RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BANGALORE, KARNATAKA

ANNEXURE- II

PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

1. / NAME OF THE CANDIDATE AND ADDRESS / CHETANA BISHT
#151/1, 13th A Cross, 6th Main,
BTM Layout 2ND STAGE
BANGALORE – 560076
2. / NAME OF THE INSTITUTION / THE OXFORD COLLEGE OF PHYSIOTHERAPY, 6/9, 6/11, 1st MAIN, 1st CROSS, BEGUR ROAD, HONGASANGARA, BANGALORE-560068
3. / COURSE OF THE STUDY AND SUBJECT / MASTER OF PHYSIOTHERAPY
CARDIO-RESPIRATORY DISORDERS AND INTENSIVE CARE – 2 years course
4. / DATE OF THE ADMISSION TO THE COURSE / 8th JUNE 2011
5. / TITLE OF THE STUDY
“A STUDY TO FIND OUT AWARENESS AMONG PHYSIOTHERAPISTS OF RECENT ADVANCES IN AIRWAY CLEARANCE TECHNIQUES”
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8 / BRIEF RESUME OF THE INTENDED WORK :
6.1. NEED OF THE STUDY :
In health, a host of mechanisms work together to maintain optimal function of the respiratory system. The mucociliary escalator and cough reflex facilitate secretion clearance and prevent airway obstruction. Many factors, including the aging process, tobacco use, environmental exposures and disease processes, interfere with secretion clearance. Chronic obstructive pulmonary disorders such as cystic fibrosis and bronchiectasis alter the production and composition of mucus. Airway obstruction and structural damage result from recurring infection, inflammatory changes and secretion retention. Technological and clinical advances offer practitioners a variety of expulsion and breathing techniques, manual therapy to help in secretion clearance, together these techniques can be referred to as Airway Clearance techniques (ACT).1
Airway Clearance techniques can be defined as the external application of a combination of forces in order to increasemucustransport. Their goal is to facilitate bronchialmucustransport andsputumexpectoration. When achieved, this can lead to beneficial long-term effects. The techniques, their intensity, duration and frequency vary between physical therapists and have changed over the years.1
Airway clearance techniques can be broadly classified into the following:2
1.  Conventional Chest physiotherapy - such as Direct Cough and Force expiration, Postural Drainage, Chest Percussion, shaking, vibration etc.
2.  Other airway clearance techniques – such as Autogenic Drainage, ACBT, Positive Expiratory Pressure, Flutter Device, R-C Cornet etc.
Autogenic drainage (AD) is a system of breathing exercises developed in 1967 by Jean Chevallier in Belgium, to sequentially attain the highest possible expiratory flows to move secretions from peripheral to central airways, without forced expirations and associated airway closure. Autogenic drainage uses controlled breathing to maximize expiratory flow with minimal airway closure, starting with the small airways and moving secretions from smaller to larger airways in 3 phases: unsticking, collection, and evacuation. The patient moves mucus with a relaxed sighing exhalation, regulating airflow and velocity with use of expiratory muscles, avoiding unnecessary expiratory resistance.3
Active Cycle of Breathing Technique (ACBT) is a cycle of techniques of breathing control, thoracic expansion exercises and the forced expiration technique. Huffing to low lung volumes will assist in mobilizing and clearing the more peripherally situated secretions and, when secretions have reached the larger more proximal upper airways, a huff or cough from a high lung volume can be used to clear them4,12.
Positive Expiratory Pressure (PEP) is an airway clearance technique that involves the application of a positive expiratory pressure between 10-20cm H20 via a facemask or mouthpiece. It has been reported to increase regional lung volume, reduce the volume of trapped gas, limit compression of compliant airways and promote ventilation through collateral channels thereby enhancing the peripheral secretions.5
Forced Expiratory Technique (FET) was developed in 1968 by Thompson and Thompson to improve the efficient of secretion removal.7 It consists of one or two huffs (forced expirations), from mid-lung volume to low lung volume, followed by a period of relaxed, controlled diaphragmatic breathing. Bronchial secretions mobilised to the upper airways are then expectorated and the process is repeated until maximal bronchial clearance is obtained. The patient can reinforce the forced expiration by self-compression of the chest wall using a brisk adduction movement of the upper arm6,12.
Postural Drainage (PD) is a widely accepted technique. It uses gravity and percussion (shaking, clapping etc) to loosen the thick, sticky mucus in the lungs so it can be removed by coughing. Unclogging the airways is critical to reducing the severity of lung infections.9
Some of the points worth mentioning in airway clearance techniques are:-
·  Some of these techniques can have some detrimental effects, for Postural Drainage has been found to have small, but statistically significant, desaturation effect on arterial oxygen while a small but significant improvement in saturation with autogenic drainage.3
·  The Active Cycle of Breathing Techniques, when compared with "conventional" physiotherapy, has been shown to increase expectoration of sputum while reducing the length of time taken for treatment. It has also been shown to be equally effective both with and without an assistant.4
·  Although some of the literature suggests no major difference between conventional and other airway clearance techniques but the reviews are mixed and not very clear. Forced expiratory technique, active cycle of breathing and autogenic drainage are all comparable in therapeutic effects to postural drainage.3
·  There might be differences among the techniques included in conventional chest physiotherapy or alternate techniques on the way these techniques are administered to the patient. For e.g. Autogenic drainage has been found to be more difficult to learn compared to active cycle of breathing techniques or postural drainage as requires substantial feedback to the patient, until he or she is able to control the volume and flow ranges breathed and becomes attuned to the auditory and chest sensations to facilitate mucociliary clearance. Because of this autogenic drainage is recommended only for patients greater than 8 years of age.3
·  Some techniques are used more even if one has alternate technique that is more effective. In a study done in U.K. it was found that nearly 95% of clinics use active cycle of breathing techniques compared to autogenic drainage for chest physiotherapy in cystic fibrosis, even though it has been found that autogenic drainage clears mucus from lungs faster than active cycle of breathing techniques. The reason for this might be the reluctance of the therapist or the comfortableness of patients with the techniques.7
·  In case of chest physiotherapy for chronic obstructive pulmonary disease (COPD) majority of the therapists prefer active cycle of breathing techniques when compared to Vibration, shaking and precussion.8
Thus, we can say that various airway clearance techniques in chest physiotherapy are in practice and there is no specific technique to be used in a specific condition. At present, the patient’s subjective preference, such as age, ease of use, ease to learn, ability to be undertaken independently or with an assistant, health condition etc , is the best measure of which technique to use.2,4
This study is needed to find out the awareness among the physiotherapists about the various evidence based airway clearance techniques. The study will help to aware the physiotherapists about advanced airway clearance techniques and this can be beneficial for the patient. Making aware is not just about telling something new; many times physiotherapists are reluctant to use techniques even if they have knowledge of these airway clearance techniques. This study will be helpful in suggesting the physiotherapists about evidence based practice if they are not practicing advance airway clearance techniques.
6.2. REVIEW OF LITERATURE :
·  Cees P van der Schans; Conventional Chest Physical Therapy for Obstructive Lung Disease (2007); reviewed conventional CPT and alternative CPT modalities in patients with obstructive lung diseases. Suggested that alternate airway clearance modalities (e.g. vibratory positive expiratory pressure, high-frequency chest wall compression and exercises) are not more effective than the conventional chest physiotherapy techniques. Only if cough and huff are insufficiently efficient should other CPT modalities be considered.
·  James B Fink; Forced expiratory technique, Direct cough and Autogenic drainage (2007); states that standard chest physical therapy with active cycle of breathing and forced expiratory technique is more effective than chest physical therapy alone. Evidence-based reviews have suggested that, though successful adoption of techniques such as autogenic drainage may require greater control and training, patients with long-term secretion management problems should be taught as many of these techniques as they can master for adoption in their therapeutic routines. Knowledge of these techniques and conscientious teaching to appropriate patients can greatly enhance the clinician’s repertoire of effective bronchial hygiene options.
·  J. A. Pryor; Physiotherapy for airway clearance in adults (1999); studied techniques that have been developed in more recent years which are effective, comfortable and can be used independent of an assistant in majority of adults.Postural drainage with chest clapping and chest shaking has, in most parts of the world, been replaced by the more effective techniques of the active cycle of breathing, autogenic drainage, R-C Cornet, Flutter, positive expiratory pressure mask.
·  J A Payor, B A Webber, M E Hodson, J C Batten; Evaluation of the forced expiration technique as an adjunct to postural drainage in treatment of cystic fibrosis; compared the effectiveness of conventional, assisted postural drainage with a technique of self-postural drainage using the forced expiration technique in patients with cystic fibrosis. Sixteen patients with cystic fibrosis were treated with conventional physiotherapy aided by an assistant. The results were compared with those produced by physiotherapy using the forced expiration technique without an assistant. The forced expiration technique cleared more sputum in less time than conventional physiotherapy.
·  S Miller, D O Hall, C B Clayton, R Nelson; Chest physiotherapy in cystic fibrosis: a comparative study of autogenic drainage and active cycle of breathing techniques with postural drainage (1994); found that ACBT was the preferred technique used in physiotherapy centers in UK, with nearly 96% of the centres using ACBT. However, it was concluded that AD is as effective as ACBT at clearing mucus in patients with cystic fibrosis.
·  Abebaw M. Yohannes, Martin J. Conolly; A national survey: percussion, vibration, shaking and active cycle breathing techniques used in patients with acute exacerbations of chronic obstructive pulmonary disease (2007); conducted a survey to investigate the use of percussion, vibration, shaking and active cycle breathing techniques (ACBT) by physiotherapists working in respiratory care and treating patients admitted with acute exacerbations of COPD (AECOPD). The findings suggested that manual chest physiotherapy techniques (vibration, percussion and shaking) were used infrequently for chest clearance in patients admitted with AECOPD, whereas ACBT was used always or often by 88% of responders.
·  Donald R. Giles, Jeffrey S. Wagener, et.al; Short-term Effects of Postural Drainage With Clapping vs Autogenic Drainage on Oxygen Saturation and Sputum Recovery in Patients With Cystic Fibrosis (1995); compared the short term effect of postural drainage and autogenic drainage (AD) on oxygen saturation, pulmonary function and sputum recovery. We conclude that AD is less likely to produce oxygen desaturation and may be better tolerated by patients with CF, while producing similar benefits in sputum clearance.
·  Andrea Bellone, Rosaria Lascioli, et.al; Chest physical therapy in Patients with Acute Exacerbation of Chronic Bronchitis: Effectiveness of three methods; compared the short-term effects of postural drainage (PD), oscillating positive expiratory pressure (using the FLUTTER device), and expiration with the glottis open in the lateral posture (ELTGOL) on oxygen saturation, pulmonary function, and sputum production in patients with an acute exacerbation of chronic bronchitis. In conclusion, it was suggested that all 3 treatments are effective in acutely removing secretions without causing any undesirable effect on oxygen saturation in patients with chronic bronchitis exacerbation. Because the techniques other than PD allow patients to do their treatment by themselves, they might represent a valid alternative to PD and should be considered very attractive first choices of chest physiotherapy in the treatment of exacerbated.
6.3. OBJECTIVES OF THE STUDY:
·  To find out the awareness about the recent evidence based techniques of airway clearance among the physiotherapists who are practicing in chest physiotherapy.
6.4. HYPOTHESES :
Since this is an exploratory study hypothesis is not applicable.
MATERIALS AND METHODS :
7.1. STUDY DESIGN : A Survey study
7.2. SOURCE OF DATA :
Physiotherapists from each hospital/clinic
7.3. METHODOLOGY :
7.3.1. POPULATION :
Physiotherapists from hospitals and clinics in and around Bangalore where chest physiotherapy is practiced.
7.3.2. SELECTION CRITERIA :
1. INCLUSION CRITERIA :
·  Physiotherapists practicing in chest physiotherapy
·  Both male and female
2.  EXCLUSION CRITERIA :
·  Physiotherapists practicing in chest physiotherapy and who are not willing to participate in the study.
7.3.3. SAMPLING METHOD AND SAMPLE SIZE :
a) Sampling method: Stratified Cluster Sampling.
7.3.4. PROCEDURE :
·  Development and validation of questionnaire –
This study will be done with a detailed self administered questionnaire which will include open ended questions such as name, experience, qualification of the physiotherapist, name of hospital, questions about the techniques in chest physiotherapy and knowledge of the physiotherapist regarding the technique they use. The questionnaire will be in English.
·  Obtaining informed consent of subject.
The informed consent will be obtained by the physiotherapist falling in selection criteria.
·  Interviewing the subjects using the questionnaire.
Interview will be conducted for 30 mins. The area should be calm and quiet. The researcher will be present during the interview in order to clarify any doubts regarding the questionnaire.
·  Collecting the data.
Once all the questions are answered, the questionnaire will be collected on the spot from the participants.
·  Data will be further used to carry out the statistical analysis
7.3.5. MATERIALS REQUIRED :
Questionnaire
7.4. STATISTICAL ANALYSIS :
Descriptive:
The details will be collected and processed according to the years of experience and summary statistics will be calculated to derive information.
7.4 a) Does the study require any investigation to be conducted on patients or other humans or animals?
NO
b) Has the ethical consent for the study has been obtained from the institution is case?
Yes
REFERENCES :
1.  Cees P Van der Schans. Airway clearance. Assessment of techniques. Paediatric Respiratory Reviews; 2002; page 110-114.
2.  Cees P Van der Sachans; Conventional Chest Physical Therapy for Obstructive Lung Disease. Respir Care. 2007; Volume 52(9), page 1198-1206.