McCormack Pamela, Burnham Paul, Southern Kevin W
Department of Respiratory Physiotherapy, Alder Hey Children's NHS Foundation Trust, Eaton Road, Liverpool, UK, L12 2AP.
Cochrane Database Syst Rev. 2017 Oct 6;10(10):CD009595. doi: 10.1002/14651858.CD009595.pub2.
Autogenic drainage is an airway clearance technique that was developed by Jean Chevaillier in 1967. The technique is characterised by breathing control using expiratory airflow to mobilise secretions from smaller to larger airways. Secretions are cleared independently by adjusting the depth and speed of respiration in a sequence of controlled breathing techniques during exhalation. The technique requires training, concentration and effort from the individual. It is important to systematically review the evidence demonstrating that autogenic drainage is an effective intervention for people with cystic fibrosis.
To compare the clinical effectiveness of autogenic drainage in people with cystic fibrosis with other physiotherapy airway clearance techniques.
We searched the Cochrane Cystic Fibrosis Trials Register, compiled from electronic database searches and handsearching of journals and conference abstract books. We also searched the reference lists of relevant articles and reviews, as well as two trials registers (31 August 2017).Dtae of most recent search of the Cochrane Cystic Fibrosis Trials Register: 25 September 2017.
We identified randomised and quasi-randomised controlled studies comparing autogenic drainage to another airway clearance technique or no therapy in people with cystic fibrosis for at least two treatment sessions.
Data extraction and assessments of risk of bias were independently performed by two authors. The authors assessed the quality of the evidence using the GRADE system. The authors contacted two investigators for further information pertinent to their published studies.
Searches retrieved 35 references to 21 individual studies, of which seven (n = 208) were eligible for inclusion. One study was of parallel design with the remaining six being cross-over in design; participant numbers ranged from 17 to 75. The total study duration varied between four days and two years. The age of participants ranged between seven and 63 years with a wide range of disease severity reported. Six studies enrolled participants who were clinically stable, whilst participants in one study had been hospitalised with an infective exacerbation. All studies compared autogenic drainage to one (or more) other recognised airway clearance technique. Exercise is commonly used as an alternative therapy by people with cystic fibrosis; however, there were no studies identified comparing exercise with autogenic drainage.The quality of the evidence was generally low or very low. The main reasons for downgrading the level of evidence were the frequent use of a cross-over design, outcome reporting bias and the inability to blind participants.The review's primary outcome, forced expiratory volume in one second, was the most common outcome measured and was reported by all seven studies; only three studies reported on quality of life (also a primary outcome of the review). One study reported on adverse events and described a decrease in oxygen saturation levels whilst performing active cycle of breathing techniques, but not with autogenic drainage. Six of the seven included studies measured forced vital capacity and three of the studies used mid peak expiratory flow (per cent predicted) as an outcome. Six studies reported sputum weight. Less commonly used outcomes included oxygen saturation levels, personal preference, hospital admissions or intravenous antibiotics. There were no statistically significant differences found between any of the techniques used with respect to the outcomes measured except when autogenic drainage was described as being the preferred technique of the participants in one study over postural drainage and percussion.
AUTHORS' CONCLUSIONS: Autogenic drainage is a challenging technique that requires commitment from the individual. As such, this intervention merits systematic review to ensure its effectiveness for people with cystic fibrosis. From the studies assessed, autogenic drainage was not found to be superior to any other form of airway clearance technique. Larger studies are required to better evaluate autogenic drainage in comparison to other airway clearance techniques in view of the relatively small number of participants in this review and the complex study designs. The studies recruited a range of participants and were not powered to assess non-inferiority. The varied length and design of the studies made the analysis of pooled data challenging.
自主引流是一种气道清理技术，由让·谢瓦利埃于1967年研发。该技术的特点是通过呼气气流进行呼吸控制，以促使分泌物从小气道向大气道移动。在呼气过程中，通过一系列受控呼吸技术调整呼吸深度和速度，分泌物得以自主清除。该技术需要个体进行训练、集中注意力并付出努力。系统回顾证明自主引流对囊性纤维化患者是一种有效干预措施的证据很重要。
比较自主引流与其他物理治疗气道清理技术对囊性纤维化患者的临床效果。
我们检索了Cochrane囊性纤维化试验注册库，该注册库通过电子数据库检索以及对期刊和会议摘要书籍的手工检索汇编而成。我们还检索了相关文章和综述的参考文献列表，以及两个试验注册库（2017年8月31日）。Cochrane囊性纤维化试验注册库的最新检索日期：2017年9月25日。
我们纳入了将自主引流与另一种气道清理技术或不进行治疗相比较的随机和半随机对照研究，研究对象为囊性纤维化患者，且治疗疗程至少为两个。
两名作者独立进行数据提取和偏倚风险评估。作者使用GRADE系统评估证据质量。作者联系了两名研究者以获取与其已发表研究相关的更多信息。
检索共获得21项个体研究的35篇参考文献，其中7项研究（n = 208）符合纳入标准。1项研究为平行设计，其余6项为交叉设计；参与者人数从17至75不等。研究总时长在4天至2年之间。参与者年龄在7至63岁之间，报告的疾病严重程度范围广泛。6项研究纳入了临床稳定的参与者，而1项研究的参与者因感染性加重而住院。所有研究均将自主引流与一种（或多种）其他公认的气道清理技术进行了比较。运动是囊性纤维化患者常用的替代治疗方法；然而，未发现有研究将运动与自主引流进行比较。证据质量总体较低或非常低。证据水平降级的主要原因是频繁使用交叉设计、结果报告偏倚以及无法使参与者设盲。综述的主要结局指标，一秒用力呼气量，是测量最常见的结局，所有7项研究均有报告；只有3项研究报告了生活质量（也是综述的主要结局）。1项研究报告了不良事件，描述了在进行主动呼吸循环技术时氧饱和度水平下降，但自主引流时未出现。7项纳入研究中有6项测量了用力肺活量，3项研究将呼气中期流速（预测百分比）作为结局指标。6项研究报告了痰液重量量。较少使用的结局指标包括氧饱和度水平、个人偏好、住院或静脉使用抗生素。在所使用的任何技术之间，除了在1项研究中自主引流被描述为优于体位引流和叩击，被参与者视为首选技术外，在测量的结局方面未发现统计学上的显著差异。
自主引流是一项具有挑战性的技术，需要个体的投入。因此，这种干预措施值得进行系统回顾，以确保其对囊性纤维化患者的有效性。从评估的研究来看，未发现自主引流优于任何其他形式的气道清理技术。鉴于本综述中的参与者数量相对较少且研究设计复杂，需要开展更大规模的研究，以更好地评估自主引流与其他气道清理技术的比较。这些研究招募了不同范围的参与者，且未进行非劣效性评估。研究的长度和设计各不相同，使得汇总数据分析具有挑战性。
