data (Prasad
aeruginosa and Burkholderia cepacia (Fauroux 1999). In five
1998a; Prasad 2000; Thomas 1995; Williams 1994; Williams 2000).
studies, all participants had an exacerbation of bronchopulmonary
Four studies were excluded because the articles did not address
infection (Hofmeyr 1986; Phillips 2004; Pryor 1979; Steven 1992;
people with CF (Hasani 1991; Hasani 1994a; Hasani 1994b; van
Webber 1985). Authors of one study noted that all of the
Hengstum 1987). Four studies were excluded because there were
participants had a history of chronic bronchopulmonary infection
no comparisons of interest (Braggion 1995; Verboon 1986; White
(Pryor 1994). One study excluded individuals who had acquired
1997; Williams 2000; Znotina 2000). Four studies were excluded
Burkholderia cepacia within the last three months (Pryor 2010).
because the description of the FET intervention did not contain
One study stratified randomisation by age, sex, and all components of ACBT (Andreasson 1987; Falk 1984; Gursli 2013;
pulmonary impairment (Reisman 1988) and another study Sutton 1983). One additional study was excluded because the
stratified randomisation by pulmonary impairment and sputum intervention of interest was not randomised (Steen 1991).
expectorated (Pryor 2010). Stratification of results based on degree
of pulmonary impairment was performed in three studies (Fauroux Risk of bias in included studies
1999; Miller 1995; Mortensen 1991). Risk of bias was assessed for sequence generation; allocation
concealment; blinding of the study participants, personnel, and
Interventions outcome assessors; incomplete outcome data (intention-to-treat
In 13 studies ACBT was specifically named as an intervention (Bilton analysis, adequate follow up); selective reporting within each
1992; Chatham 2004; Holland 2003; Howard 2000; Kofler 1994; study; and other potential sources of bias (compliance or
Miller 1995; Milne 2004; Osman 2008; Phillips 2004; Pike 1999; Pryor adherence assessment; washout reporting). Please see the figures
1994; Pryor 2010; Steven 1992). Of these studies, the components of for a summary of judgements on the risk of bias of all included
ACBT were not described in four studies (Howard 2000; Kofler 1994; studies (Figure 1; Figure 2).


Informed decisions.

Figure 1. Methodological quality summary: review authors' judgements about methodological quality items for
each included study.

Informed decisions.


Figure 1. (Continued)


Informed decisions.

Figure 2. Methodological quality graph: review authors' judgements about methodological quality items presented
as percentages across all included studies.

Allocation to blind the participants or personnel as observed in all included
studies.
Sequence generation
In one of the 19 studies, which compared HFCWO with usual The outcome assessor was reported as blinded in four studies
ACT, participants performed their usual ACT or HFCWO during (Chatham 2004; Holland 2003; Pryor 1994; Pryor 2010). In one
alternate day treatment and allocation to either treatment on day study it was noted that the laboratory researcher was blinded
one was determined using a computer-generated randomisation to the treatment administered to participants (Chatham 2004). In
table (Osman 2008). A second study used a computer-generated the other three studies, the authors noted that an independent
randomisation scheme to randomise participants to one of five data collector, who was blinded to treatment order or treatment
airway clearance therapies (Pryor 2010). Thus the risk of bias of assignment, collected the measurements (Holland 2003; Pryor
sequence generation was low in these two studies. 1994; Pryor 2010). There is a low risk bias of blinding of outcome
assessors associated with these four studies. In the remaining 15
In 17 of the 19 included studies, the authors did not specify how the studies the blinding of the outcome assessor is unclear, thus the risk
random allocation was generated. The studies made statements of bias is unclear.
that participants were randomly allocated to different treatment
groups, but did not completely define the approaches. The risk of Incomplete outcome data
bias of sequence generation was unclear in these studies (Bilton Intention-to-treat
1992; Chatham 2004; Fauroux 1999; Hofmeyr 1986; Holland 2003;
Howard 2000; Kofler 1994; Miller 1995; Milne 2004; Mortensen 1991; The use of intention-to-treat analyses was unclear in two studies
Phillips 2004; Pike 1999; Pryor 1979; Pryor 1994; Reisman 1988; that are only available as abstracts (Howard 2000; Pike 1999).
Steven 1992; Webber 1985). The risk of bias regarding intention-to-treat is unclear in these
two studies. In seven studies, intention-to-treat analyses were
Allocation concealment not performed (Holland 2003; Kofler 1994; Osman 2008; Pryor
1979; Pryor 1994; Pryor 2010; Reisman 1988). All seven studies are
Concealment of treatment allocation was reported in only one
associated with a high risk of bias because they did not include
study where authors described the use of sealed envelopes during
outcome data from participants who withdrew in the analysis. The
randomisation; therefore we judged there to be a low risk of bias
remaining 10 studies are associated with a low risk of bias. In these
due to allocation concealment associated with the study (Phillips
studies, the participants were analysed in the groups to which they
2004). In the remaining 18 studies, the allocation concealment was
were randomised.
unclear, thus the risk of bias of allocation concealment was unclear.
Adequate follow up
Blinding
It is unclear if follow up was adequate in two studies which were
Each intervention within the included studies was associated with
only available as conference abstracts (Howard 2000; Pike 1999).
a physical activity or mechanical devices (or both) which are
The risk of bias due to adequate follow up is unclear in these two
necessary to the intervention. For this reason it was not feasible
studies.

Informed decisions.

Follow up was inadequate in four studies (Kofler 1994; Pryor 1979; Other potential sources of bias
Pryor 1994; Pryor 2010). In one of these studies, which is only
Compliance Assessment
available in abstract form, 10 out of 33 (30.30%) children with CF
did not complete the program, and there was no description of Compliance was assessed in 11 out of the 19 studies (Chatham
reasons for loss to follow up (Kofler 1994). In a second study, two 2004; Fauroux 1999; Milne 2004; Mortensen 1991; Osman 2008;
out of 18 CF participants (11.11%) withdrew: one person developed Phillips 2004; Pryor 1979; Pryor 1994; Reisman 1988; Webber 1985;
a pneumothorax and the other person was unable to produce Pryor 2010). Compliance assessment involved the use of a diary in
enough sputum for an accurate assessment (Pryor 1979). In the one study (Reisman 1988), monthly review in another study (Pryor
third study, four out of 24 (16.67%) participants withdrew from the 2010), and supervision in the remaining nine studies. The risk of
study: two participants had their drug regimens changed during bias from compliance assessment is low in these 11 studies. In the
the study and two participants withdrew because of technical remaining eight studies it is unclear if compliance was assessed,
problems with the oximeter and collection of sputum (Pryor 1994). thus the risk of bias from compliance assessment is unclear.
In the fourth study, 10 out of 75 participants (13.33%) were lost
to follow up: one died, one was accepted to the transplantation Washout
list, one required a limited pleurodesis for a pneumothorax, three A total of 17 of the 19 included studies were randomised cross-
were lost to follow up, and three withdrew; the status of one of the over studies (Bilton 1992; Chatham 2004; Fauroux 1999; Hofmeyr
participants was not reported (Pryor 2010). Since the loss to follow 1986; Holland 2003; Howard 2000; Kofler 1994; Miller 1995; Milne
up was greater than 10% in all four studies, they are associated with 2004; Mortensen 1991; Osman 2008; Phillips 2004; Pike 1999; Pryor
a high risk of bias. 1979; Pryor 1994; Steven 1992; Webber 1985). Of these, three had
adequate washout periods (at least one day): one study had a
In the remaining 13 studies the follow up was adequate, thus
seven-day washout period (Miller 1995) and two studies had a one-
there is a low risk of bias of follow up associated with these
day washout period (Milne 2004; Phillips 2004); for this reason, we
studies. While all of the participants were accounted for in these 13
judged them to have a low risk of bias. One study, for which we
studies, authors in three studies reported having participants who
were able to obtain first-arm data before the first cross-over, had no
withdrew for varying reasons (Holland 2003; Osman 2008, Reisman
washout period; thus the risk of bias is high for this study (Osman
1988). In one study, one out of 27 (3.70%) participants withdrew
2008). The remaining 13 randomised cross-over studies did not
because of pain during respiratory muscle testing (Holland 2003).
describe a washout period, thus the risk of bias is unclear for these
In another study, one out of 30 (3.33%) participants withdrew
studies.
due to a hypoglycaemic episode (Osman 2008). In a third study,
four out of 67 (5.97%) participants withdrew from the study: two
Effects of interventions
participants from the ACBT+ CCPT group relocated and another
two participants from the ACBT group withdrew because of family In this section, the results are given for the comparisons of ACBT
anxiety associated with discontinuation of conventional chest with each comparator. Some comparators (i.e., PEP, oscillatory
physiotherapy used with FET (Reisman 1988). Since the loss to devices) include multiple techniques or devices, and the results
follow up was less than 10% in the studies with stated reasons for of the comparison of ACBT with each technique or device are
participant withdrawal, they were all associated with a low risk of discussed separately.
bias.
ACBT versus CCPT
Selective reporting
Four randomised studies, including 124 participants, compared
Since study protocols were unavailable to allow the comparison of ACBT with CCPT. Three studies (including 108 participants)
planned and reported outcomes, selective reporting was assessed compared ACBT with ACBT+CCPT (Osman 2008; Reisman 1988;
by comparing the outcomes outlined in the 'Methods' section with Webber 1985), and one study (including 16 participants) compared
those outlined in the 'Results' section of the published papers. The ACBT+CCPT with CCPT (Pryor 1979). One study was of parallel
risk of bias from selective reporting was unclear in three studies design (n = 63) (Reisman 1988), while the other three were of cross-
which were only available as conference abstracts (Howard 2000; over design (Osman 2008; Pryor 1979; Webber 1985). Of the four
Kofler 1994; Pike 1999). Two studies were thought to potentially studies, only the parallel study and one of the cross-over studies
involve selective reporting (Pryor 1994; Webber 1986). One study were included in the meta-analysis (Osman 2008; Reisman 1988).
stated that lung function measurements were recorded before and All three randomised cross-over studies had insufficient washout
at 5, 10, 15 and 30 minutes after treatment (Pryor 1994); while the periods, but we obtained first-arm data (before the first cross-
second study stated that lung function values were collected before over) comparing ACBT with ACBT+CCPT from the Osman study
and 30 minutes after the first daily treatment (Webber 1986). In investigators and included these data in the meta-analysis where
both studies, the authors did not report actual data, only that there possible (Osman 2008). The study consisted of multiple treatment
were no statistical differences in the lung function measurements groups of which ACBT and ACBT+CCPT were just two. Of the 29
collected at the start of treatment each day. We have judged there participants in the study as a whole, one performed ACBT before
to be a high risk of bias of selective reporting associated with these the first cross-over and five performed ACBT+CCPT before the first
two studies. In the remaining 14 studies all outcomes outlined in cross-over. For the remaining studies with insufficient washout
the 'Methods' section were reported in the 'Results' section, thus periods we contacted the study authors to obtain necessary
there is a low risk of bias from selective reporting associated with information and are awaiting their response. If new data become
these studies. available they will be included in an update of the review.

Informed decisions.

Primary outcomes therapies. They presented the MD and SD of the two treatments and
also noted that the P-value was not significant.
1. Quality of life
None of the included studies assessed this outcome. In the cross-over study with first-arm data, the ACBT treatment
group contained only one participant before the first cross-over,
2. Personal preference thus a comparison can not be made (Osman 2008).
None of the included studies assessed this outcome. 4. Sputum weight
3. Mortality The parallel study did not provide sufficient data for this outcome
None of the included studies assessed this outcome. (Reisman 1988). In the cross-over study with first-arm data, the
ACBT treatment group contained only one participant in the first-
Secondary outcomes arm before the first cross-over, thus a comparison can not be made
(Osman 2008).
1. Adverse events
None of the included studies assessed this outcome. 5. Oxygen Saturation
In the cross-over study with first-arm data, the ACBT treatment

2. Exercise tolerance
None of the included studies assessed this outcome. thus a comparison can not be made (Osman 2008).
3. Lung function 6. Number of pulmonary exacerbations
a. FEV1 in litres or % predicted The parallel study comparing ACBT with ACBT+CCPT presented
hospitalisation data for pulmonary exacerbations and for non-
i. FEV1 (litres) pulmonary admissions separately (Reisman 1988). The authors
noted that acute exacerbations were treated in the hospital. It
In the cross-over study with first-arm data, the ACBT treatment was observed that nine out of 33 participants receiving ACBT
group contained only one participant before the first cross-over, and five out of 30 participants receiving ACBT+CCPT experienced
thus a comparison can not be made (Osman 2008). pulmonary exacerbations. The nine participants in the ACBT group
ii. FEV1% (% predicted per year) had 30 hospital admissions and 347 hospital days. One participant
in the ACBT group accounted for 15 of the hospital admissions
The parallel study comparing ACBT with ACBT+CCPT presented and 150 of the hospital days. The five participants in the ACBT
individual regression slopes of pulmonary function, and these +CCPT group had eight hospital admissions and 73 hospital days.
values were used in the meta-analysis (Reisman 1988). Our analysis Our analysis showed that group differences in the number of
showed no significant difference in FEV1% between the two participants, hospital admissions, and hospital days did not reach
statistical significance. The RR for a pulmonary exacerbation was
therapies, MD 2.80% (95% CI -0.39 to 5.99) (Analysis 1.1). Although
1.64 (95% CI 0.62 to 4.34) (Analysis 1.3). The study authors
the annual decline in FEV1% is greater in the FET (ACBT) group, the
also found no significant difference in pulmonary exacerbation
study authors also noted that there was no significant difference rates between the two therapies. They presented the number
in FEV1% between the two therapies. They presented the MD, of participants, hospital admissions, and hospital days for each
standard deviation (SD), and P value between the two treatments. therapy.
In the cross-over study with first-arm data, the ACBT treatment ACBT versus PEP
thus a comparison can not be made (Osman 2008). Five studies, including 110 participants compared ACBT with PEP.
Two studies (including 28 participants) compared ACBT with ACBT
b. FVC in litres or per cent predicted +PEP (Hofmeyr 1986; Mortensen 1991), a further two studies
(including 53 participants) compared ACBT with PEP (Kofler 1994;
i. FVC (litres)
Pryor 2010), and one study (including 29 participants) compared
In the cross-over study with first-arm data, the ACBT treatment ACBT+CCPT with PEP (Osman 2008). One study was of parallel
group contained only one participant before the first cross-over, design (Pryor 2010) and four studies were cross-over studies with
thus a comparison can not be made (Osman 2008). insufficient washout periods. We obtained first-arm data (before
the first cross-over) from the Osman study comparing ACBT+CCPT
ii. FVC % (% predicted per year) with PEP and included these data in the meta-analyses where
possible. The study consisted of multiple treatment groups of
The parallel study comparing ACBT with ACBT+CCPT presented which ACBT+CCPT and PEP were just two. Of the 29 participants,
individual regression slopes of pulmonary function, and these five performed ACBT+CCPT before the first cross-over and one
values were used in the meta-analysis (Reisman 1988). Our analysis performed PEP before the first cross-over. For the remaining three
showed a non-significant difference in FVC % predicted between studies with insufficient washout periods, we have contacted the
the two therapies, MD 1.80% (95% CI -0.83 to 4.43) (Analysis 1.2). study authors to obtain necessary information and are awaiting
Although the annual decline in FVC % predicted is greater in the their response. If new data become available they will be included
FET (ACBT) group, the study authors also noted that there was in an update of the review.
non-significant difference in FVC % predicted between the two

Informed decisions.

Primary outcomes 4. Sputum weight
1. Quality of life Only the cross-over study reported on this outcome; however,
when comparing ACBT+CCPT with PEP, the PEP treatment group
The 12-month, parallel study assessed quality of life using the Short
contained only one participant before the first cross-over, thus a
Form-36 and the Chronic Respiratory Questionnaire (Pryor 2010).
comparison can not be made (Osman 2008).
This study randomised 75 participants to one of five treatment
groups, two of which were ACBT (n = 15) and PEP (n = 15). 5. Oxygen Saturation
The authors reported no significant differences across the five
treatment groups for either the physical domain (P = 0.99) or Only the cross-over study reported on this outcome; however,
the mental domain (P = 0.27) of the Short Form-36, but both the when comparing ACBT+CCPT with PEP, the PEP treatment group
physical and mental domains decreased after 12 months (P = 0.05 contained only one participant before the first cross-over, thus a
and P = 0.002, respectively). There were no significant differences at comparison can not be made (Osman 2008).
the end of the study across the five treatment groups for each of the 6. Number of pulmonary exacerbations
four domains of the Chronic Respiratory Questionnaire: dyspnoea
(P = 0.7), fatigue (P = 0.85), emotion (P = 0.39), and mastery (P The included studies did not assess this outcome.
= 0.82). The fatigue (P = 0.69), emotion (P = 0.39), and mastery
(P = 0.37) domains showed no significant differences over time. ACBT versus oscillating devices
However, there were small, clinically-important improvements in Six studies, including 152 participants, compared ACBT with
the dyspnoea ratings over the 12-month study for the ACBT (change oscillating devices. One study (including seven participants)
of 0.7) and the PEP groups (change of 0.5). This study reported compared ACBT with airway oscillating devices (AOD) (Milne 2004),
insufficient data for both the Short Form-36 and the Chronic one study (including 20 participants) compared ACBT with ACBT
Respiratory Questionnaire for inclusion in the meta-analysis. +AOD (Pryor 1994), one study (including 21 participants) compared
ACBT with AOD+forced expiration (FE) (Pike 1999), one study
None of the cross-over studies reported on quality of life. (including 10 participants) compared ACBT with HFCC (Phillips
2. Personal preference 2004), one study (including 29 participants) compared ACBT+CCPT
with AOD (flutter) and ACBT+CCPT to HFCC (HFCWO) (Osman 2008),
The included studies did not assess this outcome. and one study (including 65 participants) compared ACBT with
two different AOD devices (Cornet and Flutter) (Pryor 2010). One
3. Mortality
parallel-designed study (Pryor 2010) and two cross-over studies
The included studies did not assess this outcome. with sufficient washout periods were included in the meta-analysis
(Milne 2004; Phillips 2004). Three of the studies were of cross-
Secondary outcomes over design but had insufficient washout periods (Osman 2008;
1. Adverse events Pryor 1994; Pike 1999). For one of these cross-over studies which
had multiple treatment groups (of which ACBT+CCPT, AOD, and
The included studies did not assess this outcome. HFCC were just three), we obtained data from the study authors
for results measured before the first cross-over and included these
2. Exercise tolerance
data in the meta-analysis (Osman 2008). Of the 29 participants in
The parallel study assessed exercise tolerance using a modified this study, five performed ACBT+CCPT before the first cross-over,
shuttle test (Pryor 2010). Mean baseline scores for the ACBT and two performed AOD before the first cross-over, and 15 performed
the PEP groups were 1005.4 metres and 887.9 metres. At the end of HFCC before the first cross-over. For the remaining two cross-over
the study, there were no statistically significant differences across studies with insufficient washout periods, we have contacted the
the five treatment groups (P = 0.52). The authors did not report any study authors to obtain necessary information and are awaiting
additional data on this outcome. their response. If new data become available, they will be included
in an update of the review.
None of the cross-over studies reported on exercise tolerance.
Primary outcomes
3. Lung function
1. Quality of life
The parallel study and one cross-over study reported on this
outcome (Osman 2008; Pryor 2010). In the parallel study, there was The 12-month parallel study assessed quality of life using the
no significant difference in the final mean (SD) FEV1 between the Short Form-36 and the Chronic Respiratory Questionnaire (Pryor
ACBT group (1.94 (0.80) litres) and the PEP group (2.02 (1.17) litres) 2010). This study randomised 75 participants to one five treatment
(Pryor 2010). We estimated the mean between-group difference in groups, which included ACBT (n = 15), Cornet (n = 15), and Flutter
final values to be MD -0.08 litres (95% CI -0.85 to 0.69) (Analysis (n = 15). The authors reported no significant differences across the
2.1). Across the five arms of this study, the investigators reported no five treatment groups for either the physical domain (P = 0.99) or
significant differences in terms of FVC (P = 0.54) (Pryor 2010). the mental domain (P = 0.27) of the Short Form-36, but both the
physical and mental domains decreased after 12 months (P = 0.05
A comparison between ACBT+CCPT and PEP can not be made in the and P = 0.002, respectively). There were no significant differences
cross-over study because the PEP treatment group contained only at the end of the study across the five treatment groups for each
one participant before the first cross-over (Osman 2008). of the four domains of the Chronic Respiratory Questionnaire:
dyspnoea (P = 0.7), fatigue (P = 0.85), emotion (P = 0.39), and
mastery (P = 0.82). The fatigue (P = 0.69), emotion (P = 0.39),
and mastery (P = 0.37) domains showed no significant differences

Informed decisions.

over time. However, the dyspnoea ratings improved among the When comparing ACBT+CCPT with HFCC, our analysis showed no
Flutter (change of 1.3, moderate improvement) and ACBT (change significant difference between the two treatments, MD -0.06 litres
of 0.7, small improvement) groups, but not among the Cornet group (95% CI -0.79 to 0.68) (Analysis 6.1).
(change less than 0.5).
ii. FEV1 (%)
2. Personal preference
In the cross-over study with first-arm data, raw data were provided
The two included studies had 17 participants, and each included
for meta-analysis (Osman 2008). When comparing ACBT+CCPT with
a different therapy as a comparator. When comparing ACBT with
AOD, our analysis showed no significant difference between the two
AOD, one study reported that three participants (43%) preferred
treatments, MD 5.41% (95% CI -15.62 to 26.44) (Analysis 5.2). When
ACBT, two (29%) preferred AOD, and two (29%) had no preference
comparing ACBT+CCPT to HFCC, our analysis showed no significant
between the two treatments (Milne 2004). When comparing ACBT
difference between the two treatments, MD 0.30% (95% CI -15.63 to
with HFCC, one study reported that all 10 participants found ACBT
16.23) (Analysis 6.2).
comfortable, while six (60%) found HFCC uncomfortable (Phillips
2004). In addition, eight (80%) participants had difficulty clearing b. FVC in litres or % predicted
secretions using HFCC (Phillips 2004).
i. FVC (litres)
3. Mortality
The 12-month parallel study reported that there were no significant
None of the included studies assessed this outcome. differences in terms of FVC across the five arms (P = 0.54) (Pryor
2010).
Secondary outcomes
1. Adverse events The two cross-over studies with adequate washout periods
provided no results on FVC that were relevant for meta-analysis.
None of the included studies assessed this outcome. When comparing ACBT with AOD in one study, the authors reported
2. Exercise tolerance a mean FVC of 2.98 litres after ACBT treatment and 2.98 litres after
AOD treatment (Milne 2004). When comparing ACBT with HFCC in
One parallel study assessed exercise tolerance using a modified the second study, the authors reported a mean FVC of 2.68 litres
shuttle test (Pryor 2010). Mean baseline scores for the ACBT, (range 1.80 to 4.25) after ACBT treatment and 2.64 litres (range 1.59
Cornet, and Flutter groups were 1005.4 metres, 906.7 metres, and to 4.14) after HFCC treatment (Phillips 2004). We have contacted
1044.3 metres respectively. At the end of the study, there were no both authors for additional information and are awaiting their
statistically significant differences across the five treatment groups responses.
(P = 0.52). The authors did not report any additional data on this
outcome. In the cross-over study with first-arm data, raw data were provided
for meta-analysis (Osman 2008). When comparing ACBT+CCPT with
None of the cross-over studies reported on exercise tolerance. AOD, our analysis showed no significant difference between the
two treatments, MD -0.47 litres (95% CI -1.29 to 0.35) (Analysis 5.3).
3. Lung function
When comparing ACBT+CCPT with HFCC, our analysis showed no
a. FEV1 in litres or % predicted significant difference between the two treatments, MD -0.36% (95%
CI -1.29 to 0.56) (Analysis 6.3).
i. FEV1 (litres)
ii. FVC (%)
The parallel study reported that there was no significant difference
in the final mean (SD) FEV1 between: the ACBT group, 1.94 (0.80) In the cross-over study with first-arm data, raw data were provided
litres; the Cornet group, mean 1.90 (0.89) litres; or the Flutter group, for meta-analysis (Osman 2008). When comparing ACBT+CCPT with
mean 2.43 (0.94) (Pryor 2010). We estimated the mean between- AOD, our analysis showed no significant difference between the
group difference in final values between the ACBT and Cornet two treatments, MD -6.49% (95% CI -22.81 to 9.84) (Analysis 5.4).
groups to be MD 0.04 litres (95% CI -0.60 to 0.68) (Analysis 3.1) and When comparing ACBT+CCPT with HFCC, our analysis showed no
between the ACBT and Flutter groups to be MD -0.49 litres (95% CI significant difference between the two treatments, MD -5.08% (95%
-1.18 to 0.20) (Analysis 4.1). CI -20.62 to 10.47) (Analysis 6.4).
The two cross-over studies with adequate washout periods 4. Sputum weight
provided no results on FEV1 that were relevant for meta-analysis. In When comparing ACBT with AOD, our analysis showed no
one study the authors reported a mean FEV1 of 1.34 litres after ACBT significant difference between the two treatments, MD 1.56 g (95%
treatment and 1.38 litres after AOD treatment (Milne 2004). In the CI -20.53 to 23.65) (Analysis 4.2). The study authors also reported
other study the authors reported a mean (range) FEV1 of 1.55 litres no significant difference between the two treatments with regard
(0.87 to 2.84) after ACBT treatment and 1.48 litres (0.73 to 2.76) after to 24-hour sputum weights (Milne 2004). They presented 24-hour
HFCC treatment (Phillips 2004). We have contacted both authors for mean, SD, and the range of sputum weights post-treatment.
additional information and are awaiting their responses.
When comparing ACBT with HFCC, one study had a cross-over
In the cross-over study with first-arm data, raw data were provided design with an adequate washout, but no relevant results on wet
for meta-analysis (Osman 2008). When comparing ACBT+CCPT with sputum weight provided for meta-analysis (Phillips 2004). The
AOD, our analysis showed no significant difference between the study authors noted that participants produced a significantly
two treatments, MD 0.11 litres (95% CI -0.95 to 1.18) (Analysis 5.1). greater amount of sputum during treatment with ACBT than HFCC.

Informed decisions.

Median sputum weight was 4.1 g during ACBT and 0.7 g during HFCC 2. Personal preference
(P < 0.01). We have contacted the authors for additional information When comparing ACBT with AD, one cross-over study reported that
and are awaiting their response. nine participants (50%) preferred AD, while eight preferred (44%)
When comparing ACBT+CCPT with AOD, our analysis showed no ACBT (Miller 1995). One study participant (6%) had no preference
significant difference between the two treatments, MD 36.47 g between the two treatments.
(95% CI -16.71 to 89.65) (Analysis 5.5). When comparing ACBT + 3. Mortality
CCPT with HFCC, our analysis showed no significant difference
between the two treatments, MD 15.65 g (95% CI -39.70 to 71.00) The included studies did not assess this outcome.
(Analysis 6.5). The study authors noted that significantly more
sputum was expectorated during ACBT+CCPT than with HFCC Secondary outcomes
during treatment sessions and over a 24 hour period of time 1. Adverse events
(including treatment), while the sputum expectorated at all other
The included studies did not assess this outcome.
times (excluding treatment) was not statistically significant (Osman
2008). 2. Exercise tolerance
5. Oxygen saturation The parallel study assessed exercise tolerance using a modified
shuttle test (Pryor 2010). Mean baseline scores for the ACBT and
When comparing ACBT+CCPT with AOD, our analysis showed no
the AD groups were 1005.4 metres and 985.0 metres respectively.
significant difference between the two treatments, MD -0.81% (95%
At the end of the 12-month study period, there were no statistically
CI -2.26 to 0.65) (Analysis 5.6). When comparing ACBT+CCPT with
significant differences across the five treatment groups (P = 0.52).
HFCC, our analysis showed no significant difference between the
The authors did not report any additional data on this outcome.
two treatments, MD -1.00% (95% CI -2.45 to 0.45) (Analysis 6.6).
6. Number of pulmonary exacerbations None of the cross-over studies reported on exercise tolerance.
None of the included studies assessed this outcome. 3. Lung function

a. FEV1 in litres or % predicted
ACBT versus other breathing techniques
One parallel study and two cross-over studies compared ACBT with i. FEV1 (litres)
other breathing techniques (Miller 1995; Osman 2008; Pryor 2010).
In the parallel study, there was no significant difference in the final
The parallel study included 75 participants across five arms, two of
mean (SD) FEV1 between the ACBT group, mean 1.94 (0.80) litres,
which were ACBT and AD (Pryor 2010). We included one cross-over
study (n = 18) with a sufficient washout period in the meta-analysis and the AD group, mean 2.64 (1.22) litres (Pryor 2010). We estimated
comparing ACBT with AD (Miller 1995). The second cross-over study, the mean between-group difference in final values between the
with 29 participants, compared ACBT+CCPT with AD (Osman 2008). ACBT and AD groups to be -0.70 litres (95% CI -1.49 to 0.09) (Analysis
Although the study had an insufficient washout period, we obtained 7.1).
data from before the first cross-over from the study authors and
When comparing ACBT with AD, one study had a cross-over design
included these data in the meta-analysis. The study consisted of
with an adequate washout, but no results on FEV1 relevant for
multiple treatment groups of which ACBT+CCPT and AD were just
two; of the 29 participants, five performed ACBT+CCPT before the meta-analysis were provided (Miller 1995). The study authors noted
first cross-over and five performed AD before the first cross-over. that there was no difference in pulmonary function between
the two therapies. We have contacted the authors for additional
Primary outcomes information and are awaiting their response.
1. Quality of life A further study compared ACBT+CCPT with AD (Osman 2008); our
The 12-month parallel study assessed quality of life using the Short analysis showed no significant difference between the treatments,
Form-36 and the Chronic Respiratory Questionnaire (Pryor 2010). MD -0.51 litres (95% CI -1.72 to 0.70) (Analysis 8.1).
This study randomised 75 participants to one of five treatment
ii. FEV1 (%)
groups, which included ACBT (n = 15) and AD (n = 15). The authors
reported no significant differences across the five treatment groups
One study compared ACBT+CCPT with AD (Osman 2008); our
for either the physical domain (P = 0.99) or the mental domain (P
analysis showed no significant difference between the treatments,
= 0.27) of the Short Form-36, but both the physical and mental
MD -8.30% (95% CI -35.22 to 18.62) (Analysis 8.2).
domains decreased after 12 months (P = 0.05 and (P = 0.002,
respectively). There were no significant differences at the end of b. FVC in litres or % predicted
the study across the five treatment groups for each of the four
domains of the Chronic Respiratory Questionnaire: dyspnoea (P i. FVC (litres)
= 0.7), fatigue (P = 0.85), emotion (P = 0.39), and mastery (P = The 12-month parallel study reported that there were no significant
0.82). The fatigue (P = 0.69), emotion (P = 0.39), and mastery differences in terms of FVC across the five arms (P = 0.54) (Pryor
(P = 0.37) domains showed no significant differences over time. 2010).
However, there were small, clinically-important improvements in
the dyspnoea ratings over the 12-month study period for the ACBT When comparing ACBT with AD, one included study had a cross-
(change of 0.7) and the AD groups (change of 0.5). over design with an adequate washout, but no results on FVC

Informed decisions.

relevant for meta-analysis were provided (Miller 1995). The study 20 participants) compared ACBT with the test of incremental
authors noted that there was no difference in pulmonary function respiratory endurance (TIRE) (Howard 2000), one study (including
between the two therapies, yet more participants had improved 24 participants) compared ACBT with coughing (Steven 1992),
FVC with ACBT than AD. Results for FVC were presented as the and one study (including 20 participants) compared ACBT+CCPT
number of tests which showed an improvement. We have contacted with RIM (Chatham 2004). All five studies had a cross-over design
the authors for additional information and are awaiting their with insufficient washout periods and hence none of these were
response. included in the meta-analyses. We have contacted study authors
to obtain necessary information and are awaiting their response. If
A further study compared ACBT+CCPT with AD (Osman 2008); our new data become available they will be included in an update of
analysis showed no significant difference between the treatments, the review.
MD -0.85 litres ( 95% CI -2.13 to 0.44) (Analysis 8.3).
DISCUSSION
i. FVC (%)
Summary of main results
One study compared ACBT+CCPT with AD (Osman 2008); our
analysis showed no significant difference between the treatments, This review compared active cycle of breathing technique (ACBT)
MD -11.02% (95% CI -32.84 to 10.80) (Analysis 8.4). with other airway clearance therapies. The searching and screening
identified 19 studies which were included in the review. Of the
4. Sputum weight 19 studies, only five were included in the meta-analysis. The
Two studies reported on this outcome (Miller 1995; Osman 2008). remaining 14 studies are cross-over studies with inadequate
When comparing ACBT with AD, our analysis of data from the Miller washout periods. Due to the risk of a carry-over effect in these
study showed no significant difference in sputum weights between studies, we only used data from before the first cross-over. When
the two therapies, MD -0.40 g (95% CI -3.93 to 3.13) (Analysis possible we have contacted the study authors and in some cases
7.2). The study authors also noted that there was no significant are still awaiting their responses. Of the five studies that are
difference in sputum weights between the two therapies (Miller included in the meta-analysis, ACBT was compared with five
1995). They presented the MD and standard error (SE) between the different therapies: autogenic drainage (AD), airway oscillating
two treatments. devices (AOD), high frequency chest compression devices (HFCC),
positive expiratory pressure (PEP), and ACBT+ conventional chest
In the second study, Osman compared ACBT+CCPT with AD (Osman physiotherapy (CCPT). Quality of life and personal preference
2008), our analysis showed no significant difference in sputum were the only primary outcomes considered in the review for
weights between the two therapies, MD -3.52 g (95% CI -68.49 to which we identified studies that provided data for the analysis.
61.46) (Analysis 8.5). One study addressed quality of life, and found no differences
between ACBT and four other therapies. Four of the five studies
5. Oxygen saturation included in the analysis addressed personal preference. The results
When comparing ACBT with AD, one cross-over study with an varied - more participants preferred AD over ACBT, more preferred
adequate washout noted that there was no difference in mean ACBT over AOD, and more participants were comfortable with
oxygen saturation between the two therapies, but provided no ACBT versus HFCC. While ACBT is preferred in two of the three
results which we could enter into a meta-analysis (Miller 1995). treatment comparisons, it is important to remember that the
We have contacted the authors for additional information, and are preference of one treatment over the other was determined by
awaiting their response. less than four participants in each case. The secondary outcomes
discussed in the analysis of the review were exercise tolerance,
One study compared ACBT+CCPT with AD (Osman 2008); our lung function, sputum weight, oxygen saturation, and number of
analysis showed no significant difference in oxygen saturation pulmonary exacerbations. There were no significant differences
between the two therapies, MD -1.08 % (-3.17 to 1.01) (Analysis 8.6). when comparing ACBT with other airway clearance therapies in any
of the secondary outcomes.
6. Number of pulmonary exacerbations
The included studies did not assessed this outcome. Overall completeness and applicability of evidence
This review includes meta-analyses and a summary of five studies.
ACBT versus exercise
The studies had different intervention groups, thus they could not
One study, including 18 participants, compared ACBT with exercise be compared with each other. Two of the therapies of interest (high-
(Bilton 1992). The study has a cross-over design with an insufficient pressure PEP (hPEP) and resistive inspiratory manoeuvre (RIM))
washout period, therefore this study was not included in the meta- were not included as interventions in any of the studies. Five out
analysis. We have contacted study authors to obtain necessary of nine outcomes (56%) in total were addressed in the analysis, but
information and are awaiting their response. If new data become only one of these was one of the three primary outcomes (33%). The
available they will be included in an update of the review. sample sizes in three studies included in the analysis were less than
29 participants (Miller 1995; Milne 2004; Osman 2008), while one
ACBT versus other therapy had a sample size of 63 (Reisman 1988) and another had a sample
size of 65 (Pryor 2010). Where possible, additional data obtained
Five studies, including 106 participants compared ACBT with other
from study authors will be included in future updates of the review.
therapies. One study (including 26 participants) compared ACBT
with ACBT+non-invasive ventilation (NIV) (Holland 2003), one study
(including 16 participants) compared ACBT with ACBT+pressure
support ventilation (PSV) (Fauroux 1999), one study (including
Informed decisions.

Quality of the evidence provide the references of additional studies they thought may be
relevant.
In regards to sequence generation, allocation concealment,
blinding (of outcome assessors), and washout periods, the majority Bias may have been introduced because we only included studies
of the studies are associated with an unclear risk of bias (Figure of FET if FET was reported as containing all of the components
2). A total of 17 out of the 19 studies reported that the participants of ACBT. As stated in the Types of interventions section, we used
were randomly allocated, but the methods of randomisation were the definitions of the ACBT components as described by the Cystic
not defined, thus the risk of bias for sequence generation is unclear Fibrosis Foundation and the Cystic Fibrosis Trust as standards
in these studies. In the remaining two studies, there was a low in the process (Cystic Fibrosis Foundation 2009; Cystic Fibrosis
risk of bias for sequence generation. Allocation concealment was Trust 2002). Of the 33 excluded studies, four were excluded solely
reported in only one of the 19 studies, and the remaining studies are because FET was not reported as including all of the components
associated with an unclear risk of bias for allocation concealment. of ACBT (Andreasson 1987; Falk 1984; Sutton 1983; Gursli 2013).
Blinding of the outcome assessors was observed in four studies
and was unclear in the remaining 15 studies (Figure 1). A washout AUTHORS' CONCLUSIONS
period was not reported in 13 of the 17 randomised cross-over
studies, thus they were associated with a unclear risk of bias. One of Implications for practice
the randomised cross-over studies clearly did not have a washout
There is insufficient evidence to support or reject the use of ACBT
period, thus it had a high risk of bias. Three of the 17 randomised
over any other airway clearance therapy. It is our opinion that ACBT
cross-over studies had washout periods of at least a day, which we
is comparable with other therapies in outcomes such as personal
regarded as adequate and thus they were associated with low risk
preference, exercise tolerance, lung function, sputum weight,
of bias (Figure 1).
oxygen saturation, and number of pulmonary exacerbations.
In regards to intention-to-treat analysis, adequate follow up,
selective reporting, and compliance assessment, the majority of
Implications for research
the studies are associated with a low risk of bias (Figure 2). An The majority of studies in this review were cross-over studies
intention-to-treat analysis was used in 10 out of the 19 studies. with insufficient washout periods, increasing the risk of carry-
Follow up was adequate with a of low risk of bias in 13 of the 19 over effects. More randomised controlled studies comparing ACBT
studies. With regards to selective reporting, 14 out of the 19 studies with other airway clearance therapies are needed. Because of the
had a low risk of bias and the risk of bias due to compliance was concern of carry-over effects, cross-over study authors should allow
assessed as low in 11 of the 19 studies (Figure 1). adequate washout periods between treatments.
Potential biases in the review process The majority of included studies had immediate outcomes, as
defined by intervention durations of less than one day. Long-term
It is unlikely that we have missed any studies that address ACBT. We
studies with interventions greater than one month are needed
have hand-searched all reference lists in the studies identified from
to more adequately assess the effects of the interventions. Such
the electronic searches, as well as the included studies presented
studies may provide more data for outcomes that are important
both as full text articles and conference abstracts. In addition,
to people with cystic fibrosis, including quality of life and personal
because of the renaming of forced expiration technique (FET) as
preference.
ACBT in 1990 (Webber 1998), the electronic search included both
terms (FET and ACBT) to capture all relevant studies. Also, all study ACKNOWLEDGEMENTS
authors that were contacted for additional information were sent
a list of the studies included in the review and asked if they could We thank Laura Barnes, BS, for her clerical assistance, including her
help with article retrieval.

Informed decisions.

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1994;105(5):1420-5. employed in cystic fibrosis. In: Lawson D editor(s). Cystic
Fibrosis Horizons. Chichester: John Wiley, 1984:238.
Klig 1989 {published data only}
Rossman 1982 {published data only}
Klig S, Denning C, Jacoby J, Xia F, Gaerlan P, Bisberg D, et al. A
biopsychosocial examination of two methods of pulmonary Rossman CM, Waldes R, Sampson D, Newhouse MT. Effect
therapy [abstract]. Pediatric Pulmonology 1989;7(Suppl 4):145. of chest physiotherapy on the removal of mucus in patients
with cystic fibrosis. American Review of Respiratory Disease
Kofler 1998 {published data only} 1982;126(1):131-5.
Kofler AM, Carlesi A, Cutrera R, Leone P, Lucidi V, Rosati S,
Salh 1989 {published data only}
Turchetta A, Vezzoli P. BiPAP versus PEP as chest physiotherapy
in patients with cystic fibrosis [abstract]. Pediatric Pulmonology Salh W, Bilton D, Dodd M, Webb AK. Effect of exercise and
1998;26(Suppl 17):344. physiotherapy in aiding sputum expectoration in adults with
cystic fibrosis. Thorax 1989;44(12):1006-8.
McDonnell 1986 {published data only}
Steen 1991 {published data only}
McDonnell T, McNicholas WT, FitzGerald MX. Hypoxaemia during
chest physiotherapy in patients with cystic fibrosis. Irish Journal Steen HJ, Redmond AOB, O'Neil D, Beattie F. Evaluation of
of Medical Science 1986;155(10):345-8. the PEP mask in cystic fibrosis. Acta Paediatrica Scandinavica
1991;80(1):51-6.
Oberwaldner 1986 {published data only}
Sutton 1983 {published data only}
Oberwaldner B, Evans JC, Zach MS. Forced expirations against a
variable resistance: a new chest physiotherapy method in cystic Sutton PP, Parker RA, Webber BA, Newman SP, Garland N,
fibrosis. Pediatric Pulmonology 1986;2(6):358-67. Lopez-Vidriero MT, et al. Assessment of the forced expiration
technique, postural drainage and directed coughing in chest
Orlik 2000 {published data only} physiotherapy. European Journal of Respiratory Diseases
Orlik T. Evaluation of autodrainage methods in a selected 1983;64(1):62-8.
group of cystic fibrosis patients with home environment factors
Sutton 1985 {published data only}
taken into consideration. Medycyna Wieku Rozwojowego
2000;4(3):247-59. Sutton PP, Lopez-Vidriero MT, Pavia D, Newman SP, Clay MM,
Webber B, et al. Assessment of percussion, vibratory-shaking
Orlik T. Evaluation of the efficiency of selected thoracic and breathing exercises in chest physiotherapy. European
physiotherapy methods used in the treatment of patients with Journal of Respiratory Diseases 1985;66(2):147-52.
cystic fibrosis. Medycyna Wieku Rozwojowego 2000;4(3):233-46.
Thomas 1995 {published data only}
Orlik 2001 {published data only} Thomas J, Cook DJ, Brooks D. Chest physical therapy
* Orlik T, Sands D. Long-term evaluation of effectiveness for management of patients with cystic fibrosis. A meta-analysis.
selected chest physiotherapy methods used in the treatment of American Journal of Respiratory and Critical Care Medicine
cystic fibrosis. Medycyna Wieku Rozwojowego 2001;5(3):245-57. 1995;151(3 (Pt 1)):846-50.
Orlik T, Sands D. Long-term study of efficiencies of select

physiotherapy methods used in the treatment of cystic fibrosis

Informed decisions.

van Hengstum 1987 {published data only} * Williams MT, Parsons DW, Frick RA, Ellis ER, Martin AJ, Giles SE,
van Hengstum M, Festen J, Beurskens C, Hankel M, van Grant ER. Energy expenditure during physiotherapist-assisted
den Broek W, Buijs W, et al. The effect of positive expiratory and self-treatment in cystic fibrosis. Physiotherapy Theory &
pressure (PEP) versus forced expiration technique (FET) on Practice 2000;16(2):57-67.
tracheobronchial clearance in chronic bronchitis [abstract].
Williams MT, Parsons DW, Frick RA, Ellis ER, Martin AJ, Giles SE,
Proceedings of 15th Annual Meeting of the European Working
et al. Acute respiratory infection in patients with cystic
Group for Cystic Fibrosis; 1987; Oslo, Norway. 1987.
fibrosis with mild pulmonary impairment: comparison of two
Verboon 1986 {published data only} physiotherapy regimens. Australian Journal of Physiotherapy
2001;47(4):227-36.
* Verboon JM, Bakker W, Sterk PJ. The value of the forced
expiration technique with and without postural drainage in Wilson 1995 {published data only}
adults with cystic fibrosis. European Journal of Respiratory
Wilson GE, Baldwin AL, Walshaw MJ. Chest physiotherapy in
Diseases 1986;69(3):169-74.
patients with cystic fibrosis (CF) - a comparison of traditional
Verboon JML, Bakker W, Dijkman JH. Effect of the forced methods with the active cycle of breathing [abstract].
expiration technique and postural drainage in adults with Proceedings of 20th European Cystic Fibrosis Conference; 1995
cystic fibrosis [abstract]. Proceedings of 9th International Cystic June 18-21; Brussels, Belgium. 1995:P58.
Fibrosis Congress. June 9-15; Brighton, England. 1984:2.17.
Znotina 2000 {published data only}
Verboon JML, Bakker W, Sterk PJ. De waarde van de 'forced Znotina I, Svabe V. The effectiveness of physiotherapy
expiration technique' (FET). Nederlandische Tijdschrift for children with cystic fibrosis [abstract]. Proceedings of
Fysiotherapie 1987;97:62-4. XIIIth International Cystic Fibrosis Congress, 4-8 June 2000,
Stockholm, Sweden. 2000:152.
Webber 1986 {published data only}
Webber BA, Hofmeyr JL, Morgan MD, Hodson ME. Effects
of postural drainage, incorporating the forced expiration References to studies awaiting assessment
technique, on pulmonary function in cystic fibrosis. British Castle 1994 {published data only}
Journal of Diseases of the Chest 1986;80(4):353-9.
* Castle T, Metcalfe C, Knox A. A comparison between the active
White 1997 {published data only} cycle of breathing technique (A.C.B.T.) and positive expiratory
pressure (PEP) mask plus A.C.B.T. on sputum production
Stiller K. Are thoracic expansion exercises necessary during
and lung volumes in adults with cystic fibrosis [abstract].
the active cycle of breathing techniques for adult cystic
Proceedings of 19th European Cystic Fibrosis Conference; 1994
fibrosis patients? [abstract]. Israel Journal of Medical Sciences
May 29-June 3; Paris, France. 1994:O17.
1996;32(Suppl):S275.
Chatham 1999 {published data only}
* White D, Stiller K, Willson K. The role of thoracic expansion
exercises during the active cycle of breathing techniques. Chatham K, Nixon LS, Ionescu AA, Garwood R, Premier G,
Physiotherapy Theory Practice 1997;13(2):155-62. Shale DJ. Increased sputum expectoration in cystic fibrosis
patients after repeated resisted mueller manoeuvres. Pediatric
Williams 1994 {published data only} Pulmonology 1998;26(Suppl 17):348 no. 505.
Williams MT. Chest physiotherapy and cystic fibrosis. Why
* Chatham K, Nixon LS, Ionescu AA, Shale DJ. Repeated
is the most effective form of treatment still unclear?. Chest
inspiratory manoeuvres against a fixed resistance with
1994;106(6):1872-82.
biofeedback is more effective than standard chest
Williams 2000 {published data only} physiotherapy in aiding sputum expectoration in cystic fibrosis
[abstract]. Pediatric Pulmonology 1999;28(Suppl 19):289.
Parsons DW, Williams MT, Frick RA, Ellis ER, Martin AJ, Giles SE,
et al. Chest physiotherapy: Improvements in lung function Falk 1993 {published data only}
and ventilation are associated with physiotherapy-assisted
Falk M, Mortensen J, Kelstrup M, Lanng S, Larsen L, Ulrik CS.
treatment [abstract]. Pediatric Pulmonology 1995;Suppl 12:271.
Short-term effects of positive expiratory pressure and the forced
Williams M, Parsons D, Martin A, Ellis E, Giles S, Staugas REM, expiration technique on mucus clearance and lung function in
et al. Chest physiotherapy (CPT) and cystic fibrosis: CF [abstract]. Pediatric Pulmonology 1993;16(Suppl 9):241.
physiotherapist-assisted treatment is more energy efficient
Larsen L, Mortensen J, Falk M, Kelstrup M, Lanng S, Ulrik CS.
[abstract]. Australian and New Zealand Journal of Medicine
Radiolabelled mucus clearance in patients with cystic fibrosis
1995;25:441.
is improved by physiotherapy with positive expiratory pressure
Williams M, Parsons D, Martin A, Giles S, Staugas REM. Energy and the forced expiration technique [abstract]. Clinical
expenditure during chest physiotherapy in normal and cystic Physiology 1994;14:365.
fibrosis (CF) subjects [abstract]. Australian and New Zealand
Mortensen J, Falk M, Kelstrump M, Lanng S, Ulrik CS. Effect
Journal of Medicine 1994;25:445.
of positive expiratory pressure and the forced expiration
technique on mucus clearance in patients with cystic fibrosis

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[abstract]. European Respiratory Journal 1993;6(Suppl Deeks 2011

17):4409S. Deeks J, Higgins J, Altman D. Chapter 9 Analysing data
and undertaking meta-analysis. In: Higgins JPT, Green S
Lannefors 1992 {published data only}
(editors). Cochrane Handbook for Systematic Reviews of
Lannefors L, Wollmer P. Mucus clearance in cystic fibrosis (CF) Interventions Version 5.1.0 [updated March 2011]. The
- a comparison between postural drainage, PEP-mask and Cochrane Collaboration, 2011. Available from www.cochrane-
physical exercise [abstract]. Proceedings of 11th International handbook.org.
Cystic Fibrosis Congress; 1992; Dublin, Ireland. 1992:AHP31.
Elbourne 2002
* Lannefors L, Wollmer P. Mucus clearance with three chest
Elbourne DR, Altman DG, Higgins JPT, Curtin F, Worthington HV,
physiotherapy regimes in cystic fibrosis: a comparison between
Vail A. Meta-analyses involving cross-over trials: methodological
postural drainage, PEP and physical exercise. European
issues. International Journal of Epidemiology 2002;31(1):140-9.
Respiratory Journal 1992;5(6):748-73.
Gondor 1999
Parker 1984 {published data only}
Gondor M, Nixon PA, Mutich R, Rebovich P, Orenstein DM.
* Parker RA, Webber BA, Sutton PP, Newman SP, Garland N,
Comparison of flutter device and chest physical therapy in the
Lopez-Vidriero MT, et al. Evaluation of three individual
treatment of cystic fibrosis pulmonary exacerbation. Pediatric
components of a postural drainage treatment [abstract].
Pulmonology 1999;28(4):255-60.
Proceedings of 9th International Cystic Fibrosis Congress; 1984
June 9-15; Brighton, England. 1984:2.13. Higgins 2011
Petrone 2009 {published data only} Higgins JPT, Altman DG (editors). Chapter 8: Assessing
risk of bias in included studies. In: Higgins JPT, Green S
Petrone A, Quartieri M, Tirone F, Tirone C, Mauro GF.
(editors). Cochrane Handbook for Systematic Reviews of
Management of patients with cystic fibrosis: Role of
Interventions Version 5.1.0 [updated March 2011]. The
non invasive ventilation (NIV) and chest physiotherapy
Cochrane Collaboration, 2011. Available from www.cochrane-
[abstract]. Proceedings of the European Respiratory Society
handbook.org.
Annual Congress; 2010 Sep 18-22; Barcelona, Spain. 2010:
[E3907]. [CENTRAL: 777469; CFGD Register: PE220b; CRS: International Physiotherapy Group for CF 2009
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International Physiotherapy Group for CF. Physiotherapy for
Petrone A, Quartieri M, Tolisano A, Tirone C, Tirone F. Non people with Cystic Fibrosis: from infant to adult. www.cfww.org/
invasive ventilation (NIV) assists chest physiotherapy for docs/ipg-cf/bluebook/bluebooklet2009websiteversion.pdf
treatment of patients with cystic fibrosis [abstract]. Proceedings (accessed 10 August 2010).
of the European Respiratory Society Annual Congress; 2009 Sep
Lorin 1971
12-16; Vienna, Austria. 2009:[P1262]. [CENTRAL: 758852; CFGD
Register: PE220a; CRS: 5500050000000269] Lorin MI, Denning CR. Evaluation of postural drainage
measurement of sputum volume and consistency. American
van Hengstum 1988 {published data only} Journal of Physical Medicine 1971;50(5):215-9.
* Van Hengstum M, Festen J, Beurskens C, Hankel M, Beekman F,
Main 2005
Corstens F. Conventional physiotherapy and forced expiration
manoeuvres have similar effects on tracheobronchial clearance. Main E, Prasad A, van der Schans CP. Conventional chest
European Respiratory Journal 1988;1(8):758-61. physiotherapy compared to other airway clearance techniques
for cystic fibrosis. Cochrane Database of Systematic Reviews
2005, Issue 1. [DOI: 10.1002/14651858.CD002011.pub2]
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McIlwaine 1997
Cystic Fibrosis Foundation 2009
McIlwaine PM, Wong L, Peacock D, Davidson AGF. Long-term
Cystic Fibrosis Foundation. Airway Clearnace Techniques. comparative trial of conventional postural drainage and
www.cff.org/treatments/Therapies/Respiratory/ percussion versus positive expiratory pressure physiotherapy
AirwayClearance/ (accessed 01 April 2009). in the treatment of cystic fibrosis. Journal of Pediatrics
1997;131(4):570-4.
Cystic Fibrosis Foundation 2010
Cystic Fibrosis Foundation. Cystic Fibrosis Foundation Patient McIlwaine 2007
Registry: Annual Data Report 2010. Cystic Fibrosis Foundation, McIlwaine M. Chest physical therapy, breathing techniques
Bethesda. 2010. and exercise in children with CF. Paediatric Respiratory Reviews
2007;8(1):8-16.
Cystic Fibrosis Trust 2002
Association of Chartered Physiotherapist in Cystic McIlwaine 2015
Fibrosis(ACPCF). Clinical Guidelines For the Physiotherapy McIlwaine M, Button B, Dwan K. Positive expiratory pressure
Management of Cystic Fibrosis. www.cftrust.org.uk/aboutcf/ physiotherapy for airway clearance in people with cystic
publications/consensusdoc/C_3400Physiotherapy.pdf fibrosis. Cochrane Database of Systematic Reviews 2015, Issue 6.
(accessed 01 June 2009). [DOI: 10.1002/14651858.CD003147.pub4]

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Morrison 2014 Rubin 1999

Morrison L, Agnew J. Oscillating devices for airway clearance Rubin BK. Emerging therapies for cystic fibrosis lung disease.
in people with cystic fibrosis. Cochrane Database of Systematic Chest 1999;115(4):1120-6.
Reviews 2014, Issue 7. [DOI: 10.1002/14651858.CD006842.pub3]
Sterne 2011
Prasad 1998b Sterne J, Egger M, Moher D. Chapter 10: Addressing reporting
Prasad SA, Main E. Finding evidence to support airway biases. In: Higgins JPT, Green S (editors). Cochrane Handbook
clearance techniques in cystic fibrosis. Disability and forSystematic Reviews of Interventions Version 5.1 [updated
Rehibilitation 1998;20(6/7):235-46. March 2011]. The CochraneCollaboration, 2011. Available from
www.cochrane-handbook.org.
Pryor 1990b
Pryor JA, Webber BA, Hodson ME. Effect of chest physiotherapy Warnock 2015
on oxygen saturation in patients with cystic fibrosis. Thorax Warnock L, Gates A. Chest physiotherapy compared
1990;45(1):77. to no chest physiotherapy for cystic fibrosis. Cochrane
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Pryor JA. Physiotherapy for airway clearance in adults.
European Respiratory Journal 1999;14:1418-24. Webber 1998
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Ramsey 1996 JA, Webber BA editor(s). Physiotherapy for Respiratory and
Ramsey BW. Management of pulmonary disease in patients Cardiac Problems (Chapter 8). 2nd Edition. Edinburgh: Churchill
with cystic fibrosis. New England Journal of Medicine Livingstone, 1998:143-208.
1996;335(3):179-88.

Ratjen 2003 References to other published versions of this review
Ratjen F, Doring G. Cystic fibrosis. Lancet 2003;361(9358):681-9. McKoy 2012
RevMan 2014 [Computer program] Mckoy NA, Saldanha IJ, Odelola OA, Robinson KA. Active
cycle of breathing technique for cystic fibrosis. Cochrane
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* Indicates the major publication for the study

CHARACTERISTICS OF STUDIES
Characteristics of included studies [ordered by study ID]

Bilton 1992
Methods Study type: RCT.
Each participant used 4 treatment regimens in randomised order over 4 consecutive days.The treat-
ments were ACBT, exercise, exercise followed by ACBT, and ACBT followed by exercise. Each day con-
sist of 2 identical treatment sessions with each session lasting 20 minutes. Usual medications were un-
changed.
Participants 18 enrolled; 18 evaluated; 13 male (72.7% male).
Age: mean (21 years); median (NR); SD (NR); range (16-34 years).
Inclusion criteria: NR.
Exclusion criteria: NR.

Informed decisions.

Bilton 1992 (Continued)
Characteristics: all participants were infected with Pseudomonas aeruginosa.
Interventions ACBT: thoracic expansion exercise, breathing control and the FET. The intervention was conducted in a
gravity-assisted position for 20 minutes.
Exercise: cycling at 60% VO2 max for 20 minutes.
Exercise followed by ACBT: exercise for 10 minutes followed by 10 minutes of ACBT.
ACBT followed by exercise: ACBT for 10 minutes followed by 10 minutes of exercise.
Outcomes Outcome measures: participant preference, lung function, sputum weight.
Additional outcomes: perceived effectiveness.
Notes
Risk of bias
Bias Authors' judgement Support for judgement
Random sequence genera- Unclear risk "The subjects were studied on four consecutive days. The study period con-
tion (selection bias) tained four treatment days. The order of these was randomly allocated to each
patient."
Allocation concealment Unclear risk Unclear.

(selection bias)
Blinding (performance High risk Not possible.

bias and detection bias)
Patients

Personnel
Blinding (performance Unclear risk Unclear.

Outcome Assessors
Selective reporting (re- Low risk All outcomes outlined in the methods section were reported in the results.
porting bias)
Adequate follow up? Low risk "All 18 patients completed the study."
Compliance/ adherence Unclear risk Not reported.

assessed?
Intention-to-treat? Low risk Participants were analysed in the groups to which they were randomised.
Washout? Unclear risk No description of a washout period.

Chatham 2004
Methods Study Type: RCT.

Informed decisions.

Chatham 2004 (Continued)
Each participant was randomly allocated to alternate day treatment for 4 days. Treatments were ap-
plied once a day. The 2 treatment regimens used were CCPT+ ACBT and RIM. Inhaled or nebulised
treatments, or both, were administered before all study interventions and usual medications were un-
changed. All participants also received intravenous antibiotics for worsening respiratory symptoms.
Participants 20 enrolled; 20 evaluated; 10 male (50% male).
Age: mean (NR); median (NR); SD (NR); range (NR).
Inclusion criteria: adult participants.
Characteristics: all 20 participants were infected with Pseudomonas aeruginosa.
Interventions CCPT+ACBT: postural drainage (with percussion administered by a physiotherapist) and FET. There
were periods of relaxed breathing and thoracic expansion exercises as described in ACBT. The session
durations were 30 minutes. This intervention was identified as the standardised physiotherapy.
RIM: maximum of 36 manoeuvres. Every 6 inspiratory efforts was accompanied by a short rest inter-
val (maximum of 1 minute). The session duration varied among the participants. The RIM protocol re-
quired the use of the RT2 hand-held manometer.
Outcomes Outcome measures: sputum weight.
Additional outcomes: concentration of protein, concentration of interleukin-8 (IL-8), concentration of

HNE, FFM.
Notes FEV1 % predicted results were provided for the group whose alternate day treatment began with CCPT
+ ACBT and for the group whose alternate day treatment began with RIM. Results were not provided for
each intervention group separately.
Risk of bias
Random sequence genera- Unclear risk "Participants were randomly allocated to alternate day treatment ....."
tion (selection bias)

(selection bias)

Patients

Personnel
Blinding (performance Low risk "The laboratory researcher was blind to the treatment administered to pa-
bias and detection bias) tients."
Outcome Assessors
porting bias)
Adequate follow up? Low risk All participants were accounted for.

Informed decisions.

Chatham 2004 (Continued)
Compliance/ adherence Low risk "All treatment sessions were performed under supervision..."
assessed?

Fauroux 1999
Methods Study Type: RCT.
Each participant used 2 treatment regimens in randomised order over 2 days.The treatments were FET
and FET+PSV. Each day consisted of 2 different treatment sessions with each session lasting 20 min-
utes. Usual medications were unchanged.
Age: mean (13 years); median (NR); SD (4 years); range (6-18 years).
Inclusion criteria: age greater than 6 years; clinically stable.
Characteristics: 9 participants were colonized with Pseudomonas aeruginosa, 7 were colonised with
Burkholderia cepacia, 6 were on inhaled bronchodilators, 7 were on corticosteroids, 11 were on rhD-
Nase, 1 participant was on a lung transplant list and had been receiving PSV for the previous 6 years.
Interventions FET: As described by Pryor and Webber (Physiotherapy 1979; 65:304-7) (Pryor 1979).
FET+PSV: FET manoeuvres with PSV applied during inspiration and resting periods. PSV required the
use of a nasal mask and the pressure support generator ARM25.
Outcomes Outcome measures: participant preference, lung function, sputum weight, oxygen saturation.
Additional outcomes: heart rate; respiratory rate; maximal expiratory pressure; maximal inspiratory
pressure; PEF; FEF at 50%, 25% and 25-75%; airway resistance % predicted value.
Notes Results were stratified by pulmonary disease severity.
Risk of bias
Random sequence genera- Unclear risk "During the study, each patient received two chest physiotherapy sessions in
tion (selection bias) random order on two different days..."

(selection bias)

Patients

Personnel

Informed decisions.

Fauroux 1999 (Continued)
Outcome Assessors
porting bias)
Adequate follow up? Low risk "All the patients completed the protocol."
Compliance/ adherence Low risk A physiotherapist supervised the sessions.

assessed?

Hofmeyr 1986
Each participant used 3 treatment regimens in randomised order over 3 consecutive days. The treat-
ments were FET (gravity-assisted position), PEP+FET (gravity-assisted position) and PEP+FET (sitting
position). Each regimen was used for a 24-hour period which included 4 treatment sessions. The mean
time for each session was 21 minutes (range:10-31). The mean time for each intervention on a treat-
ment day was 83 minutes/day (range: 59-105). Bronchodilators were continued before physiotherapy
if this was a part of the participants' normal regimen. 15 participants were receiving intravenous antibi-
otic treatment and 3 were receiving oral antibiotic treatment.
Age: mean (22.5 years); median (NR); range (13-37 years).
Inclusion criteria: producing at least 20g of sputum in 24 hours; fit enough to carry out own chest phys-
iotherapy.
Exclusion criteria: participants with pneumothorax or a history of pneumothorax.
Characteristics: all 18 participants had an exacerbation of their bronchopulmonary infection.
Interventions FET (gravity-assisted position): 4 deep inspirations with relaxed expiration, breathing control, FET, and
coughing as needed.
PEP+FET (gravity-assisted position): 6 breaths with PEP, breathing control, FET, and coughing as need-
ed. PEP required the use of a PEP mask, one-way valve, and manometer.
PEP+FET (sitting position): 6 breaths with PEP, breathing control, FET, and coughing as needed. PEP re-
quired the use of a PEP mask, one-way valve, and manometer.
Outcomes Outcome measures: lung function, sputum weight, oxygen saturation.
Notes The lowest and highest points of SaO2 were provided.
Risk of bias

Informed decisions.

Hofmeyr 1986 (Continued)
Random sequence genera- Unclear risk "Each patient used the three treatment regimens in randomised order over
tion (selection bias) three consecutive days..."

(selection bias)

Patients

Personnel

Outcome Assessors
porting bias)
Compliance/ adherence Unclear risk Unclear.

assessed?

Holland 2003
ments were ACBT and ACBT+ NIV. Each day consisted of 2 treatment sessions with each session lasting
30 minutes. Bronchodilator and rhDNase were used on study days. The study had a run-in period of 2
days.
Age: mean (27 years); median (NR); SD (6.4 years); range (NR).
BMI mean: 20.6 kg/m2.
Inclusion criteria: aged 18 years or over; admitted to a university hospital with an acute exacerbation of
CF; producing more than 20 g sputum in 24 hours.
Exclusion criteria: required continuous NIV, decreased level of consciousness, pneumothorax, symp-
tomatic gastro-oesophageal reflux requiring modification of treatment, major haemoptysis (200 ml or
more over 24 hours), oxygen saturation less than 90% on room air at study entry, started home antibi-
otic treatment before day 5 of admission.
Characteristics: 26 participants were infected with Pseudomonas aeruginosa, none were colonized with
Burkholderia cepacia.

Informed decisions.

Holland 2003 (Continued)
Interventions ACBT: a sequence of 6 thoracic expansion exercises, breathing control, 6 thoracic expansion exercises,
breathing control, FET, and coughing as needed.
ACBT+NIV: ACBT with NIV administered during the entire duration of the treatment. NIV required the
use of a nasal mask and bilevel device.
Outcomes Outcome measures: participant preference; lung function; sputum weight; oxygen saturation.
Additional outcomes: inspiratory and expiratory muscle strength; breathlessness.
Notes
Risk of bias
Random sequence genera- Unclear risk "A within-subject cross-over design was used with subjects randomly allocated
tion (selection bias) to treatment order."

(selection bias)

Patients

Personnel
Blinding (performance Low risk "All measurements were obtained by an independent data collector who was
bias and detection bias) blinded to treatment order."
Outcome Assessors
porting bias)
Adequate follow up? Low risk One of 27 participants withdrew at the start of the study because of pain ex-
perienced during respiratory muscle testing. The loss to follow up was 3.70%
(<10%).

assessed?
Intention-to-treat? High risk Participants lost to follow up were not included in the analysis.

Howard 2000
Each participant was randomly allocated to alternate day treatment for 2 days. The 2 treatment regi-
mens used were ACBT and TIRE. There was a run-in period of 10 days.
Participants 20 enrolled; number evaluated (NR); gender split (NR).

Informed decisions.

Howard 2000 (Continued)
Age: Details NR.
Characteristics: 5 participants had FEV1 less than 30% predicted, 8 participants had FEV1 30-70% pre-
dicted, 7 participants had FEV1 >70% predicted.
Interventions ACBT: physiotherapy using ACBT.
TIRE: TIRE at 80% of sustained maximum inspiratory pressure until failure was indicated by a comput-
er.
Notes
Risk of bias
Random sequence genera- Unclear risk "...patients were randomly allocated..."


(selection bias)

Patients

Personnel

Outcome Assessors
Selective reporting (re- Unclear risk Unclear.

porting bias)
Adequate follow up? Unclear risk Unclear.

assessed?
Intention-to-treat? Unclear risk Unclear. Only available as an abstract.

Kofler 1994

Informed decisions.

Kofler 1994 (Continued)
Each participant was randomly allocated to alternate 4-month treatments for 8 months. The 2 treat-
ment regimens used were ACBT and PEP. Each group followed conventional therapy for CF (including
antibiotics and enzymes).
Participants 33 enrolled; 23 evaluated; gender split (NR).
Age: NR.
Characteristics: NR.
Interventions ACBT: no description.
PEP: no description.
Outcomes Outcome measures: participant preference, lung function.
Notes
Risk of bias
Random sequence genera- Unclear risk Paper states "children with cystic fibrosis were randomly assigned".

(selection bias)

Patients

Personnel

Outcome Assessors

porting bias)
Adequate follow up? High risk 10 of 33 CF children (>10 %) did not complete the program, and there was no
description of those participants lost to follow up. The loss to follow up was
30.30 % (>10%). Only available as an abstract.

assessed?
Intention-to-treat? High risk Participants lost to follow up were not included in the analysis. Only available
as an abstract.

Informed decisions.


Miller 1995
Each participant used 2 treatment regimens in randomised order over 2 days. The treatments were
ACBT and AD. Each day consisted of 2 identical treatment sessions with each session lasting 30 min-
utes. There was a 1-week washout period between the 2 treatment days. Pre-treatment included nebu-
lised bronchodilators for some participants, and saline for others.
Participants 18 enrolled; 18 evaluated; 10 male (55.6% male)
Age: mean (NR); median (NR); SD (NR); range (11-32 years).
Inclusion criteria: age greater than or equal to 11 years; clinically stable participants not receiving intra-
venous antibiotics.
Characteristics: all 18 participants were clinically stable at the time of the study and not receiving intra-
venous antibiotics.
Interventions ACBT: a postural drainage regimen was performed with ACBT (including breathing control, deep
breathing, and forced expirations).
AD: breathing control in conjunction with cough suppression to mobilise mucus. After multiple cycles,
sputum was expectorated. The position was either sitting or supine.
Outcomes Outcome measures: participant preference; lung function; sputum secretion; oxygen saturation.
Additional outcomes: heart rate; xenon-133 gas ventilation study.
Notes
Risk of bias
Random sequence genera- Unclear risk "Eighteen patients with cystic fibrosis took part in a randomised two-day
tion (selection bias) cross-over trial."

(selection bias)

Patients

Personnel

Outcome Assessors
porting bias)

Informed decisions.

Miller 1995 (Continued)
assessed?
Washout? Low risk 1-week washout period.

Milne 2004
Each participant was randomised to alternate-day treatment on 2 days. Each day consist of 2 identical
treatment sessions with each session lasting 15 minutes. There was a 1-day washout period between
the 2 treatment days. The 2 treatment regimens used were ACBT and AOD (flutter). Nebulisation thera-
py was administered before all study interventions.
Inclusion criteria: participants admitted for a course of intravenous antibiotics, participants old enough
to perform lung function test.
Exclusion criteria: pneumothorax or frank haemoptysis; participant admitted for terminal care.
Interventions ACBT: thoracic expansions; controlled breathing; FET; and coughing in a sitting position.
AOD (flutter): the device was place in the participant's mouth. Participants exhaled 10-15 times through
the flutter and then performed FET. AOD required the use of a flutter device.
Outcomes Outcome measures: participant preference; lung function; sputum weight.
Notes
Risk of bias
Random sequence genera- Unclear risk "Participants were randomised to two groups..."

(selection bias)

Patients

Personnel

Outcome Assessors

Informed decisions.

Milne 2004 (Continued)
porting bias)
Compliance/ adherence Low risk "The researcher supervised the physiotherapy sessions.".
assessed?
Washout? Low risk 1-day washout period.

Mortensen 1991
Each participant was randomised to 3 groups over 3 days.The groups included a control (spontaneous
coughing) group, an FET group, and a PEP+ FET group. Each treatment day consisted of one session
lasting 20 minutes. Usual medications were unchanged, including bronchodilators, mucolytic drugs
and antibiotics taken before treatments.
Age: mean (NR); median (20 years); SD (NR); range (15-26 years).
Height: mean (NR); median (165.5 cm); range (154-185 cm)
Characteristics: all 10 participants were infected with Pseudomonas aeruginosa and were non-smokers.
Interventions Control (spontaneous coughing): spontaneous coughing.
FET: FET; breathing control; and postural drainage (including thoracic expansion exercises, relaxation,
breathing control).
PEP+ FET: tidal volume breathing with PEP followed by FET and coughing. The intervention was con-
ducted in a sitting position. PEP required the use of a PEP mask, 1-way valve, and manometer.
Outcomes Outcome measures: lung function, sputum weight.
Additional measures: number of huffs; urine content; tracheobronchial clearance.
Notes
Risk of bias
Random sequence genera- Unclear risk "The study was a randomised, single-blinded cross-over trial."

(selection bias)

Informed decisions.

Mortensen 1991 (Continued)
Patients

Personnel

Outcome Assessors
porting bias)
Compliance/ adherence Low risk "Physiotherapy treatments were supervised by a physiotherapist".

assessed?

Osman 2008
Each participant was randomised to alternate day treatment over 4 consecutive days. The treatments
regimens were HFCWO and usual therapy. Participants received either HFCWO on days 1 and 3 and
their usual ACT on days 2 and 4 or vice versa. Treatment session were 2 times daily for 30 min. All nebu-
lised and inhaled medications were taken before treatment sessions.
Age: mean (29.4 years); median (NR); SD (8.4 years); range (NR).
Height: mean (171 cm); median (NR); SD (9 cm); range (NR)
Inclusion criteria: FEV1 ≥20% predicted, age ≥16 years, infective pulmonary exacerbations.
Exclusion criteria: current severe haemoptysis, rib fractures, pregnancy, inability to give consent, per-
sons whose usual ACT was HFCWO.
Interventions HFCWO (The Vest): This is the same as HFCC. Each participant was fitted with the appropriate sized
vest. Participants remained in a upright sitting position throughout the 30 minute treatment session.
HFCWO was applied for 8 minutes at each of three frequencies in sequence (10, 13, and 15 Hz) with
each frequency followed by a 2 minute resting period. Participants were instructed to huff or cough as
they felt necessary to expectorate secretions.
ACBT with modified PD&P and with modified PD alone: In accordance with the guidelines of the Inter-
national Physiotherapy Group for Cystic Fibrosis (International Physiotherapy Group for CF 2009).
AD in sitting and with modified PD: In accordance with the guidelines of the International Physiothera-
py Group for Cystic Fibrosis (International Physiotherapy Group for CF 2009).

Informed decisions.

Osman 2008 (Continued)
PEP: In accordance with the guidelines of the International Physiotherapy Group for Cystic Fibrosis (In-
ternational Physiotherapy Group for CF 2009).
Flutter: In accordance with the guidelines of the International Physiotherapy Group for Cystic Fibrosis
(International Physiotherapy Group for CF 2009).
Additional measures: perceived efficacy; comfort; incidence of urinary leakage.
Notes In the published article, all usual therapies are group together, including ACBT, and compared to HFC-
WO. HFCWO was described by the study authors as The Vest, which is an HFCC device. The study au-
thors were contacted and provided us with raw data for each participant including what their usual
therapies were and all first-arm data before the first cross-over.
Risk of bias
Random sequence genera- Low risk Allocation to HFCWO or usual ACT on day one was determined using a comput-
tion (selection bias) er-generated randomisation table.

(selection bias)

Patients

Personnel
Blinding (performance Unclear risk It is noted that an independent observer, blinded to the method of airway
bias and detection bias) clearance used, performed spirometry, weighed the sputum samples, and col-
Outcome Assessors lected visual analogue scales regarding perceived efficacy, comfort, and uri-
nary leakage. It is not noted whether an independent observer assessed oxy-
gen saturation.
Selective reporting (re- Low risk All outcomes outlined in the methods section were report in the results.
porting bias)
Adequate follow up? Low risk One of the participants withdrew due to a hypoglycaemic episode. The loss to
follow up was 3.33% (< 10%).
Compliance/ adherence Low risk Each airway clearance treatment sessions was supervised by a physiotherapist
assessed? to ensure optimisation and standardization.
Washout? High risk There was no washout period. Raw data were obtained from the study authors
before first crossover.

Phillips 2004

Informed decisions.

Phillips 2004 (Continued)
Each participant used 2 treatment regimens in randomised order over 2 days. Each day consisted of 2
identical treatment sessions each lasting 20 minutes. There was a 1-day washout period between the 2
treatment days. The treatment regimens used were ACBT and HFCC.
Age: mean (13.7 years); median (14 years); SD (NR); range (9-16 years).
Inclusion criteria: acute respiratory exacerbation.
Exclusion criteria: pneumothorax or haemoptysis; any vision, hearing or balance disturbance; chest
trauma.
Interventions ACBT: relaxed breathing control; 3-4 thoracic expansion exercises; and FET.
HFCC: 4x 2-phase cycles of 600 oscillations per minute for 3 minutes followed by 60 oscillations per
minute for 2 minutes. HFCC required the use of the Hayek Oscillator 1000.
Outcomes Outcome measures: participant preference; lung function; sputum weight.
Notes
Risk of bias
Random sequence genera- Unclear risk Unclear.

Allocation concealment Low risk Sealed envelopes were used.

(selection bias)

Patients

Personnel

Outcome Assessors
porting bias)
Compliance/ adherence Low risk Both treatments were supervised.

assessed?
Washout? Low risk 1-day washout period.

Informed decisions.


Pike 1999
Each participant used 2 treatment regimens in randomised order over 2 days. Each day consisted of 2
identical treatment sessions. The 2 treatment regimens used were ACBT and AOD (Flutter)+ FE.
Age: mean (NR); median (26 years); SD (NR); range (NR).
Interventions ACBT: no description.
AOD (Flutter)+ FE: no description.
Notes
Risk of bias
Random sequence genera- Unclear risk The participants were randomised, but method not described.

(selection bias)

Patients

Personnel

Outcome Assessors

porting bias)
Adequate follow up? Unclear risk Unclear.

assessed?
Intention-to-treat? Unclear risk Unclear. Only available as an abstract.

Informed decisions.


Pryor 1979
Each participant used 2 treatment regimens in randomised order over 4 days.The treatments were
CCPT and FET. The frequency of the treatment sessions varied. 12 participants needed treatment 4x
daily, 3 needed treatment 3x daily, 1 needed treatment 2x daily. Usual medications were unchanged.
Age: mean (20.5 years); median (NR); SD (NR); range (14-28 years).
Exclusion criteria: admitted for terminal care.
Characteristics: all 18 participants had an acute exacerbation of their bronchopulmonary infection.
Interventions CCPT: postural drainage (breathing expansion exercises, coughing, and percussion); chest percussion;
and shaking.
FET+CCPT: Postural drainage and FET with expansion breathing exercise; coughing; and percussion
and chest compression.
Outcomes Outcome measures: lung function; sputum weight.
Additional outcomes: rate of sputum production.
Notes Analysis included part I of the study only. Part II compares ACBT (self-administered) to ACBT (physio-
therapist administered). This is not a comparison of interest in this review.
Risk of bias
Random sequence genera- Unclear risk The treatments were given in random order.

(selection bias)

Patients

Personnel

Outcome Assessors
porting bias)
Adequate follow up? High risk Two of 18 participants withdrew from the study: 1 developed pneumothorax
and the other was unable to produce enough sputum for an accurate assess-
ment. The loss to follow up was 11.11% (>10%).

Informed decisions.

Pryor 1979 (Continued)
Compliance/ adherence Low risk "Three physiotherapists took part in the treatment sessions throughout the
assessed? study."

Pryor 1994
The treatments were randomised and remained the same for a 24-hour period. There were 3 sessions
in a day (2 monitored and 1 unmonitored). The treatments were ACBT and ACBT+AOD (flutter). Usual
medications were unchanged.
Inclusion criteria: participants admitted to the hospital as clinically stable (clinical stability was mea-
sured by the absence of any clinical changes such as fever, FEV1, FVC, FEF50, FEF75, ability to do their
own chest physiotherapy); available for 2 consecutive days as close to discharge as possible.
Exclusion criteria: participants admitted to the hospital for terminal care or with a pneumothorax or
frank haemoptysis.
Characteristics: all 24 participants had a history of bronchopulmonary infection.
Interventions ACBT: breathing control; thoracic expansion; FET.
ACBT+AOD (flutter): flutter for the first 10 minutes of the session; ACBT for the remainder.
Outcomes Outcome measures: participant preference; sputum weight; oxygen saturation.
Notes Sputum weight is reported for both the morning and afternoon sessions. Only baseline information is
extractable for lung function.
Risk of bias
Random sequence genera- Unclear risk "Treatment regimens were randomised..."


(selection bias)

Patients

Personnel
Blinding (performance Low risk "The measurement of the monitored session were taken by independent ob-
bias and detection bias) servers."

Informed decisions.

Outcome Assessors
Selective reporting (re- High risk It is stated that lung function measurements were recorded before and at 5,
porting bias) 10, 15 and 30 minutes after treatment, but results of lung function measure-
ment are not provided.
Adequate follow up? High risk 4 of 24 participants withdrew from the study; 2 participants had their drug reg-
imens changed during the study and another 2 participants withdrew because
of technical problems with the oximeter and collection of sputum. The loss to
follow up was 16.67% (>10%).
Compliance/ adherence Low risk The treatment sessions were monitored.

assessed?

Pryor 2010
Methods Study type: RCT (parallel design).
Participants 75 participants with CF
Age: median (range) 27 (17 - 63) years.
Gender split: 47 males and 28 females.
Inclusion criteria: 16 years of age or older, FEV1 ≥ 25% predicted.
Exclusion criteria: evidence of current respiratory exacerbation, past history of pneumothorax, current
severe haemoptysis, awaiting lung or heart transplantation, pregnancy, and recent (within 3 months)
acquisition of Burkholderia cepacia.
Interventions ACBT versus AD versus cornet versus flutter versus PEP.
Outcomes Measured monthly for 1 year: FEV1; FVC; MEF25; RV/TLC%; BMI; exercise capacity (modified shuttle test);
QoL.
Notes Lung function data available for 65 participants.
The author has been contacted about obtaining additional data, and we are awaiting their response.
Risk of bias
Random sequence genera- Low risk "Randomisation was computerized and used a random number sequence
tion (selection bias) stratified by FEV1% predicted..."

(selection bias)
Blinding (performance High risk Not possible

Patients

Informed decisions.

Personnel
Blinding (performance Low risk "The measurements of lung function and body mass index at 0, 6, and 12
bias and detection bias) months and the statistical analyses were undertaken by observers (physiolo-
Outcome Assessors gists and statistician) blind to the regimen to which the subjects had been ran-
domised."
porting bias)
Adequate follow up? High risk 10 of 75 (13%) of participants were lost to follow up. Additionally, 13 partici-
pants changed their airway clearance technique, but the details on this are not
provided.
Compliance/ adherence Low risk "Subjects were requested to attend monthly, for a review of their ACT..."
assessed?
Intention-to-treat? High risk Participants who were lost to follow up were not included in the analysis.
Washout? Unclear risk Not applicable (not a cross-over study).

Reisman 1988
Methods Study type: RCT (parallel design).
Participants were stratified according to sex, age, and pulmonary function. Within each stratum, partic-
ipants were then randomised to 1 of the treatment groups. The treatments were FET and CCPT + FET. In
both groups participants took pancreatic enzyme supplements, antistaphylococcal antibiotics, and in-
haled β2-bronchodilators.
Participants 67 enrolled; 63 evaluated; 38 male (60.3 % male).
Age: no mean; SD; median or range reported.
Inclusion criteria: 7< years to <21 years; FEV1>40% of the predicted value for height and sex; partici-
pants with mild to moderate pulmonary disease only.
Exclusion criteria: participants involved in any other studies.
Interventions FET: maximal and normal inspirations, forced expiration, and breathing control.
CCPT+FET: postural drainage; percussion; and FET.
Outcomes Outcome measures: lung function; number of pulmonary exacerbations.
Notes Participants were stratified by age, sex, and pulmonary impairment.
Risk of bias
Random sequence genera- Unclear risk "Subjects were randomly assigned within each stratum to one of two groups."

Informed decisions.

Reisman 1988 (Continued)
(selection bias)

Patients

Personnel

Outcome Assessors
porting bias)
Adequate follow up? Low risk 4 of 67 participants withdrew from the study: 2 participants from the CCPT +
FET group relocated and another 2 participants from the FET group withdrew
because of family anxiety associated with discontinuation of conventional
chest physiotherapy (used with FET). The loss to follow up was 5.97% (<10%).
Compliance/ adherence Low risk "... they were asked to keep a diary reporting adherence to their own physio-
assessed? therapy regimens.".
Intention-to-treat? High risk Lost to follow up participants were not included in the analysis.
Washout? High risk Not applicable (not a cross-over study).

Steven 1992
Each participant used 3 treatment regimens for 24-hour periods in randomised order over 3 consecu-
tive days.The treatments were coughing, ACBT (gravity-assisted position), and ACBT (sitting). The fre-
quency of the treatment sessions varied between 2-4 per day. The mean duration of the treatment ses-
sions was 22 minutes.
Inclusion criteria: participants who were clinically stable; producing more than 20 g of sputum in 24
hours; and fit enough to carry out their own chest physiotherapy.
Exclusion criteria: participants with a pneumothorax; frank haemoptysis; or an FEV1 which increased
more than 15% after bronchodilators.
Characteristics: all 24 participants had an exacerbation of their bronchopulmonary infection.
Interventions Coughing (sitting): coughing and breathing control.
ACBT (gravity-assisted position): postural drainage and ACBT; including breathing control, thoracic ex-
pansion, and FET.
ACBT (sitting): ACBT including breathing control; thoracic expansion; and FET.

Informed decisions.

Steven 1992 (Continued)
Outcomes Outcome measures: lung function; sputum weight; oxygen saturation.
Notes
Risk of bias
Random sequence genera- Unclear risk "Each patient used each of the three treatment regimens for a 24 hour period,
tion (selection bias) in randomised order, over three consecutive days."

(selection bias)

Patients

Personnel

Outcome Assessors
porting bias)

assessed?

Webber 1985
ments were FET and FET+ self-percussion. The treatment regimen remained unchanged for a 24-hour
period. 6 participants needed treatment 4x daily, 8 needed treatment 3x daily, 2 needed treatment 2x
daily.The individual treatment time ranged from 10-38 minutes, while the daily treatment times ranged
from 51-107 minutes. 12 participants received intravenous antibiotic treatment and four received oral
antibiotic treatment. 4 participants did not use chest compression.

Informed decisions.

Webber 1985 (Continued)
Characteristics: all 18 participants were admitted with an acute exacerbation of their bronchopul-
monary infection.
Interventions FET: postural drainage including thoracic expansion and FET including breathing control.
FET+self-percussion: postural drainage including thoracic expansion; self-percussion; and FET includ-
ing breathing control.
Notes
Risk of bias
Random sequence genera- Unclear risk "Treatment days were randomised."


(selection bias)

Patients

Personnel

Outcome Assessors
Selective reporting (re- High risk Lung function results were not reported.
porting bias)
Compliance/ adherence Low risk Treatment regimens were performed under the supervision of 3 physiothera-
assessed? pists.
ACBT: active cycle of breathing technique

AD: autogenic drainage
AOD: airway oscillating devices
BMI: body mass index
CCPT: conventional chest physiotherapy
CF: cystic fibrosis
FE: forced expiration
FEF: forced expiratory flow
FET: forced expiratory technique
FEV1: forced expiratory volume at one second
FFM: fat-free mass
FVC: forced vital capacity

Informed decisions.

HFCC: high frequency chest compression

HFCWO: high frequency chest wall oscillation
HNE: human neutrophil elastase
Hz: herz
NIV: non-invasive ventilation
NR: not reported
PD: postural drainage
PD&P: postural drainage and percussion
PEF: peak expiratory flow
PEP: positive expiratory pressure
PSV: pressure support ventilation
RCT: randomised controlled trial
rhDNase: dornase alfa
RIM: resistance inspiratory manoeuvre
SaO2: oxygen saturation
SD: standard deviation
TIRE: test of incremental respiratory endurance
VO2: oxygen consumption

Characteristics of excluded studies [ordered by study ID]

Study Reason for exclusion
Andreasson 1987 This study was excluded because FET was did not include all components of ACBT.
Asher 1982 This study was excluded because it did not address ACBT.
Bain 1988 This study was excluded because it did not address ACBT.
Baldwin 1994 This study was excluded because it did not address ACBT.
Braggion 1995 This randomised cross-over study was excluded because there was no comparison of interest. All
participants received FET after treatment periods.
Chatham 1998 This study was excluded because it did not address ACBT.
Desmond 1983 This study was excluded because it did not address ACBT.
Falk 1984 This randomised cross-over study was excluded because FET did not include all components of
ACBT.
Gursli 2013 This randomised cross-over study was excluded because the components of FET were not de-
scribed.
Hasani 1991 This article did not address CF.
Hasani 1994a This article did not address CF.
Hasani 1994b This article did not address CF.
Klig 1989 This study was excluded because it was a non-randomised cross-over study.
Kofler 1998 This study was excluded because it did not address ACBT.
McDonnell 1986 This study was excluded because it did not address ACBT.
Oberwaldner 1986 This study was excluded because it was a non-randomised controlled study.

Informed decisions.

Study Reason for exclusion
Orlik 2000 This study was excluded because it was a non-randomised controlled study.
Orlik 2001 This study was excluded because it was a non-randomised controlled study.
Prasad 1998a This article was excluded because it is a review on physiotherapy treatments in CF, thus there was
no original data.
Prasad 2000 This article was excluded because it was a review on physiotherapy treatments in CF, thus there
was no original data.
Pryor 1990a This study was excluded because it was a non-randomised study.
Rogers 1984 This study was excluded because the participants were not randomised.
Rossman 1982 This study was excluded because it did not address ACBT.
Salh 1989 This study was excluded because it was a non-randomised cross-over study.
Steen 1991 This study was excluded because while the majority of the arms were randomised, the intervention
of interest was not randomised.
Sutton 1983 This randomised cross-over study was excluded because FET did not include all components of
ACBT.
Sutton 1985 The article was excluded because it did not address ACBT.
Thomas 1995 This article was excluded because it was a review on physiotherapy treatments in CF, thus there
van Hengstum 1987 This article did not address CF.
Verboon 1986 This randomised cross-over study was excluded because it did not include a comparison of inter-
est. The 2 treatments only differed by PD, which is considered a component of ACBT in our defini-
tion.
Webber 1986 This study was excluded because it was a non-randomised study.
White 1997 This randomised cross-over study was excluded because it did not include a comparison of inter-
est. Participants were randomised to receive ACBT or ACBT without thoracic expansion.
Williams 1994 This article was excluded because it was a review on physiotherapy treatments in CF, thus there
Williams 2000 This randomised cross-over study was excluded because there was no comparison of interest. CF
participants were randomised to therapy-assisted ACBT or independent ACBT.
Wilson 1995 This study was excluded because it was a non-randomised cross-over study.
Znotina 2000 This RCT was excluded because there was no comparison of interest. Participants performed PEP/
oscillating PEP + FET with a physiotherapist (Group A) or without a physiotherapist (Group B).

CF: cystic fibrosis
FET: forced expiration technique
Informed decisions.


Characteristics of studies awaiting assessment [ordered by study ID]

Castle 1994
Methods RCT.
Participants People with CF, over 16 years old with exacerbation of chest symptoms. Excluded if needing more
than 2 sessions of physiotherapy per day.
Interventions Treatment carried out on first 2 days of first week of hospitalisation for IV antibiotics. Each treat-
ment lasted 30 minutes.
ACBT alone or ACBT+PEP
Outcomes Sputum produced.
Notes The author has been contacted about obtaining additional data, and we are awaiting their re-
sponse.

Chatham 1999
Methods RCT. Cross-over design.
Participants 12 participants in total admitted to hospital for acute exacerbation requiring IV antibiotics.
Interventions Treatment given on days 1 to 4 of hospitalisation. TIRE and physiotherapy on alternate days.
TIRE (performed to tolerance plus 30 post-treatment expectoration) versus physiotherapy (30 min-
utes plus 30 minutes post-treatment expectoration).
Outcomes Weight and volume of expectorated mucus.
sponse.

Falk 1993
Methods RCT, duration 3 days (1 intervention per day).
Participants 12 participants with CF.
Interventions FET (huff and coughing) versus FET+PEP versus control.
Each intervention lasted 20 minutes.
Outcomes Mean (SD) lung retention and median (range) number of huff and coughs and weight of sputum ex-
pectorated.
Timepoints measured: 30 minutes; 1 hour; 2 hours; 24 hours.
sponse.

Informed decisions.


Lannefors 1992
Methods Cross-over design.
Participants 9 clinically stable participants with CF.
Interventions Group 1: ACBT in position meant to clear right middle lobe.

Group 2: PEP-mask breathing in sitting position.
Group 3: physical exercise on bicycle ergometer.
On 3 different days at the same time of day for the same length of time, same number of pauses for
FET and same number of FET.
Participants maintained baseline medications including beta-2 agonists.
Outcomes Mucus clearance (measured using elimination of inhaled radiolabeled particles).
sponse.

Parker 1984
Methods RCT.
Participants 10 participants in total, but only 4 had CF.
Interventions FET (4 forced expirations in each 3 minute period, sitting upright) versus FET gravity assisted posi-
tion (4 forced expirations in each 3-minute period in appropriate postural drainage position) versus
coughing (4 double coughs in each 3-minute period, sitting upright) versus control (sitting upright).
Outcomes Dry and wet weight of sputum.
sponse.

Petrone 2009
Methods RCT.
Cross-over design with 3 arms.
Duration stated in 2009 abstract as 5 weeks in each arm, but in 2010 abstract as 6 months in each
arm.
Participants 2009 abstract cites 7 participants with following baseline characteristics: mean (SD) age 25.2 (4.7)
years; mean (SD) FEV1 % predicted 42.1 (4.7)%.
2010 abstract cites 21 participants with following baseline characteristics: mean (SD) age 27.2 (3.7)
years; mean (SD) FEV1 % predicted 44.1 (3.1)%.
Interventions Arm 1: ACBT.
Arm 2: ACBT plus oxygen therapy.
Arm 3: ACBT plus NIV.

Informed decisions.

Petrone 2009 (Continued)
Outcomes Arterial blood gas; spirometry; peak exercise capacity (shuttle walk test); sleep parameters; mean
oxygen desaturation index, respiratory exacerbations.
Notes Not clear if one trial or two separate ones - contact authors to clarify.

van Hengstum 1988
Methods RCT. 4-day treatment period - first 3 days for daily instruction and treatment and 4th day for assess-
ment.
Participants 8 participants stable for at least 6 weeks prior to study begin, mean age 23 years (range 15 - 27
years).
Interventions Group 1: postural drainage combined with percussion and directed coughing.
Group 2: FET (huffing with postural drainage, breathing exercises and if needed coughing).
Each session lasted 30 minutes.
Outcomes Sputum wet weight and dry weight, flow volume curves.
sponse.

BMI: body mass index
CF: cystic fibrosis
FET: forced expiration technique
FEV1: forced expiratory volume at one second
FVC: force vital capacity
HFCWO: high frequency chest wall oscillation
IV: intravenous
MEF25: maximal expiratory flow at 25% of forced vital capacity
NIV: non-invasive ventilation
PEF: peak expiratory flow
QoL: quality of life
RCT: randomised controlled trial
RV/TLC%: residual volume as a percentage of total lung capacity
SD: standard deviation
TIRE: test of incremental respiratory endurance

DATA AND ANALYSES

Comparison 1. ACBT versus ACBT+CCPT
Outcome or subgroup title No. of No. of Statistical method Effect size

studies partici-
pants
1 FEV1% 1 Mean Difference (Fixed, 95% CI) Subtotals only

Informed decisions.


studies partici-
pants
1.1 At 3 years 1 Mean Difference (Fixed, 95% CI) 2.80 [-0.39, 5.99]
2 FVC % 1 Mean Difference (Fixed, 95% CI) Subtotals only
2.1 At 3 years 1 Mean Difference (Fixed, 95% CI) 1.8 [-0.83, 4.43]
3 Pulmonary exacerbation 1 Risk Ratio (M-H, Fixed, 95% CI) Subtotals only
3.1 At 3 years 1 63 Risk Ratio (M-H, Fixed, 95% CI) 1.64 [0.62, 4.34]

Analysis 1.1. Comparison 1 ACBT versus ACBT+CCPT, Outcome 1 FEV1%.
Study or subgroup Experi- Control Mean Dif- Mean Difference Weight Mean Difference
mental ference
N N (SE) IV, Fixed, 95% CI IV, Fixed, 95% CI
1.1.1 At 3 years
Reisman 1988 30 33 2.8 (1.63) 100% 2.8[-0.39,5.99]
Subtotal (95% CI) 100% 2.8[-0.39,5.99]
Heterogeneity: Tau2=0; Chi2=0, df=0(P<0.0001); I2=100%
Test for overall effect: Z=1.72(P=0.09)
Favours ACBT -10 -5 0 5 10 Favours ACBT+CCPT

Analysis 1.2. Comparison 1 ACBT versus ACBT+CCPT, Outcome 2 FVC %.
Study or subgroup Experi- Control Mean Dif- Mean Difference Weight Mean Difference
mental ference
1.2.1 At 3 years
Reisman 1988 30 33 1.8 (1.34) 100% 1.8[-0.83,4.43]
Subtotal (95% CI) 100% 1.8[-0.83,4.43]
Heterogeneity: Not applicable
Favours ACBT -10 -5 0 5 10 Favours ACBT+CCPT

Analysis 1.3. Comparison 1 ACBT versus ACBT+CCPT, Outcome 3 Pulmonary exacerbation.
Study or subgroup ACBT ACBT+CCPT Risk Ratio Weight Risk Ratio
n/N n/N M-H, Fixed, 95% CI M-H, Fixed, 95% CI
1.3.1 At 3 years
Reisman 1988 9/33 5/30 100% 1.64[0.62,4.34]
Subtotal (95% CI) 33 30 100% 1.64[0.62,4.34]
Total events: 9 (ACBT), 5 (ACBT+CCPT)
Favours ACBT 0.1 0.2 0.5 1 2 5 10 Favours ACBT+CCPT

Informed decisions.

Study or subgroup ACBT ACBT+CCPT Risk Ratio Weight Risk Ratio

n/N n/N M-H, Fixed, 95% CI M-H, Fixed, 95% CI
Favours ACBT 0.1 0.2 0.5 1 2 5 10 Favours ACBT+CCPT

Comparison 2. ACBT versus PEP
Outcome or subgroup ti- No. of No. of Statistical method Effect size

tle studies partici-
pants
1 FEV1 1 Mean Difference (IV, Fixed, 95% CI) Subtotals only
1.1 Up to 1 week 1 26 Mean Difference (IV, Fixed, 95% CI) -0.08 [-0.85, 0.69]

Analysis 2.1. Comparison 2 ACBT versus PEP, Outcome 1 FEV1.
Study or subgroup ACBT PEP Mean Difference Weight Mean Difference
N Mean(SD) N Mean(SD) Fixed, 95% CI Fixed, 95% CI
2.1.1 Up to 1 week
Pryor 2010 13 1.9 (0.8) 13 2 (1.2) 100% -0.08[-0.85,0.69]
Subtotal *** 13 13 100% -0.08[-0.85,0.69]
Favours PEP -2 -1 0 1 2 Favours ACBT

Comparison 3. ACBT versus AOD (Cornet)
Outcome or subgroup ti- No. of No. of Statistical method Effect size

tle studies partici-
pants
1.1 Up to 1 week 1 27 Mean Difference (IV, Fixed, 95% CI) 0.04 [-0.60, 0.68]

Analysis 3.1. Comparison 3 ACBT versus AOD (Cornet), Outcome 1 FEV1.
Study or subgroup ACBT AOD (Cornet) Mean Difference Weight Mean Difference
3.1.1 Up to 1 week
Pryor 2010 13 1.9 (0.8) 14 1.9 (0.9) 100% 0.04[-0.6,0.68]
Subtotal *** 13 14 100% 0.04[-0.6,0.68]
Favours AOD (Cornet) -2 -1 0 1 2 Favours ACBT

Informed decisions.

Study or subgroup ACBT AOD (Cornet) Mean Difference Weight Mean Difference
Favours AOD (Cornet) -2 -1 0 1 2 Favours ACBT

Comparison 4. ACBT versus AOD (Flutter)

studies partici-
pants
2 Sputum weight 1 Mean Difference (Fixed, 95% CI) Totals not selected
2.1 Up to 1 week 1 Mean Difference (Fixed, 95% CI) 0.0 [0.0, 0.0]

Analysis 4.1. Comparison 4 ACBT versus AOD (Flutter), Outcome 1 FEV1.
Study or subgroup ACBT AOD (Flutter) Mean Difference Weight Mean Difference
4.1.1 Up to 1 week
Pryor 2010 13 1.9 (0.8) 12 2.4 (0.9) 100% -0.49[-1.18,0.2]
Subtotal *** 13 12 100% -0.49[-1.18,0.2]
Favours AOD (Flutter) -2 -1 0 1 2 Favours ACBT

Analysis 4.2. Comparison 4 ACBT versus AOD (Flutter), Outcome 2 Sputum weight.
Study or subgroup Experimental Control Mean Dif- Mean Difference Mean Difference
ference
4.2.1 Up to 1 week
Milne 2004 7 7 1.6 (11.27) 1.56[-20.53,23.65]
Favours ACBT -20 -10 0 10 20 Favours AOD


Informed decisions.

Comparison 5. ACBT+CCPT versus AOD (Flutter)
Outcome or sub- No. of No. of Statistical method Effect size

group title studies partici-
pants
1 FEV1 1 Mean Difference (Fixed, 95% CI) Subtotals only
1.1 Day 1 1 Mean Difference (Fixed, 95% CI) 0.11 [-0.95, 1.18]
3 FVC 1 Mean Difference (Fixed, 95% CI) Subtotals only
3.1 Day 1 1 Mean Difference (Fixed, 95% CI) -0.47 [-1.29, 0.35]
5 Sputum weight 1 Mean Difference (Fixed, 95% CI) Subtotals only
6 Oxygen saturation 1 Mean Difference (Fixed, 95% CI) Subtotals only

Analysis 5.1. Comparison 5 ACBT+CCPT versus AOD (Flutter), Outcome 1 FEV1.
Study or subgroup ACBT+CCPT Flutter Mean Dif- Mean Difference Weight Mean Difference
ference
5.1.1 Day 1
Osman 2008 0 0 0.1 (0.544) 100% 0.11[-0.95,1.18]
Subtotal (95% CI) 100% 0.11[-0.95,1.18]
Favours ACBT+CCPT -2 -1 0 1 2 Favours Flutter

Analysis 5.2. Comparison 5 ACBT+CCPT versus AOD (Flutter), Outcome 2 FEV1%.
ference
5.2.1 Day 1
Osman 2008 0 0 5.4 (10.731) 100% 5.41[-15.62,26.44]
Subtotal (95% CI) 100% 5.41[-15.62,26.44]

Informed decisions.

ference

Analysis 5.3. Comparison 5 ACBT+CCPT versus AOD (Flutter), Outcome 3 FVC.
ference
5.3.1 Day 1
Osman 2008 0 0 -0.5 (0.42) 100% -0.47[-1.29,0.35]
Subtotal (95% CI) 100% -0.47[-1.29,0.35]

Analysis 5.4. Comparison 5 ACBT+CCPT versus AOD (Flutter), Outcome 4 FVC %.
ference
5.4.1 Day 1
Osman 2008 0 0 -6.5 (8.327) 100% -6.48[-22.81,9.84]
Subtotal (95% CI) 100% -6.48[-22.81,9.84]

Analysis 5.5. Comparison 5 ACBT+CCPT versus AOD (Flutter), Outcome 5 Sputum weight.
ference
5.5.1 Day 1
Osman 2008 0 0 36.5 (27.134) 100% 36.47[-16.71,89.65]
Subtotal (95% CI) 100% 36.47[-16.71,89.65]


Informed decisions.

Analysis 5.6. Comparison 5 ACBT+CCPT versus AOD (Flutter), Outcome 6 Oxygen saturation.
ference
5.6.1 Day 1
Osman 2008 0 0 -0.8 (0.742) 100% -0.81[-2.26,0.65]
Subtotal (95% CI) 100% -0.81[-2.26,0.65]

Comparison 6. ACBT+CCPT versus HFCC (HFCWO)

pants

Analysis 6.1. Comparison 6 ACBT+CCPT versus HFCC (HFCWO), Outcome 1 FEV1.
Study or subgroup ACBT+CCPT HFCC Mean Dif- Mean Difference Weight Mean Difference
ference
6.1.1 Day 1
Osman 2008 0 0 -0.1 (0.375) 100% -0.06[-0.79,0.68]
Subtotal (95% CI) 100% -0.06[-0.79,0.68]
Favours ACBT+CCPT -1 -0.5 0 0.5 1 Favours HFCC

Informed decisions.

ference
Favours ACBT+CCPT -1 -0.5 0 0.5 1 Favours HFCC

Analysis 6.2. Comparison 6 ACBT+CCPT versus HFCC (HFCWO), Outcome 2 FEV1%.
ference
6.2.1 Day 1
Osman 2008 0 0 0.3 (8.128) 100% 0.3[-15.63,16.23]
Subtotal (95% CI) 100% 0.3[-15.63,16.23]
Favours ACBT+CCPT -20 -10 0 10 20 Favours HFCC

Analysis 6.3. Comparison 6 ACBT+CCPT versus HFCC (HFCWO), Outcome 3 FVC.
ference
6.3.1 Day 1
Osman 2008 0 0 -0.4 (0.47) 100% -0.36[-1.29,0.56]
Subtotal (95% CI) 100% -0.36[-1.29,0.56]

Analysis 6.4. Comparison 6 ACBT+CCPT versus HFCC (HFCWO), Outcome 4 FVC %.
ference
6.4.1 Day 1
Osman 2008 0 0 -5.1 (7.931) 100% -5.08[-20.62,10.47]
Subtotal (95% CI) 100% -5.08[-20.62,10.47]


Informed decisions.

Analysis 6.5. Comparison 6 ACBT+CCPT versus HFCC (HFCWO), Outcome 5 Sputum weight.
ference
6.5.1 Day 1
Osman 2008 0 0 15.6 (28.24) 100% 15.65[-39.7,71]
Subtotal (95% CI) 100% 15.65[-39.7,71]
Favours ACBT+CCPT -100 -50 0 50 100 Favours control HFCC

Analysis 6.6. Comparison 6 ACBT+CCPT versus HFCC (HFCWO), Outcome 6 Oxygen saturation.
ference
6.6.1 Day 1
Osman 2008 0 0 -1 (0.739) 100% -1[-2.45,0.45]
Subtotal (95% CI) 100% -1[-2.45,0.45]

Comparison 7. ACBT versus AD

studies partici-
pants
2.1 Up to 1 week 1 Mean Difference (Fixed, 95% CI) -0.4 [-3.93, 3.13]

Analysis 7.1. Comparison 7 ACBT versus AD, Outcome 1 FEV1.
Study or subgroup ACBT AD Mean Difference Weight Mean Difference
7.1.1 Up to 1 week
Pryor 2010 13 1.9 (0.8) 13 2.6 (1.2) 100% -0.7[-1.49,0.09]
Subtotal *** 13 13 100% -0.7[-1.49,0.09]
Favours AD -2 -1 0 1 2 Favours ACBT

Informed decisions.


Analysis 7.2. Comparison 7 ACBT versus AD, Outcome 2 Sputum weight.
Study or subgroup ACBT AD Mean Dif- Mean Difference Weight Mean Difference
ference
7.2.1 Up to 1 week
Miller 1995 0 0 -0.4 (1.8) 100% -0.4[-3.93,3.13]
Subtotal (95% CI) 100% -0.4[-3.93,3.13]
Favours ACBT -5 -2.5 0 2.5 5 Favours AD

Comparison 8. ACBT+CCPT versus AD

pants

Analysis 8.1. Comparison 8 ACBT+CCPT versus AD, Outcome 1 FEV1.
Study or subgroup ACBT+CCPT AD Mean Dif- Mean Difference Weight Mean Difference
ference
8.1.1 Day 1
Osman 2008 0 0 -0.5 (0.616) 100% -0.51[-1.72,0.7]
Favours ACBT+CCPT -1 -0.5 0 0.5 1 Favours AD

Informed decisions.

ference
Subtotal (95% CI) 100% -0.51[-1.72,0.7]
Favours ACBT+CCPT -1 -0.5 0 0.5 1 Favours AD

Analysis 8.2. Comparison 8 ACBT+CCPT versus AD, Outcome 2 FEV1%.
ference
8.2.1 Day 1
Osman 2008 0 0 -8.3 (13.735) 100% -8.3[-35.22,18.62]
Subtotal (95% CI) 100% -8.3[-35.22,18.62]
Favours ACBT+CCPT -50 -25 0 25 50 Favours AD

Analysis 8.3. Comparison 8 ACBT+CCPT versus AD, Outcome 3 FVC.
ference
8.3.1 Day 1
Osman 2008 0 0 -0.8 (0.655) 100% -0.85[-2.13,0.44]
Subtotal (95% CI) 100% -0.85[-2.13,0.44]

Analysis 8.4. Comparison 8 ACBT+CCPT versus AD, Outcome 4 FVC %.
ference
8.4.1 Day 1
Osman 2008 0 0 -11 (11.132) 100% -11.02[-32.84,10.8]
Subtotal (95% CI) 100% -11.02[-32.84,10.8]


Informed decisions.

Analysis 8.5. Comparison 8 ACBT+CCPT versus AD, Outcome 5 Sputum weight.

ference
8.5.1 Day 1
Osman 2008 0 0 -3.5 (33.152) 100% -3.52[-68.49,61.46]
Subtotal (95% CI) 100% -3.52[-68.49,61.46]

Analysis 8.6. Comparison 8 ACBT+CCPT versus AD, Outcome 6 Oxygen saturation.
ference
8.6.1 Day 1
Osman 2008 0 0 -1.1 (1.068) 100% -1.08[-3.17,1.01]
Subtotal (95% CI) 100% -1.08[-3.17,1.01]

WHAT'S NEW

Date Event Description
30 June 2016 New citation required but conclusions A new author (Lisa Wilson) has joined the review team. Despite
have not changed the inclusion of new data from the Pryor study, our conclusions
have not changed.
30 June 2016 New search has been performed A search of the Cystic Fibrosis and Genetic Disorders Group's Cys-
tic Fibrosis Trials Register identified four new references poten-
tially eligible for inclusion in this update. One was the full pa-
per to an abstract previously listed as awaiting classification,
but which has now been included (Pryor 2010). The second ref-
erence was to a study that has been excluded (Gursli 2013). Two
references to one study have been listed as 'Awaiting classifica-
tion' (Petrone 2009).
Two studies previously listed as 'Awaiting classification' have

now been excluded as we do not believe them to have been ran-
domised (Orlik 2000; Orlik 2001).

HISTORY
Protocol first published: Issue 3, 2009
Review first published: Issue 11, 2010

Informed decisions.

Date Event Description
22 October 2012 New citation required but conclusions Despite the inclusion of new data, there is still insufficient evi-
have not changed dence to support or reject the use of active cycle of breathing
technique (ACBT) over any other airway clearance therapy and
hence our conclusions have not changed.
22 October 2012 New search has been performed The Cysitic Fibrosis Trial Register was search and no new refer-
ences were identified.
One study, which was initially listed under 'Studies awaiting clas-
sification', has now been included (Osman 2008). The study au-
thors, who we had previously contacted for additional infor-
mation, provided us with raw data for each participant clarify-
ing which treatment they received and first-arm data before the
cross-over. There was no washout period.

CONTRIBUTIONS OF AUTHORS
Karen Robinson provided the link with the Cochrane Cystic Fibrosis and Genetic Disorders Editorial Base. The Editorial Base and all authors
developed the search strategy and searched for studies. Naomi Mckoy obtained copies of studies, entered data into RevMan and carried
out the analysis for the original review. All authors were responsible for drafting the protocol, selecting which studies to include, extracting
data, interpreting the analysis and drafting the final review. All authors were involved in updating the review.
DECLARATIONS OF INTEREST
All authors: none known.
SOURCES OF SUPPORT
Internal sources
• No sources of support supplied
External sources
• Partially funded by the Cystic Fibrosis Foundation, USA.
• National Institute for Health Research, UK.
This systematic review was supported by the National Institute for Health Research, via Cochrane Infrastructure funding to the Cochrane
Cystic Fibrosis and Genetic Disorders Group.
DIFFERENCES BETWEEN PROTOCOL AND REVIEW
We reorganised the comparator interventions. They were previously listed separately, but we have grouped them for ease of analysis and
in accordance with other physiotherapy reviews of the Cochrane CFGD Group into the following:
• Conventional chest physiotherapy (CCPT) (postural drainage, percussion, chest shaking, huffing, and coughing; excludes the use of
exercise, FET, PEP, or other mechanical devices);
• PEP (PEP mask therapy, high pressure PEP mask therapy);
• Oscillatory devices (airway oscillating devices, high frequency chest compression devices);
• Breathing Techniques (excluding ACBT, but including autogenic drainage);
• Exercise;
• Other Therapy (resistive inspiratory manoeuvre).
INDEX TERMS
Medical Subject Headings (MeSH)

Chest Wall Oscillation [methods]; Cystic Fibrosis [complications] [*therapy]; Drainage, Postural [methods]; High-Frequency
Ventilation [instrumentation]; Patient Preference; Randomized Controlled Trials as Topic; Respiratory Therapy [*methods]

Informed decisions.

MeSH check words

Humans


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Mckoy NA, Wilson LM, Saldanha IJ, Odelola OA, Robinson KA

Mckoy NA, Wilson LM, Saldanha IJ, Odelola OA, Robinson KA.

Active cycle of breathing technique for cystic fibrosis (Review) i

Active cycle of breathing technique for cystic fibrosis

Editorial group: Cochrane Cystic Fibrosis and Genetic Disorders Group

Date of last search: 25 April 2016.

Data collection and analysis

The evidence is current to: 25 April 2016.

Quality of the evidence

Active cycle of breathing technique for cystic fibrosis (Review) 2

Active cycle of breathing technique for cystic fibrosis (Review) 3

Active cycle of breathing technique for cystic fibrosis (Review) 4

METHODS Oscillatory Devices

A self-administered breathing technique that uses optimal

Active cycle of breathing technique for cystic fibrosis (Review) 5

5. Oxygen saturation assessors; compliance assessment; washout reporting; intention-

The I2 statistic measures the proportion of inconsistency in Results of the search

Data synthesis We included 35 citations representing 19 studies. Full text articles

Active cycle of breathing technique for cystic fibrosis (Review) 7

Active cycle of breathing technique for cystic fibrosis (Review) 8

Active cycle of breathing technique for cystic fibrosis (Review) 9

Active cycle of breathing technique for cystic fibrosis (Review) 10

Active cycle of breathing technique for cystic fibrosis (Review) 11

Active cycle of breathing technique for cystic fibrosis (Review) 12

None of the included studies assessed this outcome. 5. Oxygen Saturation

In the cross-over study with first-arm data, the ACBT treatment

3. Lung function 6. Number of pulmonary exacerbations

Active cycle of breathing technique for cystic fibrosis (Review) 13

Primary outcomes 4. Sputum weight

Active cycle of breathing technique for cystic fibrosis (Review) 14

Active cycle of breathing technique for cystic fibrosis (Review) 15

None of the included studies assessed this outcome. 3. Lung function

Active cycle of breathing technique for cystic fibrosis (Review) 16

Active cycle of breathing technique for cystic fibrosis (Review) 18

Active cycle of breathing technique for cystic fibrosis (Review) 19

Active cycle of breathing technique for cystic fibrosis (Review) 20

Orlik T, Sands D. Long-term study of efficiencies of select

Active cycle of breathing technique for cystic fibrosis (Review) 21

Active cycle of breathing technique for cystic fibrosis (Review) 22

[abstract]. European Respiratory Journal 1993;6(Suppl Deeks 2011

Active cycle of breathing technique for cystic fibrosis (Review) 23

Morrison 2014 Rubin 1999

Characteristics of included studies [ordered by study ID]

Participants 18 enrolled; 18 evaluated; 13 male (72.7% male).

Inclusion criteria: NR.

Exclusion criteria: NR.

Active cycle of breathing technique for cystic fibrosis (Review) 24

Exercise: cycling at 60% VO2 max for 20 minutes.

Exercise followed by ACBT: exercise for 10 minutes followed by 10 minutes of ACBT.

ACBT followed by exercise: ACBT for 10 minutes followed by 10 minutes of exercise.

Outcomes Outcome measures: participant preference, lung function, sputum weight.

Additional outcomes: perceived effectiveness.

Bias Authors' judgement Support for judgement

Allocation concealment Unclear risk Unclear.

Blinding (performance High risk Not possible.

Blinding (performance High risk Not possible.

Blinding (performance Unclear risk Unclear.

Compliance/ adherence Unclear risk Not reported.

Washout? Unclear risk No description of a washout period.

Active cycle of breathing technique for cystic fibrosis (Review) 25

Participants 20 enrolled; 20 evaluated; 10 male (50% male).

Age: mean (NR); median (NR); SD (NR); range (NR).

Inclusion criteria: adult participants.

Exclusion criteria: NR.