AARC Clinical Practice Guideline: Effectiveness of Nonpharmacologic Airway Clearance Therapies in Hospitalized Patients

TLDR

Airway clearance therapy is employed across many clinical settings, yet high‑level evidence is scarce, underscoring the need for rigorously designed studies to clarify its role. These guidelines, based on a systematic review, aim to assess whether nonpharmacologic ACT improves oxygenation, reduces ventilator duration, ICU stay, resolves atelectasis/consolidation, and enhances respiratory mechanics compared with usual care across three patient populations. The guidelines recommend against routine chest physiotherapy for uncomplicated pneumonia, routine ACT for COPD, incentive spirometry post‑operatively, and routine ACT post‑operatively; they suggest ACT only for COPD patients with symptomatic secretion retention, cough‑assist for neuromuscular disease with low peak cough flow, and early mobility for postoperative patients, while noting insufficient evidence for other ACT modalities.

Abstract

Airway clearance therapy (ACT) is used in a variety of settings for a variety of ailments. These guidelines were developed from a systematic review with the purpose of determining whether the use of nonpharmacologic ACT improves oxygenation, reduces length of time on the ventilator, reduces stay in the ICU, resolves atelectasis/consolidation, and/or improves respiratory mechanics, versus usual care in 3 populations. For hospitalized, adult and pediatric patients without cystic fibrosis, 1) chest physiotherapy (CPT) is not recommended for the routine treatment of uncomplicated pneumonia; 2) ACT is not recommended for routine use in patients with COPD; 3) ACT may be considered in patients with COPD with symptomatic secretion retention, guided by patient preference, toleration, and effectiveness of therapy; 4) ACT is not recommended if the patient is able to mobilize secretions with cough, but instruction in effective cough technique may be useful. For adult and pediatric patients with neuromuscular disease, respiratory muscle weakness, or impaired cough, 1) cough assist techniques should be used in patients with neuromuscular disease, particularly when peak cough flow is < 270 L/min; CPT, positive expiratory pressure, intrapulmonary percussive ventilation, and high-frequency chest wall compression cannot be recommended, due to insufficient evidence. For postoperative adult and pediatric patients, 1) incentive spirometry is not recommended for routine, prophylactic use in postoperative patients, 2) early mobility and ambulation is recommended to reduce postoperative complications and promote airway clearance, 3) ACT is not recommended for routine postoperative care. The lack of available high-level evidence related to ACT should prompt the design and completion of properly designed studies to determine the appropriate role for these therapies.