Do Mucus-Clearing Treatments Really Work? A Look at the Evidence (and the Myths)

I’ve been a respiratory therapist for 28 years and 4 days. Hard to believe it’s been that long. I remember learning about hypertonic saline in RT school back in ’96. By the time I hit the floors in ’97, it was already out of style — “proven useless.”

Now?

It’s back with a vengeance. I see it ordered almost every day for… whatever disease of the week.

Same with CPT.

We used to pound on the chests of every post-op patient as if soreness alone was a mucus diagnosis. Eventually studies caught up and said, “yeah… this doesn’t actually do anything.” Plus, hitting fragile 85-year-old ribs? Maybe not our best era.

Mucomyst has always been the strange child. Ordered for people who “can’t bring up secretions,” or because a doctor thinks “it’ll help.” And of course the whole room ends up smelling like rotten eggs. The only people who don’t mind are the ones so old they don’t care about anything anymore — including their own room smelling like poop, as their comode sits filled in the corner.

And after this many years in the job, you learn the difference between:

something that actually works
and
something that looks like work.

Hypertonic saline. Pulmozyme. Mucomyst. The Vest. Acapella. CPT.

We’ve all done them. We’ve all questioned them.

Some days you walk into a patient’s room and they have everything ordered. If I actually did all of it by the book, I’d be in the room for two straight hours. No thanks. Nobody’s got that kind of time.

And eventually the question creeps in:

Does any of this actually help the patient?

Or are we just doing it because we've always done it?

So I dug through the research — real numbers, solid studies, repeatable results. Because one study is not science, guys. Science is when multiple studies show the same thing again and again — and even then, people still argue about it. That’s real science. And honestly, the reason we debate it is because only God knows the full truth — we’re just here trying to figure out our tiny piece of it.

Here’s what actually holds up.

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CYSTIC FIBROSIS

The only place where mucus therapy truly delivers — even if the gains are smaller than you think.

Hypertonic Saline (3–7%)

• FEV₁ improves ~3%

• Exacerbations drop ~50%

• Good, repeatable evidence

• Helps clear mucus and improves sleep

Pulmozyme (Dornase Alfa)

• FEV₁ improves 5–12%

• Fewer infections

• Slows long-term decline

The Vest

• Works about the same as solid manual CPT

• FEV₁ improves 1–3%

• Reliable long-term airway clearance

Now here’s the part no one says out loud:

"If Pulmozyme improves FEV₁ 5–12%, that means, in 88–95% of patients, of lung function does not change.

CF is the condition where these therapies shine — and even there, the gains are modest.

Still worth it. Still life-extending. Just not magic.

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BRONCHIECTASIS (Non-CF)

Helpful, but not groundbreaking.

OPEP Devices (Acapella, Aerobika, PEP)

• Patients feel less congested

• Increased sputum production

• FEV₁ improves 1–3% (which also means it does absolutely nothing in the other 97–99% of cases).

• Some studies show 10–20% fewer exacerbations (So in 80-90% of cases it has no effect)

The Vest

• Helps move mucus

• Patients feel better

• Minimal FEV₁ impact

Bottom line:
Therapies help people feel better and cough more effectively —
but they barely move the pulmonary function numbers.

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THE VEST (General Use)

It looks dramatic. It sounds dramatic.
It helps the right patients — but it’s ordered for the wrong ones just as often.

Good for:

• CF

• Bronchiectasis

• Chronic heavy secretions

Not good for:

• Most COPD patients

• Pneumonia

• Mild secretions

• People who just “have rhonchi”

The Vest does not:

• Improve oxygenation

• Shorten hospital stays

A lot of doctors order it because it feels like “doing something.”
The evidence does not back that up for most inpatients.

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COPD

The land where tradition rules over data.

Most COPD orders look like this:

• Mucomyst

• Acapella

• Light CPT

• Maybe the Vest (usually pointless)

Mucomyst (NAC Neb)

We all know it thins mucus.
But when you actually look at outcomes?

• No meaningful FEV₁ change

• No better oxygenation

• No reduction in hospitalizations

• Bronchospasm 10–20%

• Studies are old and weak

Translation:
Mucomyst for COPD is 90% tradition, 10% actual effect.

And the smell?
Rotten eggs. Every time.

Acapella / Aerobika

This actually does something.

• Helps mobilize mucus

• Patients feel better after using it

• FEV₁ changes 0–2%

• Some studies: 10–30% fewer COPD readmissions

Not a miracle — but useful.

The Vest (in COPD)

The research says:

• Helps the small handful of COPD patients with lots of mucus

• Does little to nothing for the majority

• No significant FEV₁ improvement

• No consistent length-of-stay improvement

80–90% of COPD patients get almost no benefit.

Yet it still gets ordered on autopilot.

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PNEUMONIA

If we’re doing airway clearance here, we’re doing it for comfort — not cure.

Research shows:

• Chest PT does not cure pneumonia faster

• Vest does not improve oxygenation

• OPEP does not reduce mortality

• ACT does not reduce complications

• Does not shorten length of stay

The only tiny benefit?
A couple small studies suggest fever may break 12 hours sooner.

That’s it.

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NEUROMUSCULAR & SPINAL CORD INJURY

Finally — a therapy that actually does exactly what it should.

CoughAssist / MIE

• Increases cough flow 50–150%

• Prevents mucus plugging

• Cuts pneumonia risk

• Reduces intubations

• Reduces hospitalizations

These patients don’t have a mucus problem —
they have a weak cough problem.

This device is a game-changer.

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THE BOTTOM LINE

After almost three decades doing this job, this is the simplest way I can put it:

Some therapies help a lot.
Some help a little.
Some don’t help much at all.

But tradition sticks around forever.

And some days, when you’re dragging a Vest into the room of a COPD patient who hasn’t coughed anything up since 2003, you can feel the gap between what we know and what we’re ordered to do.

Here’s the honest breakdown:

STRONG EVIDENCE

• Pulmozyme (CF)

• Hypertonic saline (CF)

• CoughAssist (NMD, spinal injury)

MODERATE EVIDENCE

• Acapella / Aerobika

• OPEP for bronchiectasis

• The Vest for CF & bronchiectasis

WEAK EVIDENCE

• Mucomyst for COPD

• The Vest for COPD

• Chest PT for pneumonia

• OPEP for pneumonia

ALMOST NO EVIDENCE

• “We have to order something.”

I’m not trying to stir drama. I love respiratory care.
But I also like knowing the difference between what works and what’s just habit.

And honestly?

If a therapy only helps 10% of patients,
that means 90% of the time we’re basically doing busywork.
That’s not bad RT care — it’s just the reality of old habits in medicine.

And that’s why asking questions matters.

Giving Health Care Power Back to the People -- Fixing Obamacare

Why the ACA can stay — but the money should follow the consumer

The Affordable Care Act (Obamacare) has been around for over a decade now, and it’s not going anywhere. It’s helped millions of Americans gain access to health insurance who otherwise might not have had it. That’s a good thing — nobody should go without coverage in a country like ours.

But there’s something that’s never sat right about how the system works.

Right now, the government sends premium tax credits — money meant to help lower- and middle-income families afford insurance — directly to insurance companies. That means the government pays the companies first, and consumers just pick from what’s left on the shelf.

It’s a system that guarantees access — but not competition. And without competition, prices rarely go down.

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What if the money followed the person?

Imagine a system where the same ACA tax credits go directly to you — not the insurance companies. You could still use those credits to buy insurance, but you’d decide where to spend them.

You’d be free to shop around, compare plans, and reward the companies that offer the best coverage for the best price.

In other words, you’d be the customer — not the middleman.

Insurance companies would have to compete for your business. They’d have to innovate, streamline, and actually lower premiums to attract you.

Competition is what drives every healthy market — and health care should be no different.

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Keeping what works — fixing what doesn’t

We don’t have to scrap Obamacare to make this happen. The structure already exists:

• The tax credits are already there.

• The income limits and protections are already in place.

• People already use the Marketplace to compare plans.

The only change would be who gets the money first.

Right now, insurers get guaranteed payments — no matter how good or bad their service is. If consumers got the credit directly, those same companies would suddenly have a reason to earn it.

You could still choose from any approved plan. The government could still make sure everyone has access. The difference is that the power shifts from Washington and big insurers — to you.

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Why this matters

Since the ACA passed, insurance companies have grown richer, not leaner. Health care costs haven’t gone down. Premiums keep climbing. And for many families, “affordable” coverage still means sky-high deductibles.

If the goal is affordable care, then we need real competition — not government-protected monopolies.

By giving consumers control of the credits, we’d see:

• More innovation among insurance companies.

• Transparent pricing and simpler plans.

• A stronger link between value and cost.

It’s the same logic that makes every other market work — when people control the money, businesses listen.

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A simple, fair middle ground

We can keep the ACA, keep protections for people with preexisting conditions, and keep access open — all while making the system work for consumers, not just insurance companies.

Let the government fund health care, but let people choose where their dollars go.

If that sounds like common sense — it’s because it is.

Myth Buster: Don’t Panic Over One Frickin’ Study

Melatonin made headlines again this week—this time for supposedly increasing the risk of heart failure by 90 percent.

Cue the panic, the clickbait, and the sudden flood of patients ready to toss every bottle of sleep aid into the trash.

Let’s slow down.

Science Doesn’t Work on Panic

Real science isn’t built on a single data dump. It’s built on reproducibility—different teams, different patients, same results.
One study—no matter how big—only raises a question. It doesn’t answer it.

The research making the rounds came from an observational look at 130,000 people with insomnia.
The folks taking melatonin long-term seemed more likely to develop heart failure.
Interesting? Yes.
Proof? Nope.

They weren’t randomized.
They already had insomnia (a known heart-risk condition).
We don’t know their doses, their over-the-counter brands, or how accurate their medical coding was.

In other words, this study says, “Hey, we noticed something weird. Somebody should check this out.”
That’s how science starts—not how it ends.

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How This Should Actually Change Behavior

If you pop melatonin occasionally to reset after night shifts or travel, this isn’t your cue to panic.
If you’ve been taking 10 mg every night for years, maybe talk with your doc about whether you still need it.
Use data as information, not as doom.

The smarter takeaway is balance:

• Don’t treat any supplement like candy.

• Don’t assume “natural” equals “harmless.”

• And don’t change meds or supplements because of a single headline.

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What To Do Instead

• Talk to your provider before stopping or starting anything.

• Stay curious, not fearful. Ask why the data might look that way.

• Watch for follow-ups. If three or four future studies confirm the same link, then we have something real to chew on.

Until then, melatonin is still what it always was: a hormone your body already makes, sometimes helpful, sometimes over-used, rarely catastrophic.

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Bottom Line

Don’t stop taking melatonin—or any medication—because of one frickin’ study.
Science isn’t a headline. It’s a process.

Breathe. Sleep. Question everything—but don’t overreact.book

I write this and I don't even take Melatonin. Still, I'm smart enough to know that one study is not science. People tried to pull that tone on us during Covid, where one study showed masked present COVID, whan all it showed was that it reduced your risk for COVID a few percentage points. Be careful what you read. 

Live Like It Matters

Tonight, I listened to Erika Kirk, wife of Charlie Kirk, give a powerful speech about faith, courage, and purpose. Her message stuck with me, and here’s the crux of what she said — in my own words.

“They will be known by the boldness of their faith.”

How do you become courageous?
Ask yourself three questions every day:

1. What is something I can do for someone today?

2. What is something I can do to add value to the world today?

3. How can I honor God today?

You only get one life — this one.

(Tempit fugit, momento mori. Time flies. Remember, you will die. My addition here. But that's what she was referring to). 

So live like it matters.

God created you for greatness — not for something lifeless.

Greatness isn’t about how long you live; it’s about what you do with the life the Lord has blessed you with.

When you get to the end of your life, will the Lord be proud of what you stood for?
Will you be able to say you fought the good fight — that you used your time for something that mattered?
Or will you realize you wasted the precious time God gave you chasing after things that never did?

Hold that in perspective.

Stand up for truth. Defend life. Love your family fearlessly. Love this country and defend her.
Serve our God — boldly and unapologetically.

And don’t think it’s someone else’s role to do it.
It’s yours.

You do it.

Do it for the ones who will follow.

Do it for your family.

Do it for Charlie.

Erika’s words were a reminder that faith, courage, and conviction begin not with speeches or politics, but with action — one person, one choice, one day at a time.

You only get one life.

Live like it matters.

A Conversation About What’s Happened to Our Cities

It was a slow afternoon at the hospital when one of my regular patients started talking politics — not in a combative way, just matter-of-fact. He shook his head and said, “You ever notice how all these cities run by Democrats — San Francisco, Chicago, Detroit — are falling apart?”

I smiled. “I’ve noticed. And yet somehow, it’s always the Republicans’ fault.”

He laughed, but it was the kind of laugh people use when they’re tired of pretending things are okay. “Yeah,” he said. “Fifty years of the same leadership, and they still act like somebody else did it.”

We talked about it for a while — about how San Francisco used to be one of the most beautiful cities in the country, now buried under crime and addiction. How Chicago can’t seem to get a handle on violence. How Detroit, once the symbol of American industry, has never fully recovered.

He wasn’t ranting, just observing. “I don’t understand,” he said. “People keep voting for the same party, even though everything keeps getting worse.”

“Maybe they’re afraid to change,” I said. “Or maybe they keep believing it’ll finally work this time.”

Many people are drawn to socialism’s promises — equality, fairness, and security — not necessarily its track record. It sounds compassionate, even noble. But history shows it rarely delivers what it promises. That’s the thing about ideas that sound good on paper — they can crumble fast when real people get involved.

He nodded. “That’s what’s sad about it. It’s like watching someone stay in a bad relationship because they remember how it used to be.”

We both sat quietly for a second. Politics aside, we agreed on something bigger — that the people in those cities deserve better. That leaders, no matter their party, should be judged on results, not slogans.

As I left the room, he called after me, “You know, you should write that down.”

So here it is — a simple conversation between two people who care about what’s happening to our country, and wonder why common sense seems to be the one thing nobody’s voting for anymore.s://www.facebook.com/John Bottrell's Facebook

Annual Compliance Training: From Safety to Theater

The first year I sat through annual compliance training, I actually thought it mattered. Fire safety? Sure, I’ll pay attention. HIPAA? Good to know. Hand hygiene, patient rights, infection control — all important things. I took notes, stayed awake, and felt like I was learning something.

The second year, déjà vu. Same slides. Same narrator. Same quiz. Okay, still worth a refresher.

By the fifth year, I realized it never changes. Same script, same questions, same “check the box” exercise. That’s when I figured it out — this isn’t about learning, it’s about paperwork.

By year ten, it had turned into a game with my coworkers. Who could finish the fastest? Who could pass the quiz without even glancing at the material? Gone were the days of taking it seriously — now it was bragging rights in the breakroom.

These days, it’s videos on mute, quizzes answered from memory (or with AI), and compliance complete in a fraction of the time. Fully compliant, fully absurd.

Believe it or not, this didn’t start as a joke. Over the past 30+ years, federal and state regulators started requiring proof that healthcare workers were trained in specific areas. OSHA’s Bloodborne Pathogens Standard (1991) requires annual training for anyone at risk of exposure to blood. HIPAA’s Privacy Rule (1996, enforced in 2003) requires training on patient privacy and data protection, though not specifically annual — hospitals made it yearly to cover themselves. The Joint Commission has long required education on infection control, patient safety, and workplace violence. CMS has Conditions of Participation that push hospitals to prove staff competency and education. Over time, hospitals added more and more modules — partly for safety, partly for liability. Then COVID hit, and it all doubled down.

In Michigan, Governor Whitmer in 2020 added mandatory implicit bias training for healthcare workers, followed by gender sensitivity modules. That’s when it became a running joke for many of us. The bias training basically assumed you were guilty until proven innocent. The gender module even locked me out unless I answered that there were “many genders.” It had nothing to do with safety. Nothing to do with patient care. Just more clicking boxes to make someone in an office happy.

On paper, the point is good: make sure workers know safety procedures, protect patients, and keep up standards. In reality, the repetition makes everyone tune out. The very rules meant to protect us are so overdone that people lie, rush, and game the system just to get it over with. And sometimes, it really does feel like this is just busywork — something created to justify someone’s job in an office. My boss says that’s not true. Maybe he’s right. But it sure feels like it.

Look, it’s not the admin’s fault. It’s not even the hospital’s fault we have to sit through this every year. The push comes from higher up. So no blame here goes to the hospital. Still, you’d think they could do a better job of lobbying for a smarter system. Right?

Here’s a thought: instead of every year, why not every two? Or better yet, every five? That way, when training rolled around, people might actually take it seriously. They’d pay attention. It wouldn’t just fade into background noise. The truth is, annual compliance doesn’t make us safer—it just makes us better at hitting mute. Or here’s another idea: pay us. Bring us in on a day off and pay time and a half. Money talks.

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Sources

• Occupational Safety and Health Administration (OSHA). Bloodborne Pathogens Standard, 29 CFR 1910.1030. (1991, requires annual training)

• U.S. Department of Health & Human Services. HIPAA Privacy Rule. (1996, training required but frequency left to institutions)

• The Joint Commission. Hospital Accreditation Standards. (requires ongoing training in safety and infection control)

• Centers for Medicare & Medicaid Services (CMS). Conditions of Participation for Hospitals.

• State of Michigan. Public Act 30 of 2021. (Governor Whitmer’s mandate for implicit bias training in healthcare)

The Evolution of Annual Fit Testing

Sweating like a turkey in a sauna box.
Just say you don’t smell a thing — perfect fit.

The first year I did a fit test, I took it serious. Hood goes on, they spray the sweet or bitter stuff, I’m focused, I want to make sure this mask seals. Okay, I get it.

Second year, same thing. Still paying attention, still trying to do it right.

By the fifth year I’m looking around thinking… this is the exact same test, the exact same video, the exact same instructions. And I’ve got decades of this ahead of me?

By year six and beyond, it’s a different game. Hood goes on, I’m sweating like crazy, and the only thing I want is to get it over with. Do I smell anything? Nope, not a thing. Let’s move on. Videos go on mute. Quizzes get answered out of habit. Compliance box checked. Done.

What’s funny is the rule for annual testing isn’t new. OSHA wrote that in back in the 1990s. But before COVID, most places just did it once in a while — at hire, or when you changed mask models. And honestly, that worked fine. People took it seriously enough to make sure they had a good seal.

Then COVID hit. Suddenly, N95s were everywhere. Supply chains were a mess. One week you had 3M, the next week you had some no-name brand. Regulators cracked down, hospitals panicked, and the “annual” rule went from something loosely followed to something enforced to the letter. And what happens when you push people too hard? They stop caring.

It’s the same as annual compliance training. The first time you pay attention. The tenth time, you’ve got it muted and you’re just clicking through. If there’s a quiz, you know the answers already. Some people even have AI do it now. Everyone knows it, nobody admits it, and nobody’s actually learning.

Same with masks. We went from making sure they sealed properly to faking our way through because the process is miserable. Too hot, too repetitive, too pointless. People lie. People rush. And half the time, staff just end up wearing surgical masks anyway because N95s are uncomfortable.

And then there’s the gowns and gloves. They throw those at us for viruses like flu and COVID, when those are airborne. It doesn’t even line up with the science. It’s theater. Looks good for the inspectors, makes the paperwork shine, but it doesn’t actually change the way things happen on the floor.

I’ll give it this: those first couple of years, we all wanted to do it right. We wanted that mask sealed, and we wanted to feel safe. But by year five, and definitely by year forty, the truth sinks in. It’s not about the mask. It’s about the paperwork. And that’s why nobody takes it seriously anymore.

Solution: Let's compromise and do it every five years. 

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Sources

• Occupational Safety and Health Administration (OSHA). Respiratory Protection Standard 1910.134 (requires annual fit testing). osha.gov

• Centers for Disease Control and Prevention (CDC). NIOSH: Fit Testing of Filtering Facepiece Respirators. cdc.gov

• Michigan Occupational Safety and Health Administration (MIOSHA). Respiratory Protection Program Guidelines. Michigan Department of Labor & Economic Opportunity.

• Brosseau, Lisa M. and Sietsema, Margaret. “Commentary: Should Healthcare Workers Use N95 Masks Year After Year?” CIDRAP (Center for Infectious Disease Research and Policy), University of Minnesota, 2020.