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Communications to the Editor |

Questioning Flutter Therapy To the Editor: FREE TO VIEW

George Ntoumenopoulos, PhD
Author and Funding Information

Affiliations: The Alfred Hospital, Prahran, Australia ,  Michigan State University, Kalamazoo Center for Medical Studies Kalamazoo, MI Correspondence to: Douglas N. Homnick, MD, MPH, FCCP, Professor of Pediatrics and Human Development, Michigan State University, Kalamazoo Center for Medical Studies, 1000 Oakland Dr, Kalamazoo, MI 49008; e-mail: homnick@kcms.msu.edu

Correspondence to: George Ntoumenopoulos, PhD, Physiotherapy Department, The Alfred Hospital, Commercial Rd, Prahran, Australia 3181



Chest. 1999;116(1):270-271. doi:10.1378/chest.116.1.270
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Published online

To the Editor:

The recent investigation by Homnick et al (October 1998)1 was designed to compare two modes of chest physiotherapy in hospitalized patients with cystic fibrosis (CF). The authors alluded that physiotherapy using a “flutter device” (which generates rhythmic variations in positive expiratory pressure) appeared to be as effective as “standard chest physiotherapy” (a nebulous term), in the clinical management of this patient group.

These authors1failed to objectively describe the treatment procedures used in their investigation. They reported the use of guidelines from the Cystic Fibrosis Foundation or from the manufacturers of the flutter device; however, without citing references, this precludes the proper interpretation of this investigation. Williams2 reports that the poor definition of physiotherapy techniques in most CF research is “the most confounding factor when reviewing the literature.”

Baseline demographics were reported1 as being similar between the two groups studied; however, trends in the data indicated that there were younger patients and patients with lower FVC and FEV1 in the standard chest physiotherapy group, even though the differences were not statistically significant. These differences may have impacted the treatment outcome and thus limited the study conclusions.

Homnick et al1only partially identified the limitations of their investigation. Most CF physiotherapy research includes inadequate sample sizes2 that often lead authors to incorrectly conclude that there are no differences between the two therapy groups in baseline characteristics or clinical outcome, because there were no statistically significant differences (type II error). The authors1 reported that a sample size of 219 would be required to achieve 80% power; however, the details of the method used for this power calculation are not provided. Homnick et al1 failed to report important trends in the data that indicated greater improvements in clinical outcome (“clinical score” that included sputum volume, respiratory rate, pulmonary function, body temperature, and weight gain) in the standard chest physiotherapy group, even though the results were not statistically significant.

The increased staffing costs required for the provision of standard chest physiotherapy led the authors1 to argue for the use of flutter device therapy, considering the equivalence in clinical outcome. The misleading references made by Homnick et al1 to Reisman et al3 that imply that standard chest physiotherapy is potentially traumatic are of concern. Reisman et al3 demonstrated the benefits of a chest physiotherapy regimen that included postural drainage, chest wall percussion, and forced expiratory technique, which reduced the deterioration in pulmonary function and general health when compared to a less intensive form of physiotherapy (forced expiratory technique alone), thereby contradicting the statement by Homnick et al.1 Although Homnick et al1 may advocate the use of more cost-effective physiotherapy, there is inadequate evidence to support flutter device therapy. Pryor et al4 report significantly reduced clearance of airway secretions with the use of a flutter device, indicating that a simplistic approach to promoting a“ generic” therapy could be detrimental to patient outcome. The impact of modifying physiotherapy treatment on long-term patient outcome in this patient group must be rigorously investigated before modifications to treatment are suggested. Randomized controlled multicenter investigations, with adequate patient numbers and descriptions of the treatments and measurement tools are recommended before we change patient care. As pointed out by Williams,2 disease severity, treatment compliance, airway lability, and adjunctive medications are highly variable, and “it may be more appropriate to consider which physiotherapy regimens are more effective for individual patients rather than any one technique being the most effective for all patients with cystic fibrosis.”

Chest physiotherapy that includes postural drainage, forced expiratory technique, and chest wall percussion, has been demonstrated to significantly enhance the clearance of airway secretions.36 The role of these treatment regimens in the prevention of pulmonary dysfunction and morbidity must be further investigated, as recommended by Reisman et al.3 CF patients have successfully been instructed in the use of standard chest physiotherapy regimens36 independently of physiotherapists and respiratory therapists, which may refute the potential cost issues previously cited.1 Patient compliance with physiotherapy is of relevance to the use of the flutter device. The authors have not provided any evidence that patients would be any more compliant with the flutter device. A recent investigation by Scherer et al7 reported that high frequency oral and chest wall oscillation was as effective as “conventional chest physical therapy” in augmenting sputum clearance in 14 stable CF outpatients and that these modalities could be a useful way to reduce health costs. These authors,7 however, defined“ conventional chest physical therapy” as including postural drainage, mechanical chest wall percussion/vibration and coughing, yet another variant of “standard” chest physiotherapy! Aside from other methodological flaws with this research,7 the“ conventional chest physical therapy” used in this study is definitely not the most optimal form of physiotherapy for secretion clearance.2 If the aim these researchers1,7 is to justify the use of “novel” approaches to therapy to reduce health care costs, may “we” at least compare the most optimal form of physiotherapy treatment, rather than using substandard7 or poorly described treatment regimens.1 We must design better clinical research if we are to discern the most effective treatment approaches.

Homnick, DN, Anderson, K, Marks, J (1998) Comparison of the flutter device to standard chest physiotherapy in hospitalized patients with cystic fibrosis.Chest114,993-997. [PubMed] [CrossRef]
 
Williams, MT Chest physiotherapy and cystic fibrosis: why is the most effective form of treatment still unclear?Chest1994;106,1872-1882. [PubMed]
 
Reisman, JJ, Rivington-Law, B, Carey, M, et al Role of conventional chest physiotherapy in cystic fibrosis.J Pediatr1988;113,632-636. [PubMed]
 
Pryor, JA, Webber, BA, Hodson, ME, et al The Flutter VRP1 as an adjunct to chest physiotherapy in cystic fibrosis.Respir Med1994;88,677-681. [PubMed]
 
Gallon, A Evaluation of chest percussion in the treatment of patients with copious sputum production.Respir Med1991;85,45-51. [PubMed]
 
Steven MH, Pryor JA, Webber BA, et al. Physiotherapy versus cough alone in the treatment of cystic fibrosis. N Z J Physiol 1992; 31–37.
 
Scherer, TA, Barandun, J, Martinez, E, et al Effect of high-frequency oral and chest wall oscillation and conventional chest physical therapy on expectoration in patients with stable cystic fibrosis.Chest1998;113,1019-1027. [PubMed]
 

To the Editor:

In regard to Dr. Ntoumenopoulos’s response to our article (October 1998),1 we agree that most studies of airway clearance devices and techniques in cystic fibrosis consist of insufficient numbers to provide adequate statistical power to draw absolute conclusions about their comparative efficacy. However, there are also few studies such as ours that attempt to define the sample size necessary to answer this question. Of course, every study must define its variables, including methods used, and we clearly stated that our interventions were based on our hospital protocols, which are available to anyone or any institution requesting them. Regarding the comments about trends in our data, we believe that trends are trends and that they are only of interest as topics for future investigation. Extensive comment on data that is not statistically significant is not wise in our opinion. Concerning issues surrounding the potential trauma of chest physiotherapy, our use of the word trauma was not meant to imply a potentially poorer outcome; rather, it simply referred to physical trauma. Many of us who have treated children with cystic fibrosis for many years have noted the potential for chest wall trauma when manual chest physiotherapy is applied too vigorously (muscle soreness, ecchymoses, and even rib fracture in unusual cases, etc). Our attempts to introduce and study alternative airway clearance therapies is based on our evolving needs to provide for patient independence and the desire for something with potentially greater efficacy while maintaining low costs and simplicity of use.

References
Homnick, DN, Anderson, K, Marks, JH Comparison of the flutter device to standard chest physiotherapy in hospitalized patients with cystic fibrosis: a pilot study.Chest1998;114,993-997. [PubMed] [CrossRef]
 

Figures

Tables

References

Homnick, DN, Anderson, K, Marks, J (1998) Comparison of the flutter device to standard chest physiotherapy in hospitalized patients with cystic fibrosis.Chest114,993-997. [PubMed] [CrossRef]
 
Williams, MT Chest physiotherapy and cystic fibrosis: why is the most effective form of treatment still unclear?Chest1994;106,1872-1882. [PubMed]
 
Reisman, JJ, Rivington-Law, B, Carey, M, et al Role of conventional chest physiotherapy in cystic fibrosis.J Pediatr1988;113,632-636. [PubMed]
 
Pryor, JA, Webber, BA, Hodson, ME, et al The Flutter VRP1 as an adjunct to chest physiotherapy in cystic fibrosis.Respir Med1994;88,677-681. [PubMed]
 
Gallon, A Evaluation of chest percussion in the treatment of patients with copious sputum production.Respir Med1991;85,45-51. [PubMed]
 
Steven MH, Pryor JA, Webber BA, et al. Physiotherapy versus cough alone in the treatment of cystic fibrosis. N Z J Physiol 1992; 31–37.
 
Scherer, TA, Barandun, J, Martinez, E, et al Effect of high-frequency oral and chest wall oscillation and conventional chest physical therapy on expectoration in patients with stable cystic fibrosis.Chest1998;113,1019-1027. [PubMed]
 
Homnick, DN, Anderson, K, Marks, JH Comparison of the flutter device to standard chest physiotherapy in hospitalized patients with cystic fibrosis: a pilot study.Chest1998;114,993-997. [PubMed] [CrossRef]
 
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