21, 95% CI 0.05 to 0.85), reduced the duration of ventilatory assistance (MD –2.0 days, 95% CI –1.5 to –2.6) and reduced overall hospital length of stay (MD –0.75 days, 95% CI –0.1 to –1.4).43 These results were heavily influenced by trials using positive pressure techniques, which generally had more favourable outcomes than those that did not use positive pressure. In addition to the Cochrane review,44 there are two large trials of airway clearance techniques for AECOPD that have implications Crizotinib concentration for practice. A randomised controlled equivalence trial in 526 people hospitalised

with an AECOPD found no difference in quality of life at 6 months between those who received manual chest physiotherapy (active cycle of breathing technique including FET, percussion and vibration) and those who received only advice about positioning and active cycle of breathing technique.44 There was no difference in hospital length of stay between groups. The trial had broad inclusion criteria and participants did not have to be productive of sputum to take part. The

results of this study provide confidence that manual chest physiotherapy techniques do not have a routine role for people with AECOPD. Another randomised trial comparing positive expiratory pressure therapy (PEP) and FET to usual physiotherapy care in 90 people hospitalised with AECOPD found no difference between groups in the primary outcome – the Breathlessness,

Cough and Sputum Scale – at any time point during the 6-month followup.45 Although dyspnoea improved more rapidly in the PEP group in the first 8 Erlotinib solubility dmso weeks, by 6 months there were no clinically relevant or statistically significant differences between groups. When this trial is combined with previous airway clearance technique studies in a meta-analysis, the body of evidence no longer suggests an overall benefit of the techniques during AECOPD in the need for ventilatory assistance (Figure 2; for a more detailed forest plot, see Figure 3 on the eAddenda).45, 46, 47, 48 and 49 The differing results between this trial and previous studies may be related to the population studied, which included fewer people who needed ventilatory assistance, or to the more active comparison group, where usual physiotherapy care included early mobilisation.49 In summary, current evidence those for the effects of airway clearance techniques in AECOPD is inconsistent across trials, but does not suggest an overall benefit of airway clearance techniques for hospitalised patients. Whilst positive outcomes have been reported in the sickest patients (ie, those requiring or at risk of requiring invasive or non-invasive ventilatory assistance) in the most recent Cochrane review,43 these effects are small and are not supported by the results of a recent large trial.49 There is no evidence that manual chest physiotherapy techniques are useful in AECOPD.