Nova Health
NOVA HEALTHHome nursing and physiotherapy

Home chest physiotherapy · Visits across Hong Kong

Phlegm that will not clear?
Assess first, then choose a suitable clearance method

Having phlegm does not always mean that chest percussion is needed. Chest physiotherapy helps most for patients whose cough is too weak to bring up the phlegm by themselves, for example people with neuromuscular disease, a weakened cough reflex after stroke, or long-term bed rest. Our registered physiotherapists visit the home, first assess the patient’s peak cough flow and sputum, and then teach the patient and caregiver how to clear the airway, assist coughing, suction and use a ventilator. We also explain which practices have research support and which are not actually needed.

  • Registered physiotherapists in Hong Kong
  • Home visits across Hong Kong
  • 1 hour $1,000 · 1.5 hours $1,300
  • Peak cough flow and sputum assessed first
WhatsApp for a free enquiry and home assessment

Understanding the problem again

Common misunderstandings about chest physiotherapy

The research evidence on chest physiotherapy is, overall, of low certainty. Its main use is to help patients with a weak cough clear sputum in the short term. It is not a treatment for pneumonia, and it is not routine practice in chronic obstructive pulmonary disease (COPD). Knowing which patients really need it and which do not avoids wasted effort.

Patients often think
  • Phlegm means chest percussion is neededThe belief that everyone with phlegm needs chest physiotherapy
  • Chest percussion can cure pneumoniaTreating chest percussion as a way to treat pneumonia
  • COPD needs chest percussion every dayThe belief that people with chronic obstructive pulmonary disease must always do airway clearance
  • A cough assist machine is always better than coughing unaidedThe belief that using a machine to help cough is always more effective
What the evidence shows
  • It helps patients in particular situationsIt suits patients with a weak cough or with sputum building up.
  • No proof for pneumoniaThe Chen review found the certainty of evidence that chest percussion improves mortality or cure in pneumonia to be very low.
  • Not recommended as routine in COPDThe American Association for Respiratory Care (AARC) guideline does not recommend routine airway clearance for people with COPD.
  • There is not yet enough evidence to concludeMorrow’s review found insufficient evidence that the cough assist machine (MI-E) is better than other methods, so each case needs assessment.

These conclusions come mainly from Cochrane reviews and clinical guidelines. Chest physiotherapy techniques are safe in themselves and can help clear sputum in the short term. For improving quality of life and lung function, and for lowering mortality, hospital admissions or infection rates, the research evidence is of low quality or insufficient. This does not mean the techniques are useless. They need to be used for suitable patients. The details are always decided by the assessment of the respiratory doctor and the physiotherapist.

Approaches matched to the patient’s situation

Main points of chest physiotherapy

Our four service steps cover the key parts of respiratory physiotherapy: assessing first whether the patient is suitable, teaching the patient and caregiver to do it themselves, using a cough assist device when needed, and carrying it out safely at home.

01

Assessment first, because not everyone needs chest percussion

Chest physiotherapy suits patients whose cough is too weak and who have sputum building up, for example people with neuromuscular disease, a weakened cough reflex after stroke, or long-term bed rest. At the home visit we first assess the strength of the cough (peak cough flow) and the sputum, to decide which method is really needed, because not everyone with phlegm needs chest percussion.

AARC guidelineStrickland 2013 · peak cough flow PCF < 270 L/min should prompt cough assist techniques
02

Teaching the patient and caregiver to do it themselves

Clearing the airway is more than patting the back. The British Thoracic Society (BTS) guideline recommends that every patient with long-term sputum be guided by a respiratory physiotherapist, with the active cycle of breathing technique (ACBT) or oscillating positive expiratory pressure (PEP) as the first choice. We teach the patient and caregiver at home how to do it, so that they can manage on their own from day to day.

BTS guidelineHill 2018 · every person with bronchiectasis should be taught airway clearance (ACBT or oscillating PEP)
03

Using cough assist techniques to improve sputum clearance

For patients with neuromuscular disease who cannot cough sputum out with enough force, a mechanical insufflator-exsufflator (cough assist machine, MI-E) can help clear the sputum. Small studies show that the device can raise and sustain peak cough flow, but the overall research evidence is still limited, and the therapist assesses each case before deciding whether to use it.

Pilot studyJung 2018 · peak cough flow rose and was sustained for at least 45 minutes after MI-E (small neuromuscular disease study)
04

At home, with less risk of infection from hospital trips

For patients who are bedbound and cannot cough up sputum, trips to hospital are tiring and add to the risk of infection. We visit to provide chest percussion, suctioning, cough assist machine use and guidance on using the ventilator, and teach the caregiver the correct methods, so that the patient can clear sputum safely at home.

Caregiver trainingAARC / BTS · home airway clearance and caregiver training are practical options for selected patients

Why come to the home

Home conditions for sputum clearance

For patients who are bedbound and have a weak cough, trips to hospital are tiring and add to the risk of infection. Chest percussion, suctioning, cough assist machine use and ventilator support can all be carried out safely at home. The key is that the caregiver learns how to do them, and home physiotherapy can teach and follow up at the patient’s home.

Sputum clearance map of the home TRIGGER MAP

Bedside · pillowPostural drainage stationWhere there is no contraindication, body positioning uses gravity, together with percussion or vibration, to help loosen sputum deep in the lungs. The physiotherapist demonstrates safe positioning angles on the spot and explains the situations in which it should not be done.
Dining chair · sittingSelf-clearance stationThe patient and caregiver are taught the active cycle of breathing technique (ACBT) or an oscillating positive expiratory pressure (PEP) device, so that they can keep clearing sputum themselves in daily life.
Cough assist machine · suction machineEquipment stationIf the patient’s peak cough flow is low (PCF<270), we assess whether a cough assist machine (MI-E) is suitable. If the patient cannot cough sputum out, we demonstrate how to suction safely, including how to monitor oxygen saturation, limit the suction time and take infection control measures.
Ventilator · tracheostomyBreathing support stationFor patients who use a non-invasive ventilator (NIV) at home or have a tracheostomy, we teach the caregiver how to work with the equipment to help the patient clear sputum, and what warning signs to watch for.
Teaching the caregiver to take part:The physiotherapist teaches family members step by step how to do chest percussion, suctioning and use of the cough assist machine, and which danger signs to watch for, such as sputum building up, falling oxygen saturation and breathing that is getting harder. Correct posture while working and the ability to observe the patient are what keep the patient safe.

Clinical evidence

The literature on chest physiotherapy

Key figures from the literature EVIDENCE

< 270 L/minWhen peak cough flow is below this value, clinical guidelines recommend cough assist techniquesAARC guideline on non-pharmacological airway clearance (Strickland et al., 2013)
14 / 20People with bronchiectasis preferred the Acapella device, which cleared a similar amount of sputum to the active cycle of breathing technique (ACBT)ACBT vs Acapella randomised crossover trial (Patterson et al., 2005)
≥ 45 minA small pilot study showed that peak cough flow rose and was sustained after using a cough assist machine (MI-E)MI-E pilot study in neuromuscular disease (Jung et al., 2018)

The research evidence on respiratory physiotherapy is, overall, of low certainty. The techniques are safe and can help clear sputum in the short term, but there is no evidence that they treat pneumonia, lower mortality or reduce hospital admissions. We therefore explain the existing evidence, assess first which patients can really benefit, and follow the instructions of the respiratory medical team.

Is a family member full of phlegm and unable to cough it out, and you are not sure whether chest percussion or a cough assist machine is needed? You can contact us to describe the situation, and a physiotherapist will answer your questions.

WhatsApp for a free enquiry and home assessment

From the basics onward

Chest physiotherapy guide

To learn more about chest percussion techniques, peak cough flow and cough assist machines, suctioning and ventilator use at home, how to clear sputum in bronchiectasis, or who needs chest physiotherapy, you can read the related topics below.

Related physiotherapy topics 03

Pulmonary rehabilitation for COPDExercise training and breathlessness management in chronic obstructive pulmonary diseasePhysiotherapy for long-term bed restComplications of long-term bed rest and how to prevent hypostatic pneumoniaPhysiotherapy after surgeryLung complications after surgery and getting out of bed early

FAQ · Chest physiotherapy

Chest physiotherapy: common questions

NOVA HEALTH・FAQ01 – 05
Does chest percussion really work? Is it suitable for everyone with phlegm?

Chest percussion and airway clearance techniques are generally safe and can help clear more sputum in the short term (Lee et al., 2015, Cochrane). The quality of the evidence is generally low, however, and there is no evidence that they lower mortality or raise cure rates in simple pneumonia (Chen et al., 2022, Cochrane, very low certainty evidence). Airway clearance techniques are also not recommended as routine in COPD (AARC, Strickland et al., 2013). Chest percussion therefore suits patients with a lot of sputum, a weak cough or an inability to clear sputum themselves (for example neuromuscular disease, a weakened cough reflex after stroke, or long-term bed rest), and not everyone needs it.

How do I tell whether a family member needs a cough assist machine?

A commonly used clinical indicator is peak cough flow (PCF). When PCF is below 270 L/min, international guidelines recommend cough assist techniques (including the mechanical insufflator-exsufflator, MI-E) to help clear sputum and reduce retained secretions, especially for people with neuromuscular disease (AARC, Strickland et al., 2013). A physiotherapist can assess PCF and guide correct use.

Is a cough assist machine (MI-E) really better than coughing unaided?

Studies show that MI-E may raise peak cough flow, and in a small pilot study of people with neuromuscular disease the effect lasted at least 45 minutes (Jung et al., 2018). The existing evidence is still limited, however. A Cochrane review found “insufficient evidence for or against” the use of MI-E, and could not show that MI-E is always better than other cough-assist methods (Morrow et al., 2013). The decision should be made case by case after professional assessment, and not applied to everyone.

Which sputum clearance method should be used for bronchiectasis or long-term phlegm?

The British Thoracic Society (BTS) guideline recommends that every person with bronchiectasis be taught airway clearance by a respiratory physiotherapist, with the active cycle of breathing technique (ACBT) or oscillating positive expiratory pressure (oscillating PEP) as the first choice, combined with gravity-assisted positioning (postural drainage) where there is no contraindication (Hill et al., 2018). Direct comparisons show that the different methods clear sputum about equally well (Lee et al., 2017, Cochrane), so the most important thing is to choose a method that the patient is willing to keep doing over the long term.

Is suctioning dangerous? Is it safe to do at home?

Suctioning can effectively remove secretions that the patient cannot cough up, but safety matters: monitor oxygen saturation, be gentle to avoid damage to the mucosa, follow strict infection control and keep each suction to no more than 10 to 15 seconds. For intubated patients or patients on a ventilator, physiotherapy techniques (such as manual hyperinflation) can help clear sputum in the short term, but there is no evidence for hard outcomes such as mortality, so they are supportive in nature. A home-visiting physiotherapist trains the caregiver to operate the suction machine and ventilator correctly.

If phlegm cannot be coughed up, you can message us at any time to ask.

WhatsApp for a free enquiry and home assessment

1 hour $1,000 · 1.5 hours $1,300 · no minimum charge · All service fees

Disclaimer: This article is general health information and is not professional medical advice. If you have any health concerns, please consult a qualified healthcare professional.

References

  1. Strickland, S. L., Rubin, B. K., Drescher, G. S., Haas, C. F., O'Malley, C. A., Volsko, T. A., Branson, R. D., & Hess, D. R. (2013). AARC clinical practice guideline: effectiveness of nonpharmacologic airway clearance therapies in hospitalized patients. Respiratory Care, 58(12), 2187–2193. https://doi.org/10.4187/respcare.02925
  2. Hill, A. T., Sullivan, A. L., Chalmers, J. D., De Soyza, A., Elborn, J. S., Floto, R. A., et al. (2018). British Thoracic Society guideline for bronchiectasis in adults. BMJ Open Respiratory Research, 5(1), e000348. https://doi.org/10.1136/bmjresp-2018-000348
  3. Chatwin, M., Toussaint, M., Gonçalves, M. R., Sheers, N., Mellies, U., Gonzales-Bermejo, J., et al. (2018). Airway clearance techniques in neuromuscular disorders: a state of the art review. Respiratory Medicine, 136, 98–110. https://doi.org/10.1016/j.rmed.2018.01.012
  4. Morrow, B., Zampoli, M., van Aswegen, H., & Argent, A. (2013). Mechanical insufflation-exsufflation for people with neuromuscular disorders. Cochrane Database of Systematic Reviews, (12), CD010044. https://doi.org/10.1002/14651858.CD010044.pub2
  5. Lee, A. L., Burge, A. T., & Holland, A. E. (2015). Airway clearance techniques for bronchiectasis. Cochrane Database of Systematic Reviews, (11), CD008351. https://doi.org/10.1002/14651858.CD008351.pub3
  6. Lee, A. L., Burge, A. T., & Holland, A. E. (2017). Positive expiratory pressure therapy versus other airway clearance techniques for bronchiectasis. Cochrane Database of Systematic Reviews, (9), CD011699. https://doi.org/10.1002/14651858.CD011699.pub2
  7. Patterson, J. E., Bradley, J. M., Hewitt, O., Bradbury, I., & Elborn, J. S. (2005). Airway clearance in bronchiectasis: a randomized crossover trial of active cycle of breathing techniques versus Acapella. Respiration, 72(3), 239–242. https://doi.org/10.1159/000085363
  8. Jung, J. H., Oh, H. J., Lee, J. W., Suh, M. R., Park, J., Choi, W. A., & Kang, S. W. (2018). Improvement of peak cough flow after the application of a mechanical in-exsufflator in patients with neuromuscular disease and pneumonia: a pilot study. Annals of Rehabilitation Medicine, 42(6), 833–837. https://doi.org/10.5535/arm.2018.42.6.833
  9. Zisi, D., Chryssanthopoulos, C., Nanas, S., & Philippou, A. (2022). The effectiveness of the active cycle of breathing technique in patients with chronic respiratory diseases: a systematic review. Heart & Lung, 53, 89–98. https://doi.org/10.1016/j.hrtlng.2022.02.006
  10. Chen, X., Jiang, J., Wang, R., Fu, H., Lu, J., & Yang, M. (2022). Chest physiotherapy for pneumonia in adults. Cochrane Database of Systematic Reviews, (9), CD006338. https://doi.org/10.1002/14651858.CD006338.pub4
  11. McKim, D. A., Road, J., Avendano, M., Abdool, S., Côté, F., Duguid, N., et al. (2011). Home mechanical ventilation: a Canadian Thoracic Society clinical practice guideline. Canadian Respiratory Journal, 18(4), 197–215. https://doi.org/10.1155/2011/139769
  12. Bott, J., Blumenthal, S., Buxton, M., Ellum, S., Falconer, C., Garrod, R., et al. (2009). Guidelines for the physiotherapy management of the adult, medical, spontaneously breathing patient. Thorax, 64(Suppl 1), i1–i51. https://doi.org/10.1136/thx.2008.110726