airway clearance devices
DESCRIPTION
Airway Clearance DevicesTRANSCRIPT
Airway Clearance Systems Aug 13 1
National Medical Policy Subject: Airway Clearance Devices
Policy Number: NMP214
Effective Date*: March 2005
Updated: February 2007, April 2009, April 2011,
September 2011, August 2012, August 2013
This National Medical Policy is subject to the terms in the
IMPORTANT NOTICE
at the end of this document
For Medicaid Plans: Please refer to the appropriate Medicaid Manuals for
coverage guidelines prior to applying Health Net Medical Policies
The Centers for Medicare & Medicaid Services (CMS)
For Medicare Advantage members please refer to the following for coverage
guidelines first:
Use Source Reference/Website Link
National Coverage Determination (NCD)
National Coverage Manual Citation
x Local Coverage Determination (LCD)* High Frequency Chest Wall Oscillation Devices:
http://www.cms.gov/medicare-coverage-
database/search/advanced-search.aspx X Article (Local)* High Frequency Chest Wall Oscillation Devices:
LCD and Policy Article Revisions - Summary for
September 2008:
LCD and Policy Article Revisions - Summary for
March 3, 2011:
http://www.cms.gov/medicare-coverage-
database/search/advanced-search.aspx X Other MLN Matters Number: MM8304 Revised
Related Change Request CR 8304. May 31,
2013. “The Durable Medical Equipment,
Prosthetics, Orthotics, and Supplies (DMEPOS)
Competitive Bidding Program: Traveling
Beneficiary: http://www.cms.gov/Outreach-and-
Education/Medicare-Learning-Network-
Airway Clearance Systems Aug 13 2
MLN/MLNMattersArticles/Downloads/MM8304.pd
f
None Use Health Net Policy
Instructions
Medicare NCDs and National Coverage Manuals apply to ALL Medicare members
in ALL regions.
Medicare LCDs and Articles apply to members in specific regions. To access your
specific region, select the link provided under “Reference/Website” and follow the
search instructions. Enter the topic and your specific state to find the coverage
determinations for your region. *Note: Health Net must follow local coverage
determinations (LCDs) of Medicare Administration Contractors (MACs) located outside their
service area when those MACs have exclusive coverage of an item or service. (CMS Manual Chapter 4 Section 90.2)
If more than one source is checked, you need to access all sources as, on
occasion, an LCD or article contains additional coverage information than
contained in the NCD or National Coverage Manual.
If there is no NCD, National Coverage Manual or region specific LCD/Article,
follow the Health Net Hierarchy of Medical Resources for guidance.
Current Policy Statement (Update August 2013 – A Medline search failed to
reveal any studies that would cause Health Net, Inc. to change its current position)
Health Net, Inc. considers any of the following airway clearance devices medically
necessary durable medical equipment (DME) to assist in mobilizing secretions of the
respiratory tract:
Mechanical Percussors Health Net, Inc. considers mechanical percussors medically necessary for any of the
following when the patient or operator of the powered percussor has received
appropriate training by a physician or therapist:
Cystic fibrosis
Chronic bronchitis
Bronchiectasis
Asthma
Immotile cilia syndrome
FLUTTER Health Net, Inc. considers small hand-held positive expiratory pressure devices, such
as the FLUTTER mucous clearance device and the Acapella device, medically
necessary as an adjunct to airway clearance in patients when other methods have
proven inadequate or ineffective in mobilizing pulmonary secretions, who can
demonstrate effective use of the device and who have any of the following:
Cystic fibrosis
Bronchiectasis and conditions that produce increased sputum or secretions
Alpha-1-antitrypsin deficiency
Positive Expiratory Pressure Health Net, Inc. considers positive expiratory pressure (PEP) masks medically
necessary for any of the following:
Airway Clearance Systems Aug 13 3
Cystic fibrosis
Chronic obstructive pulmonary disease (COPD)
Vest Airway Clearance System Health Net, Inc. considers high-frequency chest compression systems (The Vest
Airway Clearance System, formerly known as the ThAIRapy Bronchial Drainage
System, ABI Vest) medically necessary as an alternative to chest physiotherapy in
patients age 2 years or older or 20-inch chest size, whichever comes first for any of
the following:
Cystic fibrosis in whom home chest physiotherapy (CPT) has been found to
be ineffective to adequately mobilize retained secretions or cannot be
provided; or
Lung transplant recipients within the first six months postoperatively who
are unable to tolerate standard chest physiotherapy; or
Bronchiectasis, characterized by daily productive cough for at least 6
continuous, months or, frequent (i.e. more than 2/year) exacerbations
requiring antibiotic therapy, and confirmed by high resolution, spiral, or
standard CT scan and well-documented failure of standard treatments to
adequately mobilize retained secretions; or
Neuromuscular disease (i.e., Post-polio, Acid maltase deficiency, Anterior
horn cell diseases, Multiple sclerosis, Quadriplegia, Hereditary muscular
dystrophy, myotonic disorders, other myopathies or paralysis of the
diaphragm) for patients with well-documented failure of routine chest
physiotherapy to adequately mobilize retained secretions as evidenced by
recurrent pneumonia
Medical records documentation to support medical necessity must include all of the
following:
Excessive sputum production combined with the member’s inability
to clear the sputum without assistance
A well-documented failure of standard treatments to mobilize
secretions
Frequent exacerbations requiring antibiotic therapy more than two
times per year
Diagnosis confirmed by high resolution or spiral computed
tomography (CT)
Documentation of need for at least daily chest physiotherapy (CPT)
by provider with specialty in pulmonary disease
Significant worsening of pulmonary function*
Specific documentation why this therapy is superior to other most
cost-effective therapy methods, including at least one of the
following:
The patient’s family or other resources cannot adequately perform
the required chest physiotherapy (CPT); or
Allows independent living for university of college attendarnce for
the member; or
Provides health stabilization in single adults or emancipated
individuals without able partners to assist with CPT
Airway Clearance Systems Aug 13 4
* A significant worsening of pulmonary function exists when at least two of the
following are met:
Forced expiratory capacity (FEC) of less than 80% predicted
Forced vital capacity (FVC) of less than 50% predicted
Small airway score (FEP 25-75%) decrease in one year of 25% or more
Pattern of annual or more often hospitalizations from acute pulmonary
exacerbations
Demonstration of reduction of pulmonary function while on steroids for a
year
Note: Rental of a high frequency chest compression system for three months is
required before purchase of the equipment will be considered. Patient compliance
and tolerance will determine medical necessity for purchase of the system.
Note: Intolerance to the device or failure to comply with usage meter checks is a
basis for the use of alternative methods of airway clearance.
Insufflator-Exsufflator Device Health Net, Inc. considers a mechanical insufflator-exsufflator device, such as the
CoughAssist, medically necessary in a small subset of patients with neuromuscular
disease (e.g., amyotrophic lateral sclerosis, high spinal cord injury with quadriplegia)
associated with a significant impairment of chest wall and/or diaphragmatic
movement when there is an inability to adequately clear secretions in the airways
using standard mechanisms (e.g., chest percussion, postural drainage, etc.). There
should be evidence of significantly low forced expiratory flow of less than 80%
predicted and vital capacity not associated with obstructive disease.
Note: It is not medically necessary for a patient to use both an HFCWO device and a
mechanical in-exsufflation device.
Contraindications Contraindications for high-frequency chest compression systems (The Vest Airway
Clearance System, formerly known as the ThAIRapy Bronchial Drainage System, ABI
Vest):
Unstable head injury
Unstable neck injury
Active Hemorrhage with hemodynamic instability
Subcutaneous emphysema
Recent epidural spinal infusion/anesthesia
Recent skin grafts or flaps on the thorax
Osteoporosis
Burns, open wounds and/or skin infections of the thorax
Recently placed transvenous pacemaker or subcutaneous pacemaker
Suspected pulmonary tuberculosis
Lung contusion
Bronchospasm
Complaint of chest wall pain
Osteomyelitis of ribs
History of pneumothorax, hemoptysis, or cardiac arrest in the past 30 days.
Airway Clearance Systems Aug 13 5
Note: Intrapulmonary percussive ventilation (IPV) systems, e.g., Percussionaire
device, and IPPB devices as an alternative to chest physiotherapy are not medically
necessary because there are inadequate scientifically controlled studies in the
medical literature to validate their effectiveness. There is insufficient evidence
supporting their effectiveness in the home setting.
Codes Related To This Policy NOTE:
The codes listed in this policy are for reference purposes only. Listing of a code in
this policy does not imply that the service described by this code is a covered or non-
covered health service. Coverage is determined by the benefit documents and
medical necessity criteria. This list of codes may not be all inclusive.
On October 1, 2014, the ICD-9 code sets used to report medical diagnoses and
inpatient procedures will be replaced by ICD-10 code sets. Health Net National
Medical Policies will now include the preliminary ICD-10 codes in preparation for this
transition. Please note that these may not be the final versions of the codes and
that will not be accepted for billing or payment purposes until the October 1, 2014
implementation date.
ICD-9 Codes 277.02 Cystic fibrosis with pulmonary manifestations
335.20 Amyotrophic lateral sclerosis
340 Multiple sclerosis
359.0 Congenital hereditary muscular dystrophy
359.1 Hereditary progressive muscular dystrophy
359.2 Myotonic disorders
466.11 Acute bronchiolitis due to respiratory syncytial virus (RSV)
466.19 Acute bronchiolitis due to other infectious organisms
487.1 Influenza with other respiratory manifestations
491.0 Simple chronic bronchitis
491.1 Mucopurulent chronic bronchitis
491.20 Obstructive chronic bronchitis, without exacerbation
491.21 Obstructive chronic bronchitis, with (acute) exacerbation
491.8 Other chronic bronchitis
494.0 Bronchiectasis without acute exacerbation
494.1 Bronchiectasis with acute exacerbation
506.0 Bronchitis and pneumonitis due to fumes and vapors
506.4 Chronic respiratory conditions due to fumes and vapors
516.8 Other specified alveolar and parietoalveolar pneumonopathies
518.0 Pulmonary collapse
748.61 Congenital bronchiectasis
996.84 Complications of transplanted lung
V46.0 Dependence on aspirator
V46.1 Dependence on respirator (ventilator)
V46.8 Dependence on other enabling machines
ICD-10 Codes E84.0-
E84.9 Cystic fibrosis
G12.20-
G12.9 Motor neuron disease
Airway Clearance Systems Aug 13 6
G35 Multiple sclerosis
G71.0-
G71.9 Primary disorder of muscles
J1Ø.1 Influenza due to other identified influenza virus with other respiratory
manifestations
J11.1 Influenza due to unidentified influenza virus with other respiratory
manifestations
J21.0-
J12.9 Acute bronchiolitis
J41.0-
J41.8 Simple and mucopurulent chronic bronchitis
J42 Unspecified chronic bronchitis
J47.0-
J47.9 Bronchiectasis
J68.0-
J68.9 Respiratory conditions due to inhalation of chemicals, gases, fumes and
vapors
J84.01-
J84.09 Alveolar and parieto-alveolar conditions
Q33.0-
Q33.9 Congenital malformations of lung
T86.81Ø Lung transplant rejection
T86.811 Lung transplant failure
T86.819 Unspecified complication of lung transplant
Z99.0-
Z99.12 Dependence on respirator
CPT Codes 94667 Manipulation chest wall, e.g., cupping, percussing, and vibration to
facilitate lung function; initial demonstration and /or evaluation
94668 Manipulation chest wall, e.g., cupping, percussing, and vibration to
facilitate lung function; subsequent demonstration.
HCPCS Codes A7025 High frequency chest wall oscillation system vest, replacement for use
with patient owned equipment, each
A7026 High frequency chest wall oscillation system hose, replacement for use
with patient owned equipment, each
E0480 Percussor, electric or pneumatic, home model
E0482 Cough stimulating device, alternating positive and negative airway
pressure
E0483 High frequency chest wall oscillation air-pulse generator system, (includes
hoses and vest), each
E0484 Oscillatory positive expiratory pressure device, non-electric, any type,
each
S8185 Flutter device
Scientific Rational Update – August 2013 At this time, there is insufficient peer reviewed published literature to evaluate the
safety and efficacy of intrapulmonary percussive ventilation. Its effect on health
outcomes or patient management in patients with cystic fibrosis is undefined.
Airway Clearance Systems Aug 13 7
There is a Clinical Trial on ‘Effects of IPV Assessed With Functional Imaging’ which is
currently recruiting participants. The ClinicalTrials.gov Identifier is NCT01671540 and
it was last updated on June 27, 2013. The investigators are trying to find what the
long term effects of an IPV treatment would be evaluated with classical outcome
parameters, (i.e., FEV1, Raw). The authors are also questioning if the possible effect
noticeable on this technique is comparable with the classical outcome parameters?
The estimated primary completion date is December 2013.
Scientific Rationale Update - September 2011 Additional contraindications to high-frequency chest compression systems include a
history of pneumothorax, hemoptysis, or cardiac arrest in the past 30 days. These
were added to the current list of contraindications.
Scientific Rationale Update- April 2009 Bronchiectasis is a syndrome of chronic cough and daily viscid sputum production
associated with airway dilatation and bronchial wall thickening. Multiple conditions
are associated with the development of bronchiectasis, but all require an infectious
insult plus impairment of drainage, airway obstruction, and/or a defect in host
defense. There are numerous etiologies that can induce or contribute to the
pathophysiologic processes that result in bronchiectasis, including primary infection,
bronchial obstruction, foreign body aspiration), cystic fibrosis, Young's syndrome,
primary ciliary dyskinesa, allergic bronchopulmonary aspergillosis (ABPA ),
immunodeficiency states, and autoimmune diseases.
The high frequency chest wall compressor (HFCWC), a vest worn over the thorax
that is connected to an air compressor, delivers mechanical percussions at rates and
pressures that can be varied by the patient to target different caliber airways, also
sets to patient comfort. Examples of high frequency chest wall oscillation systems
include the Vest airway clearance system (Advanced Respiratory) and Medpulse
SmartVest (ElectroMed Co). There is no published comparison study available that
has demonstrated superiority of one device over another.
A Cochrane review reported by Morrison and Agnew (2009) found no clear evidence
that oscillation was a more or less effective intervention overall than other forms of
physiotherapy. They recommended that more adequately-powered long-term
randomised controlled trials are needed. The authors identified two hundred and
sixty-five studies; thirty studies (total of 708 participants) that compared oscillating
devices with any other form of physiotherapy in people with Cystic Fibrosis (CF).
Single treatment interventions (therapy technique used only once in the comparison)
were excluded. Studies varied in duration from up to one week to one year in
duration. Nineteen of the studies were cross-over in design. Data were not published
in sufficient detail in most of these studies to perform meta-analysis. Forced
expiratory volume in one second (FEV (1) was the most frequently measured
outcome. Results did not show significant difference in effect between oscillating
devices and other methods of airway clearance on FEV (1) or other lung function
parameters. Where there has been a small but significant change in secondary
outcome variables such as sputum volume or weight this has not been wholly in
favour of oscillating devices. Participant satisfaction was reported in eleven studies,
but this was not specifically in favor of an oscillating device as some participants
preferred breathing techniques or techniques used prior to the study interventions.
The results for the remaining outcome measures were not examined or reported in
sufficient detail to provide any high level evidence.
Airway Clearance Systems Aug 13 8
Lange et al (2006) reported the results of a randomized controlled trial of HFCWC in
a group of 46 patients with ineffective airway clearance due to ALS. Patients who
received HFCWC therapy in addition to usual care reported less breathlessness,
compared with usual care alone. These patients also experienced increased nighttime
coughing, which the authors suggested may have been due to increased mobilization
of secretions.
Although the evidence regarding the efficacy of HFCWC vest therapy in patients with
non–CF-related disorders of clearance is very limited, when conventional PDT and
other devices have failed or are contraindicated, high-frequency chest wall
compression may be indicated.
Scientific Rationale Initial Respiratory health depends on consistent clearance of airway secretions. Normal
airway clearance is accomplished by two important mechanisms: the mucociliary
clearance (MCC) system and the ability to cough. Impaired MCC is linked to poor
lung function in a broad range of diseases and disabilities. When mucus secretion
and mucus clearance are not in balance, excessive, often sticky, airway mucus may
accumulate in the airways and cause serious problems. At-risk individuals are prone
to recurrent episodes of respiratory inflammation, infection and, eventually,
irreversible lung damage, and even death. Improvement of MCC is a vital treatment
goal - one that can be accomplished with an individualized plan of chest
physiotherapy. The aims are to reduce airway obstruction by improving the clearance
of secretions, to reduce the severity of the infection by clearing infected material and
to maintain optimal respiratory function and exercise tolerance.
There are individuals whose MCC and cough are not in balance due to their specific
disease or condition, such as: cystic fibrosis (CF), chronic obstructive pulmonary
disease (COPD), primary ciliary dyskinesia (PCD). These are often identified as
impaired airway clearance conditions. These individuals require external assistance
for their airway clearance needs through some sort of airway clearance therapy to
avoid retention of mucus in their lungs. Without effective airway clearance, such
patients risk gaining stagnate mucus in their lungs creating a site prone to infection.
Repeated infections typically lead to frequent hospitalizations and progressive
pulmonary deterioration, which can result in death. Passive interventions include
nebulized bronchodilating medication, postural drainage combined with chest
percussion and/or vibration, and diaphragmatic (or "quad") coughing maneuvers.
Active interventions consist of autogenic drainage or breathing and coughing
techniques such as forced expiratory technique ("huff" coughing), active cycle
breathing (deep breathing or breath stacking), and pursed lip breathing (creates
positive expiratory pressure). Usually, several of these mechanisms are utilized in an
effective pulmonary toilet program.
Pulmonary complications are major causes of morbidity and mortality for patients
with compromised airway clearance mechanisms. This is particularly true in patients
with cystic fibrosis (CF), an autosomal recessive disease characterized by a chronic
progressive course with acute exacerbations. Neuromuscular diseases (NMDs) are
characterized by progressive atrophy and weakness of skeletal muscle, skeletal-
spinal deformities, limb contractures, and restrictive lung disease leading to poor
respiratory function. Among inherited NMDs, the most prevalent include muscular
dystrophies (Duchenne, Becker, facioscapulohumeral, limb girdle), the myotonias,
and the spinal muscular atrophies. Acquired NMDs include amyotrophic lateral
Airway Clearance Systems Aug 13 9
sclerosis, multiple sclerosis, Guillain Barré Syndrome, and poliomyelitis. The principal
cause of the morbidity and mortality associated with these diseases is the production
of excessively thick and tenacious tracheobronchial mucus, which leads to airway
obstruction and secondary infection. CF patients require routine maintenance chest
physiotherapy to clear their airways (i.e., manual percussion and postural drainage)
every day to assist in the removal of mucous secretions from the lung. These
treatments may be administered one to three times a day for 20 to 30 minutes per
session by a physical therapist or another trained adult in the home, typically a
parent if the patient is a child. Conditions such as high spinal cord injuries, neuro-
muscular deficits, or severe fatigue associated with intrinsic lung disease can
diminish the effectiveness of a cough, or eliminate the ability to cough altogether.
Other conditions such as bronchiectasis and pneumonia can affect the ability of the
lungs to manage secretions and influence the viscosity and amount of sputum
produced.
Several devices have been developed as an adjunct or alternative to one or more of
the mechanisms described above when the individual is unable to clear pulmonary
secretions effectively. The Vest Airway Clearance System (formerly known as the ABI
Vest or the ThAIRapy Bronchial Drainage System) and the Percussionaire device are
oscillatory devices designed to provide self-administered airway clearance. The Vest
provides high-frequency chest compression using an inflatable vest and an air-pulse
generator. Large-bore tubing connects the vest to the air-pulse generator. The air
pulse generator creates pressure pulses that cause the vest to inflate and deflate
against the thorax, creating high-frequency chest wall oscillation and mobilization of
secretions. There are no studies with final health outcomes that demonstrate that
the ThAIRapy Vest System is equivalent or superior to other techniques designed to
improve pulmonary clearance in patients with cystic fibrosis. However, in some
situations, other methods of therapy, such as chest PT by a family member, are not
available.
The published literature includes a number of small, randomized studies that
compared different mucus clearance techniques, typically in crossover studies that
do not include final health outcomes regarding long-term stabilization or
improvement of lung function or a decrease in pulmonary exacerbations resulting in
hospitalization. Pulmonary function and weight of expectorated sputum are typically
analyzed immediately after treatment. The reliability and validity of sputum weight
as a proxy for health outcome is still unresolved. The sparse data that are available
do not suggest that any one alternative, including the various oscillatory devices,
autogenic drainage, or positive expiratory pressure, is superior to another.
Kluft and colleagues (1996) at Children’s Hospital, Washington, DC, looked at 29 CF
patients and compared traditional chest physiotherapy (CPT) with the Vest system.
Each patient received two days of each form of therapy over a four-day period.
Expectorated secretions were collected during and after treatment. The results
indicated significantly more pulmonary secretions were expectorated during
treatment with the Vest system as compared with CPT. Mechanical percussors are
typically electrical devices used in lieu of a caretaker's hands for chest percussion
and/or vibration. This method of CPT creates an internal percussion effect on the
lungs as they are held in a state of partial inspiration.
The FLUTTER mucous clearance device and Acapella device are small handheld
devices that provide positive expiratory pressure (PEP.) Exhaling through the device
creates oscillations, or "flutter" in pressures in the airway resulting in loosening of
Airway Clearance Systems Aug 13 10
mucous. Other PEP devices are used with a small volume nebulizer, and function in
conjunction with medication delivery. Mechanical Insufflator-Exsufflator
(CoughAssist) is a portable electric device which utilizes a blower and a valve to
alternately apply a positive and then a negative pressure to a patient's airway in
order to assist the patient in clearing retained bronchopulmonary secretions. Air is
delivered to and from the patient via a breathing circuit incorporating a flexible tube,
a bacterial filter and either a facemask, a mouthpiece, or an adapter to a
tracheostomy or endotracheal tube.
The published data suggest that mechanical insufflation-exsufflation (MI-E) can
improve the intermediate outcome of peak cough expiratory flow. Data regarding its
role in the clinical management of the patient consist of case series. In some studies,
patients have served as their own control, with a decreased incidence of hospitaliza-
tion among patients who switch from tracheostomy to a noninvasive approach, which
may include MI-E as one component. While controlled trials would ideally further
delineate who is most likely to benefit from MI-E, particularly those who would
benefit from having a device in the home, such trials are logistically difficult. The
heterogeneous nature of the patients, even among those with similar diseases,
almost mandates a case by case approach for these patients. For example, the
clinical utility of MI-E would not only depend on the physiologic parameters of lung
function, but also on the tempo of the disease course, the availability of home
caregivers, and patient preference and motivation. The non-investigational status for
the MI-E device is based on these considerations.
Intrapulmonary percussive ventilation (IPV) is an aerosol machine that delivers high
frequency, low-volume, positive-pressure jets of air to the airways by a pneumatic
flow interrupter at a rate of 100-300 cycles/minute via a mouthpiece. The patient is
able to control variables such as inspiratory time, peak pressure, and delivery rates.
Aerosolized medications can be delivered under pressure and with oscillations that
vibrate the chest. The patient controls variables such as inspiratory time, peak
pressure and delivery rates. The clinical data regarding the Percussionaire device are
sparse. Two small short-term studies have found IPV as effective as standard aerosol
and chest physiotherapy in preserving lung function and no advantage of IPV over
that achieved with good pulmonary care in the hospital environment. There are no
studies in the home setting. Intermittent positive pressure breathing (IPPB) devices
use pressure to passively fill the lungs when a breath is initiated. An incorporated
manometer and mechanical valves serve to terminate the flow of inspired air when a
predetermined pressure is reached on inhalation. IPPB breathing circuits are
designed to nebulize inhaled medication. Most IPPB devices are powered by
compressed air and are not suitable for home use.
Review History March 22, 2005 Medical Advisory Council Initial Approval
April 26, 2005 Medical Advisory Council Final Approval
February 2007 Update – No revisions
October 2008 Removed statement regarding endorsement of vest system by
AARC from scientific rationale
April 2009 Added High frequency chest wall oscillation devices (vest airway
clearance system) as medically necessary for bronchiectasis
and neuromuscular disease when specific criteria is met.
April 2011 Update – no revisions
Airway Clearance Systems Aug 13 11
September 2011 Update. Added Revised Medicare Table with link to LCD. Added
history of pneumothorax, hemoptysis, or cardiac arrest in the
past 30 days under contraindications.
August 2012 Update – no revisions
August 2013 Update – no revisions. Codes updated.
Patient Education Websites English
1. National Institutes of Health (NIH), National Heart Lung and Blood Institute.
Facts about cystic fibrosis. Information for Patients and the Public. NIH Pub. No.
95-3650. Bethesda, MD: NIH; November 1995.
2. Cystic Fibrosis Trust. Physiotherapy. Living with CF. London, UK: Cystic Fibrosis
Trust; 2004.
3. Cystic Fibrosis Trust. Physiotherapy for cystic fibrosis. Treatment Information.
London, UK: Cystic Fibrosis Trust; 1998.
4. International Cystic Fibrosis Support Group. Physiotherapy in cystic fibrosis.
Physiotherapy. New London, CT: International Cystic Fibrosis Support Group;
2003.
5. Medical College of Wisconsin. The facts about cystic fibrosis. Medical College of
Wisconsin Healthlink. Milwaukee, WI: Medical College of Wisconsin; April 4, 2003.
6. Merck & Co., Inc. Cystic fibrosis. In: Merck Manual of Medical Information --
Home Edition. 2nd Home ed. MH Beers, ed. Ch. 43, Section 4, Lung and airway
disorders. Whitehouse Station, NJ: Merck; 2003.
7. American Association of Respiratory Care (AARC). Suctioning of the patient in the
home. AARC Clinical Practice Guideline. Respir Care. 1999:44(1):99-104.
Accessed at: http://www.rcjournal.com/cpgs/sotpithcpg.html
8. AARC Clinical Practice Guideline. Postural Drainage Therapy. Respir Care
1991;36:1418-1426. Accessed at:
http://www.rcjournal.com/cpgs/pdtcpg.html
Spanish
1. MedlinePlus. Fibrosis Quística. Acceso en:
http://www.nlm.nih.gov/medlineplus/cysticfibrosis.html
2. Federación Española Contra La Fibrosis Quística. Acceso en:
http://www.fibrosis.org/fibrosis/marcfq.htm
3. March of Dimes. Fibrosis Quística. Acceso en:
http://www.nacersano.org/centro/9259_9971.asp
This policy is based on the following evidence-based guidelines: 1. No authors listed. AARC (American Association for Respiratory Care) clinical
practice guidelines. Postural drainage therapy. Respir Care. 1991;36(12):1418-
1426.
2. No authors listed. AARC (American Association for Respiratory Care) clinical
practice guidelines. Directed cough. Respir Care. 1993;38(5):495-499.
3. No authors listed. AARC (American Association for Respiratory Care) clinical
practice guidelines. Suctioning of the Patient in the Home. Respir Care
1999;44(1):99-104.
4. The Veterans Health Administration Clinical Practice Guideline for the
Management of Persons with Chronic Obstructive Pulmonary Disease (COPD) or
Asthma.
5. Hayes Medical Technology Directory. High-Frequency Chest Wall Compression
for Cystic Fibrosis. May 3, 2012. Updated May 20, 2013.
Airway Clearance Systems Aug 13 12
6. Hayes Medical Technology Directory. High-Frequency Chest Wall Compression
for Diseases Other than Cystic Fibrosis. June 2004. Updated Sept 2008.
Updated September 2, 2011. Updated September 20, 2012.
7. Hayes. Search & Summary. Intrapulmonary Percussive Ventilation (IPV) for
Treatment of Cystic Fibrosis in Children and Adolescents. May 20, 2013.
References – Update August 2013 1. Clinicaltrials.gov. Effects of IPV Assessed With Functional Imaging.
ClinicalTrials.gov Identifier:NCT01671540. June 2013. Available at:
http://clinicaltrials.gov/ct2/show/NCT01671540?term=NCT01671540&rank=1
2. Clinkscale D, Spihlman K, Watts P, et al. A randomized trial of conventional
chest physical therapy versus high frequency chest wall compressions in
intubated and non-intubated adults. Respir Care. 2012 Feb;57(2):221-8. 3. Cochrane Database Syst Rev. 2012 Dec 12;12:CD007862. doi:
10.1002/14651858.CD007862.pub3.Active cycle of breathing technique for
cystic fibrosis.
4. McIlwaine MP, Alarie N, Davidson GF, et al. Long-term multicentre randomised
controlled study of high frequency chest wall oscillation versus positive
expiratory pressure mask in cystic fibrosis. Thorax. 2013 Feb 13. doi:
10.1136/thoraxjnl-2012-202915. [Epub ahead of print]. References – Update August 2012 1. Atkeson AD, RoyChoudhury A, Harrington-Moroney G, et al. Patient-ventilator
asynchrony with nocturnal noninvasive ventilation in ALS. Neurology 2011;
77:549.
2. Janssens JP, Borel JC, Pépin JL, et al. Nocturnal monitoring of home non-
invasive ventilation: the contribution of simple tools such as pulse oximetry,
capnography, built-in ventilator software and autonomic markers of sleep
fragmentation. Thorax 2011; 66:438.
3. Hill NS, Kramer NR. Practical aspects of nocturnal noninvasive ventilation in
neuromuscular and chest wall disease. UpToDate. February 23, 2012.
4. Hill NS, Kramer NR. Types of noninvasive nocturnal ventilatory support in
neuromuscular and chest wall disease. UpToDate. May 14, 2012.
5. Tsolaki V, Pastaka C, Kostikas K, et al. Noninvasive ventilation in chronic
respiratory failure: effects on quality of life. Respiration 2011; 81:402.
References – Update September 2011 1. Crescimanno G, Marrone O. High frequency chest wall oscillation plus mechanical
in-exsufflation in Duchenne muscular dystrophy with respiratory complications
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