Airway Clearance (Flutter)

This leaflet gives patients advice on how to optimally use a Flutter device to clear secretions from their chest. It should be used as a guide in conjunction with advice from a respiratory physiotherapist who may make modifications based on your individual needs. It should also be read in conjunction with the manufacturer’s supporting information.

Benefits

Some people with chronic lung conditions find they have sputum (mucus) that can be difficult to clear. The Flutter aids airway clearance.

If you use your Flutter regularly it may:

• reduce your need to cough throughout the day
• reduce any feelings of breathlessness
• help reduce the number of infections, especially those requiring hospitalisation
• reduce any further damage to your lungs

Coughing

Although coughing is the most common way of clearing secretions, it is also quite hard work and can lead to fragile airways becoming irritated and even collapsing. Where possible, try to limit the amount of coughing you do. It is much better to move secretions up through your lungs by using your Flutter.

How does the Flutter work?

The Flutter provides slight resistance as you breathe out through it. This creates some back pressure in your airways which helps them to stay fully open, rather than collapsing. This means it is particularly useful for people with fragile, floppy airways. A ball and cone mechanism within the device causes the air travelling from your lungs to vibrate which helps loosen secretions from the airway walls. This can help make airway clearance easier and more effective.

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How do I use my Flutter?

Positioning when using the Flutter:

The angle at which you hold this device is critical. The Flutter should be used with the stem in a horizontal position. This causes the cone to be placed at a slight tilt and allows the ball to bounce and roll within the device which causes the vibrations you feel as you breathe out.

You can then tilt the device up or down until you get the desired fluttering from the device.

1. Get into a comfortable position, with your shoulders and arms relaxed. The Flutter can be used whilst sitting, lying down or in a particular position advised by a respiratory physiotherapist but ensure that the Flutter is well positioned.
2. Breathe in slowly through your nose, at a comfortable speed.
3. Breathe out through your mouth, at a comfortable speed, without the Flutter.
4. Avoid letting your shoulders rise up.
5. You should feel your tummy softly moving in and out with your breathing.
6. Maintain this relaxed breathing for one to two minutes, or as guided by your respiratory physiotherapist.
7. Place the Flutter mouthpiece in your mouth and ensure you have a tight seal around it with your lips.
8. Breathe in slowly through your nose and slightly deeper than normal.
9. Pause for two to five seconds to allow your lungs to fill properly.
10. Breathe out through the Flutter at a steady rate so that you feel the vibrations in your chest.
11. Breathe out to a comfortable level.
12. Try to ensure your cheeks stay still as you breathe out; they should not vibrate.
13. Repeat these breaths in and out through the Flutter five to ten times as advised by your respiratory physiotherapist.
14. Try to suppress your cough during these breaths.
15. Repeat the relaxed breathing for another one to two minutes.
16. If you can feel sputum ready to be cleared, try one or two huffs or cough (described below).
17. Repeat the above steps for 20 to 30 minutes.

Huffing

Huffing is designed to move the secretions from the smaller airways upwards to where it is easier to cough and clear. This technique requires practice and should be checked by a respiratory physiotherapist to ensure you are being as effective as possible.

It may not be necessary to huff after every set of breaths through the Flutter. However, you should try to do one or two towards the end of each session to ensure any secretions are cleared.

1. Take a slow breath in through your nose, a little deeper than normal, but not all the way in.
2. Open your mouth to an ‘O’ shape and huff the air out, as if trying to steam up a mirror.
3. You should feel your tummy muscles working to push out the air.
4. The secretions should move upwards so you can cough them up or perform a short, sharp huff to move them into your mouth.
5. Avoid huffing too hard as excessive force may make you wheezy.
6. If done correctly, as you breathe out you should hear crackles which may be quite subtle and quiet if there are not many secretions, or louder and more coarse if there are a lot of secretions.
7. Limit the number of huffs to one or two to reduce the chance of becoming wheezy or starting a coughing fit.

Putting it all together

Airway clearance is most effective when used in combination with your inhalers or nebulisers. It is advisable to use your bronchodilator (also known as a reliever which is usually blue in colour, for example Salbutamol, Ventolin, about 10 to 15 minutes before you try to clear your secretions. This will help open your airways, allowing air and secretions to move more easily and prevent you from feeling wheezy.

If you have a nebulised antibiotic, use this after your airway clearance. This will ensure the nebulised antibiotic can get into the smallest airways and be more effective. Find a time and place where you can comfortably complete the full session and make airway clearance part of your daily routine. How long and how many times? Your respiratory physiotherapist will advise you on how many sessions you should do a day. This will depend upon the amount of sputum you usually produce. Each session usually takes 20 to 30 minutes. During an exacerbation (a worsening of your symptoms) you may find it beneficial to increase the number of times you clear your airways through the day. This may be because you have more secretions, they may be thicker so more difficult to clear, or you may be getting more breathless and not able to tolerate your usual airway clearance in one session.

Keeping your Flutter clean

It is important to keep your Flutter clean to avoid bacteria growing on it, which may cause more infections. The manufacturer’s supporting information should include specific recommendations on how to do this, so keep it safe for future use.

It is important to wash your Flutter daily in warm soapy water, rinse and allow to air dry. You should also sterilise your Flutter once a week by either:

• boiling in distilled, deionised or de-mineralised water for five minutes, or
• placing in a steam steriliser, following the manufacturer’s guidance (not in the microwave due to metallic parts).