Impact of hypertonic saline nebulisation combined with oscillatory positive expiratory pressure on sputum expectoration and related symptoms in cystic fibrosis: a randomised crossover trial

Objective:To evaluate the impact of combining nebulised hyaluronic acid plus hypertonic saline (HA+HS) with oscillatory positive expiratory pressure (oscillatory-PEP) on sputum expectoration and related symptoms in adults with cystic fibrosis (CF). Design: Randomised crossover trial.SettingSeven centres. Participants Twenty-two outpatients with CF.Interventions. Usual care (HA+HS followed by autogenic drainage)and combined therapy (HA+HS with oscillatory-PEP followed by autogenic drainage]. Each treatment was performed for 5days.Main outcome measures: Sputum expectoration was measured during the nebulisation period (primary outcome), during autogenic drainage and for 24 hours post-intervention. The Cough and Sputum Assessment Questionnaire (CASA-Q)and its domains(cough symptoms, cough impact, sputum symptoms and sputum impact), the Leicester Cough Questionnaire (LCQ) and lung function tests were used. Tolerance and patient preference were registered. Results: Twenty-two participants [mean age 25(standard deviation8)years, percentage predicted forced expiratory volume in 1 second 67(22)]were recruited. Combined therapy promoted greater sputum expectoration than usual care during the nebulisation period {median difference 1.8 ml[95%confidence interval (CI)0.2to 6.2]}. Both treatments led to similar expectoration during autogenic drainage and for 24 hours post-intervention. Combined therapy led to a greater improvement in the sputum symptoms domain [6.7points(95%CI 3.3 to 13.3]and total CASA-Q score [2.4points (95%CI 0.1to 9.3)]compared with usual care. No differences in LCQ score or lung function were observed.Fewer adverse events were reported using combined therapy, which was selected as the preferred intervention. Conclusions: Combined nebulisation increased immediate sputum expectoration, improved sputum symptoms and reduced adverse events compared with usual care in patients with CF.