Description:
Oscillatory devices are alternatives to the standard daily percussion and postural drainage method of airway clearance for patients with cystic fibrosis. There are several types of devices, including high-frequency chest compression with an inflatable vest and oscillating positive expiratory pressure devices, such as the Flutter and Acapella devices. Respiratory therapies and other providers may also use oscillatory devices are also proposed for other respiratory conditions such as diffuse bronchiectasis, chronic obstructive pulmonary disease and respiratory conditions associated with neuromuscular disorders.

For individuals who have cystic fibrosis who receive oscillatory devices, the evidence includes randomized controlled trials (RCTs) and a systematic review. Relevant outcomes are symptoms, quality of life, hospitalizations and medication use. The RCTs had mixed findings and limitations such as small sample sizes and large dropout rates. A systematic review identified 35 RCTs comparing oscillatory devices with another recognized airway clearance techniques; some were published only as abstracts. The review authors could not pool findings due to heterogeneity in study designs and outcome measures, and they concluded that additional adequately powered RCTs with long-term follow up are needed to make conclusions about oscillatory devices for cystic fibrosis. The evidence is insufficient to determine the effects of the technology on health outcomes.

For individuals who have bronchiectasis who receive oscillatory devices, the evidence includes RCTs and a systematic review. Relevant outcomes are symptoms, quality of life, hospitalizations and medication use. A 2015 systematic review identified 7 small RCTs on several types of oscillatory devices; only 1 RCT reported the clinically important outcomes of exacerbations or hospitalizations. Only 3 RCTs reported on quality of life, and findings were mixed. The evidence is insufficient to determine the effects of the technology on health outcomes.

Clinical input obtained in 2008 was supportive of the use of oscillatory devices to treat patients with cystic fibrosis and bronchiectasis, in certain situations. The most commonly mentioned clinical criteria were patients who failed or were intolerant of other methods of mucus clearance and patients who lacked caregivers to provide chest physical therapy. Thus, these devices may be considered medically necessary when chest physical therapy has failed or is unavailable, or is not tolerated by the patient.

For individuals who have COPD who receive oscillatory devices, the evidence includes RCTs and systematic reviews. Relevant outcomes are symptoms, quality of life, hospitalizations and medication use. Only a few controlled studies have evaluated oscillatory devices for the treatment of COPD, and they tend to have small sample sizes, short follow-up periods and limitations in their analyses (e.g., lack of intention to treat analysis and between-group comparisons). Moreover, the published studies have mixed findings and do not clearly support the use of oscillatory devices in COPD patients. The evidence is insufficient to determine the effects of the technology on health outcomes.

For individuals who have respiratory conditions related to neuromuscular disorders who receive oscillatory devices, the evidence includes 2 RCTs and a systematic review. Relevant outcomes are symptoms, quality of life, hospitalizations and medication use. One of the RCTs was not powered to detect statistical significance. The other RCT, conducted in patients with amyotrophic lateral sclerosis, did not find significant improvement after high-frequency chest wall compression devices versus usual care in primary outcomes, in pulmonary function measures or in most secondary outcomes. The evidence is insufficient to determine the effects of the technology on health outcomes.

Background 
Oscillatory devices are designed to move mucus and clear airways; the oscillatory component can be intra- or extrathoracic. Some devices require the active participation of patients. They include oscillating positive expiratory pressure devices, such as Flutter and Acapella, in which the patient exhales multiple times through a device. The Flutter device is a small pipe-shaped, easily portable handheld device, with a mouthpiece at one end. It contains a high-density stainless steel ball that rests in a plastic circular cone. During exhalation, the steel ball moves up and down, creating oscillations in expiratory pressure and airflow. When the oscillation frequency approximates the resonance frequency of the pulmonary system, vibration of the airways occurs, resulting in loosening of mucus. The Acapella device is similar in concept but uses a counterweighted plug and magnet to create air flow oscillation.

Other airway clearance techniques also require active patient participation. For example, autogenic drainage and an active cycle breathing technique both involve a combination of breathing exercises performed by the patient. Positive expiratory pressure therapy requires patients to exhale through a resistor to produce positive expiratory pressures during a prolonged period of exhalation. It is hypothesized that the positive pressure supports the small airway such that the expiratory airflow can better mobilize secretions.

High-frequency chest wall oscillation devices (e.g., the Vest Airway Clearance System, ThAIRapy Bronchial Drainage System, SmartVest Airway Clearance System) are passive oscillatory devices designed to provide airway clearance without the active patient participation. The Vest Airway Clearance System 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 inflate and deflate the vest against the thorax, creating high-frequency chest wall oscillation and mobilization of pulmonary secretions.

The Percussionaire device is another type of passive oscillatory device; it delivers intrapulmonary percussive ventilation. This device combines internal thoracic percussion through rapid minibursts of inhaled air and continuous therapeutic aerosol delivered through a nebulizer.

All of these techniques may be alternatives to daily percussion and postural drainage in patients with cystic fibrosis, also known as check physical therapy. Daily percussion and postural drainage need to be administered by a physical therapist or another trained adult in the home, often a parent if the patient is a child. The necessity for regular therapy can be particularly burdensome for adolescents or adults who lead independent lifestyles. Oscillatory devices can also potentially be used by patients with other respiratory disorders to promote bronchial secretion drainage and clearance, such as diffuse bronchiectasis and chronic obstructive pulmonary disease. Additionally, they could benefit patients with neuromuscular disease who have impaired cough clearance.

This evidence review addresses the outpatient use of oscillatory devices. We do not address inpatient device use (e.g., in the immediate postsurgical period) here.

Regulatory Status 
Several oscillatory devices have been cleared for marketing by the U.S. Food and Drug Administration through the 510(k) process, including those listed in Table 1.

Table 1. Select Oscillatory Devices Cleared by the Food and Drug Administration

Device	Manufacturer	Clearance Date
Flutter® Mucus Clearance Device	Axcan Scandipharm (for marketing in the United States)	1994
Vest™ Airway Clearance System	Hill-Rom	1998
Acapella® device	DHD Healthcare	1999
RC Cornet™ Mucus Clearing Device	PARI Respiratory Equipment	1999
inCourage® System	RespirTech	2005
AerobiKA oscillating PEP device	Trudell Medical	2013
Vibralung Acoustical Percussor	Westmed	2014
The vest airway clearance system	Hill-Rom	2015
The Monarch™ Airway Clearance System	Hill-Rom	2017

PEP: positive expiratory pressure.

Food and Drug Administration product codes: BYI, BYT.

Policy:
Use of an oscillatory PEP device may be considered MEDICALLY NECESSARY in patients with hypersecretory lung disease (i.e., produce excessive mucus) who have difficulty clearing the secretions and recurrent disease exacerbations.

High-frequency chest wall compression devices and IPV devices may be considered MEDICALLY NECESSARY in patients with cystic fibrosis, chronic diffuse bronchiectasis or neuromotor disorders (i.e., cerebral palsy, multiple sclerosis, traumatic head and spinal cord injuries) (other neuromuscular diseases will require individual review)  as determined by specific criteria (see Policy Guidelines sections) [including chest computed tomography (CT) scan] when standard chest physical therapy has failed OR standard chest physical therapy is unavailable or not tolerated. In considering the chest wall compression and IPV devices, there should be demonstrated need for airway clearance. There should also be documented failure of standard treatments; i.e., the patient has frequent severe exacerbations of respiratory distress involving inability to clear mucus despite standard treatment (chest physical therapy and, if appropriate, use of an oscillatory PEP device) or valid reasons why standard treatment cannot be performed, such as inability of the caregiver to perform it.

High-frequency chest wall compression devices and intrapulmonary percussive ventilation devices are considered NOT MEDICALLY NECESSARY as an alternative to chest physical therapy in patients with cystic fibrosis or chronic bronchiectasis in any other clinical situations. There are no clinical data to show that these devices provide any additional health benefit compared with conventional chest physical therapy in situations other than those specified here.

Other applications of high-frequency chest wall compression devices and intrapulmonary percussive ventilation devices, including, but not limited to, their use as an adjunct to chest physical therapy or their use in other lung diseases, such as chronic obstructive pulmonary disease or respiratory conditions associated with neuromuscular disorders, are investigational and/or unproven and therefore considered NOT MEDICALLY NECESSARY.

Policy Guidelines:
For this policy, chronic diffuse bronchiectasis is defined by daily productive cough for at least six continuous months or more than two times per year exacerbations requiring antibiotic therapy and confirmed by high-resolution or spiral chest computed tomography scan.

For the chest wall compression devices, a trial period to determine patient and family compliance may be considered. Those who appear to benefit most from the compression devices are adolescents and adults, due to lifestyle factors in which manual P/PD may essentially not be available.

A trial period may also be helpful because patients’ responses to the various types of devices can be variable. The types of devices should be considered as alternative, and not equivalent, devices.

Benefit Application
BlueCard/National Account Issues
Oscillatory devices such as the Flutter^® device, the Vest^™ Airway Clearance System and Percussionaire IPV^® device have been primarily investigated as an alternative (not adjunct) to conventional chest physical therapy. Since the published clinical data do not suggest that these devices are associated with an increased health benefit, their use primarily represents a convenience to the patient, and it is on this basis that they are considered not medically necessary (unless conventional chest physical therapy has failed or is unavailable).

Rationale  
This evidence review was created in November 1997 and has been updated regularly with searches of the PubMed database. The most recent literature update was performed through April 19, 2021.

Evidence reviews assess the clinical evidence to determine whether the use of a technology improves the net health outcome. Broadly defined, health outcomes are length of life, quality of life, and ability to function-including benefits and harms. Every clinical condition has specific outcomes that are important to patients and to managing the course of that condition. Validated outcome measures are necessary to ascertain whether a condition improves or worsens; and whether the magnitude of that change is clinically significant. The net health outcome is a balance of benefits and harms.

To assess whether the evidence is sufficient to draw conclusions about the net health outcome of a technology, 2 domains are examined: the relevance and the quality and credibility. To be relevant, studies must represent 1 or more intended clinical use of the technology in the intended population and compare an effective and appropriate alternative at a comparable intensity. For some conditions, the alternative will be supportive care or surveillance. The quality and credibility of the evidence depend on study design and conduct, minimizing bias and confounding that can generate incorrect findings. The randomized controlled trial (RCT) is preferred to assess efficacy; however, in some circumstances, nonrandomized studies may be adequate. Randomized controlled trials are rarely large enough or long enough to capture less common adverse events and long-term effects. Other types of studies can be used for these purposes and to assess generalizability to broader clinical populations and settings of clinical practice.

Cystic Fibrosis
Clinical Context and Therapy Purpose
The purpose of oscillatory positive expiratory pressure (PEP) therapy in patients who have cystic fibrosis (CF) is to provide a treatment option that is an alternative to or an improvement on existing therapies.

The question addressed in this evidence review is: Does use of oscillatory devices improve health outcomes in patients with CF?

The following PICO was used to select literature to inform this review.

Populations
The relevant population of interest is individuals with CF.

Interventions
The therapy being considered is the application of oscillatory PEP. Oscillatory PEP devices are intended to be used primarily in the home setting by patients themselves.

Comparators
The following therapy is currently being used: standard chest physical therapy.

Outcomes
The general outcomes of interest are reductions in respiratory symptoms due to airway restrictions caused by a mucous buildup in the lungs, quality of life (QOL), hospitalizations, and medication use. Changes in outcomes over a minimum 3-month period should be considered meaningful.

Study Selection Criteria
Methodologically credible studies were selected using the following principles:

• To assess efficacy outcomes, comparative controlled prospective trials were sought, with a preference for RCTs.
• In the absence of such trials, comparative observational studies were sought, with a preference for prospective studies.
• To assess long-term outcomes and adverse effects, single-arm studies that capture longer periods of follow-up and/or larger populations were sought.
• Studies with duplicative or overlapping populations were excluded.

Review of Evidence
Systematic Reviews
A number of RCTs and a Cochrane systematic review of RCTs have evaluated oscillatory devices for treating patients with CF. The Cochrane review addressed a variety of oscillatory devices, was last updated by Morrison and Milroy (2020 ),¹ and is summarized in Table 2. Outcomes included pulmonary function, sputum weight and volume, hospitalization rate, and QOL measures. Meta-analysis was limited due to the variety of devices, outcome measures, and lengths of follow-up used. Reviewers concluded that there was a lack of evidence supporting the superiority of oscillatory devices versus any other form of physical therapy or that 1 device was superior over another, and that there is a need for adequately powered RCTs with long-term follow-up.

Table 2. Characteristics of Systematic Reviews

Study	Dates	Trials	Participants	N (Range)	Design	Duration
Morrison et al. (2014)1	Inception to July 2019	39	Patients with cystic fibrosis	1114 (4 – 166)	RCT and controlled studies	2 d to 2.8 y

Randomized Controlled Trials
Representative recent RCTs follow. Trial characteristics and results are summarized in Tables 3 and 4. Gaps related to relevance, study design, and conduct are summarized in Tables 5 and 6.

Mcllwaine et al. (2013) published an RCT comparing high-frequency chest wall oscillation (HFCWO) with PEP mask therapy.² The primary outcome measure was the number of pulmonary exacerbations requiring an antibiotic. At the end of 1 year, patients in the PEP arm had a statistically significant lower incidence of pulmonary exacerbations requiring antibiotics compared with HFCWO group. The time to first pulmonary exacerbation was 220 days in the PEP group and 115 days in the HFCWO group (p = .02). There were no statistically significant differences in pulmonary measures, including the forced expiratory volume in 1 second (FEV1).

Sontag et al. (2010) published a multicenter RCT that compared postural drainage, the Flutter device, and HFCWO.³ At study termination, patients had a final assessment; the length of participation ranged from 1.3 to 2.8 years. An intention-to-treat analysis found no significant differences between treatment groups in the modeled rate of decline for percent predicted FEV1 or forced vital capacity (FVC). The small sample size and high dropout rate limited the conclusions drawn from this trial.

Pryor et al. (2010) evaluated 75 patients age 16 years and older with CF from a single center in the U.K.⁴ Sixty-five (87%) of 75 patients completed the trial and were included in the analysis. Although the study was described as a noninferiority trial, it was not statistically analyzed as such. Instead, no statistically significant differences among the regimens in the primary outcome measure of FEV1 were construed as evidence for noninferiority.

Radtke et al. (2018) evaluated 15 adult patients with cystic fibrosis using the Flutter with moderate intensity interval cycling exercise to measure pulmonary diffusing capacity.⁵ The outcomes of interest included pulmonary function, sputum viscosity and volume, hospitalization rate and QOL measures. The results yielded no differences in absolute changes in pulmonary diffusion capacity. This study is not represented in the study tables within this review.

Table 3. Summary of Key RCT Characteristics

Study	Countries	Sites	Dates	Participants	Interventions
					Active	Comparator
Mcllwaine et al. (2013)2	Canada	12	2008 – 2012	Children with CF age > 6 y (n = 107)	HFCWO (n = 56)	PEP mask therapy (n = 51)
Sontag et al. (2010)3	U.S.	20	1999 – 2002	Adults and children with CF (n = 166)	2 active Tx: flutter (n = 58) and vest (n = 57)	Postural drainage (n = 58)
Pryor et al. (2010)4	U.K.	1	NR	Patients with CF ≥ 16 y (n = 75)	Cornet (n = 15), Flutter (n = 15), PEP (n = 15), autogenic drainage (n = 15)	Active cycle of breathing technique (n = 15)

CF: cystic fibrosis; HFCWO: high- frequency chest wall oscillation; NR: not reported; PEP: positive expiratory pressure; RCT: randomized controlled trial; Tx: treatment. 

Table 4. Summary of Key RCT Outcomes 

Study	N	No. of PEs Requiring Antibiotics	Spirometry	Quality of Life
Mcllwaine et al. (2013)2	107	88	Cannot confirm	Not applicable
HFCWO			Data not reported	Outcome not evaluated
N		96
Median		2.00
Range		1.00 – 3.00
Positive expiratory pressure			Data not reported	Outcome not evaluated
N		49
Median		1.00
Range		0.00 – 2.00
p		0.007	No difference	Not applicable
Sontag et al. (2010)3
Flutter		Outcome not evaluated	Data not reported	Outcome not evaluated
Vest		Outcome not evaluated	Data not reported	Outcome not evaluated
Postural drainage		Outcome not evaluated	Data not reported	Outcome not evaluated
p			No difference
Pryor et al. (2010)4	65	Not applicable	65	Not applicable
Active cycle of breathing techniques		Outcome not evaluated	FEV1 at 0 mo: 2.01FEV1 at 12 mo: 1.94	Small improvement (0.7)a
Autogenic drainage		Outcome not evaluated	FEV1 at 0 mo: 2.68 FEV1 at 12 mo: 2.64	Small improvement (0.5)a
Cornet		Outcome not evaluated	FEV1 at 0 mo: 1.93FEV1 at 12 mo: 1.90	No difference (< 0.5)a
Flutter		Outcome not evaluated	FEV1 at 0 mo: 2.46FEV1 at 12 mo: 2.43	Moderate improvement (1.3)a
Positive expiratory pressure		Outcome not evaluated	FEV1 at 0 mo: 2.17 FEV1 at 12 mo: 2.02	Small improvement (0.8)a
p		Not applicable	No difference	Not reported

FEV ₁: forced expiratory volume in 1 second; HFCWO: high-frequency chest wall oscillation; PE: pulmonary exacerbations; RCT: randomized controlled trial.
^a Minimal important differences in the Chronic Respiratory Questionnaire. A change of 0.5 represents a small difference in symptoms, 1.0 a moderate difference, and 1.5 a large difference 

Table 5. Study Relevance Limitations

Study	Populationa	Interventionb	Comparatorc	Outcomesd	Follow-Upe
Mcllwaine et al. (2013)2
Sontag et al. (2010)3
Pryor et al. (2010)4

The study limitations stated in this table are those notable in the current review; this is not a comprehensive gaps assessment.
^a Population key: 1. Intended use population unclear; 2. Clinical context is unclear; 3. Study population is unclear; 4. Study population not representative of intended use.
^b Intervention key: 1. Not clearly defined; 2. Version used unclear; 3. Delivery not similar intensity as comparator; 4.Not the intervention of interest.
^c Comparator key: 1. Not clearly defined; 2. Not standard or optimal; 3. Delivery not similar intensity as intervention; 4. Not delivered effectively.
^d Outcomes key: 1. Key health outcomes not addressed; 2. Physiologic measures, not validated surrogates; 3. No CONSORT reporting of harms; 4. Not establish and validated measurements; 5. Clinical significant difference not prespecified; 6. Clinical significant difference not supported.
^e Follow-Up key: 1. Not sufficient duration for benefit; 2. Not sufficient duration for harms.calculated.

Table 6. Study Design and Conduct Limitations

Study	Allocationa	Blindingb	Selective Reportingd	Follow-Upe	Powerd	Statisticalf
Mcllwaine et al. (2013)2	3. Allocation concealment unclear	1.Not blinded to treatment assignment		1. Eighty-eight (82%) of 107 randomized patients completed the trial. Trial limitations were a nearly 20% dropout rate.	4. Trial stopped early without enrolling expected number of patients and might have been underpowered to detect clinically significant differences between groups
Sontag et al. (2010)3	3. Allocation concealment unclear	1.Not blinded to treatment assignment		1. Dropout rates were high; trial ended early: 35 (60%), 16 (31%), and 5 (9%) patients withdrew from the postural drainage, Flutter, and Vest groups, respectively. Most common reasons for withdrawal after 60 days were moved or lost to follow-up (n = 13) and lack of time (n = 7).	4. Trial ended earlier than planned
Pryor et al. (2010)4	3. Allocation concealment unclear	1. Not blinded to treatment assignment		1. Ten of 75 randomized patients were lost to follow-up

The study limitations stated in this table are those notable in the current review; this is not a comprehensive gaps assessment.
FEV1: forced expiratory volume in 1 second.
^a Allocation key: 1. Participants not randomly allocated; 2. Allocation not concealed; 3. Allocation concealment unclear; 4. Inadequate control for selection bias.
^b Blinding key: 1. Not blinded to treatment assignment; 2. Not blinded outcome assessment; 3. Outcome assessed by treating physician.
^c Selective Reporting key: 1. Not registered; 2. Evidence of selective reporting; 3. Evidence of selective publication.
^d Data Completeness key: 1. High loss to follow-up or missing data; 2. Inadequate handling of missing data; 3. High number of crossovers; 4. Inadequate handling of crossovers; 5. Inappropriate exclusions; 6. Not intent to treat analysis (per protocol for noninferiority trials).
^e Power key: 1. Power calculations not reported; 2. Power not calculated for primary outcome; 3. Power not based on clinically important difference 
^f Statistical key: 1. Analysis is not appropriate for outcome type: (a) continuous; (b) binary; (c) time to event; 2. Analysis is not appropriate for multiple observations per patient; 3. Confidence intervals and/or p values not reported; 4.Comparative treatment effects not calculated.

Section Summary: Cystic Fibrosis
A number of RCTs evaluating oscillatory devices have reported mixed findings and limitations (eg, small sample sizes, large dropout rates). A systematic review identified 39 RCTs comparing oscillatory devices with another recognized airway clearance techniques; some were published only as abstracts. The study findings were not pooled due to heterogeneity in designs and outcome measures. The systematic review concluded that results from additional RCTs with adequate power and long-term follow-up would permit conclusions on the effect of oscillatory devices on outcomes for CF.

Bronchiectasis
Clinical Context and Therapy Purpose
The purpose of oscillatory PEP therapy in patients who have bronchiectasis is to provide a treatment option that is an alternative to or an improvement on existing therapies.

The question addressed in this evidence review is: Does use of oscillatory devices improve health outcomes in patients with bronchiectasis?

The following PICO was used to select literature to inform this review.

Populations
The relevant population of interest is individuals with bronchiectasis.

Interventions
The therapy being considered is the application of an oscillatory PEP. Oscillatory PEP devices are intended to be used primarily in the home setting by patients themselves.

Comparators
The following therapy is currently being used: standard chest physical therapy.

Outcomes
The general outcomes of interest are reductions in respiratory symptoms due to airway restrictions (e.g., pulmonary exacerbations), QOL, hospitalizations, and medication use. Changes in outcomes over a minimum 3-month period should be considered meaningful.

Study Selection Criteria
Methodologically credible studies were selected using the following principles:

• To assess efficacy outcomes, comparative controlled prospective trials were sought, with a preference for RCTs.
• In the absence of such trials, comparative observational studies were sought, with a preference for prospective studies.
• To assess long-term outcomes and adverse effects, single-arm studies that capture longer periods of follow-up and/or larger populations were sought.
• Studies with duplicative or overlapping populations were excluded.

Review of Evidence
Systematic Reviews
Lee et al. (2015) published a Cochrane review of airway clearance techniques for treating bronchiectasis, which is summarized in Table 7.⁶ Of 7 RCTs included, 6 were crossover trials. Five trials used a PEP device, 1 used HFCWO, and 1 used postural drainage. Reviewers did not pool study findings due to heterogeneity among studies. Primary outcomes of interest were pulmonary exacerbations, hospitalizations for bronchiectasis, and QOL.

Table 7. Characteristics of Systematic Reviews 

Study	Dates	Trials	Participants	N (Range)	Design	Duration
Lee et al. (2015)6	1966 – 2015	7 RCTs	Adults and children diagnosed with bronchiectasis based on plain-film chest radiography, bronchography, high-resolution computed tomography or physician diagnosis	1107 (8 –37)	1 RCT, 6 crossover RCTs	Immediate (within 24 h) and "long-term" (> 24 h)

RCT: randomized controlled trial.

Randomized Controlled Trials
Representative recent RCTs follow. Trial characteristics and results are summarized in Tables 8 and 9. Gaps related to relevance, study design, and conduct are summarized in Tables 10 and 11.

Murray et al. (2009) reported on a crossover study with 20 patients. The number of exacerbations did not differ statistically at 12 weeks.⁷ Cough-related QOL was significantly better after 12 weeks of any airway clearance technique compared with no airway clearance. Cochrane reviewers noted that the study was not blinded, and that patient-reported QOL measures may have been subject to bias.

Herrero-Cortina et al. (2016) reported on a crossover RCT with 31 patients.⁸ The interventions were temporary PEP, autogenic drainage, and slow expiration with the glottis opened in the lateral position. There were no significant differences among treatments in the mean sputum clearance during the 24-hour period after each intervention, cough severity (measured using the total Leicester Cough Questionnaire score), or in lung function measures (e.g., FEV1).

Table 8. Summary of Key RCT Characteristics

Study	Countries	Sites	Dates	Participants	Interventions
					Active	Comparator
Murray et al. (2009)7	U.K.	1	NR	Patients radiologically diagnosed with bronchiectasis (n = 20)	Acapella Choice (n = 20)	No chest physical therapy (n = 20)
Herrero-Cortina et al. (2016)8	Spain	1	2010 – 2013	Patients radiologically diagnosed with bronchiectasis (n = 31)	Slow expiration with glottis opened in lateral posture (n = 31) and temporary PEP (n = 31)	Autogenic drainage (n = 31)

NR: not reported; PEP: positive expiratory pressure; RCT: randomized controlled trial.  

Table 9. Summary of Key RCT Outcomes

Study	Total LCQ Score Difference	24-h Sputum Volume Difference, mL	No. of Exacerbations
	Median (IQR)	Median (IQR)
Murray et al. (2009)7	20	20	Not applicable
Acapella	1.3 (-0.17 – 3.25)	2 (0 – 6)	5
No Acapella	0 (-1.5 – 0.5)	-1 (-5 to 0)	7
p	.002	.02	.48
Herrero-Cortina et al. (2016)8
Autogenic drainage	0.5 (0.1 to 0.5); .01	-1.4 (5.1 to 1.2)	Not studied
ELTGOL	0.9 (0.5 to 2.1); .001	-1.6 (-4.8 to 1.0)	Not studied
TPEP	0.4 (0.1 to 1.2); .04	-2.5 (-8.6 to 0.1)	Not studied
p	See above	.01	Not applicable

CI: confidence interval; ELTGOL: expiration with glottis opened in lateral posture; IQR: interquartile range; LCQ: Leicester Cough Questionnaire; RCT: randomized controlled trial; TPEP: temporary positive expiratory pressure.  

Table 10. Study Relevance Limitations

Study	Populationa	Interventionb	Comparatorc	Outcomesd	Duration of Follow-Upe
Murray et al. (2009)7
Herrero-Cortina et al. (2016)8					1, 2. Only 24-h follow-up is not enough

The study limitations stated in this table are those notable in the current review; this is not a comprehensive gaps assessment.
^a Population key: 1. Intended use population unclear; 2. Clinical context is unclear; 3. Study population is unclear; 4. Study population not representative of intended use.
^b Intervention key: 1. Not clearly defined; 2. Version used unclear; 3. Delivery not similar intensity as comparator; 4.Not the intervention of interest.
^c Comparator key: 1. Not clearly defined; 2. Not standard or optimal; 3. Delivery not similar intensity as intervention; 4. Not delivered effectively.
^d Outcomes key: 1. Key health outcomes not addressed; 2. Physiologic measures, not validated surrogates; 3. No CONSORT reporting of harms; 4. Not establish and validated measurements; 5. Clinical significant difference not prespecified; 6. Clinical significant difference not supported.
^e Follow-Up key: 1. Not sufficient duration for benefit; 2. Not sufficient duration for harms.

Table 11. Study Design and Conduct Limitations

Study	Allocationa	Blindingb	Selective Reportingd	Data completenesse	Powere	Statisticalf
Murray et al. (2009)7	3. Allocation concealment unclear	1. Not blinded to treatment assignment 2. Not blinded outcome assessment 3. Outcome assessed by treating physician			3. Power not based on clinically important difference
Herrero-Cortina et al. (2016)8		1. Not blinded to treatment assignment 2. Not blinded outcome assessment 3. Outcome assessed by treating physician			1. Power calculations not reported 2. Power not calculated for primary outcome 3. Power not based on clinically important difference

The study limitations stated in this table are those notable in the current review; this is not a comprehensive gaps assessment,
^a Allocation key: 1. Participants not randomly allocated; 2. Allocation not concealed; 3. Allocation concealment unclear; 4. Inadequate control for selection bias.
b Blinding key: 1. Not blinded to treatment assignment; 2. Not blinded outcome assessment; 3. Outcome assessed by treating physician.
^c Selective Reporting key: 1. Not registered; 2. Evidence of selective reporting; 3. Evidence of selective publication.
^d Data Completeness key: 1. High loss to follow-up or missing data; 2. Inadequate handling of missing data; 3. High number of crossovers; 4. Inadequate handling of crossovers; 5. Inappropriate exclusions; 6. Not intent to treat analysis (per protocol for noninferiority trials).
^e Power key: 1. Power calculations not reported; 2. Power not calculated for primary outcome; 3. Power not based on clinically important difference 
^f Statistical key: 1. Analysis is not appropriate for outcome type: (a) continuous; (b) binary; (c) time to event; 2. Analysis is not appropriate for multiple observations per patient; 3. Confidence intervals and/or p values not reported; 4.Comparative treatment effects not calculated.

Section Summary: Bronchiectasis
A 2015 systematic review identified 7 small RCTs assessing several types of oscillatory devices; only 1 reported the clinically important outcomes exacerbations or hospitalizations. Three reported on QOL, and trial findings were mixed. A 2016 crossover RCT did not find a significant benefit of temporary PEP compared with other airway clearance techniques.

Chronic Obstructive Pulmonary Disease
Clinical Context and Therapy Purpose
The purpose of oscillatory PEP therapy in patients who have chronic obstructive pulmonary disease (COPD) is to provide a treatment option that is an alternative to or an improvement on existing therapies.

The question addressed in this evidence review is: Does use of oscillatory devices improve health outcomes in patients with COPD?

The following PICO was used to select literature to inform this review.

Populations
The relevant population of interest is individuals with COPD.

Interventions
The therapy being considered is the application of an oscillatory PEP. Oscillatory PEP devices are intended to be used primarily in the home setting by patients themselves.

Comparators
The following therapy is currently being used: standard therapy.

Outcomes
The general outcomes of interest are reductions in respiratory symptoms due to airway restrictions (e.g., pulmonary exacerbations), QOL, hospitalizations, and medication use. Changes in outcomes over a minimum 3-month period should be considered meaningful.

Study Selection Criteria
Methodologically credible studies were selected using the following principles:

• To assess efficacy outcomes, comparative controlled prospective trials were sought, with a preference for RCTs.
• In the absence of such trials, comparative observational studies were sought, with a preference for prospective studies.
• To assess long-term outcomes and adverse effects, single-arm studies that capture longer periods of follow-up and/or larger populations were sought.
• Studies with duplicative or overlapping populations were excluded.

Review of Evidence
Systematic Reviews
Systematic reviews have evaluated studies of airway clearance techniques in patients with COPD.^9,10,11 Two early reviews addressed various techniques (i.e., they were not limited to studies on oscillatory devices) while the most recent review was specific to oscillatory devices. These are summarized in Table 12. Studies included in the systematic reviews were mostly small. and reviewers noted that quality of evidence was generally poor. The meta-analysis conducted by Alghamdi et al. found oscillatory PEP to reduce exacerbations (odds ratio 0.37, 95% confidence interval [CI] 0.19 – 0.72) and improved 6 minute walk distance (mean difference, 49.8 m, 95% CI 14.2 to 85.5 m), but the authors noted the need for higher-quality studies.¹¹

Table 12. Characteristics of Systematic Reviews  

Study	Dates	Trials	Participants	N (Range)	Design	Duration
Ides et al. (2011)9	1980 – 2008	26	Patients with COPD	659 (7 – 58)	Not reported	Unclear
Osadnik et al. (2012)10	Inception to 2009 (PEDro) or 2011 (CAGR)	28	Participants with investigator-defined COPD, emphysema or chronic bronchitis	907 (5 – 96)	RCTs (parallel and crossover)	24 h to > 8 wk
Alghamdi et al. (2020)11	Inception to March 2020	8	Patients with COPD	381 (15 – 120)	RCT and crossover	5 d to 2 y

CAGR: Cochrane Airways Group Specialised Register of trials; COPD: chronic obstructive pulmonary disease; PEDro: Physiotherapy Evidence Database; RCT: randomized controlled trial.

Randomized Controlled Trials
Representative recent RCTs follow. Trial characteristics and results are summarized in Tables 13 and 14. Gaps related to relevance, study design and conduct are summarized in Tables 15 and 16.

Chakrovorty et al. (2011) reported results of a crossover RCT among patients with moderate-to-severe COPD and mucus hypersecretion.¹² Patients received HFCWO or conventional treatment in random order, for 4 weeks, with a 2-week washout period between treatments. The primary outcome was QOL as measured using the St. George's Respiratory Questionnaire (SGRQ). Only 1 of 4 dimensions of the SGRQ (the symptom dimension) improved after HFCWO compared with baseline, with a decrease in mean score from 72 to 64 (p = .02). None of the 4 SGRQ dimensions improved after conventional treatment. There were no significant pre- to post-treatment differences in secondary outcomes (e.g., FEV1, FVC).

Svenningsen et al. (2016) reported on results of an unblinded, industry-funded, randomized crossover study.¹³ Each intervention period lasted 21 to 28 days. In the nonsputum producers, scores differed significantly only on the Patient Evaluation Questionnaire total score. In patients who were sputum-producers at baseline, pre- versus post-PEP scores differed significantly for FVC, 6-minute walk distance, SGRQ total score, and the Patient Evaluation Questionnaire ease of bringing up sputum and patient global assessment subscales. It is unclear if the interventions were clinically meaningful. The crossover studies had similar limitations including no between-group comparisons (i.e., outcomes after oscillatory device use vs the control intervention), lack of intention-to-treat analysis, and short-term follow-up (immediate posttreatment period).

Goktalay et al. (2013) reported on the results of a parallel-group RCT.¹⁴ Patients were randomized to 5 days of treatment with medical therapy plus HFCWO (n = 25) or medical therapy only (n = 25). At day 5, outcomes including FEV1, modified Medical Research Council dyspnea scale scores, and the 6-minute walk distance, did not differ significantly between groups. This short-term trial included hospitalized patients who might differ from COPD patients treated on an outpatient basis.

Table 13. Summary of Key RCT Characteristics 

Study	Countries	Sites	Dates	Participants	Interventions
					Active	Comparator
Chakrovorty et al. (2011)12	U.K.	1	NR	Patients with at least 1 COPD exacerbation with FEV1 < 0.8, FEV1/FVC < 0.7, and a daily wet sputum volume of > 25 mL (N = 38)	SmartVest Airway Clearance System (n = 22)	No SmartVest Airway Clearance System (n = 22)
Svenningsen et al. (2016)13	Canada	1	NR	COPD patients self-identified as sputum-producers or non-sputum-producers (N = 32)	Oscillatory PEP (AerobiKA device) (n = 27)	No oscillatory PEP (n = 27)
Goktalay et al. (2013)14	Turkey	1	2009 – 2011	Patients with stage 3 or 4 COPD hospitalized for COPD exacerbations (N = 50)	HFCWO plus medical Tx (n = 25)	Medical Tx only (n = 25)

COPD: chronic obstructive pulmonary disease; FEV1: forced expiratory volume in 1 second; FVC: forced vital capacity; HFCWO: high-frequency chest wall oscillation; NR: not reported; PEP: positive expiratory pressure; RCT: randomized controlled trial; Tx: treatment.

Table 14. Summary of Key RCT Results  

Study	SGRO Total Scores	BODE Index
Chakrovorty et al. (2011)12
SmartVest	Baseline: 63; End of treatment: 60	Not assessed
No SmartVest	Baseline: 62; End of treatment:62	Not assessed
p	NS	Not applicable
Svenningsen et al. (2016)13
Oscillatory positive expiratory pressure	Sputum-producers: 40 (12); Non-sputum-producers: 36	Not assessed
Control	Sputum-producers: 49; Non-sputum-producers:35	Not assessed
p	.01 (sputum-producers);.64 (non-sputum-producers)	Not applicable
Goktalay et al. (2013)14
HFCWO plus medical treatment	Not assessed	Day 0: 7.72; Day 3: 7.00; Day 5: 6.44
Medical treatment only	Not assessed	Day 0: 7.72; Day 3: 7.48; Day 5: 7.24
p	Not applicable	Uninterpretable

BODE: body mass index, airflow obstruction, dyspnea, and exercise; HFCWO: high-frequency chest wall oscillation; NS: not significant; RCT: randomized controlled trial; SGRO: St George's Respiratory Questionnaire.

Table 15. Study Relevance Limitations

Study	Populationa	Interventionb	Comparatorc	Outcomesd	Duration of Follow-Upe
Chakrovorty et al. (2011)12
Svenningsen et al. (2016)13
Goktalay et al. (2013)14					1. Not sufficient duration for benefits (short-term follow-up for 5 d)

The study limitations stated in this table are those notable in the current review; this is not a comprehensive gaps assessment.
a Population key: 1. Intended use population unclear; 2. Clinical context is unclear; 3. Study population is unclear; 4. Study population not representative of intended use.
b Intervention key: 1. Not clearly defined; 2. Version used unclear; 3. Delivery not similar intensity as comparator; 4.Not the intervention of interest.
c Comparator key: 1. Not clearly defined; 2. Not standard or optimal; 3. Delivery not similar intensity as intervention; 4. Not delivered effectively.
d Outcomes key: 1. Key health outcomes not addressed; 2. Physiologic measures, not validated surrogates; 3. No CONSORT reporting of harms; 4. Not establish and validated measurements; 5. Clinical significant difference not prespecified; 6. Clinical significant difference not supported.
e Follow-Up key: 1. Not sufficient duration for benefit; 2. Not sufficient duration for harms.

Table 16. Study Design and Conduct Limitations  

Study	Allocationa	Blindingb	Selective Reporting c	Data Completeness d	Power e	Statisticalf
Chakrovorty et al. (2011)12	3. Allocation concealment unclear	1. Not blinded to treatment assignment 2. Not blinded outcome assessment 3. Outcome assessed by treating physician		1. High loss to follow-up or missing data: 8 out of 30 withdrew due to COPD exacerbations	2. Power not calculated for primary outcome
Svenningsen et al. (2016)13	3. Allocation concealment unclear	1. Not blinded to treatment assignment		1. High loss to follow-up or missing data: 16% withdrew from trial	2. Power not calculated for primary outcome
Goktalay et al. (2013)14	1. Participants not randomly allocated 2. Allocation not concealed	1. Not blinded to treatment assignment 2. Not blinded outcome assessment 3. Outcome assessed by treating physician			1. Power calculations not reported 2. Power not calculated for primary outcome 3. Power not based on clinically important difference

The study limitations stated in this table are those notable in the current review; this is not a comprehensive gaps assessment.
COPD: chronic obstructive pulmonary disease.
^a Allocation key: 1. Participants not randomly allocated; 2. Allocation not concealed; 3. Allocation concealment unclear; 4. Inadequate control for selection bias.
b Blinding key: 1. Not blinded to treatment assignment; 2. Not blinded outcome assessment; 3. Outcome assessed by treating physician.
^c Selective Reporting key: 1. Not registered; 2. Evidence of selective reporting; 3. Evidence of selective publication.
^d Data Completeness key: 1. High loss to follow-up or missing data; 2. Inadequate handling of missing data; 3. High number of crossovers; 4. Inadequate handling of crossovers; 5. Inappropriate exclusions; 6. Not intent to treat analysis (per protocol for noninferiority trials).
^e Power key: 1. Power calculations not reported; 2. Power not calculated for primary outcome; 3. Power not based on clinically important difference 
^f Statistical key: 1. Analysis is not appropriate for outcome type: (a) continuous; (b) binary; (c) time to event; 2. Analysis is not appropriate for multiple observations per patient; 3. Confidence intervals and/or p values not reported; 4.Comparative treatment effects not calculated.

Section Summary: Chronic Obstructive Pulmonary Disease
Only a few controlled studies have evaluated oscillatory devices for the treatment of COPD, and they tended to use intention-to-treat analysis and between-group comparisons. The published studies reported mixed findings and did not support the use of oscillatory devices in COPD patients.

Respiratory Conditions Related to Neuromuscular Disorders
Clinical Context and Therapy Purpose
The purpose of oscillatory PEP therapy in patients who have respiratory conditions related to neuromuscular disorders is to provide a treatment option that is an alternative to or an improvement on existing therapies.

The question addressed in this evidence review is: Does use of oscillatory devices improve health outcomes in patients with respiratory conditions related to neuromuscular disorders?

The following PICO was used to select literature to inform this review.

Populations
The relevant population of interest is individuals with respiratory conditions related to neuromuscular disorders.

Interventions
The therapy being considered is the application of an oscillatory PEP. Oscillatory PEP devices are intended to be used primarily in the home setting by patients themselves.

Comparators
The following therapy is currently being used: standard therapy.

Outcomes
The general outcomes of interest are reductions in respiratory symptoms due to airway restrictions (e.g., pulmonary exacerbations), QOL, hospitalizations, and medication use. Changes in outcomes over a minimum 3-month period should be considered meaningful.

Study Selection Criteria
Methodologically credible studies were selected using the following principles:

To assess efficacy outcomes, comparative controlled prospective trials were sought, with a preference for RCTs;

In the absence of such trials, comparative observational studies were sought, with a preference for prospective studies;

To assess long-term outcomes and adverse effects, single-arm studies that capture longer periods of follow-up and/or larger populations were sought;

Studies with duplicative or overlapping populations were excluded

Review of Evidence
Systematic Reviews
A Cochrane review by Winfield et al. (2014) evaluated the nonpharmacologic management of respiratory morbidity in children with severe global developmental delay treated with airway clearance techniques.¹⁵ Reviewers included RCTs and nonrandomized comparative studies. They identified 3 studies on HFCWO (1 RCT, 2 pre-post) and one on PEP (pre-post), with sample sizes from 15 and 28 patients. As a result of heterogeneity, a meta-analysis was not conducted. It is summarized in Table 17.

Table 17. Characteristics of Systematic Reviews

Study	Dates	Trials	Participants	N (Range)	Design	Duration
Winfield et al. (2014)14	Inception to Nov 2013	15	Children up to 18 y with a diagnosis of severe neurologic impairment and respiratory morbidity	Not reported	RCTs and nonrandomized comparative studies	Unclear

RCT: randomized controlled trial.

Randomized Controlled Trials
Representative recent RCTs follow. Trial characteristics and results are summarized in Tables 18 and 19. Gaps related to relevance, study design and conduct are summarized in Tables 20 and 21.

Yuan et al. (2010) reported results of a parallel-arm RCT.¹⁶ Both groups were instructed to perform the assigned treatment for 12 minutes, 3 times a day for the study period (mean, 5 months). There were no statistically significant differences between groups on primary outcomes. No therapy-related adverse events were reported in either group.

Lange et al. (2006) reported on results of a parallel-arm RCT in adults with amyotrophic lateral sclerosis.¹⁷ Patients were randomized to 12 weeks of HCFWO or usual care. There were no statistically significant between-group differences in pulmonary measures (FVC predicted, capnography, oxygen saturation, or peak expiratory flow). There was also no significant difference in the amyotrophic lateral sclerosis Functional Rating Scale respiratory subscale score (worsening) at 12 weeks. Of symptoms assessed as secondary outcomes, there was significantly less breathlessness and night cough in the HCFWO group than in the usual care group, and groups did not differ significantly on other symptoms, including the noise of breathing, suction frequency, suction amount, day cough, and nocturnal symptoms.

Table 18. Summary of Key RCT Characteristics  

Study	Countries	Sites	Dates	Participants	Interventions
					Active	Comparator
Yuan et al. (2010)16	U.S.	1	NR	Patients with cerebral palsy or neuromuscular disease attending a pediatric pulmonary clinic (N = 28)	HCFWO (n = 12)	Standard chest physical therapy (n = 11)
Lange et al. (2006)17	U.S.	6	NR	Adults with amyotrophic lateral sclerosis (N = 46).	HCFWO (n = 22)	No treatment (n = 24)

HFCWO: high-frequency chest wall oscillation; NR: not reported; RCT: randomized controlled trial.  

Table 19. Summary of Key RCT Outcomes   

Study	Populationa	Interventionb	Comparatorc	Outcomesd	Duration of Follow-Upe
Yuan et al. (2010)16
Lange et al. (2006)17

HFCWO: high- frequency chest wall oscillation; IV: intravenous; RCT: randomized controlled trial; TDI:Transitional Dyspnea Index  

Table 20. Study Relevance Limitations

Study	Populationa	Interventionb	Comparatorc	Outcomesd	Duration of Follow-Upe
Yuan et al. (2010)16
Lange et al. (2006)17

The study limitations stated in this table are those notable in the current review; this is not a comprehensive gaps assessment.
^a Population key: 1. Intended use population unclear; 2. Clinical context is unclear; 3. Study population is unclear; 4. Study population not representative of intended use.
^b Intervention key: 1. Not clearly defined; 2. Version used unclear; 3. Delivery not similar intensity as comparator; 4.Not the intervention of interest.
^c Comparator key: 1. Not clearly defined; 2. Not standard or optimal; 3. Delivery not similar intensity as intervention; 4. Not delivered effectively.
^d Outcomes key: 1. Key health outcomes not addressed; 2. Physiologic measures, not validated surrogates; 3. No CONSORT reporting of harms; 4. Not establish and validated measurements; 5. Clinical significant difference not prespecified; 6. Clinical significant difference not supported.
^e Follow-Up key: 1. Not sufficient duration for benefit; 2. Not sufficient duration for harms.

Table 21. Study Design and Conduct Limitations 

Study	Allocationa	Blindingb	Selective Reportingd	Data Completenessd	Powere	Statisticalf
Yuan et al. 2010)16	1. Allocation concealment unclear	1. Not blinded to treatment assignment 2. Not blinded outcome assessment (except chest X-rays) 3. Outcome assessed by treating physician		1. High loss to follow-up or missing data 12% missing data and all in treatment group	1, 2, 3. Trial was exploratory and was not powered to detect statistically significant findings on of the primary outcomes
Lange et al. (2006)17	1. Allocation not concealed	1. Not blinded to treatment assignment 2. Not blinded outcome assessment 3. Outcome assessed by treating physician		1. High loss to follow-up or missing data 15% missing data at 12 wk	2. Power not calculated for primary outcome 3. Power not based on clinically important difference

The study limitations stated in this table are those notable in the current review; this is not a comprehensive gaps assessment.
HFCWO: high-frequency chest wall oscillation.
^a Allocation key: 1. Participants not randomly allocated; 2. Allocation not concealed; 3. Allocation concealment unclear; 4. Inadequate control for selection bias.
^b Blinding key: 1. Not blinded to treatment assignment; 2. Not blinded outcome assessment; 3. Outcome assessed by treating physician.
^c Selective Reporting key: 1. Not registered; 2. Evidence of selective reporting; 3. Evidence of selective publication.
^d Data Completeness key: 1. High loss to follow-up or missing data; 2. Inadequate handling of missing data; 3. High number of crossovers; 4. Inadequate handling of crossovers; 5. Inappropriate exclusions; 6. Not intent to treat analysis (per protocol for noninferiority trials).
^e Power key: 1. Power calculations not reported; 2. Power not calculated for primary outcome; 3. Power not based on clinically important difference 
^f Statistical key: 1. Analysis is not appropriate for outcome type: (a) continuous; (b) binary; (c) time to event; 2. Analysis is not appropriate for multiple observations per patient; 3. Confidence intervals and/or p values not reported; 4.Comparative treatment effects not calculated.

Section Summary: Respiratory Conditions Related to Neuromuscular Disorders
Two RCTs and a systematic review have evaluated oscillatory devices for treatment of respiratory conditions in neuromuscular disorders. One RCT was not powered to detect statistical significance. The other, conducted in amyotrophic lateral sclerosis patients, did not find statistically significant improvement after HCFWO compared with usual care for the primary outcomes (pulmonary function measures) or most secondary outcomes.

Summary of Evidence
For individuals who have cystic fibrosis who receive oscillatory devices, the evidence includes randomized controlled trials (RCTs) and a systematic review. Relevant outcomes are symptoms, QOL , hospitalizations, and medication use. The RCTs reported mixed findings and limitations such as small sample sizes and large dropout rates. A systematic review identified 39 RCTs comparing oscillatory devices with another recognized airway clearance techniques; some were published only as abstracts. Reviewers could not pool findings due to heterogeneity in study designs and outcome measures and concluded that additional adequately powered RCTs with long-term follow-up would be needed to make conclusions about oscillatory devices for cystic fibrosis. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

For individuals who have bronchiectasis who receive oscillatory devices, the evidence includes RCTs and a systematic review. Relevant outcomes are symptoms, QOL , hospitalizations, and medication use. A 2015 systematic review identified 7 small RCTs on several types of oscillatory devices; only 1 reported the clinically important outcomes of exacerbations or hospitalizations. Only 3 RCTs reported on QOL , and findings were mixed. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

For individuals who have COPD who receive oscillatory devices, the evidence includes RCTs and systematic reviews. Relevant outcomes are symptoms, QOL , hospitalizations, and medication use. Only a few controlled studies have evaluated oscillatory devices for the treatment of chronic obstructive pulmonary disease, and they tend to have small sample sizes, short follow-up periods, and limitations in their analyses (eg, lack of intention-to-treat analysis and between-group comparisons). Moreover, the published studies reported mixed findings and did not clearly support the use of oscillatory devices in this population. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

For individuals who have respiratory conditions related to neuromuscular disorders who receive oscillatory devices, the evidence includes 2 RCTs and a systematic review. Relevant outcomes are symptoms, QOL , hospitalizations, and medication use. One of the RCTs was not powered to detect statistically significant differences. The other RCT, conducted in patients with amyotrophic lateral sclerosis, did not find significant improvements after high-frequency chest wall compression devices versus usual care in primary outcomes, in pulmonary function measures, or in most secondary outcomes. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

The purpose of the following information is to provide reference material. Inclusion does not imply endorsement or alignment with the evidence review conclusions.

Clinical Input From Physician Specialty Societies and Academic Medical Centers
While the various physician specialty societies and academic medical centers may collaborate with and make recommendations during this process, through the provision of appropriate reviewers, input received does not represent an endorsement or position statement by the physician specialty societies or academic medical centers, unless otherwise noted.

In response to requests, input was received from 2 academic medical centers while this policy was under review in 2008. Input indicated the available studies demonstrated that these oscillatory devices are comparable with chest physical therapy for cystic fibrosis and bronchiectasis. The most commonly mentioned clinical criteria were patients who failed or were intolerant of other methods of mucus clearance and patients who lacked caregivers to provide chest physical therapy. Input did not support the use of oscillatory devices for treatment of chronic obstructive pulmonary disease.

Practice Guidelines and Position Statements
Guidelines or position statements will be considered for inclusion in ‘Supplemental Information’ if they were issued by, or jointly by, a U.S. professional society, an international society with U.S. representation, or National Institute for Health and Care Excellence (NICE). Priority will be given to guidelines that are informed by a systematic review, include strength of evidence ratings, and include a description of management of conflict of interest.

American College of Chest Physicians
In 2006, the guidelines from the American College of Chest Physicians recommended (level of evidence: low) that, in patients with cystic fibrosis, devices designed to oscillate gas in the airway, either directly or by compressing the chest wall, can be considered as an alternative to chest physical therapy.¹⁸

Cystic Fibrosis Foundation
In 2009, the Cystic Fibrosis Foundation published guidelines on airway clearance therapies based on a systematic review of evidence.¹⁹ The Foundation recommended airway clearance therapies for all patients with cystic fibrosis but stated that no therapy had been demonstrated to be superior to others (level of evidence: fair; net benefit: moderate; grade of recommendation: B).

U.S. Preventive Services Task Force Recommendations
Not applicable

Ongoing and Unpublished Clinical Trials
Some currently ongoing trials that might influence this review are listed in Table 22.

Table 22. Summary of Key Trials 

NCT No.	Trial Name	Planned Enrollment	Completion Date
Ongoing
NCT03013452	Oscillating PEP vs Autogenic Drainage in People With Bronchiectasis (oPEP-vs-AD)	50	Jun 2020
NCT04271969	Clinical Effectiveness Of High Frequency Chest Wall Oscillation (HFCWO) In A Bronchiectasis Population	100	Jun 2022

NCT: national clinical trial; PEP; positive expiratory pressure.

References: 

1. Morrison L, Milroy S. Oscillating devices for airway clearance in people with cystic fibrosis. Cochrane Database Syst Rev. Apr 30 2020; 4: CD006842. PMID 32352564
2. 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. Aug 2013; 68(8): 746-51. PMID 23407019
3. Sontag MK, Quittner AL, Modi AC, et al. Lessons learned from a randomized trial of airway secretion clearance techniques in cystic fibrosis. Pediatr Pulmonol. Mar 2010; 45(3): 291-300. PMID 20146387
4. Pryor JA, Tannenbaum E, Scott SF, et al. Beyond postural drainage and percussion: Airway clearance in people with cystic fibrosis. J Cyst Fibros. May 2010; 9(3): 187-92. PMID 20153269
5. Radtke T, Boni L, Bohnacker P, et al. Acute effects of combined exercise and oscillatory positive expiratory pressure therapy on sputum properties and lung diffusing capacity in cystic fibrosis: a randomized, controlled, crossover trial. BMC Pulm Med. Jun 14 2018; 18(1): 99. PMID 29898704
6. Lee AL, Burge AT, Holland AE. Airway clearance techniques for bronchiectasis. Cochrane Database Syst Rev. Nov 23 2015; (11): CD008351. PMID 26591003
7. Murray MP, Pentland JL, Hill AT. A randomised crossover trial of chest physiotherapy in non-cystic fibrosis bronchiectasis. Eur Respir J. Nov 2009; 34(5): 1086-92. PMID 19541717
8. Herrero-Cortina B, Vilaro J, Marti D, et al. Short-term effects of three slow expiratory airway clearance techniques in patients with bronchiectasis: a randomised crossover trial. Physiotherapy. Dec 2016; 102(4): 357-364. PMID 26712530
9. Ides K, Vissers D, Vissers D, et al. Airway clearance in COPD: need for a breath of fresh air? A systematic review. COPD. Jun 2011; 8(3): 196-205. PMID 21513439
10. Osadnik CR, McDonald CF, Jones AP, et al. Airway clearance techniques for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. Mar 14 2012; (3): CD008328. PMID 22419331
11. Alghamdi SM, Barker RE, Alsulayyim ASS, et al. Use of oscillatory positive expiratory pressure (OPEP) devices to augment sputum clearance in COPD: a systematic review and meta-analysis. Thorax. Oct 2020; 75(10): 855-863. PMID 32788259
12. Chakravorty I, Chahal K, Austin G. A pilot study of the impact of high-frequency chest wall oscillation in chronic obstructive pulmonary disease patients with mucus hypersecretion. Int J Chron Obstruct Pulmon Dis. 2011; 6: 693-9. PMID 22259246
13. Svenningsen S, Paulin GA, Sheikh K, et al. Oscillatory Positive Expiratory Pressure in Chronic Obstructive Pulmonary Disease. COPD. 2016; 13(1): 66-74. PMID 26430763
14. Goktalay T, Akdemir SE, Alpaydin AO, et al. Does high-frequency chest wall oscillation therapy have any impact on the infective exacerbations of chronic obstructive pulmonary disease? A randomized controlled single-blind study. Clin Rehabil. Aug 2013; 27(8): 710-8. PMID 23503735
15. Winfield NR, Barker NJ, Turner ER, et al. Non-pharmaceutical management of respiratory morbidity in children with severe global developmental delay. Cochrane Database Syst Rev. Oct 19 2014; (10): CD010382. PMID 25326792
16. Yuan N, Kane P, Shelton K, et al. Safety, tolerability, and efficacy of high-frequency chest wall oscillation in pediatric patients with cerebral palsy and neuromuscular diseases: an exploratory randomized controlled trial. J Child Neurol. Jul 2010; 25(7): 815-21. PMID 20357238
17. Lange DJ, Lechtzin N, Davey C, et al. High-frequency chest wall oscillation in ALS: an exploratory randomized, controlled trial. Neurology. Sep 26 2006; 67(6): 991-7. PMID 17000967
18. McCool FD, Rosen MJ. Nonpharmacologic airway clearance therapies: ACCP evidence-based clinical practice guidelines. Chest. Jan 2006; 129(1 Suppl): 250S-259S. PMID 16428718
19. Flume PA, Robinson KA, O'Sullivan BP, et al. Cystic fibrosis pulmonary guidelines: airway clearance therapies. Respir Care. Apr 2009; 54(4): 522-37. PMID 19327189

Coding Section

Codes	Number	Description
CPT	No Code
ICD-9 Procedure	93.18	Breathing exercise
ICD-9 Diagnosis	277.00-277.09	Cystic fibrosis code range
	494.0, 494.1	Bronchiectasis without and with acute exacerbations, respectively
HCPCS	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
	E0481	Intrapulmonary percussive ventilation system and related accessories
	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
ICD-10-CM (effective 10/01/15)	E84.0-E84.9	Cystic fibrosis code range
	J47.1-J47.9	Bronchiectasis code range
ICD-10-PCS (effective 10/01/15)		ICD-10-PCS codes are only used for inpatient services. There are no ICD-10-PCS codes for devices and there is no is no specific ICD-10-PCS code for this therapy.
	F07C62ZZ	Physical rehabilitation and diagnostic audiology, rehabilitation, motor treatment, respiratory system-whole body, therapeutic exercise
Type of Service	Pulmonary
Place of Service	Home

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross Blue Shield Association technology assessment program (TEC) and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

"Current Procedural Terminology © American Medical Association. All Rights Reserved" 

History From 2014 Forward     

06/20/2022	Annual review, no change to policy intent. Updating rationale and references
06/01/2021	Annual review, no change to policy intent. Updating rationale and references.
06/02/2020	Annual review, no change to policy intent. Updating rationale and references.
06/10/2019	Annual review, no change to policy intent.
07/03/2018	Annual review, no change to policy intent. Updating rationale and references. Removing Bird IPV from regulatory status.
07/24/2017	Interim review , updating background, description, rationale and references. Adding Afflovest to table 1.
06/08/2017	Annual review, no change to policy intent. Updating Title, background, description, regulatory status, rationale and references.
05/12/2017	Correct review date. No other changes made.
06/01/2016	Annual review, no change to policy intent.
06/29/2015	Interim review, changing annual review date, added the following verbiage to the medically necessary conditions for high-frequency chest wall compression devices; "neuromotor disorders (i.e. cerebral palsy, multiple sclerosis, traumatic head and spinal cord injuries) (other neuromuscular diseases will require individual review) " No other changes made.
03/11/2015	Annual review, no change to policy intent. Updated background, description, regulatory status, rationale and references.
03/10/2014	Annual review.  Updated rationale, references, regulatory status. Added benefit application. Updated policy verbiage without change to policy intent.