Structure and function of the mucus clearance system of the lung

Cold Spring Harbor Perspectives in Medicine

Volumn 3, Issue 8, 2013, Pages

  Button, Brenda M ^a   Button, Brian ^b  

^a MONASH UNIVERSITY   (Australia)

^b UNIVERSITY OF NORTH CAROLINA SCHOOL OF MEDICINE   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

BACTERIA (MICROORGANISMS);

ARTICLE; BRONCHUS; CHEMISTRY; CYSTIC FIBROSIS; GENETICS; HUMAN; ION TRANSPORT; LUNG; METABOLISM; MUCUS; PATHOPHYSIOLOGY; PHYSIOTHERAPY; RESPIRATORY TRACT MUCOSA; SECRETION (PROCESS); TREATMENT OUTCOME;

BRONCHI; CYSTIC FIBROSIS; HUMANS; ION TRANSPORT; LUNG; MUCUS; PHYSICAL THERAPY MODALITIES; RESPIRATORY MUCOSA; TREATMENT OUTCOME;

EID: 84881051634     PISSN: None     EISSN: 21571422     Source Type: Journal    
DOI: 10.1101/cshperspect.a009720     Document Type: Article

References (123)

1. AARC. 1991. AARC (American Association for Respiratory Care) clinical practice guideline. Postural drainage therapy. Respir Care 36: 1418-1426.
2. Althaus P. 1989. The bronchial hygiene assistedby theflutter VRP1 (Module regulatorof a positive pressure oscillation on expiration). Eur Respir J 2 (Suppl 8): 693.
3. Althaus P. 2009. Oscillating PEP-Flutter therapy. International Physiotherapy Group/Cystic Fibrosis, http://www.cfww.org.
4. App EM, Kieselmann R, Reinhardt D, Lindemann H, Das-Gupta B, King M, Brand P. 1998. Sputum rheology changes in cystic fibrosis lung disease following two different types of physiotherapy: Flutter vs autogenic drainage. Chest 114: 171-177.
5. Arens R, Gozal D, Omlin KJ, Vega J, Boyd KP, Keens TG, Woo MS. 1994. Comparison of high frequency chest compression and conventional chest physiotherapy in hospitalized patients with cystic fibrosis. Am J Respir Crit Care Med 150: 1154-1157.
6. Basser PJ, McMahon TA, Griffith P. 1989. The mechanism of mucus clearance in cough. J Biomech Eng 111: 288-298.
7. Benali R, Pierrot D, Zahm JM, de Bentzmann S, Puchelle E. 1994. Effect of extracellular ATP and UTP on fluid transport by human nasal epithelial cells in culture. Am J Respir Cell Mol Biol 10: 363-368.
8. 0-tri-phosphate plus amiloride on mucociliary clearance in adult cystic fibrosis. Am J Respir Crit Care Med 153: 1796-1801.
9. Boucher RC. 1994. Human airway ion transport. Part one. Am J Respir Crit Care Med 150: 271-281.
10. Boucher RC. 2007a. Airway surface dehydration in cystic fibrosis: Pathogenesis and therapy. Annu Rev Med 58: 157-170.
11. Boucher RC. 2007b. Evidence for airway surface dehydration as the initiating event in CF airway disease. J Intern Med 261: 5-16.
12. Braggion C, Cappelletti LM, Cornacchia M, Zanolla L, Mastella G. 1995. Short-term effects of three chest phys-iotherapy regimens in patients hospitalized for pulmonary exacerbations of cystic fibrosis: A cross-over randomized study. Pediatr Pulmonol 19: 16-22.
13. Button B, Boucher RC. 2008. Role of mechanical stress in regulating airway surface hydration and mucus clearance rates. Respir Physiol Neurobiol 163: 189-201.
14. Button BM, Heine RG, Catto-Smith AG, Phelan PD, Olinsky A. 1997. Postural drainage and gastro-oesopha-geal reflux in infants with cystic fibrosis. Arch Dis Child 76: 148-150.
15. Button BM, Heine RG, Catto-Smith AG, Phelan PD. 1998. Postural drainage in cystic fibrosis: Is there a link with gastro-oesophageal reflux? J Paediatr Child Health 34: 330-334.
16. Button BM, Heine RG, Catto-Smith AG, Olinsky A, Phelan PD, Ditchfield MR, Story I. 2003. Chest physiotherapy in infants with cystic fibrosis: To tip or not? A five-year study. Pediatr Pulmonol 35: 208-213.
17. Button BM, Roberts S, Kotsimbos TC, Levvey BJ, Williams TJ, Bailey M, Snell GI, Wilson JW. 2005. Gastro-esophageal reflux (symptomatic and silent): Apotentially significant problem in patients with cystic fibrosis before and after lung transplantation. J Heart Lung Transplant 24: 1522-1529.
18. Button B, Picher M, Boucher RC. 2007. Differential effects of cyclic and constant stress on ATP release and muco-ciliary transport byhuman airway epithelia.J Physiol 580: 577-592.
19. Button B, Cai L-H, Ehre C, Kesimer M, Hill DB, Sheehan JK, Boucher RC, Rubinstein M. 2012. A periciliary brush promotes the lung health by separating the mucus layer from airway epithelia. Science 337: 937-941.
20. Cecins NM, Jenkins SC, Pengelley J, Ryan G.1999. The active cycle of breathing techniques-To tip or not to tip? Respir Med 93: 660-665.
21. Chevaillier J. 1984. Autogenic drainage. In Cystic fibrosis horizons (ed. Lawson D), p. 235. Wiley, New York.
22. Cloutier M. 2007. Respiratory physiology. Mosby Elsevier, Philadelphia.
23. Dab I, Alexander F. 1979. The mechanism of autogenic drainage studied with flow volume curves. Monogr Pae-diatr 10: 50-53.
24. Davis CW. 2002. Regulationof mucin secretion from invitro cellular models. Novartis Found Symp 248: 113-131, 277-282.
25. Davis IC, Matalon S. 2007. Epithelial sodium channelsinthe adult lung-Important modulators of pulmonary health and disease. Adv Exp Med Biol 618: 127-140.
26. Dentice R, Elkins M. 2011. Timing of dornase alfa inhalation for cystic fibrosis. Cochrane Database Syst Rev CD007923.
27. Dentice RL, Elkins MR, Bye PT. 2012. Adults with cystic fibrosis prefer hypertonic saline before or during airway clearance techniques: A randomised crossover trial. J Physiother 58: 33-40.
28. Dietl P, Haller T, Mair N, Frick M. 2001. Mechanisms of surfactant exocytosis in alveolar type II cells in vitro and in vivo. News Physiol Sci 16: 239-243.
29. Dwyer TJ, Alison JA, McKeough ZJ, Daviskas E, Bye PT. 2011. Effects of exercise on respiratory flow and sputum properties in patients with cystic fibrosis. Chest 139: 870-877.
30. Egan ME. 2002. CFTR-associated ATP transport and release. Methods Mol Med 70: 395-406.
31. Elkins M, Dentice R. 2012. Timing of hypertonic saline inhalation for cystic fibrosis. Cochrane Database Syst Rev 2: CD008816.
32. Elkins MR, Alison JA, Bye PT. 2005. Effect of body position on maximal expiratory pressure and flow in adults with cystic fibrosis. Pediatr Pulmonol 40: 385-391.
33. Fainardi V, Longo F, Faverzani S, Tripodi MC, Chetta A, Pisi G. 2011. Short-term effects of high-frequency chest compression and positive expiratory pressure in patients with cystic fibrosis. J Clin Med Res 3: 279-284.
34. Falk M, Kelstrup M, Andersen JB, Kinoshita T, Falk P, Stovring S, Gothgen I. 1984. Improving the ketchup bottle method with positive expiratory pressure, PEP, in cystic fibrosis. Eur J Respir Dis 65: 423-432.
35. Fink JB, Mahlmeister MJ. 2002. High-frequency oscillation of the airway and chest wall. Respir Care 47: 797-807.
36. Fischer H, Illek B, Machen TE. 1998. Regulation of CFTR by protein phosphatase 2B and protein kinase C. Pflugers Arch 436: 175-181.
37. Flume PA, Mogayzel PJ Jr, Robinson KA, Goss CH, Rosenblatt RL, Kuhn RJ, Marshall BC. 2009. Cystic fibrosis pulmonary guidelines: Treatment of pulmonary exacerbations. Am J Respir Crit Care Med 180: 802-808.
38. Fredberg JJ. 1978. A modal perspective of lung response. J Acoust Soc Am 63: 962-966.
39. Frownfelter D, Dean E. 2006. Cardiovascular and pulmonary physical therapy: Evidence and practice. Mosby & Elsevier Health Sciences, St. Louis, MO.
40. Frownfelter D, Massery M. 2006. Facilitating airway clearance with coughing techniques. In Cardiovascular and pulmonary physical therapy: Evidence and practice (ed. Frownfelter D, Dean E), pp. 363-376. Mosby & Elsevier Health Sciences, St. Louis, MO.
41. Gallon A. 1992. The use of percussion. Physiotherapy 78: 85-89.
42. Giles DR, Wagener JS, Accurso FJ, Butler-Simon N. 1995. Short-term effects of postural drainage with clapping vs autogenic drainage on oxygen saturation and sputum recovery in patients with cystic fibrosis. Chest 108: 952-954.
43. Greger R, Schreiber R, Mall M, Wissner A, Hopf A, Briel M, Bleich M, Warth R, Kunzelmann K. 2001. Cystic fibrosis and CFTR. Pflugers Arch 443: S3-S7.
44. Groth S, Stafanger G, Dirksen H, Andersen JB, Falk M, Kelstrup M. 1985. Positive expiratory pressure (PEP-mask) physiotherapy improves ventilation and reduces volume of trapped gas in cystic fibrosis. Bull Eur Physi-opathol Respir 21: 339-343.
45. {thorn} transport across airway epithelia. Am J Physiol 275: C303-C308.
46. Grygorczyk R, Hanrahan JW. 1997. CFTR-independent ATP release from epithelial cells triggered by mechanical stimuli. Am J Physiol 272: C1058-C1066.
47. Hanrahan JW, Mathews CJ, Grygorczyk R, Tabcharani JA, Grzelczak Z, Chang XB, Riordan JR. 1996. Regulation of the CFTR chloride channel from humans and sharks. J Exp Zool 275: 283-291.
48. Hansen LG, Warwick WJ. 1990. High-frequency chest compression system to aid in clearance of mucus from the lung. Biomed Instrum Technol 24: 289-294.
49. Hebestreit A, Kersting U, Basler B, Jeschke R, Hebestreit H. 2001. Exercise inhibits epithelial sodium channels in patients with cystic fibrosis. Am J Respir Crit Care Med 164: 443-446.
50. Hebestreit H, Kieser S, Junge S, Ballmann M, Hebestreit A, Schindler C, Schenk T, Posselt HG, Kriemler S. 2010. Long-term effects of a partially supervised conditioning programme in cystic fibrosis. Eur Respir J 35: 578-583.
51. Hodson ME. 2000. Treatment of cystic fibrosis in the adult. Respiration 67: 595-607.
52. Homnick DN, Anderson K, Marks JH. 1998. Comparison of the flutter device to standard chest physiotherapy in hospitalized patients with cystic fibrosis: A pilot study. Chest 114: 993-997.
53. Inanlou MR, Baguma-Nibasheka M, Kablar B. 2005. The role of fetal breathing-like movements in lung organo-genesis. Histol Histopathol 20: 1261-1266.
54. Johnson FL, Donohue JF, Shaffer CL. 2002. Improved sputum expectoration following a single dose of INS316 in patients with chronic bronchitis. Chest 122: 2021-2029.
55. Jones DP, Ellam SV, Riddle H, Watson BW. 1975. The measurement of air flow in a forced expiration using a pressure-sensitive transistor. Med Biol Eng 13: 71-77.
56. Kim CS, Iglesias AJ, Sackner MA. 1987. Mucus clearance by two-phase gas-liquid flow mechanism: Asymmetric periodic flow model. J Appl Physiol 62: 959-971.
57. Kluft J, Beker L, Castagnino M, Gaiser J, Chaney H, Fink RJ. 1996. A comparison of bronchial drainage treatments in cystic fibrosis. Pediatr Pulmonol 22: 271-274.
58. Knowles MR, Clarke LL, Boucher RC. 1991. Activation by extracellular nucleotides of chloride secretion in the airway epithelia of patients with cystic fibrosis. N Engl J Med 325: 533-538.
59. Kreda SM, Gynn MC, Fenstermacher DA, Boucher RC, Gabriel SE. 2001. Expression and localization of epithelial aquaporins in the adult human lung. Am J Respir Cell Mol Biol 24: 224-234.
60. Kreda SM, Okada SF, van Heusden CA, O'Neal W, Gabriel S, Abdullah L, Davis CW, Boucher RC, Lazarowski ER. 2007. Coordinated release of nucleotides and mucin from human airway epithelial Calu-3 cells. J Physiol 584: 245-259.
61. {thorn} channels by CFTR and purinergic stimulation. Kidney Int 60: 455-461.
62. {thorn} transport via hydrolysis of PIP2. FASEB J 19: 142-143.
63. Kuys SS, Hall K, Peasey M, Wood M, Cobb R, Bell SC. 2011. Gaming console exercise and cycle or treadmill exercise provide similar cardiovascular demand in adults with cystic fibrosis: A randomised cross-over trial. J Physiother 57: 35-40.
64. Lannefors L. 2009. Positive expiratory pressure. International Physiotherapy Group/Cystic Fibrosis, http://www.cfww.org.
65. Lannefors L, Wollmer P. 1992. Mucus clearance with three chest physiotherapy regimes in cystic fibrosis: A comparison between postural drainage, PEP and physical exercise. Eur Respir J 5: 748-753.
66. Lannefors L, Button BM, McIlwaine M.2004. Physiotherapy in infants and young childrenwith cysticfibrosis: Current practice and future developments. J R Soc Med 97: 8-25.
67. Lapin CD. 2002. Airway physiology, autogenic drainage, and active cycle of breathing. Respir Care 47: 778-785.
68. Laube BL, Links JM, LaFrance ND, Wagner HN Jr, Ro-senstein BJ. 1989. Homogeneity of bronchopulmonary distribution of 99mTc aerosol in normal subjects and in cystic fibrosis patients. Chest 95: 822-830.
69. Lazarowski ER, Boucher RC. 2001. UTP as an extracellular signaling molecule. News Physiol Sci 16: 1-5.
70. Lazarowski ER, Boucher RC. 2009. Purinergic receptors in airway epithelia. Curr Opin Pharmacol 9: 262-267.
71. Lazarowski ER, Mason SJ, Clarke L, Harden TK, Boucher RC. 1992. Adenosine receptors on human airway epithelia and their relationship to chloride secretion. Br J Pharmacol 106: 774-782.
72. Leith DE. 1985. The development of cough. Am Rev Respir Dis 131: S39-S42.
73. Levitzky MG. 1991. Pulmonary physiology. McGraw-Hill, New York.
74. McCarren B, Alison JA. 2006. Physiological effects of vibration in subjects with cystic fibrosis. Eur Respir J 27: 1204-1209.
75. McIlwaine PM, Wong LT, Peacock D, Davidson AG. 1997. Long-term comparative trial of conventional postural drainage and percussion versus positive expiratory pressure physiotherapy in the treatment of cystic fibrosis. J Pediatr 131: 570-574.
76. McIlwaine M, Wong LT, Chilvers M, Davidson GF. 2010. Long-term comparative trial of two different physiotherapy techniques; postural drainage with percussion and autogenic drainage, in the treatment of cystic fibrosis. Pediatr Pulmonol 45: 1064-1069.
77. McIlwaine MP, Alarie N, Davidson GF, Lands LC, Ratjen F, Milner R, Owen B, Agnew JL. 2013. Long-term multi-centre randomised controlled study of high frequency chest wall oscillation versus positive expiratory pressure mask in cystic fibrosis. Thorax doi: 10.1136/thoraxjnl-2012-202915.
78. Mead J, Turner JM, Macklem PT, Little JB. 1967. Significance of the relationship between lung recoil and maximum expiratory flow. J Appl Physiol 22: 95-108.
79. Mead J, Takishima T, Leith D. 1970. Stress distribution in lungs: A model of pulmonary elasticity. J Appl Physiol 28: 596-608.
80. Miller S, Hall DO, Clayton CB, Nelson R. 1995. Chest physiotherapy in cystic fibrosis: A comparative study of auto-genic drainage and the active cycle of breathing techniques with postural drainage. Thorax 50: 165-169.
81. Morrison L, Agnew J. 2009. Oscillating devices for airway clearance in people with cystic fibrosis. Cochrane Database Syst Rev CD006842.
82. Morse DM, Smullen JL, Davis CW. 2001. Differential effects of UTP, ATP, and adenosine on ciliary activity of human nasal epithelial cells. Am J Physiol Cell Physiol 280: C1485-C1497.
83. Murray JF. 1986. Ventilation. In The normal lung (The basis for diagnosis and treatment of pulmonary disease) (ed. Murray JF), pp. 114-117. W.B. Saunders, Philadelphia.
84. Myers LB, Horn SA. 2006. Adherence to chest physiotherapy in adults with cystic fibrosis. J Health Psychol 11: 915-926.
85. Natale JE, Pfeifle J, Homnick DN. 1994. Comparison of intrapulmonary percussive ventilation and chest physiotherapy: A pilot study in patients with cystic fibrosis. Chest 105: 1789-1793.
86. Newhouse PA, White F, Marks JH, Homnick DN. 1998. The intrapulmonary percussive ventilator and flutter device compared to standard chest physiotherapy in patients with cystic fibrosis. Clin Pediatr 37: 427-432.
87. Oberwaldner B. 2009. Hi-PEP. International Physiotherapy Group/Cystic Fibrosis, http://www.cfww.org.
88. Oberwaldner B, Evans JC, Zach MS. 1986. Forced expirations against a variable resistance: A new chest physiotherapy method in cystic fibrosis. Pediatr Pulmonol 2: 358-367.
89. Oberwaldner B, Theissl B, Rucker A, Zach MS. 1991. Chest physiotherapy in hospitalized patients with cystic fibro-sis: A study of lung function effects and sputum production. Eur Respir J 4: 152-158.
90. O'Clock GD, Lee YW, Lee J, Warwick WJ. 2010.Asimulation tool to study high-frequency chest compression energy transfer mechanisms and waveforms for pulmonary disease applications. IEEE Trans Biomed Eng 57: 1539-1546.
91. Oermann CM, Sockrider MM, Giles D, Sontag MK, Ac-curso FJ, Castile RG. 2001. Comparison of high-frequency chest wall oscillation and oscillating positive expiratory pressure in the home management of cystic fibrosis: A pilot study. Pediatr Pulmonol 32: 372-377.
92. Okada SF, Nicholas RA, Kreda SM, Lazarowski ER, Boucher RC. 2006. Physiological regulation of ATP release at the apical surface of human airway epithelia. J Biol Chem 281: 22992-23002.
93. Orenstein DM. 2003. Heads up! Clear those airways! Pediatr Pulmonol 35: 160-161.
94. Pfleger A, Theissl B, Oberwaldner B, Zach MS. 1992. Self-administered chest physiotherapy in cystic fibrosis: A comparative study of high-pressure PEP and autogenic drainage. Lung 170: 323-330.
95. Phillips GE, Pike SE, Jaffe A, Bush A. 2004. Comparison of active cycle of breathing and high-frequency oscillation jacket in children with cystic fibrosis. Pediatr Pulmonol 37: 71-75.
96. Picher M, Burch LH, Boucher RC. 2004. Metabolism of P2 receptor agonistsin human airways: Implications for mu-cociliary clearance and cystic fibrosis. J Biol Chem 279: 20234-20241.
97. Pryor JA. 2009. Active cycle of breathing techniques. International Physiotherapy Group/Cystic Fibrosis, http://www.cfww.org.
98. Pryor JA, Webber BA, Hodson ME. 1990. Effect of chest physiotherapy on oxygen saturation in patients with cystic fibrosis. Thorax 45: 77.
99. Pryor JA, Tannenbaum E, Scott SF, Burgess J, Cramer D, Gyi K, Hodson ME. 2010. Beyond postural drainage and percussion: Airway clearance in people with cystic fibrosis. J Cyst Fibros 9: 187-192.
100. Purohit DM, Caldwell C, Levkoff AH. 1975. Letter: Multiple rib fractures due to physiotherapy in a neonate with hyaline membrane disease. Am J Dis Child 129: 1103-1104.
101. Ransford GA, Fregien N, Qiu F, Dahl G, Conner GE, Salathe M. 2009. Pannexin 1 contributes to ATP release in airway epithelia.AmJRespir Cell Mol Biol 41: 525-534.
102. Ressler B, Lee RT, Randell SH, Drazen JM, Kamm RD. 2000. Molecular responses of rat tracheal epithelial cells to transmembrane pressure. Am J Physiol Lung Cell Mol Physiol 278: L1264-L1272.
103. Robinson KA, McKoy N, Saldanha I, Odelola OA. 2010. Active cycle of breathing technique for cystic fibrosis. Cochrane Database Syst Rev CD007862.
104. 2 secretory channel in mouse airways. J Biol Chem 284: 14875-14880.
105. Rossman CM, Waldes R, Sampson D, Newhouse MT. 1982. Effect of chest physiotherapy on the removal of mucus in patients with cystic fibrosis. Am Rev Respir Dis 126: 131-135.
106. Salh W, Bilton D, Dodd M, Webb AK. 1989. Effect of exercise and physiotherapy in aiding sputum expectoration in adults with cystic fibrosis. Thorax 44: 1006-1008.
107. Scherer TA, Barandun J, Martinez E, Wanner A, Rubin EM. 1998. Effect of high-frequency oral airway and chest wall oscillation and conventional chest physical therapy on expectoration in patients with stable cystic fibrosis. Chest 113: 1019-1027.
108. Schmid A, Clunes LA, Salathe M, Verdugo P, Dietl P, Davis CW, Tarran R. 2011. Nucleotide-mediated airway clearance. Subcell Biochem 55: 95-138.
109. Schoni MH. 1989. Autogenic drainage: A modern approach to physiotherapy in cystic fibrosis. J R Soc Med 82: 32-37.
110. Sontag MK, Quittner AL, Modi AC, Koenig JM, Giles D, Oermann CM, Konstan MW, Castile R, Accurso FJ. 2010. Lessons learned from a randomized trial of airway secretion clearance techniques in cystic fibrosis. Pediatr Pulmonol 45: 291-300.
111. 2 conductance in polarized T84 cells by luminal extracellular ATP. Am J Physiol 268: C425-C433.
112. Sutton PP, Lopez-Vidriero MT, Pavia D, Newman SP, Clarke SW. 1983. Effect of chest physiotherapy on the removal of mucus in patients with cystic fibrosis. Am Rev Respir Dis 127: 390-391.
113. Tarran R, Button B, Picher M, Paradiso AM, Ribeiro CM, Lazarowski ER, Zhang L, Collins PL, Pickles RJ, Fred-berg JJ, et al. 2005. Normal and cystic fibrosis airway surface liquid homeostasis. The effects of phasic shear stress and viral infections. J Biol Chem 280: 35751-35759.
114. Tonnesen P, Stovring S. 1984. Positive expiratory pressure (PEP) as lung physiotherapy in cystic fibrosis: A pilot study. Eur J Respir Dis 65: 419-422.
115. Toussaint M, de Win H, Steens M, Soudon P. 2003. Effects of intrapulmonary percussive ventilation on mucus clearance in Duchennes muscular dystrophy patients: A preliminary report. Resp Care 48: 940-947.
116. Van Ginderdeuren F. 2009. Autogenic drainage. International Physiotherapy Group/Cystic Fibrosis, http://www.cfww.org.
117. Volsko TA, DiFiore J, Chatburn RL. 2003. Performance comparison of two oscillating positive expiratory pressure devices: Acapella versus Flutter. Respir Care 48: 124-130.
118. West JB. 2004. Respiratory physiology-The essentials. Lip-pincott Williams & Wilkins, Baltimore.
119. Williams MT. 1994. Chest physiotherapy and cystic fibrosis. Why is the most effective form of treatment still unclear? Chest 106: 1872-1882.
120. Yankaskas JR, Marshall BC, Sufian B, Simon RH, Rodman D. 2004. Cystic fibrosis adult care: Consensus conference report. Chest 125: 1S-39S.
121. Yuan N, Kane P, Shelton K, Matel J, Becker BC, Moss RB. 2010. Safety, tolerability, and efficacy of high-frequency chest wall oscillation in pediatric patients with cerebral palsy and neuromuscular diseases: An exploratory randomized controlled trial. J Child Neurol 25: 815-821.
122. Zach MS, Oberwaldner B. 1992. Effect of positive expiratory pressure breathing in patients with cystic fibrosis. Thorax 47: 66-67.
123. Zach M, Oberwaldner B, Hausler F. 1982. Cystic fibrosis: Physical exercise versus chest physiotherapy. Arch Dis Child 57: 587-589.