第29期 文献推荐‖气道廓清技术操作指南

Introduction

Airway-clearance therapies (ACTs) have long been considered an important part of care of the patient with cystic fibrosis (CF). This is based upon our understanding of the pathophysiology of CF lung disease. There is ineffective mucociliary clearance 1 and, from very early in life, there is obstruction of the small airways by mucus. Mucociliary clearance is an important defense mechanism of the airways, and patients are vulnerable to chronic infection of the airways. There is an exaggerated inflammatory response, with the airways containing bacteria, inflammatory cells, and cellular breakdown products (eg, neutro phil-derived deoxyribonucleic acid and filamentous actin(F-actin). 3-6 All of this material increases the tenacity and stickiness of the airway secretions, and the airways become further obstructed. 7,8 Since the mucociliary clearance system isn’t working, it makes sense to use other methods to help clear the airway secretions, if only to relieve the obstruction. In addition, these secretions contain bacteria and inflammatory mediators that continue to injure the airways as well as recruit new inflammatory cells. Therefore, clearance of airway secretions does more than merely relieve obstruction; it also reduces the amount of infection and inflammation present in the airways.

气道廓清技术（ACT）长期以来一直被认为是囊性纤维化（CF）患者护理的重要组成部分。这是基于我们对CF疾病病理生理学的理解。CF患者粘液-纤毛运输系统失能并且从很早就有粘液阻塞小气道。粘液-纤毛运输系统是气道的重要防御机制，CF患者呼吸道容易发生慢性感染，产生异常炎症反应，气道粘液中含有细菌、炎症细胞和细胞分解产物（例如中性粒细胞衍生的脱氧核糖核酸和丝状肌动蛋白（F-actin）。所有这些物质都增加了呼吸道分泌物的粘稠性，导致气道进一步阻塞。由于粘液-纤毛运输系统失能，所以为了缓解气道阻塞使用相关的廓清方法帮助清除气道分泌物有意义的。此外，这些分泌物含有细菌和炎症介质，这些介质继续损伤气道，并产生新的炎性细胞。因此，清除呼吸道分泌物不仅可以缓解阻塞，而且还可以减少呼吸道中的感染和炎症。

What Is Airway Clearance?

ACTs are physical or mechanical means of facilitating the removal of tracheobronchial phlegm through the external and/or internal manipulation of air flow, and the evacuation of phlegmvia coughing. One of the earliest forms of therapy, which continues to be a primary method,is chest physiotherapy, or percussion and postural drain age. In 1959, British physiotherapist Jocelyn Reed first reported that“clapping and pressure vibrations,during long expirations, are the most effective forms of mechanical stimulus to elimination of secretions in the treatment of lung abscess, collapsed lobes, and bronchiectasis.” 9 ACTs have evolved over the years, using imaginative strategies such as high-frequency chest-wall compression using an inflatable vest connected to an air compressor, hand-held expiratory vibratory devices, and, more recently, acoustic waves to vibrate the mucus from the airway walls. The respiratory therapist has an extensive menu of airway clearance modalities from which to choose (Table 1), each with advantages and disadvantages. The intent of this paper is not to discuss the techniques for delivering the numerous airway-clearance modalities; however, we have included the instructions that we give to our patients and families on these therapies (Appendix). The intent is to help guide the therapist in choosing an ACT that is appropriate for a CF patient at different stages of life. The challenge for the therapist is to match the therapy with the patient so that there is the most effective clearance of airway phlegm.

ACTs是通过外部和/或内部气流控制，促进气管支气管痰移动，并通过咳嗽排出痰的物理或机械手段。胸部物理疗法或叩诊和体位引流是最早的治疗形式之一，目前仍然是主要的方法。1959年，英国理疗师Jocelyn Reed首次报告说：“在治疗肺脓肿、肺叶塌陷和支气管扩张时，长呼气时拍打和振动是消除分泌物最有效的机械刺激形式”，使用富有想象力的策略，如使用充气背心连接到空气压缩机，手持式呼气振动装置，以及最近的声学装置振动气道壁上的粘液。呼吸治疗师有大量的气道清除方法可供选择（表1），每种方法都有优缺点。本文的目的不是讨论各种气道清除廓清技术；我们已包括了我们对患者和家属关于这些治疗方法的指导（附录）。目的是帮助指导治疗师选择适合CF患者不同阶段的技术。治疗师面临的挑战是如何将治疗与患者相匹配，以便最有效地清除气道内的痰液。

Cystic Fibrosis Pulmonary Guidelines

The Cystic Fibrosis Foundation established the Pulmonary Therapies Committee to develop guidelines for medications and therapies to maintain the lung health of patients with CF. Thus far, there are published recommendations for medications used chronically 10 and for ACTs. 11 A systematic review of the published literature was used to develop these recommendations. An important realization in the development of the ACT guidelines was the lack of large, long-term studies of airway clearance. It is not that there isn’t any evidence to support ACT for patients with CF; there are, in fact, a large number of studies, but most have small numbers of patients, are performed over short periods of time (some only a single treatment), and many have no comparator. A prior systematic review concluded that ACT increases mucus transport for the short-term, but the authors could not draw conclusions about the long-term effects or benefits. 12 Another review noted that, despite the “dearth of high-level evidence to support any secretion clearance technique,” the lack of evidence does not mean lack of benefit.The Pulmonary Therapies Committee felt that the existing evidence supporting ACT compared to no therapies was fair in quality overall. They expressed concern that because ACT is so fundamental to CF treatment, a large controlled trial designed to explicitly prove the benefits of ACT could not be completed. They determined that the overall benefit of ACT was moderate, based upon the various outcomes that had been studied with a variety of therapies, including increased sputum production, increased lung function in the short-term, reduced rate of decline of lung function, and increased exercise tolerance. In the end, they recommended that some form of ACT be performed as a routine in all patients. 11

囊性纤维化基金会成立了肺治疗委员会，以制定药物和治疗指南，以维持CF患者的肺健康。到目前为止，已经公布了长期使用和ACTs的药物建议。通过对已发表文献的系统回顾来制定这些建议。在制定ACT指南的过程中，一个重要的认识是缺乏对气道廓清的大规模、长期研究。这并不是说没有任何证据支持ACT治疗CF患者；事实上，有大量的研究，但大多数研究的患者人数很少，而且都是在短时间内完成的（有些只是单一的治疗），而且许多研究没有对照。先前的一项系统综述认为ACT在短期内增加了粘液的运输，但作者不能得出长期的效应或收益。另一篇评论指出，尽管“缺乏支持任何分泌物清除技术的高水平证据”，但缺乏证据确实如此不意味着没有好处，肺治疗委员会认为，与没有治疗相比，现有的证据支持在质量上是恰当的。他们表达了这样的担忧，ACT对CF治疗至关重要，但一个旨在明确证明ACT益处的大型对照试验无法实现。基于各种治疗方法研究的结果他们认为ACT的总体益处是适度的，包括增加痰量、短期内增加肺功能、降低肺功能下降率和增加运动耐力。最后，他们建议对所有患者进行某种形式的ACT治疗。

There were other important findings in the systematic review that led to specific recommendations by the committee. First, there weren’t any data to suggest that one type of ACT was better than any other. Second, patients will express preferences, and it is believed that patients are more likely to use therapies they believe to be beneficial. Finally, aerobic exercise seemed to offer benefits to a regimen of airway clearance in addition to the other well known benefits of exercise. 14

系统回顾中还有其他重要的结果，以至于委员会提出具体建议。首先，没有任何数据表明一种行为优于其他行为。其次,病人将表达偏好,相信患者更有可能使用治疗他们认为是有益的。最后，有氧运动似乎除了运动的其他众所周知的收益外，还对气道清除有好处。

Implementing the Airway-Clearance Therapy Guidelines

Now that we have recommendations regarding ACT, we must address how to implement them in our CF clinics.We must find a way to communicate these recommendations to our patients and their families, and help them finda method of ACT that works best for them. Given the third recommendation that patient preference matters, it seems rational to introduce the patients to all of the available therapies. Then they can make an informed decision as towhich of the therapies they are most likely to use. However, there are important factors in the choice of therapies.For example, an infant is not capable of performing most of the available therapies and is dependent upon others (ie, parents) to perform the treatment, typically percussion and postural drainage. On the other hand, a person who lives alone will not have a partner to assist with percussion and postural drainage, and so will probably benefit more froma type of ACT that can be performed independently (eg, high-frequency chest compression). Therefore, there are a number of factors to consider regarding recommendations of specific ACT, including independence, effectiveness, ease of use, flexibility, treatment durations, comfort, convenience, and interruption to daily living. It has been our experience that patients will benefit from more than one type of ACT, and so we introduce them to all of the options at an appropriate time of their life (Fig. 1). Before discussing how to introduce various therapies to patients, it is useful to express our other basic tenets of ACT:

现在我们有了关于ACT的建议，我们必须解决如何在我们的CF诊疗中实施这些建议。我们必须找到一种方法，将这些建议传达给我们的病人和他们的家人，并帮助他们找到一种最适合他们的行动方法。鉴于第三条建议，病人的偏好很重要，向病人介绍所有可用的治疗方法似乎是合理的。然后他们可以做出一个明智的决定，他们最可能使用哪种疗法。然而，在治疗的选择上有一些重要的因素。例如，婴儿不能进行大多数可用的治疗，需要依赖他人(即父母)进行治疗，通常是叩击和体位引流。另一方面，独自生活的人没有同伴协助叩击和体位引流，因此可能会从可独立进行的动作(如高频胸压)中获益更多。因此，对于具体的行为的建议，有许多因素需要考虑，包括独立性、有效性、易用性、灵活性、治疗时间、舒适度、方便性和对日常生活的干扰。我们的经验,患者将受益于超过一种类型的行为,所以我们把他们介绍给所有的选择在适当的时候他们的生活(图1)。在讨论如何介绍各种治疗的病人,是有用的表达我们的其他基本原则的行为

1. The physician prescribes the therapy but does not necessarily know what is best. The CF team typically includes an expert in ACT, most often a respiratory therapistor a physical therapist. The therapist’s role is to work with the patient and family to determine the most appropriate ACT and educate them as to its proper performance.

1医生开处方治疗，但不一定知道什么是最好的。CF团队通常包括ACT方面的专家，最常见的是呼吸治疗师和物理治疗师。治疗师的角色是与患者和家属一起确定最合适的行为，并教育他们正确的廓清技巧。

2. Airway clearance is an active process. Most patients will be performing their therapies on themselves in the out-patient setting. Even in the hospital setting, the therapist or parent who is performing ACT on a patient works with the patient to assist clearance of the airway secretions. The patient should play an active role in making the therapy effective by coughing throughout and performing deep breath-holds and forced expiratory maneuvers at appropriate times. No single method of airway clearance is better than another. This is similar to the CF Pulmonary Therapies Committee’s second recommendation.Although no therapy has been shown better than the others, this does not mean that one form of therapy won’t prove superior to the others for the individual patient. What is also apparent is that one form of ACT may prove useful at one time, but another will be more effective at another time. Similarly, patients may be able to use one form of therapy when they are home (eg, percussion and postural drainage) but may need a different therapy when they are away from home living alone (eg, college).

2. 气道廓清是一个主动的过程。大多数病人会在门诊环境中对自己进行治疗。即使在医院里，治疗师或父母也会帮助病人清理气道分泌物。患者应该在治疗中发挥积极主动的作用，通过不断咳嗽和在适当的时候进行深呼吸和用力呼气动作来促进排痰。这类似于CF肺治疗委员会的第二个建议。没有最好的技术，但有最适合病人的技术。同样的是，某个技术在某一时刻可能有用，但另一时刻需要另外的技术更有效。同样，病人在家时可以使用某种技术(如叩诊和体位引流)，但离开家独自生活时可能需要另一种技术(如大学)。

3. Airway clearance is boring. There is no way around this reality. ACT is tedious, monotonous, and takes time to perform effectively. This is another reason for patients to have access to more than one form of therapy.

3.气道廓清很乏味。这是没有办法回避的现实。ACT是乏味单调的，并且需要一定的时间来有效地执行。这是患者需要多种治疗方式的另一个原因。

4.Be creative. This has more than one meaning. First,there are a number of fun activities and toys for children that can serve as a method of airway clearance. Take a walk down an aisle of party favors and look at all of the toys that behave like positive-expiratory-pressure (PEP) devices. Second, we ask our patients to perform lengthy therapies several times daily. We need to work with them to help them figure out a way to get these therapies into their routine. Listen to the patients to learn how they spend their day, either at work or at school, and discuss ways to incorporate ACT into that schedule. We must try to adapt the therapies to the patient’s needs and let the therapies be less interruptive to their daily living.

4要创造性的。这有不止一种意思。首先，有一些有趣的活动和玩具，可以作为儿童气道廓清的方法。走在派对礼品的走道上，看看哪些类似正呼气压(PEP)设备的玩具。第二,我们要求我们的病人每天执行几次漫长的治疗。我们需要与他们合作，帮助他们找到将这些技术纳入日常生活的方法。倾听病人，了解他们是如何度过一天的，无论是在工作中还是在学校中，并讨论如何将ACT纳入日程。我们必须努力使治疗适应病人的需要，让治疗对他们的日常生活少一些干扰。

Implementing Airway-Clearance Therapies:A Timeline for the Newly Diagnosed Patient

The infant (birth to 18 months old) is completely dependent upon the caregiver (eg, parent) for performance of ACT. Most of the other therapies are inappropriate for the infant. Therefore, the parents of the newly diagnosed infant with CF should be introduced to percussion and postural drainage. The therapist will meet with the parents initially to teach them the technique, and will meet with them at subsequent clinic visits to evaluate their technique and re-educate as needed

婴儿(出生至18个月大)的ACT完全依赖照顾者(如父母)。大多数技术都不适合婴儿。因此，父母的新生儿CF应介绍叩诊和体位引流。治疗师将首先与父母会面，教他们使用该技术，并将在随后的回访中评估他们的掌握情况并根据需要进行再调整。

Toddlers (18 months to 4 years) are often ready to try high-frequency chest compression. There are currently 3 high-frequency chest compression devices available on the market: The Vest (Hill-Rom, St Paul, Minnesota), In Courage (Respirtech,StPaul,Minnesota), and Smart Vest(Electromed, New Prague, Minnesota). These devices are expensive, and so we confirm with the patient’s  insurance carrier that such durable medical equipment will be covered. We introduce each of the devices to the patient and family at a clinic visit or in the hospital; the parent or caregiver will then be able to make an informed decision on whichmachine to choose, if it is clear the patient will use the device. Also, at this young age the patient should be taught blowing games (eg, pinwheel, bubbles) to prepare them for the prolonged exhalation maneuvers they will need to master prior to their first spirometric test. Huff cough instruction can also start during this time.

幼儿（18个月到4岁）可以准备尝试高频胸部压迫。目前市面上有3种高频胸部压迫装置：The Vest、The Courage和smart Vest。这些设备很贵，因此我们向患者的保险公司确认这个设备可以报销。我们会在门诊或医院向患者和家属介绍每种设备；如果患者明确会使用这些设备，父母或护理人员将能够理性地决定选择哪种机器。此外，在这个年龄阶段，应该教给病人吹呼气的游戏（如风车、泡泡），让他们为他们在第一次肺活量测试前掌握的长时间呼气动作做好准备。在这段时间内，也可以开始进行咳嗽指导。

School-age children (5 years to preteen) can begin basic active cycle breathing techniques. Patients can be taught breath hold sand prolonged exhalation maneuvers.The huffcough or forced expiratory technique can be mastered at these ages, and portable devices such as PEP or oscillating PEP (eg, Acapella or Flutter) should be used. Patients need to have access to portable devices for use while away from home, such as at camp, on sleep-overs, or while being driven to school. Patients this age should be encouraged to participate in sports. Exercise needs to be a part of CF patients daily routine. Not only does exercise improve cardiovascular health and self esteem, it can also act as a method of removing secretions. 15 Some patients report that when they run, bike, or swim, these movements cause a vibration and loosening of the mucus in the chest. There have not been enough controlled trials to demonstrate that exercise is an effective form of airway clearance, but the Pulmonary Guidelines Committee found that exercise should be considered an adjunct to a patient’s airway-clearance routine.

学龄儿童（5岁至早产儿）可以开始基本的主动循环呼吸技术。可以教会病人屏气和长时间的呼气动作。在这些年龄段，可以掌握呼气咳嗽或用力呼气技术，并应使用便携式设备，如PEP或振荡PEP（如Acapella或Flutter）。患者需要在外出时使用便携式设备，如在营地过夜或开车上学。应该鼓励这个年龄段的病人参加体育运动。运动需要成为CF患者日常生活的一部分。运动不仅能改善心血管健康和自信心，还能起到清除分泌物的作用。有些病人报告说，当他们跑步、骑自行车或游泳时，会引起胸部粘液的振动和松动。目前还没有足够多的对照试验证明运动是一种有效的气道清除方式，但是肺指南委员会发现，运动应该被视为患者气道廓清常规的一种辅助手段。

Preteen to early teen CF patients express a need to be“not different” from their peers. It is common for parents to complain that their child “will not do anything” when asked about airway clearance. This is a very challenging time in life because teenagers want to be independent and to make their own decisions, and often they choose to skip performance of ACT. But this is the most vulnerable time for patients, and one in which we see a greater rate of decline in their lung function. 16 Patients at this age can improve on the techniques of active cycle breathing technique and huff cough, and learn autogenic drainage. When done properly, these techniques are effective and they canbe done inconspicuously. We must negotiate with the teens to help them establish a routine that is effective, convenient, and causes little interruption in their lifestyle. They should learn that breathing techniques can be done at any time and they do not require an external device or care giver.

青春期前到青春期早期的CF患者表现出与同龄人“没有区别”的需要。当被问及气道清理的问题时，父母经常抱怨他们的孩子“什么都不做”。这是生活中一个非常具有挑战性的时期，因为青少年想要独立，想要自己做决定，他们经常选择忽略ACT。但这又是病人最脆弱的时候，我们看到他们的肺功能下降率更高。这个年龄段的患者可以提高主动循环呼吸技巧和咳嗽巧，学习自体引流。如果处理得当，这些技巧是有效的，而且可以在不引人注意的情况下进行。我们必须与青少年协商，帮助他们建立一个有效、方便、不会对他们的生活方式造成干扰的日常生活方式。他们应该知道呼吸技巧可以在任何不需要外部设备或护理人员的时候完成。

By the time they reach adulthood (age 18 years and up), patients with CF will have been introduced to the entire ACT armamentarium, including percussion and postural drainage, high-frequency chest compression, PEP, oscillating PEP (eg, Acapella), autogenic drainage, active cycle breathing technique, and intrapulmonary percussive ventilation. All adults should have more than one technique available to them, and we must work with them to establish a routine that fits with a busy lifestyle that includes school,work,and familytime.As their lung disease reachesa more severe stage, they must realize that they are likely to require increased time spent with ACT.

CF患者到成年(18岁及以上)时，将使用全套ACT设备，包括叩击和体位引流、高频胸壁压迫、PEP、振荡PEP(如节律呼吸)、自体引流、主动循环呼吸技术和肺内叩击通气。所有的成年人都应该有不止一种可用的技巧，我们必须帮助他们建立一种适合繁忙生活的日常方法，包括上学、工作和家庭时间。当他们的肺疾病到达更严重的阶段，他们必须意识到他们可能需要更多的时间花在ACT上。

Implementing Airway-Clearance Therapy:The Patient Who Transfers to Your Center

Like many others, people with CF may move to a different city, and will transfer their care to a different CF center. When we see a new patient for the first time, we try to learn what therapies the patient is currently performing and assess their technique, providing tips for improvement as needed. We also perform a survey of their knowledge of all of the other therapies. Do they have knowledge of the other therapeutic options? Have they tried them? What did they like or not like about those therapies? We will then make plans for a future clinic visit to introduce them to the therapies they have not tried, following the same timeline noted above.

像许多其他人一样，CF患者可能会搬到另一个城市，并将他们的护理转移到另一个CF中心。当我们第一次见到新患者时，我们会尝试了解患者目前正在执行的治疗方法，并评估他们的技术，根据需要提供改进建议。我们还对他们所有其他疗法的知识进行了调查。他们是否了解其他治疗方法？他们试过了吗？他们喜欢还是不喜欢这些疗法？然后，我们将为未来的临床访问制定计划，向他们介绍他们没有尝试过的治疗方法，遵循上述时间表一样的方法。

Implementing Airway-Clearance Therapy:The Hospitalized Patient

Patients with CF may experience acute worsening of symptoms, such as increasing cough and sputum production, often called a pulmonary exacerbation. The CF pulmonary guidelines on treatment of a pulmonary exacerbation suggest that ACTs may need to be changed during such an event. 11 In situations where the exacerbation is mild and out-patient therapy is planned, the patient can be advised to increase the time spent with therapy, or to perform the therapies more frequently, or even to consider analternative therapy. For those who are ill enough to warrant admission to the hospital, there is an opportunity for therapists to become fully engaged. At the start of the hospitalization it is most important to begin with a therapy the patient finds the most comfortable. It is a time to establish early success in clearance of secretions and to establish a trusting relationship between the therapist and the patient. As the patient improves, this is now an opportunity to evaluate the patient’s ability to perform airway clearance on their own as well as introduce therapies they have not yet tried

CF患者可能出现急性症状恶化，如咳嗽和痰液增多，通常称为急性加重。关于急性加重治疗的CF指南建议，在这种情况下，联合ACT可能需要改变。在病情加重较轻且计划进行门诊治疗的情况下，可以建议患者增加治疗时间，或更频繁地进行治疗，甚至考虑替代治疗。对于那些病情严重到需要住院的病人，治疗师有机会全身心投入。在开始住院治疗的时候，最重要的是要让病人感到最舒服的疗法。这是一个建立早期成功的清除分泌物和建立信任关系之间的治疗师和病人。随着患者病情的改善，这是一个评估患者自主气道清除的能力的机会，同时也可以介绍他们尚未尝试过的治疗方法

A Role for Exercise

A question asked frequently in the CF clinic is, “Can my 30 min of running take the place of my ACT?” Indeed,there are many patients with CF who participate in regular exercise activities that are fairly rigorous. The Pulmonary Guidelines Committee recommended aerobic exercise as an adjunctive therapy for airway clearance. Although there was not sufficient evidence to conclude that exercise was as effective as other ACT, there was evidence that exercise does result in clearance of secretions and there is improvement in quality of life. 15 There are additional benefits to aerobic exercise: increased endurance, increased self esteem, and improved cardiovascular health. 14 Patients with CF who have greater fitness have better survival. 17 It is our perception that the patients in our clinic who exercise regularly tend to have better overall health.

CF就诊时经常问到的一个问题是:“我的30分钟跑步能代替ACT吗?”“事实上，许多CF患者都参加了相当严格的定期锻炼活动。肺指南委员会推荐有氧运动作为气道廓清的辅助疗法。虽然没有足够的证据证明运动和其他行为一样有效，但有证据表明运动确实能清除分泌物，改善生活质量。有氧运动还有额外的好处，如增加耐力，增强自信心，改善心血管健康。适应性强的CF患者有更好的生存率。我们认为，在我们诊所经常锻炼的病人总体健康状况更好。

Summary

The CF Pulmonary Guidelines Committee came to the same conclusion that most clinicians had already believed: that performance of techniques of airway clearance works for patients with CF. We do not have evidence that any single method of ACT is best for all patients, but we are fortunate to have many therapies from which to choose. The opportunity for the therapist and the entire CF team is to work with the patients and families to find the therapies that work for the individuals, given the myriad of resources they have and the hurdles they face. It is important to listen to the patients as they will help us figure out what works best for them, and they will teach us tricks that will work for other patients as well.

CF指南委员会得出的结论与大多数临床医生已经确认的结论相同：气道廓清技术对CF患者有效。我们没有证据表明任何单一的ACT方法对所有患者都是最好的，但我们幸运的是，有许多治疗方法可供选择。治疗师和整个CF团队的机会是与患者和家属合作，找到适合个人的治疗方法，因为他们拥有大量的资源和面临的障碍。倾听患者的意见是很重要的，因为他们会帮助我们找出对他们最有效的方法，他们也会教给我们一些对其他患者同样有效的技巧。

Chest Physiotherapy

What is chest physiotherapy(CPT) ?

CPT is away to help get secretions out of the airways in order to improve airflow inside the lungs.This isachieved most successfully by applying percussion and vibration to the chest wall in positions that allow forproper drainage.There are 3  main components of CPT, including percussion， vibration，and postural drainage.

什么是胸部物理疗法(CPT) ?

CPT是帮助分泌物排出气道，以改善肺通气。最适合的方法是在胸壁位置叩击和振动，使其能进行适当的引流。CPT有3个主要组成部分，包括叩诊、振动和体位引流。

Percussion Percussion is a rhythmic clapping onthe exterior chest wall.The propertechnique involves cupping of thehands(or fingers) ， working from thewrists， and“clapping”tthe chest wallover a specific area.Percussion is doneover one area andposition at a timeand for atleast 1 minute.The duration，clapping frequency，and pressure of thepercussion are dependent upon the age，needand tolerance of the patient.

扣拍

扣拍是胸壁外有节奏的拍击。正确的方法包括手(或手指)呈杯形，从手腕开始，并“拍击”胸部的特定区域。每次在一个区域和位置叩击至少1分钟。拍击的持续时间、拍击的频率和打击的压力取决于患者的年龄、需要和耐受力。

Vibration Vibration immediately follows percussion of each area and position. Lay one of your hands over the otherhand and place themon the chest over the area that was percussed (alternatively you may place your handson either side of the chest wall) .Tense up(or contract) your shoulder muscles and exert some pressure tocause your hands to move rapidly (vibrate) .Instruct the child to take in a deep breath and then apply thevibrations while they are exhaling. Effective vibration will transmit through the chest wall,help in loosen-ing secretions，and promote a spontaneous cough

振动 紧接着扣拍区域和位置进行振动。将手叠掌后放在需要振动的部位（也可以将手放在胸壁的两侧）。牵拉（或收缩）肩部肌肉并施加一些压力，使你的手快速振动。指导孩子深呼吸，然后在他们呼气时的振动。有效的振动通过胸壁传递，从而松动分泌物，进而促进自发性咳嗽。

Postural Drainage Placing your child in specific positions allows for gravity to assist in the movement of secret ons to the largeairways(main bronchi) ， where they can then be coughed out of the lungs. We discourage positions that in-clude head-down posit in in gas this can cont bute to gastroesophageal reflux(GER) ，which is the regurgitation of stomach contents back up the esophagus.

体位引流 把你的孩子放在特定的位置，通过重力作用将分泌物到大气道(主支气管)，然后更容易被咳出。我们不鼓励这种头底脚高的姿势，这种姿势会导致胃食管反流(GER)，也就是胃内容物反流到食道。

CPT can be done before meals or atleast 1 hour after eating.Spend 2  minutes on each segmen，or longerin a specific area of the lung if it is problematic.The entire therapy session should last 30 minutes. Patient participation during the session can include deep breath holds while applying percussion to a certain area，then a forced exhalation can aid in dislodging the secretions.

CPT可在餐前或餐后至少1小时进行。在每个节段上花2分钟，如果有问题，在特定区域花更长时间。整个治疗过程应该持续30分钟。病人参与过程中可以包括深呼吸，同时叩击某一特定区域，然后用力呼气有助于排出分泌物。

Upper lobes Apical segments：Have the childs it upright and per cuss over the shoulderarea on each side.This maybe done from the front(Panel A) or from theback(Panel B) ， whichever is more comfortable.

肺上叶 肺尖节段：让孩子们直立起来，每个节段都在肩上侧面。这个可以从前面（图A）或背面（图 B）完成，以更舒适的为准。

Posterior segments：Have the child lean for ward(PanelC) .Per cuss over upper back on both sides.Avoidpercussing over the spine.

背后:让孩子身体前倾(图C)，两侧的上背部每节。避免叩击脊柱。

Anterior segments：Have the child lay flat on back Percuss just under the collarbone (Panel D) .Avoidper cussing over the sternum.

前段:让孩子平躺，叩诊锁骨下(图 D),避免撞击胸骨。

Right middle lobe Have the child lying on her left side with head supported by a pillow.Lift thearm above the head and percuss over the middle area of the right chest just under the armpit(Panel E) .

右中叶 让孩子靠左边躺着，头靠枕头。将手臂举过头顶，叩击右胸腋下的中间部位(图E)。

left lingula

The child lies on her right side and the left arm is placed behind her(Panel F) .Per cuss over the middle area of theribs.

左侧

孩子右侧卧着，左臂放在身后(图F)。

Lower lobes Superior segments：Have the child lie flat on her stomach.Prop pillows under the chest(Panel G) .Percuss over the shoulder blade area on either side of spine.Then prop pillows under the hips (Panel H) and percussin the same area.

下肺上段:让孩子俯卧位。胸部下垫枕头(图G)。叩击脊柱两侧的肩胛骨区域。然后把枕头垫在臀部(图H)及叩击同样的部位。

Basalsegments：Place the child on her side supported by pillow and have her lean for ward(Pane I).Percuss over the back and side.Then have the child move the pillow to support her head(Panel J) and per cussin the same area.Repeat on both sides.

基底节:用枕头支撑着孩子，让她侧卧位(图I)。在背部和侧面敲击。然后让孩子移动枕头来支撑她的头(图J)和扣拍同一区域。两边重复。

Blowing Therapies

What are blowing therapies? Blowing or breathing games encourage toddlers to take deep breaths and manipulate exhalation.This helpswith clearing secretions from the airways， but also helps the child to become more aware of his or her breath iand prepare for future pulmonary function testing.

什么是呼气技术? 呼气或呼吸游戏鼓励幼儿深呼吸和控制呼气。这有助于清除呼吸道的分泌物，也有助于孩子更加了解自己的呼吸，为将来的肺功能测试做准备。

Examples of blowing therapies

Blowing Bubbles-have the child take a deep breath and gently exhale.As the child masters bubbleblowing， this will encourage a longer exhalation time.Bubble Water-Place a straw in a glass of water.Have the child blow into the straw and make lotsof bubbles.This produces positive expiratory pressure(PEP) and encourages along exhalation time.

吹泡泡——让孩子深吸一口气，然后轻轻呼气。当孩子学会吹泡泡，这将鼓励更长的呼气时间。将一根吸管放在一杯水中。让孩子往杯中吹气，吹出许多泡泡。这会产生呼气正压(PEP)，并延长呼气时间。

Toys that promote deep breaths and long exhalation：Harmonica PinWheel  Hunting Bird Whistles.

促进深呼吸和长呼吸的玩具：口琴、口笛、口哨。

High Frequency Chest Compression

What is High Frequency ChestCompression(HFCC)?

HFCC use san inflatable vest that covers the chest and attaches with hoses to an air-pulse generator.The genera-to rinflates and deflates the vest at different frequencies(Hz) .These oscillations compress and release the chestwall， thus manipulating airflow to dislodge secretions and moving them towards the larger airways where thesecretions can be coughed out.

HFCC使用一件覆盖胸部充气背心，并通过软管连接到一个空气脉冲发生器。这些振荡压缩和释放胸壁，从而控制气流振动分泌物并将其移动到更大的气道，在那里分泌物可以被咳出。

The basics of HFCC 1.An inflatable vest is attached by tubing to an air-pulse generator. 2.Vest size is determined by measuring chest circumference at the nipple line.The sizes range from 16-60inches. 3.When ordering the device， talk to the company representative to determine vest style options. 4.The vest inflates and deflates using high frequency oscillations， which vibrate the airflow in the airways toloosen secretions. 5.The basic controls on the vest models are：a.Frequency of vibration in Hz(hertz)b.Inflation pressure of the vestc.Timer 6.Vest therapy has evolved from using a single vibration or Hz setting to using various Hz settings， recognizingthat changing the Hz frequency and vest pressure amplitude can optimize the efficiency of vest therapy. 7.Vest therapy sessions were originally thought to be a passive therapy；that is， patients sat through a 30-minutesession while inhaling nebulized medications.Current vest therapy protocol should include： a.Changing the frequencies. b.Pausing the therapy session for active coughing. c.Delivering inhaled medication throughout the therapy session. d.Inhaled antibiotics and corticosteroids should be taken after completion of vest therapy session.

HFCC的基础知识 

1. 1.充气背心通过油管连接到空气脉冲发生器上。

2. 2.背心的尺寸是通过测量乳头线处的胸围来确定的。尺寸从16-60英寸不等。

3. 3.当订购设备时，与公司代表谈话，以确定背心的型号选择。

4. 4.背心的充气和放气使用高频振荡，振动气流在气道，以减少分泌物。

5. 5.背心模型的基本控制是:

a振动频率，单位为Hz(赫兹)

b充气压力

c时间 

6.背心治疗已经从使用单一的振动或Hz设置演变为使用各种Hz设置，认识到改变Hz频率和背心压力振幅可以优化背心治疗的效率。

 7.背心疗法最初被认为是一种被动疗法;也就是说，患者在吸入喷雾药物的同时坐着接受30分钟的治疗。

目前的背心治疗方案应包括: a改变频率。 b剧烈咳嗽暂停治疗。 c在整个治疗过程中给予吸入药物。 d吸入抗生素和皮质类固醇应在背心治疗结束后服用。

Example of Ramping Session using the Hill Rom Vest

Hill Rom背心使用示例

Active Cycle Breathing Technique

What is active cycle breathing technique(ACBT) ?

ACBT is a breathing technique that utilizes breathing control，thoracic expansion(deep breathing) ，and forcedexpiratory techniques(huff coughing) to loosen airway secretions.By alternating deep breaths with breathholds and forced exhalations， the secretions a removed from small airways to large airways where they can becoughed out.Patients can perform this technique in different positions，but for training purposes it is best to be sittingstraight up and relaxed in a chair.

什么是主动循环呼吸技术(ACBT) ?

主动循环呼吸技术是一种利用呼吸控制、胸部扩张(深呼吸)和用力呼气技术(咳嗽)来松动气道分泌物的呼吸技术。通过深呼吸、屏气和用力呼气的交替，分泌物从小气道转移到大气道，从而排出。病人可以在不同的体位使用这项技术，但为了训练目的，最好是在椅子上坐直并且放松。

The basic cycle is as follows：

1.Breathing control or gentle diaphragmatic breathing：relax the shoulders and breathe in through thenose and exhale through the mouth with 3-4 normal sized breaths. 2.Thoracic expansion(deep breath) ：make a full inspiration followed by a 3-4 second breath hold， thena relaxed expiration 3.Back to breathing control for 3-4 breaths. 4.Thoracic expansion and breath hold for 3-4 breaths. 5.Forced exhalation， or huff， for 2-3 exhalations to cough up secretions. 6.Repeat these steps for several cycles until airway secretions have cleared.

其步骤如下:

1.呼吸控制或温和的横膈膜呼吸:放松肩膀，通过鼻子吸气，嘴巴呼气，正常呼吸3-4次。 2.胸部扩张(深呼吸):充分吸气，屏气3-4秒，然后放松呼气 3.恢复呼吸控制3-4次呼吸。 4.胸部扩张，屏气3-4次呼吸。 5.用力呼气或呵气，呼气2-3次以咳出分泌物。 6.重复这些步骤几个循环，直到呼吸道分泌物清除。

Huff Coughing：Normal coughing may cause bronchial closure， use of excessive energy， and little sputum production.Huff coughing is a gentle coughing technique that includes 3mini huff coughs to loosense cretions from the peripheral small airways and a final forced huff to expectorate the sputum. 1.Deflation Breaths-have patient deflate excess air from their lungs by slowing breathing rate down andperforming prolonged exhalation (4-5 seconds) for 3-4 breaths. 2.Take as low deep breath but not a maximum breath. 3.Shape your mouth like an“O”. 4.Do a mini/short cough by contracting the upper abdominal muscles.This can be described as pushing atennis ball out of an open mouth while making a“huff"noise. 5.Take in a quick partial breath and repeat“huff a second time with this smaller breath. 6.Take in an even smaller breath and“huff'for a third time.(The patient is nowata very low lung volumethat helps loosen the secretions from the lungs.) 7.Take a forced full breath but not a maximum breath. 8.Give a forced， hard“huff”and cough out the sputum. 9.Repeat the steps i fairway secretions are not cleared.

缩唇呼吸咳嗽：正常的咳嗽可能导致支气管塌陷闭合，能量消耗过多且较难排出。呼气咳嗽是一种温和的咳嗽技巧，它包括3次的轻微咳嗽，以松动周围小气道的粘液，最后用力呼气排痰。

 1.缩唇呼吸通过减慢呼吸速率和长时间呼气（4-5秒）进行3-4次呼吸，将肺部多余的空气排出。

 2.尽量深呼吸，但不要做最大呼吸。

 3.把你的嘴做成“O”形。

 4.收缩腹部肌肉。这个可以形容为张开的嘴把球吐出来，同时发出“呼”的声音。

 5.做一次快速的部分呼吸，用这个小呼吸重复第二次“呼气”。

 6.轻微吸气，第三次“呼气”。（现在病人的肺容量很低，这有助于从肺部释放分泌物。）

 7.用力吸气，但不要用力过大。

 8.用力“呼气”，咳出痰来。

 9.重复上述步骤，指导气道分泌物清除。

Autogenic Drainage

1What is Autogenic Drainage? Autogenic drainage was first described by Jean Che vail lier in 1967.It is a breathing technique that helps thepatient drain the lungs from within(autogenic) by breathing at different lung volumes in 3 phases： Phase 1-unsticking/loosening the phlegm in the small airways Phase 2-collecting/moving phlegm to the middle airways Phase 2-evacuating/moving the phlegm out by huffing

什么是自主引流? 1967年，Jean Chevaillier首次提出了AD。这是一种通过在3个阶段以不同的肺容量呼吸，帮助患者从内部排出的呼吸技术，: 第一阶松动段小气道的痰 第二阶段收集/移动痰到中间气道 第二阶段通过呼气将痰排出

Unsticking 1.Sit in a relaxed position；clear your nose and throat of secretions. 2.Start the session with breathing control， breathing in through the nose and out through the mouth. 3.Inhale through the nose and take in a deep breath and hold for 3-4 seconds；then exhale air out of the mouthfor as long as you can to reach low lung volume. 4.Inhale through the nose a small breath and hold 3 seconds. 5.Exhale through the mouth and squeeze out as much air as you can. 6.Repeat this low lung volume breathing atleast 3  times or until you：hear the secretions crackle while exhaling feel the secretions moving， or feel an urge to cough.

松动 1.坐在放松的姿势；清除鼻子和喉咙的分泌物。 2.以呼吸控制开始训练，用鼻子吸气，用嘴呼气。 3.用鼻子吸气，深呼吸，保持3-4秒；然后尽可能长时间呼出肺中的空气，以达到低肺容量。 4.用鼻子轻轻吸气，保持3秒钟。 5.用嘴呼气，尽量挤出空气。 6.重复这种低肺容量呼吸至少3次，或者直到你：呼气时听到有分泌物的声音，感觉分泌物在移动，或者有咳嗽的冲动

Collecting 1.Take a deep breath and hold for 3-4 seconds and exhale(but not as low as in the un sticking phase) . 2.Inhale through the nose a slightly larger breath and hold for 3-4 seconds. 3.Exhale through the mouth a normal sized exhalation. 4.Repeat normal-sized breaths(with breath hold after inspiration and a normal exhalation) for 3 breaths. Evacuating 1.Take a deep breath and hold for 3-4 seconds. 2.Exhale forcefully with a huff cough.

聚集 1.深呼吸，保持3-4秒，然后呼气(但不要像在松动那样弱)。 2.用鼻子吸气，口气稍微大一点，保持3-4秒。 3.通过嘴呼气，正常大小的呼气。 4.重复正常大小的呼吸(吸气后屏气，正常呼气)3次。 

咳出 1.深呼吸，保持3-4秒。 2.用力呼气，咳嗽。

Each phase should take approximately 2-3minutes. Coughing should be avoided until the evacuation phase，but if patient must cough， they should do 2-3huff coughs.As patient becomes more comfortable with auto-genic drainage，they will probably learn to move secretions by developing their own personal method

每个阶段大约需要2-3分钟。在排出前应避免咳嗽，但如果病人必须咳嗽，则应进行2-3次呼气咳嗽让自体引流变得更舒服，他们可能会通过找到自己的个人方法来学习移动分泌物

PEP Therapy

What is Positive Expiratory Pressure(PEP) therapy? Hand-held Positive Expiratory Pressure(PEP) devices are used as a form of airway clearance by having thepatient exhale through an expiratory resistor which creates positive pressure or backpressure in the lungs.Thispositive pressures tents the airways open and helps get air behind phlegm and expectorated by coughing. The Acapella，Flutter and Quake devices also have an oscillating component that causes the airway walls to vibrateduring exhalation thus loosening the secretions.

什么是呼气正压技术？ 手持呼气正压（PEP）装置是通过阻力阀呼气，它在肺中产生正压力或反压力。这种正压可以使气道打开，帮助空气进入痰后，通过咳嗽咳出，Acapella，Flutter and Quake也有一个振荡的成分，它能使呼气时气管壁振动，从而使分泌物变松。

Technique 1.Have patient in a sitting position. 2.Do a couple of relaxed breaths-air in through the nose and out through the mouth. 3.Take a slightly deeper than normal breath and hold for 3  seconds. 4.Exhale through the device with lips tight on the mouthpiece and cheeks tight for 3-4 seconds. 5.Repeat 10-12 breaths. 6.Perform 3-4 Huff coughs. 7.Repeat the cycle 5-6 times for approximately 15-20 minutes.

技术

1.让病人取坐位。 2.做几次放松的呼吸—经鼻吸气，嘴巴呼气。 3.比正常呼吸深一点，保持3秒钟。 4.通过该设备呼气，嘴唇紧靠吹口，脸颊紧靠3-4秒。 5.重复10到12次。 6.进行3-4次呼气咳嗽。 7.重复这个循环5-6次，大约15-20分钟。

Intrapulmonary Percussive Ventilation

What is in trapulmonary percussive ventilation(IPV) ? IPV is a form of airway clearance that uses a pneumatic device (Phasitron) to deliver high flow， mini bursts of air to the lungs at rates of 100to300per minute.An aerosol mist of 1mL perminute is delivered during thepercussion，which loosens the retained secretions.IPV is to be used on patients who have increased sputum andare unable to clear secretions effectively on their own。IPV is a hospital-based unit that runs off of a  50 psi gas source(left figure) The Impulsator is the home-based unit that runs off of electricity(115V/60Hz) (right figure)

什么是肺内叩击通气(IPV) ? IPV是一种气道廓清技术，使用气动装置(Phasitron)以每分钟100到300次的速度向肺部输送高流量的低流速空气。叩击时每分钟喷射1mL气雾剂，使潴留的分泌物松弛。IPV可用于痰液增多和无法自己有效清除分泌物的患者。

IPV是一个基于医院使用的仪器，使用50磅每平方英寸 的气源(左图) 脉冲式是家用的仪器，用电(115V/60Hz)(右图)

Therapy Session •Have the patients it in an upright position. •Assemble the circuit in accordance with manufacturer's directions. •Fill the nebulizer with prescribed medications(1mLper minute of therapy time) •Start the frequency at the“Easy”position which is 300Hz.

•The beginning operating pressure should be 20-25psi， or until chest wall movement is seen and patientremains comfortable •Have the patient breathe through the circuit for 1-2 minutes before depressing the P has itron button， whichwill trigger percussions. •Have the patient inhale and exhale through the percussions， keeping their lips sealed on the mouthpieceand cheeks tight. The patient can rest between percussion sessions by releasing the percussion button and can continuebreathing the aerosolized medication. •The frequency can be decreased by50Hz every 5 minutes， working to 100Hz， which would be the“Hard"position. •Huff coughing should be performed every 5  minutes or as necessary.

•患者直立位。 •按照制造商的说明组装电路。 •将处方药物注入喷雾器(治疗时间为每分钟1ml) •从“最小”频率的启动，即300Hz。 •开始操作时的压力应在20-25psi，或直到看到胸壁有运动且病人感觉舒适为止 •让患者通过循环呼吸1-2分钟，然后按下Phasitron按钮，该按钮将触发叩击。 •让病人通过叩击来吸气和呼气，保持嘴唇在口器上密封，脸颊收紧。 •病人在叩诊过程之间可以通过释放叩击按钮休息，并继续呼吸雾化的药物。 •频率可每5分钟降低50hz，工作至100Hz，属于“硬”位置。 •咳嗽应该每5分钟或必要时进行一次。

本文来源于Lester MK, Flume PA. Airway-clearance therapy guidelines and implementation. Respir Care. 2009 Jun;54(6):733-50; discussion 751-3. doi: 10.4187/ 002013209790983205. PMID: 19467161.有删减。