Acute Effects of a Flutter Device in COPD

Not Applicable

Completed

• Conditions: Chronic Obstructive Pulmonary Disease
• Interventions: Device: Flutter Sham exercises; Device: Flutter valve exercises; Device: Flutter and bronchodilator exercises

• Registration Number: NCT01832961
• Lead Sponsor: Imperial College London

Brief Summary

Chronic obstructive pulmonary disease (COPD) is characterised by airflow limitation that is not fully reversible, and is usually progressive and associated with an abnormal inflammatory response of the lungs to noxious particles or gases, most commonly cigarette smoking. The disease affects not only the large central airways but also the small, more peripheral airways deeper into the lung, defined as less than 2 mm in diameter.

Besides medical treatment, physiotherapy plays a major role in treatment and various methods have been suggested to remove airway of secretions. The flutter is a simple and small device shaped like a pipe that creates a positive expiratory pressure (PEP) and high frequency oscillation when the expired air passes through it. These vibrations are thought to mobilise airway secretions facilitating their clearance and improving breathing.

Standard blowing tests, like spirometry, where patients blow forcedly into a machine, have previously been used to investigate the efficacy of flutter devices. However, spirometry assesses the damage of larger airways but not small airways, also known as the "silent zone" which, crucially, are specifically damaged in COPD.

In this study the investigators hypothesise that because the flutter helps clear the airways from the excessive thick mucus produced by COPD patients, these patients may find it easier to breathe and have lower resistance to moving air in and out of their lungs.

The main objective of this study is to compare the effect of a flutter or a sham device on small airways damage using impulse oscillometry (IOS), a non-invasive method that, contrary to other common blowing tests, measures small airway resistance during normal breathing.

In addition, because COPD is characterised by inflammation, the investigators would also like to measure a gas the patients blow out, nitric oxide (NO) the levels of which reflect airway inflammation. This will give to investigators an insight into the relationship between airway inflammation and small airway function.

Detailed Description

Chronic obstructive pulmonary disease (COPD) is characterised by airflow limitation that is not fully reversible. This limitation is usually progressive and associated with an abnormal inflammatory response of the lungs to noxious particles or gases.

Patients suffering from COPD may show pathologic changes not only in the large but also in the small airways, which are defined as less than 2mm in diameter. Airway inflammation may cause increased thick mucus secretions which can narrow the airways increasing the resistance to the airflow.

Physiotherapy to remove secretions is indicated for patients with COPD who have regular sputum or those with thick secretions and various techniques and physiotherapy devices can be applied for the removal of secretions. The flutter is a simple and small device shaped like a pipe that creates a positive expiratory pressure (PEP) and high frequency oscillation as expired air passes through it. These vibrations and PEP are thought to mobilise airway secretions facilitating their clearance and improving airflow.

The effects of the flutter device have been studied in different patient groups, but especially in lung diseases characterised by mucus hypersecretion such as COPD, cystic fibrosis and bronchiectasis. In COPD, even though the flutter device increases the volume of expectorated secretions, its beneficial effects on pulmonary function as assessed by spirometry and plethysmography are inconclusive. However, these standard lung function tests (such as spirometry) asses the large airways, but do not provide an accurate estimate of the small airways which have been described by some authors as "the silent zone".

The investigators hypothesise that the use of impulse oscillometry (IOS), a non-invasive technique that provides information on small airway resistance during normal breathing, may reveal the effect of the flutter device which may have not been accurately measured by spirometry in previous studies.

In addition, the investigators would like to measure exhaled nitric oxide (NO) levels which reflect airway inflammation and may therefore be useful to determine the association between small airway disease and inflammation.

In summary, the symptoms of patients with COPD improve following breathing exercises with a flutter device, however, the effect of this device on lung function is unclear. The investigators hypothesise that the combined use IOS and NO, would help understand and quantify the effects of the flutter device on the small airways disease in COPD.

The main objective of this study is to measure the effect of a 30 minutes breathing exercise with a flutter device on airway resistance as assessed by impulse oscillometry in patients with COPD.

The secondary objective is to investigate the association between inflammation, airway resistance and volume of secretions in COPD patients.

Basic Information
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Recruitment & Eligibility
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Study & Design
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Trial Locations

Study Timeline

• Study First Submitted: 2013-03-25
• Study Start: 2013-04
• Study First Submitted QC: 2013-04-12
• Study First Posted: 2013-04-16
• Primary Completion: 2013-12
• Study Completion: 2013-12
• Results First Submitted: 2019-08-14
• Status Verified: 2020-02
• Results First Submitted QC: 2020-02-13
• Last Update Submitted: 2020-02-13
• Results First Posted: 2020-02-27
• Last Update Posted: 2020-02-27

Recruitment & Eligibility

• Status: COMPLETED
• Sex: All
• Target Recruitment: 15

Inclusion Criteria

• patients with COPD meeting the Global Initiative for Obstructive Lung Disease (GOLD) guidelines, with forced expiratory volume in the first second of expiration (FEV1) <80% predicted, FEV1/FVC ratio <70% predicted (FVC= forced vital capacity), and total lung capacity (TLC) >80% predicted), with or without sputum, will be included.

The severity of COPD will be classified according to GOLD criteria:

Stage I: mild FEV1/FVC<0.70 and FEV1>80% predicted; Stage II: moderate FEV1/FVC<0.70 and 50<FEV1<80% predicted; Stage III: severe FEV1/FVC<0.70 and 30<FEV1<50% predicted; Stage IV: very severe FEV1/FVC<0.70 and FEV1<30% or FEV1<50% predicted plus chronic respiratory failure,

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Exclusion Criteria

Patients with:

• Upper respiratory tract infection within the previous 28 days
• Treatment with antibiotics within 4 weeks prior the study
• Acute dyspnoea or hemoptysis
• Chest pain or recent history of rib fracture or pneumothorax
• Acute cardiovascular events in the previous 3 months
• Any history or evidence of renal, gastrointestinal or hepatic disease
• Any history and evidence of neuropsychiatric disease
• Alcohol, drug abuse or any other condition associated with poor compliance
• Breast feeding
• Pregnancy
• Other complications that hinder the completion of the tests
• Unable to provide written informed consent

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Study & Design

• Study Type: INTERVENTIONAL
• Study Design: CROSSOVER

Arm && Interventions

Group	Intervention	Description
flutter-sham exercises	Flutter Sham exercises	30 minutes of breathing exercise with flutter-sham device
flutter valve exercises	Flutter valve exercises	30 minutes of breathing exercises with flutter device
flutter-sham exercises	Flutter and bronchodilator exercises	30 minutes of breathing exercise with flutter-sham device
flutter valve exercises	Flutter and bronchodilator exercises	30 minutes of breathing exercises with flutter device

Primary Outcome Measures

Name	Time	Method
Airways Resistance (IOS) - Resonant Frequency (Fres)	Baseline test, after breathing exercises with flutter or flutter-sham device and after 20 minutes of rest	Airways resistance were measured by impulse oscillometry (IOS) method.
Airways Resistance (IOS)	Baseline test, after breathing exercises with flutter or flutter-sham device and after 20 minutes of rest	Airways resistance were measured by impulse oscillometry (IOS) method.
Airways Resistance (IOS) - Reactance Area (Ax)	Baseline test, after breathing exercises with flutter or flutter-sham device and after 20 minutes of rest	Airways resistance were measured by impulse oscillometry (IOS) method.

Secondary Outcome Measures

Name	Time	Method
Cough	During each session	Number of spontaneously reported cough episodes during each visit were collected.
Exhaled Nitric Oxide (FeNO)	Baseline and immediately after intervention	Exhaled nitric oxide will be measured by chemiluminescence method.
Spirometry - Forced Expiratory Volume at 1 Second (FEV1) and Forced Vital Capacity (FVC)	Baseline and immediately after intervention	Forced expiratory volume in 1s (FEV1) and forced vital capacity (FVC) were measured using a dry wedge spirometer (Jaeger Co, Wurzburg, Germany)
Secretion - Volume	During each session	Expectorated secretion volume during each visit were collected, weighted and classified with a purulence score.
Secretion - Purulence Score	In each session	The expectorated secretion was collected, weighted and classified with a purulence score based on a previously described numerical visual scale, which ranges from 1 (mucoid) to 5 (yellow/green).; Referee of the Purulence score: Barnes PJ, Dweik RA, Gelb AF, et al. Exhaled nitric oxide in pulmonary diseases: a comprehensive review. Chest. 2010;138:682-692.

Trial Locations

Locations (1)

Asthma Lab, Royal Brompton Hospital, National Heart and Lung Institute, Imperial College London; 🇬🇧 London, United Kingdom