Cystic fibrosis physiotherapy

Physiotherapy in  CF involves a range of treatments, techniques, and guidance to help with the symptoms and complications of CF. This includes:

• Airway clearance techniques to help loosen and remove the mucus that builds up in the lungs
• Physical activity to help improve lung function, heart health, bone health, muscle strength, blood sugar control, and overall health and wellbeing
• Managing sinus disease
• Helping with inhaled treatments
• Helping with oxygen therapy
• Treating joint, bone, and muscle problems and improving posture
• Techniques and exercises to help with leaking from the bladder.

Your CF physiotherapist will work with you to develop a routine that suits your age, ability, health, and needs. It may also be designed to treat a certain problem.

Airway clearance is important because it helps to stop thick mucus from building up and blocking airways in your lungs.  This helps to stop bacteria that get stuck in the mucus from causing an infection. Infections can lead to swelling, block the smaller airways, and result in more mucus being produced. All of these things can lead to lung damage. Your lungs can’t repair any damage, so it’s better to try and prevent the damage from happening.

There are many different types of airway clearance you can do, also known as airway clearance techniques. These can range from simple breathing exercises to using an airway clearance device (machine or equipment).

Everyone's lungs are different, and the amount of airway clearance needed will vary from person to person. No one technique has been shown to be better than another. This may be because each person's chest can behave very differently. People may also prefer different techniques at different times in their life. 

Your CF physiotherapist will work with you to find the technique, or mix of techniques, that work best for you. It is important that you are happy with the technique you're using, as physiotherapy is done daily. 

Some airway techniques don't need equipment and focus on breathing exercises to clear mucus. These include:

• Active Cycle of Breathing Techniques (ACBT), which is a cycle of deep breathing, huffing, coughing and relaxed breathing to move mucus. You use deep breathing to move the mucus, rest in between deep breaths, and then clear the mucus with a huff. You can combine ACBT with other devices and techniques. Young children can be taught to do ACBT. Find out more in our ACBT leaflet.
• Autogenic Drainage (AD), which uses high flows of air to move mucus from smaller to bigger airways. Once the mucus has moved to the bigger airways, it is easier to clear.  Children can be taught how to do AD. Find out more in our AD leaflet.

Breathing exercises may be combined with postural drainage (PD). This involves placing a person in different positions to use gravity to drain mucus from the lungs. Your CF physiotherapist will tell you which positions to use during your airway clearance. Traditional PD included some positions where a person would lay with their head tipped down below their body, but research has shown that these positions increase reflux of food from the stomach so these positions aren’t used anymore.

Percussions and vibrations are another technique that might be done with breathing exercises and/or PD to help loosen mucus. Percussion or chest clapping involves using a cupped hand to clap the chest rhythmically, which you can do yourself or with a helper. Vibrations involve giving several short rhythmic squeezes to your chest as you breathe out. Your CF physiotherapist will show you how do this safely. To find out more about positioning and percussion for babies and young children, read our leaflet on airway clearance for babies and young children with CF.

Other techniques use a device to help to clear mucus. Some use positive pressure to help open up your airways and some also create vibrations within the airways. This helps to move mucus higher up in your airway, where it easier to huff and cough out. These techniques include:

• Positive Expiratory Pressure (PEP), where you breathe out through a mask or mouthpiece against a resistance to build up pressure behind mucus to move it. There are several different PEP devices. Your CF physiotherapist will check your PEP device regularly, as the resistance setting may need to be changed. Find out more about how to use a PEP mask.
• Bubble PEP is a type of PEP that can be fun for young children as it is more likely playing. It uses exactly the same action as PEP, but instead of a mask or mouthpiece, you blow out through a plastic tube which is put into soapy water. Blowing into the tube to create bubbles makes the pressure. You can read more in our Bubble PEP leaflet.
• Oscillating Positive Expiratory Pressure e.g. Flutter®, Acapella® (see our Acapella choice leaflet), where you breathe out against a resistance to create PEP and also vibrate your airways to move mucus.
• High Frequency Chest Wall Oscillation (HFCWO), which is an electric air pulse generator that connects to an inflatable jacket (vest) to vibrate the chest. Here is a statement by the Association of Chartered Physiotherapists in Cystic Fibrosis regarding the current evidence behind the vest.

Be sure to discuss any new airway clearance technique that you would like to try with your CF physiotherapist. They will discuss whether there is good research for the device and whether there are any positives and/or negatives to consider.

It's also important to know that airway clearance devices are included in the funding that CF centres get and if your CF physiotherapist has recommended that you try a particular device, then this should be provided for you.

Read more about:

Airway clearance for adults and children

Airway clearance for young children and babies

How many times you need airway clearance, how often, and what type will vary from person to person and may even change on a day-to-day basis for some people. You may need to change your physiotherapy routine if you are unwell or feel you have more mucus. Your CF physiotherapist will help you learn how to assess your chest and to decide how much airway clearance to do each session.

It’s vital to start airway clearance as soon as you have signs of a chest infection to help prevent lung damage. Even if you don’t have a chest infection, you may still need to do daily airway clearance to keep your lungs healthy. It will also help you to get into a routine and know you are doing it correctly for when you are ill.

If you aren’t producing much mucus, treatment sessions may only need to last 10–15 minutes, but if  you are producing a lot of mucus it could take 45–60 minutes. Most people do two treatments a day, but the number and length of your sessions may need to increase depending on how much mucus your lungs are producing. If no mucus is present, exercise may play a greater role in your airway clearance techniques.

Your CF physiotherapist will advise you on what is best for you. Use our airway clearance plan to help keep track of your airway clearance routine.

A CF physiotherapist should assess all newly diagnosed people with CF and advise when and how they should start doing airway clearance. This may not be immediately in screened infants with no symptoms, and exercise/activity may play a greater role. At all ages, the advice will be based on an individual assessment.

The families of babies with CF will be taught how to do airway clearance with their child. As you grow older with CF, your physiotherapist will aim to find a technique that you can carry out on your own, so that you do not have to rely on someone else to help. 

Breathing exercises can be introduced from the age of two to three as a game. Older children can start doing airway clearance themselves with supervision. Most teenagers and adults become completely independent, and only need help if they have increased mucus.

Exercise helps with lung function, heart health, muscle strength and posture, blood sugar control, bone health, mood, general fitness, and overall health and well-being. People with CF should aim to do a range of physical activities on a regular basis to get the most health benefits. Both airway clearance and exercise are important parts of CF physiotherapy.

Exercise can help loosen mucus in the lungs and make airway clearance techniques quicker and easier. Your CF physiotherapist will help you to find ways of exercising that are best for you and advise you on how exercise can help with airway clearance.

Posture is the position that we hold our bodies in when we are sitting or standing. It is important to maintain the best posture we can to avoid problems such as pain and stiffness now or as you get older.

Poor posture can also impact lung function. People with CF are more likely to develop a rounded upper back for many reasons, so keeping the spine flexible may prevent future problems.

Your CF physiotherapist will be able to offer advice and help to assess and treat any joint or back problems you may have. 

Download our leaflet on how to improve your posture

Some people with CF may develop problems with urinary or faecal incontinence (leaking wee or poo) when coughing, sneezing, laughing, and/or exerting themselves. If this should happen to you it is important to tell your physiotherapist as soon as possible and not be embarrassed, as they can teach you pelvic floor exercises to help. They may also refer you on to a specialist.

Take a look at our factsheet to learn more about how to do pelvic floor exercises.

Download our factsheet

Many people with CF will take inhaled medications as part of their treatment. This may be to loosen the mucus, hydrate the airways, open up the airways, reduce inflammation of the airways and/or to deliver antibiotics to treat infections.

These medications may come in nebulised (inhaling a mist) or dry powder form. There are many different nebuliser devices and inhalers available. You should check the information that comes with your nebuliser and/or inhaler and talk to your CF Team about cleaning and looking after your equipment.

Often the timing of these alongside airway clearance and exercise is important to ensure your treatment is as effective as possible. Please ask your physiotherapist for advice if you are not sure when to take your inhaled medicines. 

Download our inhaled therapy factsheet

We have worked with the Association of Chartered Physiotherapists in Cystic Fibrosis (ACPCF) to produce a series of leaflets to complement the advice and teaching physiotherapists give people with cystic fibrosis.

See all physiotherapy leaflets

We have worked with the Association of Chartered Physiotherapists in Cystic Fibrosis (ACPCF) to produce information on physiotherapy, to complement the advice and teaching physiotherapists give people with cystic fibrosis.

Physiotherapy resources for clinicians