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Evaluation of a novel sputum clearance technique - Hydro-acoustic therapy

(HAT) in adult patients with cystic fibrosis: A feasibility study

Article in Chronic Respiratory Disease · November 2010

DOI: 10.1177/1479972310376082 · Source: PubMed

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 Chronic Respiratory
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Disease

Evaluation of a novel sputum clearance technique−−hydro-acoustic therapy (HAT) in adult patients with
cystic fibrosis: A feasibility study
NA Jarad, T. Powell and E. Smith
Chronic Respiratory Disease 2010 7: 217
DOI: 10.1177/1479972310376082

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Original Paper
Chronic Respiratory Disease
7(4) 217–227
Evaluation of a novel sputum ª The Author(s) 2010
Reprints and permission:
sagepub.co.uk/journalsPermissions.nav
clearance technique—hydro-acoustic DOI: 10.1177/1479972310376082
crd.sagepub.com
therapy (HAT) in adult patients with
cystic fibrosis: A feasibility study

NA Jarad, T Powell, and E Smith

Abstract
This study was designed to investigate the efficacy, safety and patients’ acceptance of a novel system for sputum
clearance—Hydro Acoustic Therapy (HAT) in patients with cystic fibrosis (CF). This is a prospective cross-
over study where 18 patients received 6 sessions of physiotherapy over 6 separate days. These consisted
of 2 sessions of either HAT, flutter valve or and sitting in the bath with sounds without vibration (placebo) for
30 minutes each. The efficacy was investigated by measuring the weight of wet and dry sputum after each
session and by change in spirometry values. The preference was assessed by a questionnaire completed by
patients at the end of the study about their preference of which type of physiotherapy received. The weight
of both dry and wet sputum produced was similar in the 3 arms of the study. Spirometry values but not oxygen
saturation were reduced after HAT and flutter therapy sessions. HAT therapy was preferred to flutter and
placebo in terms of breathlessness, ease of sputum production and relaxation. Of the patients, 70% stated
that they would choose HAT as their preferred physiotherapy method compared to 0% for flutter (w2 ¼
20.3, p < 0.0001). There were no procedure-related complications in any of the 3 arms of the study. HAT was
found to be safe, well tolerated and favoured by the majority of CF patients. The effect of HAT, however, on
sputum production was not superior to flutter or placebo.

Keywords
cystic fibrosis, physiotherapy, hydro-acoustic therapy, spirometry, sputum clearance

Introduction Airway clearance techniques include postural

drainage, active cycle breathing with and without
Cough productive of thick sputum is a common symp-
chest percussion. Sputum clearance can be enhanced
tom in patients with cystic fibrosis (CF). The compo-
by using adjuvant devices such as flutter valve, posi-
sition of sputum in this group of patients provides a
tive expiratory pressure (PEP) masks and external
good medium for growth of bacteria including P aer-
high-frequency vibrating vests.
uginosa and Staphylococcus aureus.1-4 Repeated pul-
Inhaled pharmacological agents that help with spu-
monary exacerbations caused by these bacteria lead to
tum clearance are also used. Nebulized recombinant
progressive lung damage leading to respiratory fail-
human DNA splitting enzymes (rh DNAse) is used
ure, which is the main cause of premature mortality
to break down the bacterial DNA molecule in the
in CF patients.5,6
Despite lack of evidence for long-term efficacy of
airway clearance,7 daily physiotherapy continues to
be a fundamental part of management of CF Department of Respiratory Medicine, Bristol Royal Infirmary,
patients.8,9 Most therapeutic techniques aim at improv- Bristol
ing sputum clearance and enhancing the function of
Corresponding author:
the mucociliary escalator by decreasing viscosity NA Jarad, Consultant Physician in Respiratory Medicine, Bristol
of sputum and dislodging sputum off the bronchial Royal Infirmary, Bristol BS2 8HW, UK
wall. Email: Nabil.Jarad@uhbristol.nhs.uk
218
sputum, which is responsible for increased sputum
viscosity.10,11 Other agents such as inhaled hyperos-
molic drugs are used. Both high concentration saline
(hypertonic saline)12 and mannitol13 in CF patients
has been found to be effective.
A recent systematic review of clinical trials found
no difference in the efficacy of conventional chest
physiotherapy to self-administered airway clearance
techniques in CF patients.14 Several other studies
attempted to compare available methods of chest phy-
siotherapy in CF patients with the aim of identifying
the most effective technique. The majority of these
studies found little difference in the volume of sputum
produced and change in lung function tests.15,16
In clinical practice, the method of physiotherapy
advised for each individual patient depends largely
on his/her preference. Despite this, it is recognized that
lack of tolerance and lack of adherence to daily phy-
siotherapy exists irrespective of the method used.17
Hydro acoustic therapy (HAT) is a novel method in
which sound waves are externally delivered onto the
chest wall of patients while immersed in bath water.
The treatment is relatively passive with the patient
simply sitting in a bath of warm water while being
exposed to water-borne sound waves delivered to the
chest wall. The procedure can be self-administered
and the equipment is relatively inexpensive. Prelimi-
nary tests showed HAT to be well tolerated and more
effective in terms of the weight of expectorated spu-
tum than the VEST. Comparison with the VEST in
this study was made as it is a device that works to
clear sputum in a similar method to HAT, using an
external vibratory source to dislodge sputum from air-
way walls. In this study, efficacy was assessed as the
weight of dry sputum produced18 but not lung func-
tion tests. Patients’ preference was not sought. The
bath used in this comparison was large, cumbersome
and was not fit to be commercially distributed.
A new and smaller version of the HAT bath has
been developed. This provided an opportunity to
examine the efficacy and tolerability of this technique
and to compare it to other methods of physiotherapy.
This is the purpose of this study.
Patients and methods
The study was approved by the Central and South
Bristol Research Ethics Committee, reference num-
ber: E5805.
Inclusion criteria were CF patients with daily spu-
tum production, age over 16 years, forced expiratory
Chronic Respiratory Disease 7(4)
volume in the first second (FEV1) < 80% of predicted
value and baseline oxygen saturation on room air of
over 85%.
Patients were excluded if they were chronically
infected with Burkhulderia Cenocepacia or were
dependent on oxygen due to hypoxia or dyspnoea.
Exclusion criteria also included suspected pregnancy,
fear of water or pneumothorax within the previous
3 months.
All patients were enrolled during a period of clini-
cal stability. For the purpose of this study, this is
defined as being away from any pulmonary exacerba-
tions requiring oral or intravenous (IV) antibiotics for
at least 4 weeks. If exacerbations occurred at any time
in the study, the next treatment was postponed by at
least 4 weeks. If patient had two exacerbations, it was
planned that they were withdrawn from the study. In
the event, this did not happen to any patient.
All methods of treatment were carried out with the
patients sitting in the same HAT bath in order to
account for the effect of water humidity on sputum
production. Three methods of treatment were com-
pared—HAT, flutter valve and placebo. The order
of methods was randomized.
Patients were asked to take their medications in the
usual manner. They were asked not to perform their
morning physiotherapy prior to treatment sessions.
They were asked to collect, in a separate pot each day,
the morning sputum produced with cough for the 2
days prior to visit one. The weight of daily wet and
dry sputum was used as a baseline.
The bath measured 240 cm in length, 170 cm in
width and 170 cm in height. It was equipped with a
water-sealed door. Patients undergoing HAT were
submerged underwater to the neck level. The bath
has an on/off switch button which the patient can
press (Figure 1). The acoustic waves were delivered
from two sound sources placed at each sides of the
bath at the patients’ chest wall level. The amplitude
of the sound was set at 158 dB re 1 micro Pascal.
Three frequencies were delivered each for 10 min-
utes: the Helmholtz resonance frequency of the
lungs (at 20 Hz), the measured ‘breathing mode’
resonance frequency (at 40 Hz) and an intermediate
frequency (at 30 Hz). This was based on previous
experience in which it is found that this treatment
regimen was safe and most effective.19,20 This fre-
quency is similar to that used in the external vibrat-
ing device (the VEST) and higher than devices that
apply vibration through the airways such as positive
expiratory pressure valve.
Jarad et al.
b below 85% or by 5% from the base line, the treatment
c was planned to be terminated. This did not happen to
a over two successive days. Each session lasted for
d
Figure 1. The hydro-acoustic therapy (HAT) bath. A, A
patient in the bath. (a) The water sealed door; (b) the on/
off safety switch that can be operated by patients and (c)
the monitoring of pulse and oxygen saturation using a
pulse oximeter; (d) the sound source box. B, Schematic
presentation showing the position of the seat and the
sound source.
The bath was filled with mains tap water up to a
pre-identified level. Warm and cold water were mixed
aiming at achieving water temperature at 37 C. There
was no external heating applied as water temperature
remained tolerable throughout the 30 minutes of the
study. At the end of the procedure, the water was dis-
posed off via a hose attached to the bottom corner of
the bath into the main drainage system of the lab
room.
At their arrival to the unit, patients were rested for
20 minutes and were dressed in swimming suits. All
female patients underwent pregnancy tests prior to
HAT treatment as per the requirement of the Research
Ethics Committee.
Baseline measurements of spirometry using the
same spirometer (Micro Medical Limited) were mea-
sured prior to each treatment and 60 minutes after the
219
end of the study. The best of three attempts was
chosen. Blood pressure, pulse rate, resting respiratory
rate and resting oxygen saturation while breathing
room air were measured throughout the treatment
period every 5 minutes. If oxygen saturation fell
any patients throughout the study.
Patients received two sessions of each method
30 minutes. Therefore, patients received 6 sessions
in total. There was at least 1 week interval between
any two types of therapy to allow a washout period
and to obviate any carryover effect. Throughout
each treatment session, sputum was collected in a
pre-weighed pot. Sputum collection with just cough-
ing was continued for further 60 minutes after
patients had left the bath.21 All visits were per-
formed in the mornings at approximately the same
time of the day.
For the flutter valve arm of the study, patients used
the device while sitting in the bath. As per manufac-
turer’s instruction, patients sat with their back straight
and head tilted slightly. To start with, the angle at
which the flutter was held was horizontal to the floor.
Afterwards, patients were advised to alter the angle to
give the strongest fluttering sensation. The flutter was
used in cycles of 5 to 10 breaths with a breath hold of
2 to 3 seconds before breathing out through the flutter.
The valve was used for 5 minutes alternatively with
5 minutes breathing normally. This cycle continued
for a total of 30 minutes.
The placebo arm consisted of patients sitting in the
bath with sounds without waves being generated from
loudspeakers fitted at the side of the bath and deliv-
ered for 30 minutes in a similar manner to the HAT
treatment. The sound amplitude was exactly similar
to the one used at the HAT arm (158 dB re 1 micro
Pascal). Patients were not told whether they were
receiving HAT or placebo.
The bath was cleaned and disinfected after each use
using a sponge with a soap and water. A regular sam-
ple of the water was taken once weekly (54 samples in
total) and was sent for microbiology detection and
culture.
The risk of electrical shock from the HAT equip-
ment was ensured to be negligible. All equipment
using higher voltage was outside of the chamber.
These circuits were protected with ground fault
interrupters to automatically shut off power upon any
electrical contact with water.
220
Table 1. Demographic data
Sex (male: female) 10:8
Age, mean (SD) 24 (4.8)
BMI, mean (SD) 20.8 (2.8)
Main method of physiotherapy
Active cycle breathing
Exercise
Autogenic drainage
Chest percussion
Flutter valve
PEP mask
BMI: body mass index, PEP: positive expiratory pressure.
At the end of the study, patients were asked to
complete a questionnaire of their preferred type of
treatment.
Sputum preparation
This was done at the department of microbiology at
Bristol Royal Infirmary using their standard proce-
dure of measuring the weight of wet and dry sputum.
The same method has been described in a previous
study.21 In short, sputum was collected in a pre-
weighed 50 mL specimen pots. The wet samples were
weighed using Ohaus (Model CT200-S) scales. Dry-
ing the sputum was done by placing the specimen for
12 hours in a deep-freezing refrigerator at 70 C.
The dry sputum was weighed immediately after
removal using the same scale.
Statistical analysis
The statistical analysis was performed with the help of
the Biomedical Statistics Unit at the Research and
Development Department at University Hospital,
Bristol.
Each session was regarded as a separate event. Data
on sputum weight were not normally distributed; there-
fore, all comparisons for weight of wet and dry sputum
were made using the Mann-Whitney U test for
unpaired comparisons and Wilcoxon’s tests for paired
comparison. On the other hand, the analyses underta-
ken for spirometry values were carried out using
matched paired and unpaired t test as these were nor-
mally distributed. Data for preference for each
technique in the questionnaire were made using
chi-square methods with Yates correction as some of
the comparisons contained a small number of
observations.
Chronic Respiratory Disease 7(4)
Results
Nineteen adult CF patients (8 female) were enrolled
in the study. Diagnosis of CF was well established
during childhood in all patients. Sixteen patients were
homozygous for the delta F508 mutation and two car-
5
ried other genes. One patient withdrew consent due to
3
2 time constraints, leaving 18 patients who completed
3 the three arms of the study. Patients’ demographic
4 data are illustrated in Table 1. Thirteen (72%) patients
1 brought morning sputum on 2 successive days prior to
the first study day. This was used as a baseline for
analysis.
Sputum production
To assess the reproducibility of sputum production,
the weight of wet and dry pre-treatment sputum over
the 2 successive days for each method were com-
pared. There were no differences in the weight of wet
and dry sputum produced for any of the study arms
(Table 2).
The weight of the early morning sputum (repre-
senting overnight sputum) was significantly greater
than the weight of sputum produced after either
method. However, when comparing the three study
arms, the weight of wet and dry sputum varied but
there was no statistical difference for HAT, flutter and
placebo (Table 3).
Spirometry values
The values of pre-treatment for all spirometry mea-
surements were similar for the three trial arms. This
was tested as a quality assurance to ensure that there
were no pulmonary exacerbations in the intervals
between treatments.
The values of all lung function tests prior to each
treatment arm in the second study day were similar
to that in the first study day. This method was used
in order to ensure that any change in spirometry val-
ues following each treatment session on the first day
did not carry over until the following day (Table 4).
FEV1 values were significantly reduced after the
treatment with HAT and flutter. Forced vital capacity
(FVC) was reduced after HAT but not after flutter.
Measurements for small airways including forced
expiratory flow at 75% of vital capacity (FEF 75) and
FEF at 25 to 75 of vital capacity (FEF 25–75) were
reduced after HAT and flutter. All lung function para-
meters remained unchanged in the placebo arm of the
study (Table 5).
Jarad et al. 221

Table 2. Median and inter-quartile comparisons of weight of the sputum in the 2 study days for each method used in this
triala
Wet sputum Dry sputum
n Day 1 Day 2 Day 1 Day 2
Morning collection 13
Median 3.5 1.5 0.50 0.35
25% percentile 1.08 0.44 0.35 0.27
75% percentile 5.1 1.5 1.11 0.75
HAT 18
Median 0.86 1.83 0.02 0.05
25% percentile 0 0 0 0
75% percentile 8.3 6.6 0.31 0.33
Flutter 18
Median 0.66 0 0.03 0
25% percentile 0 0 0 0
75% percentile 5.6 7.6 0.27 0.42
Placebo 18
Median 2.83 2.15 0.06 0.05
25% percentile 0 0 0 0
75% percentile 6.33 5.95 0.3 0.29
HAT: hydro-acoustic therapy.
a
p Value was not significant for all comparisons performed using the Wilcoxon’s matched pair tests.

Table 3. Median and 25% and 75% percentile for the total weight of wet and dry sputum for all the methods over 2 daysa
n Wet sputum Dry sputum
Morning collection 26
Median 2.16 0.41
25% percentile–75% percentile 0.85–5.4 0.29–0.89
HAT 36
Median 1.02 0.02
25% percentile–75% percentile 0.0–6.6 0–0.28
Flutter 36
Median 0.57 0.01
25% percentile–75% percentile 0–5.3 0–0.27
Placebo 36
Median 2.8 0.05
25% percentile–75% percentile 0–5.1 0–0.28
HAT: hydro-acoustic therapy, N: number of treatments.
a
The weight of sputum during morning collection was greater than those produced by any methods (p < 0.001 for all methods). p Values
were not significant for any comparison for any of the three treatment arms. Mann-Whitney U test was used in this comparison.

Patients’ preference high preference to HAT in comparison to their usual

The questionnaire used and the proportion of patients
that chose either option is outlined in Table 6. On the
whole, patients found HAT and placebo to be prefer-
able to flutter device in terms of the ease by which spu-
tum was cleared, breathlessness and relaxation. When
asked of their preferred method for daily physiother-
apy, no patients chose the flutter valve. There was a
physiotherapy and flutter (Table 6 and Figure 2).
Examination of water specimen
Out of 54 samples of bath water, one sample grew
scanty amount of P fluorescence. This bacteria did
not grow on the sputum of the corresponding
patient.
222 Chronic Respiratory Disease 7(4)

Table 4. Lung function tests in the 2 study days before and after each type of treatmenta
HAT Flutter Placebo
Day 1 Day 2 Day 1 Day 2 Day 1 Day 2
FEV1
Before 1.82 (0.64) 1.87 (0.71) 1.89 (0.73) 1.83 (0.71) 1.76 (0.58) 1.79 (0.65)
After 1.75 (0.64) 1.79 (0.68) 1.85 (0.72) 1.79 (0.69) 1.75 (0.62) 1.77 (0.67)
FVC
Before 2.98 (0.87) 3.10 (0.8) 3.20 (0.94) 3.16 (0.89) 3.11 (0.80) 3.11 (0.83)
After 2.85 (0.79) 3.00 (0.85) 3.17 (0.86) 3.12 (0.89) 3.06 (0.82) 3.05 (0.87)
FEF 75%
Before 2.84 (1.76) 2.87 (2.21) 2.84 (1.96) 2.75 (1.89) 2.43 (1.44) 2.73 (1.84)
After 2.68 (1.96) 2.64 (1.92) 2.75 (1.89) 2.89 (2.19) 2.46 (1.55) 2.66 (1.89)
FEF 25–75
Before 2.31 (1.61) 2.39 (1.94) 2.37 (1.69) 2.42 (1.94) 2.0 (1.33) 2.15 (1.72)
After 2.18 (1.63) 2.11 (1.73) 2.31 (1.60) 2.28 (1.82) 2.0 (1.40) 2.15 (1.58)
FEV1: forced expiratory volume in the first second, FVC: forced vital capacity, FEF 75: forced expiratory flow at 75% of vital capacity,
FEF 25–75: forced expiratory flow between 25% and 75% of vital capacity, HAT: hydro-acoustic therapy.
a
The values prior to treatment were similar for all study arms (two tailed t test) and did not differ in the 2 study days for all methods
(paired t test). This suggests that the decline in some lung function values after treatment had recovered by the following day (see also
Table 5 and text).

Table 5. Change in lung function parameter before and after each type of treatmenta
HAT Flutter Placebo
FEV1 (litre)
Pre-treatment 1.86 (0.66) 1.86 (0.71) 1.78 (0.61)
Post-treatment 1.78 (0.64) 1.82 (0.70) 1.76 (0.63)
p value 0.001 0.028 0.133
FVC (litre)
Pre-treatment 3.01 (0.82) 3.19 (0.91) 3.11 (0.8)
Post-treatment 2.92 (0.79) 3.15 (0.83) 3.01 (0.83)
p Value 0.041 0.30 0.77
FEF 75 (litre/second)
Pre-treatment 2.89 (1.93) 2.86 (2.04) 2.58 (1.63)
Post-treatment 2.68 (1.87) 2.73 (1.95) 2.56 (1.71)
p Value 0.07 0.007 0.43
FEF 25–75 (litre/second)
Pre-treatment 2.37 (1.72) 2.40 (1.76) 2.00 (1.31)
Post-treatment 2.16 (1.63) 2.29 (1.69) 2.01 (1.48)
p Value 0.048 0.03 0.90
FEV1: forced expiratory volume in the first second, FVC: forced vital capacity, FEF 75: forced expiratory flow at 75% of vital capacity,
FEF 25–75: forced expiratory flow between 25% and 75% of vital capacity, HAT: hydro-acoustic therapy.
a
Data are expressed as mean (SD) and compared using paired t test.

Discussion was not commonplace. The use of flutter valve, on the

This is the first study to methodically evaluate HAT
as a physiotherapy technique in CF patients in terms
of outcome, safety and acceptance. The physiotherapy
method closest to HAT which applies similar physical
principles is the vibrating vests. When this study was
conducted, the use of the vests in the United Kingdom
other hand, was common amongst CF patients.
This study showed comparable results in terms of
sputum production to the flutter device and placebo.
However, HAT was felt by patients to be more prefer-
able than placebo or flutter valve for several para-
meters including the ease by which sputum was
Jarad et al. 223

Table 6. The questionnaire administered after the last of the six sessionsa
Q1. Regarding your breathlessness, HAT is:
much worse than the physiotherapy technique that you used to do 0%
Slightly worse than the physiotherapy technique that you used to do 17.6%
similar than the physiotherapy technique that you used to do 35.3%
Slightly better than the physiotherapy technique that you used to do 23.5%
much better than the physiotherapy technique that you used to do 23.5%
Q2. Regarding your breathlessness, HAT is:
much worse than the flutter device 0%
Slightly worse than the flutter device 5.9%
similar than the flutter device 29.4%
Slightly better than the flutter device 29.4%
much better than the flutter device 35.3%
Q3. Regarding your breathlessness, placebo is:
much worse than the flutter device 0%
Slightly worse than the flutter device 11.8%
similar than the flutter device 23.5%
Slightly better than the flutter device 41.2%
much better than the flutter device 23.5%
Q4. Regarding your breathlessness, placebo is:
much worse than HAT 0%
Slightly worse than HAT 23.5%
similar to HAT 52.9%
Slightly better than HAT 17.6%
much better than HAT 5.9%
Q5. Regarding the ease by which phlegm is coughed up, HAT is:
much worse than the physiotherapy technique that you used to do 0%
Slightly worse than the physiotherapy technique that you used to do 18.8%
similar than the physiotherapy technique that you used to do 43.8%
Slightly better than the physiotherapy technique that you used to do 31.3%
much better than the physiotherapy technique that you used to do 6.3%
Q6. Regards to the ease by which the phlegm is coughed up, HAT is:
much worse than the flutter device 0%
Slightly worse than the flutter device 12.5%
similar to the flutter device 25.0%
slightly better than the flutter device 31.3%
much better than the flutter device 31.3%
Q7. Regards to the ease by which the phlegm is coughed up, placebo is
much worse than the flutter device 6.3%
slightly worse than the flutter device 25.0%
similar to the flutter device 37.5%
slightly better than the flutter device 18.8%
much better than the flutter device 12.5%
Q8. Regards to ease by which the phlegm is coughed up, placebo is
much worse than HAT 12.5%
slightly worse than HAT 25.0%
similar to HAT 50.0%
slightly better than HAT 0%
much better than HAT 12.5%

(continued)
224 Chronic Respiratory Disease 7(4)

Table 6 (continued)
Q9. Regards to relaxation, HAT is:
much worse than the flutter device 0%
slightly worse than the flutter device 11.8%
similar to the flutter device 0%
slightly better than the flutter device 17.6%
much better than the flutter device 70.6%
Q10. Regards to relaxation, placebo is:
much worse than the flutter device 0%
slightly worse than the flutter device 0%
similar to the flutter device 11.8%
slightly better than the flutter device 23.5%
much better than the flutter device 64.7%
Q11. Regards to relaxation, placebo is:
much worse than HAT 0%
slightly worse than HAT 18.8%
similar to HAT 50.0%
slightly better than HAT 31.3%
much better than HAT 0%
Q12. Overall I found the HAT therapy
Very unpleasant 0%
Slightly unpleasant 17.6%
OK 23.5%
Slightly pleasant 17.6%
Very pleasant 41.2%
Q13. Overall I found the Flutter therapy
Very unpleasant 11.8%
Slightly unpleasant 23.5%
OK 64.7%
Slightly pleasant 0%
Very pleasant 0%
Q14. Overall I found the placebo therapy
Very unpleasant 0%
Slightly unpleasant 5.9%
OK 35.3%
Slightly pleasant 17.6%
Very pleasant 41.2%
Q15. If available I would prefer for physiotherapy
My usual physiotherapy technique 29.4%
Physiotherapy using HAT 70.6%
Physiotherapy using EST 0%
Physiotherapy using the flutter device 0%
HAT: hydro-acoustic therapy.
a
The proportion of patients who chose each item of the questionnaire is outlined on the right. Patients were not told which trial they
received HAT or placebo until after the last trial session. Flutter was used while patients’ were sitting in the bath.

produced, breathlessness during physiotherapy and described previously. The weight of the morning spu-
relaxation. tum produced by patients was found to be similar over
Our study demonstrated several other aspects of 2 successive days, which would suggest that the
sputum production in CF patients, which were not amount of sputum produced is probably similar on a
Jarad et al.
χ2 = 20.35
p<0.001
20
Yes
No
Number of patients
10
0 drainage.23 Conversely, another study raised concern
Prefers HAT Prefers flutter
Figure 2. Patient’s preference of hydro-acoustic therapy
(HAT) versus flutter valve as their physiotherapy. This
graph shows that no patients preferred flutter device
whereas the majority of patients would have a preference
to using HAT as their usual physiotherapy (Please also see
Table 6).
day-to-day basis during disease stability. It would also
suggest that the effect of the three techniques was
short-lived and lasted for less than 24 hours.
Several spirometry values were temporarily reduced
after treatment by HAT and flutter but not after placebo.
This is not unique to this study. Other studies showed
similar adverse short-term physiological effect after
physiotherapy. One study that compared active cycle
breathing with autogenic drainage showed a temporary
oxygen de-saturation during physiotherapy in several
patients during the active cycle breathing arm.22 This
phenomenon was also reported in other circumstances.
FEV1 and FVC were temporarily reduced after sputum
induction by 3% saline in chronic obstructive pulmon-
ary disease (COPD) patients.23
The reason for reduced lung function after phy-
siotherapy is not clear. One possibility is that all mod-
alities of physiotherapy might cause a temporary
bronchospasm. Another reason may be that phy-
siotherapy dislodges sputum from smaller to larger and
more proximal airways, thus causing temporary reduc-
tion in lung function tests. Whatever the reason for this,
the reduction was short-lived. The comparison of the
values for the 2 study days showed that all lung func-
tion values returned to pre-study base line prior to
treatment on the second study day.
Several studies have compared the efficacy of phy-
siotherapy techniques in CF patients. In one of the
earliest studies, forced expiratory technique was
225
found to clear more sputum in less time when com-
pared with postural drainage.24 In a more recent study
that compared autogenic drainage with active cycle
breathing in CF patients,25 the two techniques yielded
similar results in terms of several outcome measures
that included weight of sputum, lung function tests
and lung ventilation as measured by inhaled isotope
distribution. Unlike our study, patients’ preference
did not differ for the two methods.
Studies investigating flutter valve showed variable
results. In one report, a reduction in sputum viscosity
with flutter was found when compared with autogenic
that flutter may increase sputum retention as some CF
patients produced less sputum when using flutter
device as an adjunct to active cycle breathing com-
pared with active cycle breathing alone.26
Adherence to physiotherapy remains to be a
problem.17 The reason for this seems to lie in the
effort and time needed to perform physiotherapy, both
of which are added burden to an already symptomatic
disease with a taxing treatment regime.
In our study, no patients chose flutter over HAT
as their preferred technique if the choice became
available. The preference of HAT over flutter was
not due to the effect of patients being immersed in
warm water as we eliminated this effect by conduct-
ing the three arms of study while patients sat in the
same bath for a similar period. This favourable feed-
back may have been due to the passiveness of HAT
together with the feel of chest vibrations generated
by the sound waves that were similar to localized
Jacuzzi effect. This positive attitude may enhance
the adherence rate to HAT as a method for daily
physiotherapy.
In conclusion, the HAT technique was as effective
as flutter device in terms of sputum clearance, but was
highly preferred against patients’ usual physiotherapy
and the flutter device. The technique was found to
be safe.
For future commercial application, the design of
the bath needs to undergo technical changes to make
it more effective. The frequencies and the amplitude
of the sound waves may need to be flexible and adjus-
table by patients to achieve maximum effectiveness
without becoming uncomfortable. The bath needs to
have changes in the design to make smaller and easier
to fill, to empty and to clean by unwell patients so that
it can be used at home. All these changes are techni-
cally possible and might help HAT to become a reli-
able and usable method of chest physiotherapy in CF
226
patients. It is envisaged that HAT may be used to
deliver at least one of the two daily physiotherapy
treatments in sputum-producing CF patients. The
HAT session could be combined with other morning
activities such as bathing, shaving and even taking
nebulized treatment, thus minimizing the time
needed to perform the several morning activities by
CF patients.
We have not investigated the value of HAT during
exacerbations because we needed disease stability
status for comparing methods of physiotherapy. But
the favourable response for HAT on breathlessness,
the ease of sputum production and relaxation would
make this technique ideal during pulmonary exacer-
bations treated at home and for CF patients suffering
from fatigue.
Acknowledgment
We are very grateful to Mr Peter Cartwright and Mr Jeremy
Nedwell for their assistance in constructing the Bath and
for their technical assistance during the study. We thank
Hannah Douglass, CF Physiotherapy at Bristol Royal
Infirmary for her advice.
Conflicts of interest
The authors had no conflicts of interest.
Funding
This study was funded by Aco-Med UK.
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