Manual airway clearance techniques in adults and adolescents: What level of evidence?

Background. - The aim of this systematic literature review was to grade the levels of evidence of the most widely used manual airway clearance techniques. Methods. - A literature search was conducted over the period 1995-2014 from the Medline, PEDro, ScienceDirect, Cochrane Library, REEDOC and kinedoc databases, with the following keywords: 'postural drainage', 'manual vibrations', 'manual chest percussion', 'directed cough', 'increased expiratory flow', 'ELTGOL', 'autogenic drainage' and 'active cycle of breathing technique'. Results. - Two-hundred and fifty-six articles were identified. After removing duplicates and reading the titles and abstracts, 63 articles were selected, including 9 systematic reviews. This work highlights the lack of useful scientific data and the difficulty of determining levels of evidence for manual airway clearance techniques. Techniques were assessed principally with patients with sputum production (cystic fibrosis, DDB, COPD, etc.). It also shows the limited pertinence of outcome measures to quantify congestion and hence the efficacy of airway clearance techniques. Conclusion. - The 1994 consensus conference summary table classifying airway clearance techniques according to physical mechanism provides an interesting tool for assessment, grouping together techniques having identical mechanisms of action. From the findings of the present systematic review, it appears that only ELTGOL, autogenic drainage and ACBT present levels of evidence 'B'. All other techniques have lower levels of evidence. Level of evidence. - II.