The halls of the Seattle Convention Center were buzzing last week as over a thousand CF professionals descended upon the Pacific Northwest for NACFC 2025. Between navigating the jam-packed session schedules, squeezing through crowded poster halls, and trying to catch presentations that overlapped with discipline group meetings, I found myself constantly reminded of why this annual pilgrimage matters so much. The energy was palpable, researchers presenting groundbreaking data, clinicians sharing real-world experiences, and all of us collectively grappling with what CF care looks like in this new era of highly effective modulator therapy.

The Modulator Revolution: Transforming, Not Replacing

One of the overarching themes throughout the conference focused on highly effective modulator therapy and its impacts on comprehensive CF care. We're living in remarkable times. Triple-combination CFTR modulators, including elexacaftor/tezacaftor/ivacaftor (Trikafta), are now the standard of care for most CF patients, dramatically improving lung function, sweat chloride levels, quality of life, and survival. As someone who works with pediatric patients daily, I've witnessed these transformations firsthand, kids who previously struggled with persistent coughs now running around the clinic, families reporting fewer hospitalizations, and growth charts finally trending upward.

But here's what I kept coming back to during those Seattle sessions: while people with CF taking modulators report better physical health and improved quality of life, these medications don't completely normalize CFTR protein activity. This means our fundamental approach to CF care, including physical therapy, airway clearance, and exercise still remains as crucial as ever, just in an evolving context.

The Exercise vs. Airway Clearance Debate: Why Not Both?

In the hallway conversations between sessions and during those impromptu coffee catch-ups, one question kept resurfacing among my PT colleagues: "Are we still pushing airway clearance as hard in the modulator era?" It's a fair question, especially when some people with CF are using exercise as a substitute for traditional airway clearance techniques.

But here's where the evidence gets really interesting. Research comparing exercise, physiotherapy, and combinations of both found that any treatment which included physiotherapy either alone or in combination with exercise produced significantly higher sputum weight during treatment time than exercise alone. In practical terms: exercise alone was less effective at clearing secretions than the other approaches.

This doesn't mean exercise isn't valuable, quite the opposite. Physical exercise improves pulmonary function through a combination of hyperventilation, mechanical vibration, coughing, and changes in sputum flow, leading to increased mucus clearance. The Cystic Fibrosis Foundation clinical practice guidelines recommend aerobic exercise as an adjunctive therapy for airway clearance, recognizing its additional overall health benefits.

The key word here is "adjunctive." Exercise is phenomenally beneficial, but it works best alongside, not instead of traditional airway clearance techniques.

What This Means for Our Patients and Families

As pediatric physical therapists working in CF care, we're not just treating lungs, we're supporting growing bodies, developing minds, and entire family systems. The evidence tells us several important things:

First, the committee determined that although there's a paucity of controlled trials assessing long-term effects of airway clearance techniques, the evidence quality overall is fair and the benefit is moderate, recommending airway clearance be performed regularly in all patients. Even with modulators improving CFTR function, airway clearance remains a cornerstone of care.

Second, no form of airway clearance therapy has been shown to be superior to another, so the prescription should be individualized to the patient. This is where we shine as therapists, working with each family to find what works for their unique situation, their child's preferences, and their daily routine.

Third, the combination approach matters. In one study, the treatment option patients preferred to continue at home was exercise followed by physiotherapy. Our job is to help families find sustainable, effective routines that incorporate both movement and targeted airway clearance.

Looking Forward: Questions We're Still Asking

Walking through those packed Seattle conference halls, I was struck by how many questions we're still exploring. How will modulator therapy initiated in early childhood affect long-term lung development? What's the optimal frequency and duration of airway clearance for kids on highly effective modulators? How do we support the mental health and well-being of our CF community as the landscape of living with CF continues to shift?

These aren't just academic questions, they're the real-world challenges we navigate with families every single day in clinic.

The Bottom Line

NACFC 2025 reinforced what many of us experience clinically: we're in an incredible era of CF care, but we haven't reached a finish line. Studies have shown that regular physical activity and exercise provide multiple benefits for people with CF that go beyond improved lung function. And combining that exercise with evidence-based airway clearance techniques gives our patients the best possible chance at healthy lungs and full, active lives.

The Seattle rain may have cleared by the time we all headed home, but the message was crystal clear: in the modulator era, comprehensive CF care means embracing both the revolutionary and the foundational. It means continuing to champion exercise while still supporting consistent airway clearance. It means individualizing care while following evidence-based guidelines. And it means showing up for our patients and families with the same dedication, whether we're in a packed convention center or in our everyday clinic rooms.

Want to stay connected? I share insights from pediatric CF care, evidence-based practice tips, and reflections on integrative therapeutic approaches right here in Beyond Balance. If this resonated with you, I'd love to have you subscribe to future editions, hit that subscribe button to join our community of clinicians committed to comprehensive, thoughtful pediatric care.

Have thoughts on exercise and airway clearance in your practice? Attended NACFC and want to share your takeaways? Let's connect in the comments or reach out directly. After all, the best insights often come from the conversations that happen after the conference sessions end.

Until next time, keep moving, keep clearing, keep caring.