Comparison of three methods of sputum clearance in patients with an acute exacerbation of chronic obstructive pulmonary disease (COPD).

INTERVENTION: Treatment arm 1. A variable resistance positive expiratory pressure (PEP) device (TheraPEP 'Registered Trademark'), it has six resistance setting with pressures ranging from 10cmH2O to 20cmH2O. The participant will be instructed to sit upright with elbows resting on a table holding the theraPEP 'Registered Trademark' device in front of them. The participant will be instructed to seal their lips around the mouth piece and exhale with a little force for three seconds only so the blue disc rises and reaches between the lower and upper black line. They will repeat this for 10 breaths, followed by two huffs (Forced expiratory technique (FET) – a demonstration maybe helpful) and a cough. The full set will be repeated two more times to complete each session. There will be a two minute rest between each set. The first treatment session will be supervised and participants will be instructed to complete two further unsupervised sessions, one in the afternoon and another later that night. Participants will complete a diary after each treatment session. Participants will be shown how to and instructed to increase the resistance if they are reaching the top black line too easily as per the usual method of use. Treatment arm 2 ‐ Bubble‐PEP is a threshold resistor PEP system constructed using a plastic bottle, 10cm water and flexible plastic tubing. Bubble‐PEP to be set up with 10cm of water (line marked on the bottle), a length of suction tubing placed down the handle of a two litre new plastic bottle. The bubble‐PEP device will be set up on a table in front of the participant with the participant sitting upright. Participants will be instructed to seal their lips around the tubing and exhale with a little force for three seconds only to create bubbles. Participants will repeat this for 10 breaths, followed by two huffs (FET – a demonstration maybe helpful) and a cough. The full set is to be repeated two more times to complete the treatment session. There will be a two minute rest between each set. Participants will be supervised for their first session and a handout given. Participants will be instructed to complete 2 further unsupervised sessions, one in the afternoon and one later that night. Participants will complete a diary after each treatment session. The water in the bottle will be changed after each treatment session and refilled to the marked line to ensure 10cm of water as per the Counties Manukau District Health Board (CMDHB) bubble–PEP device procedure CONDITION: Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) PRIMARY OUTCOME: Breathlessness, cough and sputum scale (BCSS) SECONDARY OUTCOME: Ease of expectoration on visual analogue scale Health‐related quality of life (HRQoL) ‐ COPD Assessment Test (CAT). Length of hospital stay Lung function specifically forced expiratory volume in 1 second (FEV1) and forced vital capacity (FVC) as measured by bedside spirometry INCLUSION CRITERIA: Diagnosis of mild, moderate or severe COPD (as defined by spirometry) based on the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines 18 years or over. Admitted to Middlemore Hospital medical wards. English speaking and reading Consent to research Exacerbation with reported sputum based on GOLD definition from COPDx Guidelines (An exacerbation is an event in the natural course of the disease characterised by a change in the patient’s baseline dyspnoea, cough, and/or sputum that is beyond normal day‐to‐day variations, is acute in onset, and may warrant a change in regular medication in a patient with underlying COPD)