American Academy of Pediatrics – Section on Pediatric Pulmonology and Sleep Medicine
View all recommendations from this societyReleased August 17, 2020
Do not routinely use airway clearance therapy in conditions such as asthma, bronchiolitis, and pneumonia.
There is little evidence that airway clearance techniques play any significant role in the management of children with an acute respiratory problem or, chronically, in the outpatient setting for any condition other than bronchiectasis. Airway clearance techniques appear to be safe and somewhat effective for children with stable bronchiectasis and suppurative chronic bronchitis (such as cystic fibrosis) and may account for improvements in sputum expectoration, selected measures of lung function, symptoms, and health-related qualities of life. Common strategies for maintaining a clear airway in patients who have chronically impaired clearance of pulmonary secretions include 1) chest percussion alone; 2) chest percussion combined with proper positioning and postural drainage; 3) augmentation of the patient’s own cough; 4) manually assisted coughing (MAC), active cycle of breathing technique, forced expiratory technique, and autogenic drainage; and 5) positive pressure therapy with the use of Flutter valves®, positive expiratory pressure (PEP) therapy, intermittent positive pressure breathing (IPPB), intrapulmonary percussive ventilation (IPV), high-frequency chest wall compression (HFCWC), and even continuous positive airway pressure (CPAP). In both Cochrane and Hayes reviews, chest physical therapy techniques did not appear to reduce the overall severity of disease for bronchiectasis but there may be reduction in the rate of progression of disease and improvement in the health-related qualities of life noted above.
There may be some advantages to certain techniques and devices in neuromuscular disease with impaired ability to expectorate airway secretions, both acutely and chronically. Physicians should not routinely prescribe airway clearance techniques in previously healthy children with acute bronchiolitis, pneumonia, or an exacerbation of asthma.
These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician.
How The List Was Created
The AAP Section on Pediatric Pulmonology and Sleep Medicine (SOPPSM) expressed interest in Choosing Wisely at Celebration of Pediatric Pulmonology in 2015. Over the course of the 2-day meeting, group breakouts occurred during which the attendees identified the top 21 potential Choosing Wisely recommendations. These were voted on and ranked by the attendees. The AAP Section on Pediatric Pulmonology and Sleep Medicine (SOPPSM) membership was then surveyed to select the top 5 items on the basis of the scientific evidence provided. The list was extensively peer reviewed, refined, and approved by all relevant AAP Committees, Councils, and Sections. The AAP Board of Directors and Executive Committee awarded the final approval.
AAP’s disclosure and conflict of interest policy can be found at www.aap.org.
Sources
Hayes Reviews: (Publication Date: March 28, 2014/Annual Review: Mar 15, 2017). High-Frequency Chest Wall Compression for Diseases Other than Cystic Fibrosis. (Publication Date: April 30, 2015/Annual Review: April 4, 2017). CoughAssist Mechanical Insufflation-Exsufflation Device (Philips Respironics) for Respiratory Insufficiency. (Publication Date: April 21, 2016). Intrapulmonary Percussive Ventilation for Home Use in Children.
Lee AL, Burge AT, Holland AE. Airway clearance techniques for bronchiectasis. Cochrane Database Syst Rev. 2015;(11):CD008351.
Figuls MR, Gine-Garriga M, Rugeles CG, Perrotta C, Vilaro J. Chest physiotherapy for acute bronchiolitis in pediatric patients between 0 and 24 months old. Cochrane Database Syst Rev. 2016;(2):CD004873.
Gajdos V, Katsahian S, Beydon N, et al. Effectiveness of chest physiotherapy in infants hospitalized with acute bronchiolitis: a multicenter, randomized, controlled trial. PLoS Med. 2010;7(9):e1000345
De Boeck K, Vermeulen F, Vreys M, Moens M, Proesmens M. Airway clearance techniques to treat acute respiratory disorders in previously healthy children: where is the evidence? Eur J Pediatr. 2008;167(6):607–612.
Strickland SL, Rubin BK, Drescher GS, et al. AARC clinical practice guideline: effectiveness of non-pharmacologic airway clearance therapies in hospitalized patients. Respir Care. 2013;58(12):2187-2193.
Panitch HB. Respiratory implications of pediatric neuromuscular disease. Respir Care. 2017;62(6):826-848.
