2 Clinicians started to choose this newer form of postural drainage under mounting criticism of intermittent positive-pressure breathing therapy, which was replaced with routine use of CPT. 1 In the 1960s through the 1970s there was an increase in the use of CPT, a more aggressive adjunct to postural drainage. Postural drainage was used in adults as early as 1901, in the treatment of bronchiectasis. Traditional CPT has 4 components: postural drainage, percussion, chest-wall vibration, and coughing. Newer techniques considered part of chest physical therapy (CPT) include maneuvers to improve the efficacy of cough, such as the forced expiration technique, intrapulmonary percussive ventilation, positive expiratory pressure (PEP) therapy, oscillatory PEP, high-frequency chest compression, and specialized breathing techniques such as autogenic drainage. These techniques include postural drainage, percussion, chest-wall vibration, and promoting coughing. The respiratory therapist implements classic airway-clearance techniques to remove secretions from the lungs. That being said, Hess questioned, in a Journal conference summary regarding airway clearance, “Does the lack of evidence mean a lack of benefit?” 1 Reasonable evidence is limited in this patient population, and is far from conclusive, so we have taken the liberty of utilizing experience and supportive evidence from adult clinical trials to assist in our quest to clarify the role of airway maintenance and clearance in pediatric acute disease. Many airway-clearance techniques are not benign, particularly if they are not used as intended. This attitude can lead to inappropriate orders and inadvertent complications. There is a perception that airway clearance may not help, but it won't hurt either. While most studies have focused on the primary outcome of sputum production, it is not clear whether sputum volume is an appropriate indication for or outcome of airway clearance. Many clinicians feel that if the patient is producing secretions, we should do something about it. Yet airway maintenance and clearance therapy take a great deal of the respiratory therapist's time. The lack of scientific rigor, among other issues, has led to a deficiency of high-level evidence. One of the major obstacles in device research, particularly airway clearance or maintenance modality, is proper blinding and equipoise. Wherever possible we have chosen pediatric-specific evidence to support our conclusions. This paper focuses on the pediatric airway clearance and maintenance aspect of acute respiratory diseases, specifically in the hospital environment, biophysical and biochemical characteristics of the lung that prevail during pulmonary exacerbations, physiology and pathological processes unique to children, and other considerations. In the pediatric patient, distinct differences in physiology and pathology limit the application of adult-derived airway clearance and maintenance modalities. Traditional airway maintenance, airway clearance therapy, and principles of their application are similar for neonates, children, and adults. Unfortunately, more questions than answers remain. Available disease-specific evidence of airway-clearance techniques and airway maintenance will be discussed whenever possible. Airway-clearance techniques consume a substantial amount of time and equipment. Much of this is probably due to the limited ability to assess outcome and/or choose a proper disease-specific or age-specific modality. Many new airway clearance and maintenance techniques have evolved, but few have demonstrated true efficacy in the pediatric patient population. One of the staples of respiratory care has been chest physiotherapy and postural drainage. This paper focuses on airway-clearance techniques and airway maintenance in the pediatric patient with acute respiratory disease, specifically, those used in the hospital environment, prevailing lung characteristics that may arise during exacerbations, and the differences in physiologic processes unique to infants and children. Yet there are distinct differences in physiology and pathology between children and adults that limit the routine application of adult-derived airway-clearance techniques in children. Traditional airway maintenance and clearance therapy and principles of application are similar for neonates, children, and adults.
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