Heads up! clear those airways!

Morbidity and mortality in cystic fibrosis (CF) relate largely to the extent of pulmonary dysfunction, which in turn results from years of airway infection and inflammation. Early and vigorous treatment probably improves prognosis, although it is not yet clear which aspects of comprehensive care are helpful early on, and which might even be harmful. Keeping the airways clear of thick viscid mucus has long been a cornerstone of therapeutic programs for CF. There is general agreement that airway clearance is important for the patient with copious purulent airway secretions, but less agreement in the asymptomatic patient. The case for early institution of airway clearance procedures includes the finding of white cells and mediators of inflammation in the airways of even asymptomatic infants. The use of gravity to help in airway clearance is an old and logical idea (after all, isn’t it true that—like seat belt use—‘‘[gravity] is not just a good idea; it’s the law! ’’). ‘‘Postural drainage’’ for years was synonymous with airway clearance, and the head-down positionwas integral to most CF centers’ versions of airway clearance. As early as 1977, there was evidence from Toronto that tracheal mucus transport was abnormal when older CF patients were upright, and close to normal with the patient assuming the 258 head-down position. Yet there have been questions about the importance, or even efficacy, of gravity-aided positions. Newer techniques (each with many proponents), such as high-frequency chest wall oscillation (‘‘the vest’’), the Flutter valve, and autogenic drainage, generally are performed with the patient in one position, usually upright. One small study with patients studied left-side down even showed the counterintuitive result of better clearance of radiolabelled particles from the dependent lung. Button et al. from Melbourne have alerted us to the down side of positioning the head and lungs down, lower than the lower esophageal sphincter, at least in young infants with CF during chest physical therapy. It has been known for some time that position is a major factor in gastroesophageal reflux, and that some positions are provocative for reflux. Furthermore, there are suggestions that reflux can worsen lung disease in CF and can cause upper respiratory symptoms. In the current issue of Pediatric Pulmonology, Button et al., page 208, extended their previous work and compared the effects of standard postural drainage chest physical therapy with a modified regimen that omitted the head-down positions over 5 years in 20 infants diagnosed presymptomatically by newborn screening. Patients randomly assigned to modifiedCPT (no head down) had significantly fewer days with upper respiratory tract symptoms and shorter courses of antibiotics in the first year of life than those with standard CPT. They had better chest X-ray scores at 21⁄2 years old, and better pulmonary function at 5 years. The study is not definitive, given the relatively small numbers of patients, especially at follow-up, and the lack of a non-CPT control group. The world probably needs a study comparingmodified (no head-down positions) chest PTwith no chest PT. However, until such a study is done, most of us will probably want to continue to use some chest PT in young infants, for several reasons: 1) the belief that the airway inflammation known to be present in these infants is not innocent; 2) the belief that amounts of mucus too small to cause symptoms may be amenable to clearance with the extra help of daily chest PT; and (perhaps most important) 3) the belief that both parents and infants who are accustomed to the daily regimen of airway clearance will be prepared to institute these techniques with greater frequency in the inevitable event of a pulmonary exacerbation. Until proven otherwise, the results of Button et al. are compelling enough to suggest