Physiotherapy Techniques and Equipment

Percussion (or manual chest physiotherapy) is mostly used in babies and small children and your physiotherapist will teach you how to do this if appropriate.

Percussion is a rhythmical patting over the chest either with a cupped hand, 2 fingers, or with percussion cups. This helps to dislodge mucus in your child’s lungs. 

We advise using a towel or a small layer of clothing to help cushion the skin and percussion can be used in many different positions to help target different parts of the lungs.

Your child’s physiotherapist will help you decide the best positions and times to carry out this treatment. Remember to discuss any concerns you have with your physiotherapist especially if you are worried about finding time to fit physiotherapy into your daily schedule.

Advice: 

1. Try to complete the percussion physiotherapy before feeding or wait at least an hour after feeding to avoid reflux (heartburn) or your baby being sick.
2. Do not tip your baby’s head lower that their hips! This can lead to reflux or your baby being sick. 

The Pari PEP device uses a series of different sized holes from 1.5-5, which determine the expiratory pressure generated. The pressure can be measured by placing a device called a manometer in the circuit. These devices can be used with a face mask or mouth-piece.

Your physiotherapist will advise you on the best position(s) in which to carry out your treatment, which hole(s) to set it on, and the correct number of breaths and cycles to optimise your physiotherapy routine. If you have questions about Pari PEP therapy, or need some help with your technique, please contact your physiotherapist who will be able to help you. 

If you have questions about Pari PEP therapy, or need some help with your technique, please contact your physiotherapist who will be able to help you. 

Cleaning of your device is essential after each use as your device can potentially be a source of infection if it is not cleaned regularly. 

Check with your physiotherapist how best to clean your device, but usually it is recommended to clean with warm soapy water, then rinse with clean water and allow to air dry. 

We recommend you store your device in a clean dry container.  This helps to stop reintroducing any bacteria back into your chest.

It is also recommended that your device is sterilised once a week. Your physiotherapist will be able to inform you of the local guidelines or follow the manufacturers’ instructions. 

You do not require a fancy device to do bubble PEP, this can be achieved with a plastic bottle and some water and this is a great way to test out bubble PEP.

Fill a clean, plastic bottle (1 litre bottle/ sterile water bottle) with approximately 10-15 cm of water. Use tubing with a diameter of 5 – 10 mm (suction tubing or smoothie straw size) and approximately 40 – 60 cm long (this generates a PEP of approximately 10 – 20 mmHg). Increasing the water level increases the pressure needed to create bubbles and reduces the oscillations from the bubbles. Using a lower water level will reduce the pressure but help to increase the oscillations. The oscillations help produce a vibratory effect inside the airways which helps to loosen and dislodge the sputum from the walls of the airways. 

Your/your child’s physiotherapist will be able to advise you whether more oscillation or PEP are required.

We advise you/your child do this over the sink or to place a tray/towel underneath the bottle to catch any overflow as it can get messy! 

As your child grows, they will learn the difference between sucking and blowing. This allows for a more fun and effective way to do physiotherapy.  Playing blowing games and blowing bubbles will help to develop this skill.

Ask your child to take a slightly more than normal breath in through their nose and then breathe out through the tubing to create bubbles. The level of water creates a back pressure during the breath out which helps to keep the airways open and get air behind the sputum to help it move up from the lungs towards the throat.

After a set number of breaths encourage your child to huff and cough to clear their chest. Your child’s physiotherapist will advise on number of breaths and cycles to optimise the airway clearance routine. 

To make this more fun, you could add a few drops of soap liquid and food dye to the water.

If you have questions about bubble PEP therapy, or need some help with your technique, please contact your physiotherapist who will be able to help you. 

The Acapella can be used with face mask or mouth-piece. The expiratory pressure and frequency of oscillations can be adjusted for individuals using the frequency/resistance dial (1 - 5) at the back of the Acapella.

The oscillations are created as you breathe out through the device, rocking the insert back and forth (with the help of a magnet). The frequency of these oscillations range between 11 – 15 Hz, similar to what healthy cilia in those without PCD.

Your physiotherapist will advise you on the best position(s) to carry out your treatment, resistance setting, and the number of breaths and cycles to optimise your physiotherapy routine. 

If you have questions about the Acapella, or need some help with your technique, please contact your physiotherapist who will be able to help you. 

The Aerobika (also known as a OPEP – Oscillating Positive Expiratory Pressure Therapy), works in a similar way to the Acapella. The oscillations created on the breath out cause vibrations within the lungs which help to dislodge and loosen secretions from the walls of the airways. The resistance can be set by moving the black pointer at the front of the Aerobika to the desired level.

Your physiotherapist will advise you on the position(s) to carry out your treatment, resistance setting, and the number of breaths and cycles to optimise your physiotherapy routine.                     

If you have questions about the Aerobika, or need some help with your technique, please contact your physiotherapist who will be able to help you. 

The Flutter is a small pipe-shaped device. There is a mouth-piece at one end and a perforated cover at the other, which contains a stainless steel ball. The oscillations in the Flutter are created when you breathe out through the device with enough pressure to move the ball and cause it to ‘flutter’ within the cone. The oscillatory vibrations from the movement of the ball both help to keep airways open, dislodge sputum from the lining of the airways and move it to the larger airways. 

Your physiotherapist will advise you on the best position(s) to carry out your treatment, number of breaths and cycles to optimise your physiotherapy routine. 

If you have questions about the Flutter device, or need some help with your technique, please contact your physiotherapist who will be able to help you. 

There are a number of different medications that can be nebulised, for a variety of reasons. The ones most frequently used by people with PCD are:

Salbutamol - this is a bronchodilator; it helps to open up your airways to stop them being tight or wheezy.

Hypertonic saline- this is salty solution that makes your sputum less sticky and easier to cough up. Most people will use this before doing their physio or combine it with their Aerobika or PEP device (see adjuncts).

Nebulised antibiotics (e.g colomycin/tobramycin) - these are used to treat bacteria growing in your sputum, most commonly this is pseudomonas.

Your doctor will decide if you need a nebuliser. Before starting any of these medications you will need to have a ‘test dose’ to check you can tolerate them. Your PCD team will arrange this with you; it will involve doing your lung function (with a spirometer) before and after nebulising the medication to make sure it remains stable.

Your nebuliser pot and mouthpiece/mask must be kept clean and dry to stop germs growing that could cause chest infections. Any medication left behind in the nebuliser pot can crystallise and block the nebuliser if it is not cleaned.

You should never share your nebuliser or equipment with anyone else, even if it is cleaned regularly.

Your nebuliser machine will need servicing from time to time, and the disposable equipment should be changed regularly. Your physiotherapy team can advise you on how often you need to do this, please ask them if you are unsure.

Each time you use your nebuliser you should:

• Disconnect the tubing from the mouthpiece or facemask and nebuliser pot, as the tubing should not be washed.
• Unscrew the nebuliser pot and wash all the pieces along with the facemask or mouthpiece in warm soapy water.
• Rinse thoroughly under clean, running water.
• Leave to air dry on a clean surface.
• If you have a steriliser, put all the cleaned parts in and turn on according to the manufacturer’s instructions.
• Once a week, disconnect the compressor from the mains electricity and wipe the surface with a clean, slightly damp cloth. Never immerse the nebuliser unit in water.

Autogenic drainage, commonly referred to as AD, is a breathing technique that moves mucus from the lower airways towards the mouth.  It can take a bit of practice to perfect your AD technique, but once you have mastered it AD can be very effective for people with PCD.  

AD is a useful technique to know because you do not need any equipment so you can use AD any time you feel that you need to clear secretions.

Physiotherapists will often talk about three stages with AD:

1. Unstick – breathing in and out at low lung volumes, trying to move secretions from the furthest airways.  At this stage you are aiming to exhale all the way to the bottom of your lung capacity
2. Collect – breathing in and out at mid lung volumes, trying to move the secretions further towards your mouth.  
3. Evacuate – the crackles should be louder as the sputum has moved up near your mouth and your breath in is to your maximum.  Once the secretions have moved high enough for you to clear them you can huff and/or cough to clear the secretions.

Other things to consider:

• Throughout each of the stages of AD you should aim to take a slightly deeper than normal breath in and out.  It isn’t the size of breath that changes as you progress through each stage, but which part of the lung you are breathing from.
• Try to breathe in through your nose, if possible, using your tummy muscles
• Aim to pause for 2 -3 seconds after your “in” breath, keeping your glottis open.  This can be tricky to achieve initially but your physio can help to show you how to do this.
• Exhale with a “sigh” but not too forcefully or you may cause some of your airways to close which will stop sputum moving up from the lower airways.
• Aim to move through to the next stage of AD (see below) when you hear the crackles at the beginning of your out breath.
• Try not to cough until you have moved your secretions near to the top of your lungs and you can huff or cough to clear them(see Huffing and Coughing section below).

If you have any questions about AD or want help with your technique, get in touch with your PCD physiotherapist who will be able to help you.   

The active cycle of breathing technique, usually shortened to ACBT, is a simple set of exercises that has been shown to move mucus from the lower parts of the lungs.  It is important that you ask your physiotherapist to teach you ACBT so that you learn to do it correctly.  ACBT can also be adapted to suit your needs, e.g. if you are feeling short of breath.  ACBT consists of the following steps:

1. Breathing Control

Breathe in and out slowly through your nose, if possible, using your tummy muscles.  Breathing control will allow your airways to relax and will also allow you to catch your breath in between the other parts of ACBT.  If you are short of breath you can spend a longer time doing breathing control until you feel you have caught your breath again.

2. Thoracic Expansion Exercises

These are deeper breaths that aim to move air to the lower parts of your lungs and behind the secretions to move them upwards. Take a long slow breath in through your nose, if you can, using your tummy muscles.  Then exhale out gently 3 – 5 times.  When you have done your deep breaths go back to breathing control.

3. Huff

The huff is an important part of ACBT which helps move the secretions out of your lungs.  To huff imagine that you are trying to mist up a mirror.  Slowly take a deep breath in, make an “O” shape with your mouth and then breathe out quickly and forcefully.

Babies will cough spontaneously and swallow secretions from their lungs. This is fine if it is done little and often throughout the day. Sometimes if there is a large volume of secretions being swallowed, the baby/child may vomit to remove the mucus.

As the child grows and can understand, they will be taught how to huff and cough and are encouraged to expectorate the sputum rather than swallow it.