What would be the best nursing intervention to clear airway secretions from a trauma patient?

1. Fahy JV, Dickey BF. Airway mucus function and dysfunction. New Engl J Med. (2010) 363:2233–47. 10.1056/NEJMra0910061 [PMC free article] [PubMed] [CrossRef] [Google Scholar]

2. Randell SH, Boucher RC. Effective mucus clearance is essential for respiratory health. Am J Respir Cell Mol Biol. (2006) 35:20–8. 10.1165/rcmb.2006-0082SF [PMC free article] [PubMed] [CrossRef] [Google Scholar]

3. Wanner A, Salathé M, O'Riordan TG. Mucociliary clearance in the airways. Am J Respir Crit Care Med. (1996) 154:1868–902. 10.1164/ajrccm.154.6.8970383 [PubMed] [CrossRef] [Google Scholar]

4. Nici L, Donner C, Wouters E, Zuwallack R, Ambrosino N, Bourbeau J, et al.. (2006) American Thoracic Society/European Respiratory Society statement on pulmonary rehabilitation. AMJ Respir Crit Care Med. 173:1390–413. 10.1164/rccm.200508-1211ST [PubMed] [CrossRef] [Google Scholar]

5. Elkins M, Jones A, van der Schans CP. Positive expiratory pressure physiotherapy for airway clearance in people with cystic fibrosis. Cochr Database Syst Rev. (2006) CD003147. 10.1002/14651858.CD003147.pub3 [PubMed] [CrossRef] [Google Scholar]

6. Main E, Prasad A, Schans C. Conventional chest physiotherapy compared to other airway clearance techniques for cystic fibrosis. Cochr Database Syst Rev. (2005) 1:CD002011. 10.1002/14651858.CD002011.pub2 [PMC free article] [PubMed] [CrossRef] [Google Scholar]

7. Morrison L, Agnew J. Oscillating devices for airway clearance in people with cystic fibrosis. Cochr Database Syst Rev. (2009). 10.1002/14651858.CD006842.pub2 [PubMed] [CrossRef] [Google Scholar]

8. Warnock L, Gates A, van der Schans CP. Chest physiotherapy compared to no chest physiotherapy for cystic fibrosis. Cochr Database Syst Rev. (2013). 10.1002/14651858.CD001401.pub2 [PubMed] [CrossRef] [Google Scholar]

9. Hess DR. The evidence for secretion clearance techniques. Respir Care. (2001) 46:1276–93. [PubMed] [Google Scholar]

10. Hill K, Patman S, Brooks D. Effect of airway clearance techniques in patients experiencing an acute exacerbation of chronic obstructive pulmonary disease: a systematic review. Chron Respir Dis. (2010) 7:9–17. 10.1177/1479972309348659 [PubMed] [CrossRef] [Google Scholar]

11. Lapin CD. Airway physiology, autogenic drainage, and active cycle of breathing. Respir Care. (2002) 47:778–85. [PubMed] [Google Scholar]

12. Nelson HP. Postural drainage of the lungs. Br Med J. (1934) 2:251 10.1136/bmj.2.3840.251 [PMC free article] [PubMed] [CrossRef] [Google Scholar]

13. Cecins NM, Jenkins SC, Pengelley J, Ryan G. The active cycle of breathing techniques—to tip or not to tip?. Respir Med. (1999) 93:660–5. 10.1016/S0954-6111(99)90107-5 [PubMed] [CrossRef] [Google Scholar]

14. Eaton T, Young P, Zeng I, Kolbe J. A randomized evaluation of the acute efficacy, acceptability and tolerability of flutter and active cycle of breathing with and without postural drainage in non-cystic fibrosis bronchiectasis. Chron Respir Dis. (2007) 4:23–30. 10.1177/1479972306074481 [PubMed] [CrossRef] [Google Scholar]

15. Currie DC, Munro C, Gaskell D, Cole PJ. Practice, problems and compliance with postural drainage: a survey of chronic sputum producers. Br J Dis Chest. (1986) 80:249–53. 10.1016/0007-0971(86)90060-4 [PubMed] [CrossRef] [Google Scholar]

16. Fink JB. Positioning versus postural drainage. Respir Care. (2002) 47:769–77. [PubMed] [Google Scholar]

17. Bott J, Blumenthal S, Buxton M, Ellum S, Falconer C, Garrod R, et al.. Guidelines for the physiotherapy management of the adult, medical, spontaneously breathing patient. Thorax. (2009) 64 (Suppl. 1):i1–52. 10.1136/thx.2008.110726 [PubMed] [CrossRef] [Google Scholar]

18. McCarren B, Alison JA, Herbert RD. Vibration and its effect on the respiratory system. Aust J Physiother. (2006) 52:39–43. 10.1016/S0004-9514(06)70060-5 [PubMed] [CrossRef] [Google Scholar]

19. Lee AL, Burge A, Holland AE. Airway clearance techniques for bronchiectasis. Cochr Database Syst Rev. (2013) CD008351 10.1002/14651858.CD008351.pub2 [PubMed] [CrossRef] [Google Scholar]

20. Gallon A. Evaluation of chest percussion in the treatment of patients with copious sputum production. Respir Med. (1991) 85:45–51. 10.1016/S0954-6111(06)80209-X [PubMed] [CrossRef] [Google Scholar]

21. Pryor JA, Webber BA, Hodson ME, Batten JC. Evaluation of the forced expiration technique as an adjunct to postural drainage in treatment of cystic fibrosis. Br Med J. (1979) 2:417–8. 10.1136/bmj.2.6187.417 [PMC free article] [PubMed] [CrossRef] [Google Scholar]

22. Pryor JA, Webber BA, Hodson ME. Effect of chest physiotherapy on oxygen saturation in patients with cystic fibrosis. Thorax. (1990) 45:77. 10.1136/thx.45.1.77 [PMC free article] [PubMed] [CrossRef] [Google Scholar]

23. Menkes HA, Traystman RJ. Collateral ventilation. Am Rev Respir Dis. (1977) 116:287–309. [PubMed] [Google Scholar]

24. Mckoy NA, Saldanha IJ, Odelola OA, Robinson KA. Active cycle of breathing technique for cystic fibrosis. Cochr Database Syst Rev. (2012) (12). 10.1002/14651858.CD007862.pub3 [PubMed] [CrossRef] [Google Scholar]

25. Pryor JA, Tannenbaum E, Scott SF, Burgess J, Cramer D, Gyi K, et al.. Beyond postural drainage and percussion: Airway clearance in people with cystic fibrosis. J Cyst Fibrosis. (2010) 9:187–92. 10.1016/j.jcf.2010.01.004 [PubMed] [CrossRef] [Google Scholar]

26. Heyningen V. Cystic fibrosis: horizons. Proceedings of the 9th International Congress, Brighton, England, June 9th-15th 1984. Edited by D. Lawson. Chichester: John Wiley. 1984. 446 pages. $15.00. ISBN 0 471 90439 2. Genet Res. (1984) 44:359–60. 10.1017/S0016672300026598 [CrossRef] [Google Scholar]

27. Falk M, Kelstrup M, Andersen JB, Kinoshita T, Falk P, Støvring S, et al.. Improving the ketchup bottle method with positive expiratory pressure, PEP, in cystic fibrosis. Eur J Respir Dis. (1984) 65:423–32. [PubMed] [Google Scholar]

28. Van der Schans CP, van der Mark TW, De Vries G, Piers DA, Beekhuis H, Dankert-Roelse JE, et al.. Effect of positive expiratory pressure breathing in patients with cystic fibrosis. Thorax. (1991) 46:252–6. 10.1136/thx.46.4.252 [PMC free article] [PubMed] [CrossRef] [Google Scholar]

29. Darbee JC, Ohtake PJ, Grant BJ, Cerny FJ. Physiologic evidence for the efficacy of positive expiratory pressure as an airway clearance technique in patients with cystic fibrosis. Phys Ther. (2004) 84:524–37. 10.1093/ptj/84.6.524 [PubMed] [CrossRef] [Google Scholar]

30. Oberwaldner B, Evans JC, Zach MS. Forced expirations against a variable resistance: a new chest physiotherapy method in cystic fibrosis. Pediatr Pulmonol. (1986) 2:358–67. 10.1002/ppul.1950020608 [PubMed] [CrossRef] [Google Scholar]

31. App EM, Kieselmann R, Reinhardt D, Lindemann H, Dasgupta B, King M, et al.. Sputum rheology changes in cystic fibrosis lung disease following two different types of physiotherapy: flutter vs autogenic drainage. Chest. (1998) 114:171–7. 10.1378/chest.114.1.171 [PubMed] [CrossRef] [Google Scholar]

32. McIlwaine PM, Wong LT, Peacock D, Davidson AGF, of Paediatrics FD . Long-term comparative trial of conventional postural drainage and percussion versus positive expiratory pressure physiotherapy in the treatment of cystic fibrosis. J Pediatr. (1997) 131:570–4. 10.1016/S0022-3476(97)70064-7 [PubMed] [CrossRef] [Google Scholar]

33. McIlwaine PM, Wong LT, Peacock D, Davidson AGF. Long-term comparative trial of positive expiratory pressure versus oscillating positive expiratory pressure (flutter) physiotherapy in the treatment of cystic fibrosis. J Pediatr. (2001) 138:845–50. 10.1067/mpd.2001.114017 [PubMed] [CrossRef] [Google Scholar]

34. McIlwaine MP, Alarie N, Davidson GF, Lands LC, Ratjen F, Milner R, et al.. Long-term multicentre randomised controlled study of high frequency chest wall oscillation versus positive expiratory pressure mask in cystic fibrosis. Thorax. (2013) 68:746–51. 10.1136/thoraxjnl-2012-202915 [PubMed] [CrossRef] [Google Scholar]

35. Lee AL, Burge AT, Holland AE. Positive expiratory pressure therapy versus other airway clearance techniques for bronchiectasis. Cochr Libr. (2017) 9:CD011699. 10.1002/14651858.CD011699.pub2 [PMC free article] [PubMed] [CrossRef] [Google Scholar]

36. Fauroux B, Guillemot N, Aubertin G, Nathan N, Labit A, Clément A, et al.. Physiologic benefits of mechanical insufflation-exsufflation in children with neuromuscular diseases. Chest. (2008) 133:161–8. 10.1378/chest.07-1615 [PubMed] [CrossRef] [Google Scholar]

37. Morrow B, Zampoli M, van Aswegen H, Argent A. Mechanical insufflation-exsufflation for people with neuromuscular disorders. Cochr Database Syst Rev. (2013) CD010044. 10.1002/14651858.CD010044.pub2 [PubMed] [CrossRef] [Google Scholar]

38. Homnick DN. Mechanical insufflation-exsufflation for airway mucus clearance. Respir Care. (2007) 52:1296–307. [PubMed] [Google Scholar]

39. Cesareo A, LoMauro A, Santi M, Biffi E, D'Angelo MG, Aliverti A. Acute effects of mechanical insufflation-exsufflation on the breathing pattern in stable subjects with duchenne muscular dystrophy. Respir Care. (2018) 63:955–65. 10.4187/respcare.05895 [PubMed] [CrossRef] [Google Scholar]

40. Bach JR. Mechanical insufflation/exsufflation: has it come of age? A commentary. Eur J Res. (2003) 21:385–6. 10.1183/09031936.03.00098702 [PubMed] [CrossRef] [Google Scholar]

41. Mustfa N, Aiello M, Lyall RA, Nikoletou D, Olivieri D, Leigh PN, et al.. Cough augmentation in amyotrophic lateral sclerosis. Neurology. (2003) 61:1285–7. 10.1212/01.WNL.0000092018.56823.02 [PubMed] [CrossRef] [Google Scholar]

42. Sancho J, Servera E, Díaz J, Marín J. Efficacy of mechanical insufflation-exsufflation in medically stable patients with amyotrophic lateral sclerosis. Chest. (2004) 125:1400–5. 10.1378/chest.125.4.1400 [PubMed] [CrossRef] [Google Scholar]

43. Vianello A, Corrado A, Arcaro G, Gallan F, Ori C, Minuzzo M, et al.. Mechanical insufflation–exsufflation improves outcomes for neuromuscular disease patients with respiratory tract infections. Am J Phys Med Rehabil. (2005) 84:83–8. 10.1097/01.PHM.0000151941.97266.96 [PubMed] [CrossRef] [Google Scholar]

44. Chatwin M, Simonds AK. The addition of mechanical insufflation/exsufflation shortens airway-clearance sessions in neuromuscular patients with chest infection. Respir Care. (2009) 54:1473–9. [PubMed] [Google Scholar]

45. Chatwin M, Toussaint M, Gonçalves MR, Sheers N, Mellies U, Gonzales-Bermejo J, et al.. Airway clearance techniques in neuromuscular disorders: a state of the art review. Respir Med. (2018) 136:98–110. 10.1016/j.rmed.2018.01.012 [PubMed] [CrossRef] [Google Scholar]

46. Sivasothy P, Brown L, Smith IE, Shneerson JM. Effect of manually assisted cough and mechanical insufflation on cough flow of normal subjects, patients with chronic obstructive pulmonary disease (COPD), and patients with respiratory muscle weakness. Thorax. (2001) 56:438–44. 10.1136/thorax.56.6.438 [PMC free article] [PubMed] [CrossRef] [Google Scholar]

47. Fink JB, Mahlmeister MJ. High-frequency oscillation of the airway and chest wall. Respir Care. (2002) 47:797–807. [PubMed] [Google Scholar]

48. Chatwin M, O'Driscoll D, Corfield D, Morrell M, Simonds A. Controlled trial of intrapulmonary percussion in adults and children with stable severe neuromuscular disease. Am J Crit Care Med. (2004) 169:A438. [Google Scholar]

49. Nava S, Barbarito N, Piaggi G, De Mattia E, Cirio S. Physiological response to intrapulmonary percussive ventilation in stable COPD patients. Respir Med. (2006) 100:1526–33. 10.1016/j.rmed.2006.01.010 [PubMed] [CrossRef] [Google Scholar]

50. Toussaint M, De Win H, Steens M, Soudon P. Effect of intrapulmonary percussive ventilation on mucus clearance in duchenne muscular dystrophy patients: a preliminary report. Respir Care. (2003) 48:940–7. [PubMed] [Google Scholar]

51. Clini EM, Degli Antoni F, Vitacca M, Crisafulli E, Paneroni M, Chezzi-Silva S, et al.. Intrapulmonary percussive ventilation in tracheostomized patients: a randomized controlled trial. Intens Care Med. (2006) 32:1994–2001. 10.1007/s00134-006-0427-8 [PubMed] [CrossRef] [Google Scholar]

52. Newhouse PA, White F, Marks JH, Homnick DN. The intrapulmonary percussive ventilator and flutter device compared to standard chest physiotherapy in patients wit cystic fibrosis. Clin Pediatr. (1998) 37:427–32. 10.1177/000992289803700705 [PubMed] [CrossRef] [Google Scholar]

53. Paneroni M, Clini E, Simonelli C, Bianchi L, Degli Antoni F, Vitacca M. Safety and efficacy of short-term intrapulmonary percussive ventilation in patients with bronchiectasis. Respir Care. (2011) 56:984–8. 10.4187/respcare.01098 [PubMed] [CrossRef] [Google Scholar]

54. Reychler G, Debier E, Contal O, Audag N. Intrapulmonary percussive ventilation as an airway clearance technique in subjects with chronic obstructive airway diseases. Respir Care. (2018) 63:620–31. 10.4187/respcare.05876 [PubMed] [CrossRef] [Google Scholar]

55. King M, Phillips DM, Gross D, Vartian V, Chang HK, Zidulka A. Enhanced tracheal mucus clearance with high frequency chest wall compression. Am Rev Respir Dis. (1983) 128:511–5. 10.1164/arrd.1983.128.3.511 [PubMed] [CrossRef] [Google Scholar]

56. Chang HK, Weber ME, King M. Mucus transport by high-frequency nonsymmetrical oscillatory airflow. J Appl Physiol. (1988) 65:1203–9. 10.1152/jappl.1988.65.3.1203 [PubMed] [CrossRef] [Google Scholar]

57. Braggion C, Cappelletti LM, Cornacchia M, Zanolla L, Mastella G. Short-term effects of three chest physiotherapy regimens in patients hospitalized for pulmonary exacerbations of cystic fibrosis: a cross-over randomized study. Pediatr Pulmonol. (1995) 19:16–22. 10.1002/ppul.1950190104 [PubMed] [CrossRef] [Google Scholar]

58. Allan JS, Garrity JM, Donahue DM. The utility of high-frequency chest wall oscillation therapy in the post-operative management of thoracic surgical patient. Chest. (2003) 124:235 10.1378/chest.124.4_MeetingAbstracts.235S-b [CrossRef] [Google Scholar]

59. Osman LP, Roughton M, Hodson ME, Pryor JA. Short-term comparative study of high frequency chest wall oscillation and European airway clearance techniques in patients with cystic fibrosis. Thorax. (2010) 65:196–200. 10.1136/thx.2008.111492 [PMC free article] [PubMed] [CrossRef] [Google Scholar]

60. Nicolini A, Cardini F, Landucci N, Lanata S, Ferrari-Bravo M, Barlascini C. Effectiveness of treatment with high-frequency chest wall oscillation in patients with bronchiectasis. BMC Pulmon Med. (2013) 13:21. 10.1186/1471-2466-13-21 [PMC free article] [PubMed] [CrossRef] [Google Scholar]

61. D'Abrosca F, Garabelli B, Savio G, Barison A, Appendini L, Oliveira LV, et al.. Comparing airways clearance techniques in chronic obstructive pulmonary disease and bronchiectasis: positive expiratory pressure or temporary positive expiratory pressure? A retrospective study. Braz J Phys Ther. (2017) 21:15–23. 10.1016/j.bjpt.2016.12.001 [PMC free article] [PubMed] [CrossRef] [Google Scholar]

62. Nicolini A, Mollar E, Grecchi B, Landucci N. Comparison of intermittent positive pressure breathing and temporary positive expiratory pressure in patients with severe chronic obstructive pulmonary disease. Arch Bronconeumol. (2014) 50:18–24. 10.1016/j.arbr.2013.12.008 [PubMed] [CrossRef] [Google Scholar]

63. Nicolini A, Mascardi V, Grecchi B, Ferrari-Bravo M, Banfi P, Barlascini C. Comparison of effectiveness of temporary positive expiratory pressure versus oscillatory positive expiratory pressure in severe COPD patients. Clin Respir J. (2018) 12:1274–82. 10.1111/crj.12661 [PubMed] [CrossRef] [Google Scholar]

64. Mascardi V, Grecchi B, Barlascini C, Banfi P, Nicolini A. Effectiveness of temporary positive expiratory pressure (T-PEP) at home and at hospital in patients with severe chronic obstructive pulmonary disease. J Thorac Dis. (2016) 8:2895. 10.21037/jtd.2016.10.69 [PMC free article] [PubMed] [CrossRef] [Google Scholar]

65. Venturelli E, Crisafulli E, DeBiase A, Righi D, Berrighi D, Cavicchioli PP, et al.. Efficacy of temporary positive expiratory pressure (TPEP) in patients with lung diseases and chronic mucus hypersecretion. The UNIKO® project: a multicentre randomized controlled trial. Clin Rehabil. (2013) 27:336–46. 10.1177/0269215512458940 [PubMed] [CrossRef] [Google Scholar]

66. Bertelli L, Di Nardo G, Cazzato S, Ricci G, Pession A. Free-Aspire: a new device for the management of airways clearance in patient with ineffective cough. Pediatr Rep. (2017) 9:7270. 10.4081/pr.2017.7270 [PMC free article] [PubMed] [CrossRef] [Google Scholar]

67. Garuti G, Verucchi E, Fanelli I, Giovannini M, Winck JC, Lusuardi M. Management of bronchial secretions with Free Aspire in children with cerebral palsy: impact on clinical outcomes and healthcare resources. Ital J Pediatr. (2016) 42:7. 10.1186/s13052-016-0216-0 [PMC free article] [PubMed] [CrossRef] [Google Scholar]

68. Belli S, Cattaneo D, D'Abrosca F, Prince I, Savio G, Balbi B. A pilot study on the non-invasive management of tracheobronchial secretions in tracheostomised patients. Clin Respir J. (2019) 13:637–42. 10.1111/crj.13074 [PubMed] [CrossRef] [Google Scholar]

69. Patrizio G, D'Andria M, D'Abrosca F, Cabiaglia A, Tanzi F, Garuti G, et al.. Airway clearance with expiratory flow accelerator technology: effectiveness of the “free aspire” device in patients with severe COPD. Turk Thorac J. (2019) 20:209. 10.5152/TurkThoracJ.2018.18053 [PMC free article] [PubMed] [CrossRef] [Google Scholar]

70. Fauroux B, Boulé M, Lofaso F, Zérah F, Clément A, Harf A, et al. Chest physiotherapy in cystic fibrosis: improved tolerance with nasal pressure support ventilation. Pediatrics. (1999) 103:e32 10.1542/peds.103.3.e32 [PubMed] [CrossRef] [Google Scholar]

71. Flight WG, Shaw J, Johnson S, Webb AK, Jones AM, Bentley AM, et al.. Long-term non-invasive ventilation in cystic fibrosis—Experience over two decades. J Cyst Fibrosis. (2012) 11:187–92. 10.1016/j.jcf.2011.11.006 [PubMed] [CrossRef] [Google Scholar]

72. Holland AE, Denehy L, Ntoumenopoulos G, Naughton MT, Wilson JW. Non-invasive ventilation assists chest physiotherapy in adults with acute exacerbations of cystic fibrosis. Thorax. (2003) 58:880–4. 10.1136/thorax.58.10.880 [PMC free article] [PubMed] [CrossRef] [Google Scholar]

73. Moran F, Bradley JM, Piper AJ. Non-invasive ventilation for cystic fibrosis. Cochr Database Syst Rev. (2009) CD002769 10.1002/14651858.CD002769.pub3 [PubMed] [CrossRef] [Google Scholar]

74. Young AC, Wilson JW, Kotsimbos TC, Naughton MT. Randomised placebo controlled trial of non-invasive ventilation for hypercapnia in cystic fibrosis. Thorax. (2008) 63:72–7. 10.1136/thx.2007.082602 [PubMed] [CrossRef] [Google Scholar]

75. Lazzeri M, Lanza A, Bellini R, Bellofiore A, Cecchetto S, Colombo A, et al.. Respiratory physiotherapy in patients with COVID-19 infection in acute setting: a Position Paper of the Italian Association of Respiratory Physiotherapists (ARIR). Monaldi Arch Chest Dis. (2020) 90. 10.4081/monaldi.2020.1285 [PubMed] [CrossRef] [Google Scholar]

76. Felten-Barentsz KM, van Oorsouw R, Klooster E, Koenders N, Driehuis F, Hulzebos EH, et al.. Recommendations for hospital-based physical therapists managing patients with COVID-19. Phys Ther. (2020) 100:1444–57. 10.1093/ptj/pzaa114 [PMC free article] [PubMed] [CrossRef] [Google Scholar]

77. Vitacca M, Lazzeri M, Guffanti E, Frigerio P, D'Abrosca F, Gianola S, et al.. Italian suggestions for pulmonary rehabilitation in COVID-19 patients recovering from acute respiratory failure: results of a Delphi process. Monaldi Arch Chest Dis. (2020) 90. 10.4081/monaldi.2020.1444 [PubMed] [CrossRef] [Google Scholar]

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Different ACTs and their characteristics.

	Patients typology	Degree of collaboration of the patient	Cough efficacy	Pro	Con	Time of execution	Need for …
Postural Drainage	COPD, cystic fibrosis, post-surgery (precaution)	Average - Good	Yes	Low cost, studied for a long time, combine with other techniques	Patients with reduced flows, patients with cognitive impairment, highly deconditioned patients, patients with reduced cough reflex, thoracic trauma	10′−30′ (2–3 times/day)	Mobilize secretions from periphery of the lung
Manual techniques	COPD, cystic fibrosis	Average - Good	Yes	Low cost, detach secretions from the bronchial wall, Combine with other techniques	Patients with reduced flows, patients with cognitive impairment, highly deconditioned patients, patients with reduced cough reflex	20′ (2–3 times/day)	Mobilize secretions from periphery of the lung. Facilitate expectoration
Active Cycle of Breathing Techniques	COPD hypersecretive Bronchiectasis Cystic fibrosis Pre/post-surgery	Good	Yes	Free. It combines lung re-expansion and PEP effect.Self-management	Patients with reduced flows, patients with cognitive impairment, agitated or confused, patients not spontaneously breathing	20′ (2–3 times/day)	Mobilize secretions from the periphery of the lung. Facilitate expectoration
Autogenous Drainage	COPD hypersecretive Bronchiectasis Cystic fibrosis Pre/post-surgery	Average - Good	Yes	Free. It combines lung re-expansion and PEP effect. Self-management	Patients too young, patients with cognitive impairment, highly deconditioned patients, patients with reduced cough reflex, difficult to teach	20′ (2–3 times/day)	Mobilize secretions from the periphery of the lung
PEP Systems (PEP mask, PEP Bottle, thera PEP. etc.)	COPD hypersecretive Bronchiectasis Cystic fibrosis Pre/post-surgery	Good	Yes	Low cost, easy to use and transportable. Excellent for managing the early stages of COPD. Self-management	Patients with reduced flows, patients with cognitive impairment, highly deconditioned patients, Pneumothorax, active haemoptysis	10′−15′ (1–2 times /day)	Mobilize secretions from the periphery of the lung, increasing lung volume (FRC and VT), reduction of hyperinflation
OPEP Systems (Aerobika, Acapella, Flutter, Cornet, etc.)	COPD hypersecretive Bronchiectasis Cystic fibrosis Pre/post-surgery	Average - Good	Yes	Low cost, easy to use and transportable, the vibration allows a better action on the denser secretions. Excellent for managing the early stages of disease. Self-management.	Patients with reduced flows, patients with cognitive impairment, highly deconditioned patients, Pneumothorax, active haemoptysis	10′−15′ (1–2 times/day)	Mobilize secretions from the periphery of the lung; the swing facilitates the detachment of secretions, increasing lung volume (FRC and VT), reduction of hyperinflation
Cough Assist (E70, Kalos, Nippy, etc.)	NMD, post coma, ABI (with attention to glottic functionality)	From Good (in synchrony with device) to Absent	NO	Useful for those with: weak muscle, conditions with ineffective cough, In case of ineffectiveness of the air-stacking maneuver, Weakness of respiratory mm, with ineffective cough (Peak cough flow (PCEF) <270 l / min.) Maximum Expiratory Pressure (MEP) <50 cmH2O highly studied machines, guidelines present x NMD	Complete paralysis of the glottis (risk of collapse of the airways in exhalations), Recent barotrauma, pneumothorax, Hemodynamic instability, Recent thoracic surgery, Bullous emphysema, pneumomediastinum, Recent abdominal surgery, Maxillofacial trauma, Epistaxis, requires trained staff, Expensive	10′−30′ (2–3 times/day)	Mobilize and remove secretions in patient with ineffective cough reflex using a Δ pressure
IPPV (or percussionaire)	COPD (hypercapnic), bronchiectasis, Cystic Fibrosis	From Good to Low	Yes	Form of ventilation, it also helps to reduce hypercapnia and improves oxygenation; useful for patients with thick secretions.	Expensive, not widespread; to know its use well. Difficult to domicile	30′	Optimize the ventilation of the patient; facilitate the detachment and ascent of secretions (through the “rupture” of the mucus)
T -PEP (temporary positive expiratory pressure)	COPD hyper secretive Bronchiectasis Cystic fibrosis Pre/post-surgery	Average - Good	Yes	Good feedback for the patient during the execution of the maneuver. Useful for ACOS patients, patients with reduced expiratory flows. Self-management.	Patients with cognitive impairment, with reduced cough reflex. costly	15′−20′ (1–2 times/day)	Maintain a prolonged and constant expiratory flow with low pressures facilitating the ascent of mucus
Vest (o smart Vest)	COPD, Bronchiectasis, Cystic Fibrosis	From good to absent	Yes	Easy to use, comfortable	For patients with ineffective cough need to join a Cough assist; expensive	20′ /die (even several times a day)	Mobilize secretions through vibrations on the chest wall.
Expiratory Flow Acceleration	COPD, Bronchiectasis, post-surgery, post-transplant, Cystic Fibrosis, NMD (Healthy Lung), ABI (if impossible use cough assist)	From good to absent	Not necessarily	Cystic fibrosis Self-management. Pre/post-surgery (thoraco-abdominal, ENT, cardiac) Brain damage Neuromuscular pathologies (ALS, MS, etc.) Excellent for tracheostomized patients and with low flows Self-management even for the most compromised patients	Not effective on very dense and viscous secretions (need to act on the rheology of the mucus); ineffective on tachypnoeic patients (the patient must breathe on his TV)	15′−30′ (but more in monitored and hypersecreted patients)	Accelerate the expiratory flow (Venturi system) facilitating the ascent of the secretions up to the upper airways or to the glottis (to then be swallowed)
NIV	Cystic fibrosis, Pre/post-surgery	Average - Good	Yes	Amplifies inspired flow. It combines lung re-expansion and PEP effect.	For patients with ineffective cough need to join a Cough assist; expensive	20′ /die	Re-expand and unblock areas at risk of atelectasis or bronchial encumbrance