3.15 Flutter & Acapella
Category: UWHC Patient Care Policy
Effective Date: March 1, 2016
Manual: Respiratory Care Services
Section: Airway Clearance
The Flutter and Acapella are hand held devices used to help loosen mucus in the airway so patients can
expectorate more easily. Both devices combine the effects of positive expiratory pressure and oscillation
to facilitate secretion clearance.
A. Pneumothorax or hemothorax
C. Tympanic membrane rupture
D. Recent facial, oral, or skull surgery or trauma
F. Esophageal surgery
A. Flutter is ordered through CS.
B. Acapella valves are stocked in the RT Equipment Center.
A. All patients will be assessed by the Respiratory Care Practitioner (RCP) to determine if the
appropriate indications for therapy are present.
B. Therapy will be provided in accordance with a provider’s order.
C. Appropriate Health Facts for You (HFFY) will be given if therapy is being planned for home.
D. Acapella and flutter will only be performed on patients with Cystic Fibrosis, bronchiectasis,
Bronchiolitis Obliterans, or captivating lung disease.
E. Patients with FEV1 less than 1.0L/sec. may not be able to generate enough force to perform an
adequate treatment. Alternate forms of airway clearance should be considered.
F. Increased work of breathing may lead to hypoventilation and hypercarbia.
G. All AFCH patients will:
1. Have therapy before meals, school, and bedtime.
2. Be encouraged not to refuse therapies.
3. Cough after taking 20 Flutter or Acapella breathes.
4. Be encouraged to expectorate mucus (Especially after age 7 years).
5. Patients with Cystic Fibrosis will have therapies done 4 x daily.
a. Alternating airway clearance techniques may be performed per provider’s order.
b. Notify the Pediatric Pulmonary physician when modification is necessary.
6. Nasal or oropharyngeal suctioning can be done if secretions cannot be mobilized by other
means, and a provider’s order is present.
H. The order of therapies should be:
2. Hypertonic Saline (can be given with ACT)
3. Dnase (can be given with ACT)
4. Airway Clearance Technique
5. Aerosolized Antibiotic
6. Inhaled Steroid
A. Review and acknowledge the provider’s order.
B. Review patient's chart. Review the patient’s most recent PFT’s if applicable. Patients with an
FEV1 of less than 1 liter/second may not be able to generate enough force to perform an adequate
treatment. Consider alternate forms of airway clearance.
C. Obtain the appropriate equipment.
D. Introduce yourself to the patient &/or family. Explain the reason for the procedure.
E. Instruct patient to sit upright with head tilted back, so airway is open.
F. Have the patient place the mouthpiece in their mouth and tightly seal their lips around it.
G. Instruct the patient to take a deep breath in through their nose and hold for 2-3 seconds. This
allows the air to distribute equally throughout the lungs.
H. While keeping cheeks hard and flat while exhaling through the mouth as long as possible with a
moderate force. Exhalation should be 3 – 4 times longer than inspiration.
I. Vibratory Devices
The angle of the flutter valve is critical. Start with the stem of the flutter horizontal to
the floor with the cone of the flutter at a slight tilt. This tilt insures that the ball bounces
and rolls during exhalation producing the vibrations that loosen mucus. Determine the
best vibration or flutter by placing a hand on the patient's back or chest during exhalation.
a. With the Acapella, the angle of the device is not important. Vibration should be
felt when placing a hand on the patient’s chest or back.
b. The Acapella frequency adjustment dial should initially be set at 3. Adjust the
dial to optimize the vibration and the patient’s expiratory time. The patient
should be able to exhale for 3-4 seconds while the device vibrates. The dial can
then be turned to a higher number, clockwise to increase resistance and allow the
patient to exhale at a lower flow rate, or turned to a lower number counter
clockwise, to decrease the resistance. Once the proper range has been identified,
the patient may be instructed to exhale harder or softer, or dial adjustments may
be made to optimize the response the user feels from the vibratory pressure.
c. A nebulizer may be added to the back of the Acapella by the frequency adjustment
device to allow for better drug deposition.
J. Nose clips may be necessary to prevent air from being exhaled through their nose.
K. Do 20 deep breaths with prolonged expirations through the device followed by a huff cough.
A huff cough is performed by taking a deep breath in, holding it for 1-3 seconds, and then forcing
the air out of the lungs saying the word "huff" at the same time.
L. Repeat the breathing and coughing sequence for at least 20 minutes or until cough is no longer
M. Cleaning and disinfecting Acapella should be done daily. Details are given in Acapella’s UW
Health Facts for You.
A. Health Facts for You
1. #4915 Flutter
2. #6006 Acapella
1. Flutter patient instruction manual
2. Acapella instruction manual
3. AARC Clinical Practice Guidelines
a. Directed Cough
b. Use of Positive Airway Pressure Adjuncts to Bronchial Hygiene.
4. “Cystic Fibrosis Pulmonary Guidelines,” Flume, O’Sullivan et al,
Am. J. Resp. Critical Care Med, vol 176, pp957-969 2007.
Approved by Director and Medical Director of Respiratory Care: