Airway Clearance Methods
IPV (Intrapulmonary percussive ventilation)
What is it?
The patient seals their mouth on one end of the tube, and then the IPV machine delivers rapid oscillations of pressure back and forth. This does two things: it moves a column of air back and forth in the airways. It also causes percussion from inside the lungs, hence the name “intrapulmonary percussive ventilation.”
When to use?
Think of this as the “big gun” to clear airway secretions (i.e. large pneumonia, bronchiestasis, etc…). Older and frail patients however may not tolerate. Must be given with at least one bronchodilator.
The Vest
What is it?
A form of High Frequency Chest Wall Oscillation (HFCWO), this is essentially a rubber vest placed on the patient that rapidly inflates and deflates. You can think of this as an external version of IPV.
When to use?
Also considered one of the “big guns,” this can be used alternatively to IPV. It’s usually given BID, treatments are 30 minutes long. Although traditionally used more for cystic fibrosis patients in the past, the Vest can be used for the same patients we use IPV for (i.e. large pneumonia, bronchiestasis, etc…).
Acapella/flutter:
What is it?
The acapella is a small portable device with a valve that opens and closes during the expiratory phase. This interruption in expiration helps to loosen airway secretions. Flutter is actually a little different to acapella (ball valve versus disc valve) but for our purposes it’s the same thing. Whether you order acapella or flutter at Stanford or the VA, you will get acapella since it’s what we carry.
When to use?
Great for minimal secretions, bronchial secretions or older/frail patients. Probably one of the most commonly used methods for airway clearance at Stanford/VA. Can be used with or without bronchodilators. The great thing about acapella is it can be taught to patients and they can take this home with them.
CPT (Chest physiotherapy):
What is it?
Manual percussion of the chest to break up secretions. Respiratory therapists also have machines to aid with this. Has less efficacy than other modalities listed above.
When to use?
Great adjunct to IPV or acapella if these modalities are not working.
Peak Expiratory Pressure (PEP device)
What is it?
Resistance to expiration, providing PEEP. In theory, this causes airways to stay open, leading to facilitation in coughing up secretions.
When to use?
Rarely, best in patients with respiratory muscle weakness (i.e. spine patients).
IPPB (intermittent positive pressure breathing):
What is it?
Uses a positive pressure to inflate the lungs. It can be used to help open airways (i.e. lung recruitment) but almost no role in airway secretion.
When to use?
Almost never, not even carried at Stanford anymore, used rarely at the VA.
Incentive Spirometry
Just a note… This has no role in airway clearance. Its role is in improving lung volumes and minimizing atelectasis.
(Errol Ozdalga MD,