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Positive expiratory pressure physiotherapy for airway clearance in people with cystic fibrosis

Overview of attention for article published in Cochrane database of systematic reviews, June 2015
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  • In the top 5% of all research outputs scored by Altmetric
  • High Attention Score compared to outputs of the same age (93rd percentile)
  • Good Attention Score compared to outputs of the same age and source (73rd percentile)

Mentioned by

1 news outlet
15 tweeters
4 Facebook pages
1 Wikipedia page


27 Dimensions

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258 Mendeley
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Positive expiratory pressure physiotherapy for airway clearance in people with cystic fibrosis
Published in
Cochrane database of systematic reviews, June 2015
DOI 10.1002/14651858.cd003147.pub4
Pubmed ID

Maggie McIlwaine, Brenda Button, Kerry Dwan


Chest physiotherapy is widely prescribed to assist the clearance of airway secretions in people with cystic fibrosis. Positive expiratory pressure (PEP) devices provide back pressure to the airways during expiration. This may improve clearance by building up gas behind mucus via collateral ventilation and by temporarily increasing functional residual capacity. Given the widespread use of PEP devices, there is a need to determine the evidence for their effect. This is an update of a previously published review. To determine the effectiveness and acceptability of PEP devices compared to other forms of physiotherapy as a means of improving mucus clearance and other outcomes in people with cystic fibrosis. We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register comprising of references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings. The electronic database CINAHL was also searched from 1982 to 2013.Most recent search of the Group's Cystic Fibrosis Trial Register: 02 December 2014. Randomised controlled studies in which PEP was compared with any other form of physiotherapy in people with cystic fibrosis. This included, postural drainage and percussion, active cycle of breathing techniques, oscillating PEP devices, thoracic oscillating devices, bilevel positive airway pressure (BiPaP) and exercise. Studies also had to include one or more of the following outcomes: change in forced expiratory volume in one second; number of respiratory exacerbations; a direct measure of mucus clearance; weight of expectorated secretions; other pulmonary function parameters; a measure of exercise tolerance; ventilation scans; cost of intervention; and adherence to treatment. Three authors independently applied the inclusion and exclusion criteria to publications and assessed the risk of bias of the included studies. A total of 26 studies (involving 733 participants) were included in the review. Eighteen studies involving 296 participants were cross-over in design. Data were not published in sufficient detail in most of these studies to perform any meta-analysis. These studies compared PEP to active cycle of breathing techniques (ACBT), autogenic drainage (AD), oral oscillating PEP devices, high frequency chest wall oscillation (HFCWO) and Bi level PEP devices (BiPaP) and exercise.Forced expiratory volume in one second was the review's primary outcome and the most frequently reported outcome in the studies. Single interventions or series of treatments that continued for up to three months demonstrated no significant difference in effect between PEP and other methods of airway clearance on this outcome. However, long-term studies had equivocal or conflicting results regarding the effect on this outcome. A second primary outcome was the number of respiratory exacerbations. There was a lower exacerbation rate in participants using PEP compared to other techniques when used with a mask for at least one year. Participant preference was reported in 10 studies; and in all studies with an intervention period of at least one month, this was in favour of PEP. The results for the remaining outcome measures were not examined or reported in sufficient detail to provide any high-level evidence. The only reported adverse event was in a study where infants performing either PEP or postural drainage with percussion experienced some gastro-oesophageal reflux. This was more severe in the postural drainage with percussion group. Many studies had a risk of bias as they did not report how the randomisation sequence was either generated or concealed. Most studies reported the number of dropouts and also reported on all planned outcome measures. Following meta-analyses of the effects of PEP versus other airway clearance techniques on lung function and patient preference, this Cochrane review demonstrated that there was a significant reduction in pulmonary exacerbations in people using PEP compared to those using HFCWO in the study where exacerbation rate was a primary outcome measure. It is important to note, however, that there may be individual preferences with respect to airway clearance techniques and that each patient needs to be considered individually for the selection of their optimal treatment regimen in the short and long term, throughout life, as circumstances including developmental stages, pulmonary symptoms and lung function change over time. This also applies as conditions vary between baseline function and pulmonary exacerbations.However, meta-analysis in this Cochrane review has shown a significant reduction in pulmonary exacerbations in people using PEP in the few studies where exacerbation rate was a primary outcome measure.

Twitter Demographics

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Mendeley readers

The data shown below were compiled from readership statistics for 258 Mendeley readers of this research output. Click here to see the associated Mendeley record.

Geographical breakdown

Country Count As %
Spain 5 2%
United Kingdom 2 <1%
South Africa 1 <1%
Italy 1 <1%
Portugal 1 <1%
United States 1 <1%
Canada 1 <1%
Unknown 246 95%

Demographic breakdown

Readers by professional status Count As %
Student > Bachelor 68 26%
Student > Master 47 18%
Unspecified 29 11%
Researcher 27 10%
Student > Postgraduate 26 10%
Other 61 24%
Readers by discipline Count As %
Medicine and Dentistry 104 40%
Nursing and Health Professions 55 21%
Unspecified 42 16%
Agricultural and Biological Sciences 10 4%
Social Sciences 7 3%
Other 40 16%

Attention Score in Context

This research output has an Altmetric Attention Score of 24. This is our high-level measure of the quality and quantity of online attention that it has received. This Attention Score, as well as the ranking and number of research outputs shown below, was calculated when the research output was last mentioned on 03 May 2018.
All research outputs
of 12,886,920 outputs
Outputs from Cochrane database of systematic reviews
of 10,471 outputs
Outputs of similar age
of 233,207 outputs
Outputs of similar age from Cochrane database of systematic reviews
of 254 outputs
Altmetric has tracked 12,886,920 research outputs across all sources so far. Compared to these this one has done particularly well and is in the 95th percentile: it's in the top 5% of all research outputs ever tracked by Altmetric.
So far Altmetric has tracked 10,471 research outputs from this source. They typically receive a lot more attention than average, with a mean Attention Score of 20.4. This one has done well, scoring higher than 79% of its peers.
Older research outputs will score higher simply because they've had more time to accumulate mentions. To account for age we can compare this Altmetric Attention Score to the 233,207 tracked outputs that were published within six weeks on either side of this one in any source. This one has done particularly well, scoring higher than 93% of its contemporaries.
We're also able to compare this research output to 254 others from the same source and published within six weeks on either side of this one. This one has gotten more attention than average, scoring higher than 73% of its contemporaries.