4 Discussion
In this population, patients with CF or their caregivers were familiar with several forms of airway clearance and reported ~1 hour of daily time commitment to these therapies. Those receiving CFTR modulators reported decreasing their airway clearance, and some respondents reported performing little (< 30 minutes per day) airway clearance.
While respondents were familiar with many forms of airway clearance, their past 30-day usage indicated preference for exercise, followed by vest, huff coughing and PEP devices. Male and female patients used each of the airway clearance forms roughly equally, but there were trends towards greater vest usage in females and exercise in males, which is consistent with observations in prior studies.24,25Although we hypothesized there would be difference in airway clearance practices by age group, children, adolescents, and adults reported similar use of airway clearance methods and overall time commitment. The lack of significant differences between age categories in time spent on airway clearance could be related to the relatively small sample size in this study. The most important contributor to time spent on airway clearance in our cohort was the use of a vest device.
Whether exercise is an acceptable substitute for traditional airway clearance remains controversial.6,26-28 Exercise is common in patients with CF, and many patients either incorporate exercise into their airway clearance or use exercise as a replacement for traditional airway clearance.26 Exercise may improve ease of expectoration and sputum clearance and may have similar effects to traditional airway clearance in the short term.29 Some advocate the use of exercise as airway clearance in part because exercise is more easily accepted by society, which helps to normalize the lives of patients with CF.28 However, others contend that traditional airway clearance techniques are still the superior method for mucus clearance.27
Despite the inherent challenges of exercise and airway clearance, many respondents considered these therapies important for maintaining their health. However, it remains unclear which forms of airway clearance are optimal for patients with CF. Many studies suggest no method of airway clearance is superior to others.29-31 Even within a class of airway clearance treatments, there is significant variability. For instance, there is no clear evidence that one type of oscillating PEP device is superior to another.30 Patients with CF or their caregivers may wish to use airway clearance techniques that best meet their individual needs, after considering comfort, convenience, flexibility, practicality, and cost.31
4.2 Advantages
An advantage of this study is that our survey compares airway clearance methods from the patient perspective. This could provide better understanding of why some methods are preferred by patients. Knowing how patients think or feel about airway clearance methods could help clinicians understand potential barriers to using airway clearance, including pain or discomfort, time commitment, and perceived lack of efficacy. This study also compares the importance of airway clearance relative to medications and other CF therapies from the perspective of the patient. This information may help the CF research community plan future studies aimed at simplifying CF care plans.
4.3 Limitations
Because this study was voluntary, there is some risk of selection or responder bias. The study was anonymous and used self-reported time commitment. Thus, we could not confirm the time spent on airway clearance by an independent objective measure. Finally, this was a single-center study, which potentially limits generalizability to other centers or to populations with lower eligibility for CFTR modulator treatments. However, the distributions of age, gender, CFTR theratypes, and pulmonary function among survey responses were similar to our recent reports.32,33 Thus, the results of this survey are likely to be representative for our center.
4.4 Implications
Patients with CF are familiar with several methods of airway clearance. In this study, people with CF or their caregivers consider CFTR modulators more important than airway clearance, and respondents receiving these drugs report decreased time spent for airway clearance. Additionally, our survey indicates people with CF and their caregivers prefer some methods of airway clearance over others and may consider exercise as an adequate replacement for traditional forms of airway clearance. Despite this, people with CF still consider airway clearance important for maintaining health.