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Belli S, Prince I, Savio G, Paracchini E, Cattaneo D, Bianchi M, Masocco F, Bellanti MT, Balbi B. Airway Clearance Techniques: The Right Choice for the Right Patient. Front Med (Lausanne) 2021; 8:544826. [PMID: 33634144 PMCID: PMC7902008 DOI: 10.3389/fmed.2021.544826] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Accepted: 01/14/2021] [Indexed: 12/23/2022] Open
Abstract
The management of bronchial secretions is one of the main problems encountered in a wide spectrum of medical conditions ranging from respiratory disorders, neuromuscular disorders and patients undergoing either thoracic or abdominal surgery. The purpose of this review is illustrate to the reader the different ACTs currently available and the related evidence present in literature. Alongside methods with a strong background behind as postural drainage, manual techniques or PEP systems, the current orientation is increasingly aimed at devices that can mobilize and / or remove secretions. Cough Assist, Vacuum Techniques, systems that modulate airflow have more and more scientific evidence. Different principles combination is a new field of investigation that goes toward an increasing of clinical complexity that will facing us.
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Affiliation(s)
- Stefano Belli
- Pulmonary Rehabilitation Department, Istituti Clinici Scientifici Maugeri, Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS), Institute of Veruno, Novara, Italy
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Basavaraj A, Choate R, Addrizzo-Harris D, Aksamit TR, Barker A, Daley CL, Anne Daniels ML, Eden E, DiMango A, Fennelly K, Griffith DE, Johnson MM, Knowles MR, Metersky ML, Noone PG, O'Donnell AE, Olivier KN, Salathe MA, Schmid A, Thomashow B, Tino G, Winthrop KL. Airway Clearance Techniques in Bronchiectasis: Analysis From the United States Bronchiectasis and Non-TB Mycobacteria Research Registry. Chest 2020; 158:1376-1384. [PMID: 32622820 DOI: 10.1016/j.chest.2020.06.050] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 06/02/2020] [Accepted: 06/04/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND In patients with bronchiectasis, airway clearance techniques (ACTs) are important management strategies. RESEARCH QUESTION What are the differences in patients with bronchiectasis and a productive cough who used ACTs and those who did not? What was the assessment of bronchiectasis exacerbation frequency and change in pulmonary function at 1-year follow up? STUDY DESIGN AND METHODS Adult patients with bronchiectasis and a productive cough in the United States Bronchiectasis and NTM Research Registry were included in the analyses. ACTs included the use of instrumental devices and manual techniques. Stratified analyses of demographic and clinical characteristics were performed by use of ACTs at baseline and follow up. The association between ACT use and clinical outcomes was assessed with the use of unadjusted and adjusted multinomial logistic regression models. RESULTS Of the overall study population (n = 905), 59% used ACTs at baseline. A greater proportion of patients who used ACTs at baseline and follow up continuously had Pseudomonas aeruginosa (47% vs 36%; P = .021) and experienced an exacerbation (81% vs 59%; P < .0001) or hospitalization for pulmonary illness (32% vs 22%; P = .001) in the prior two years, compared with those patients who did not use ACTs. Fifty-eight percent of patients who used ACTs at baseline did not use ACTs at 1-year follow up. There was no significant change in pulmonary function for those who used ACTs at follow up, compared with baseline. Patients who used ACTs at baseline and follow up had greater odds for experiencing exacerbations at follow up compared with those patients who did not use ACTs. INTERPRETATION In patients with bronchiectasis and a productive cough, ACTs are used more often if the patients have experienced a prior exacerbation, hospitalization for pulmonary illness, or had P aeruginosa. There is a significant reduction in the use of ACTs at 1-year follow up. The odds of the development of a bronchiectasis exacerbation are higher in those patients who use ACTs continuously, which suggests more frequent use in an ill bronchiectasis population.
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Affiliation(s)
| | - Radmila Choate
- Research, the COPD Foundation, Miami, FL; College of Public Health, University of Kentucky, Lexington, KY
| | | | - Timothy R Aksamit
- Pulmonary Disease and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Alan Barker
- Department of Pulmonology, OHSU School of Medicine, Portland, OR
| | - Charles L Daley
- Division of Mycobacterial and Respiratory Infections, National Jewish Health, Denver, CO
| | | | - Edward Eden
- Icahn School of Medicine, Mt Sinai West and Mt Sinai St Luke's Hospitals, Mt Sinai, NY
| | - Angela DiMango
- Center for Chest Disease, Columbia College of Physicians and Surgeons, New York, NY
| | - Kevin Fennelly
- National Heart Lung and Blood Institute, NIH, Bethesda, MD
| | | | | | | | - Mark L Metersky
- Division of Pulmonary and Critical Care Medicine, University of Connecticut School of Medicine, Farmington, CT
| | - Peadar G Noone
- University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | | | | | - Andreas Schmid
- University of Miami Miller School of Medicine, Miami, FL
| | - Byron Thomashow
- Center for Chest Disease, Columbia College of Physicians and Surgeons, New York, NY
| | - Gregory Tino
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Kevin L Winthrop
- Department of Pulmonology, OHSU School of Medicine, Portland, OR; Department of Infectious Disease, OHSU School of Medicine, Portland, OR
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The Efficacy of Therapeutic Respiratory Muscle Training Interventions in People with Bronchiectasis: A Systematic Review and Meta-Analysis. J Clin Med 2020; 9:jcm9010231. [PMID: 31952338 PMCID: PMC7019679 DOI: 10.3390/jcm9010231] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 01/08/2020] [Accepted: 01/10/2020] [Indexed: 12/11/2022] Open
Abstract
Background: Respiratory muscle dysfunction is an important health problem with high morbidity and mortality and associated costs in patients with bronchiectasis (BC). The aim of this study was to analyse the effects of therapeutic respiratory muscle training (RMT) interventions on improving sputum clearance, ventilator function, muscle strength and functional capacity in BC. Methods: Systematic review and meta-analysis were conducted following PRISMA guidelines. Two independent investigators searched using several electronic databases. The methodological quality of nine studies was assessed using the PEDro scale. Study selection/eligibility criteria: The following were included: randomised controlled trials, randomised crossover trials and pilot studies of patients with BC that used the intervention as RMT (inspiratory/expiratory) and evaluations of respiratory muscle strength (maximal expiratory pressure/maximal inspiratory pressure). This systematic review was registered in PROSPERO (CRD42017075101). Nine studies were included, five of which obtained an A recommendation grade, three with B, and one with C. Study quality was poor to good (mean PEDro Score of 6.375 out of 10). Studies had small sample sizes (8–98). Results show improvements on PImax in favour of therapeutic respiratory muscle training intervention (MD = 6.08; 95% CI = 1.38, 10.77; p < 0.01; I2 = 92%). However, high heterogeneity was identified on meta-analysis.
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Pereira MC, Athanazio RA, Dalcin PDTR, de Figueiredo MRF, Gomes M, de Freitas CG, Ludgren F, Paschoal IA, Rached SZ, Maurici R. Brazilian consensus on non-cystic fibrosis bronchiectasis. J Bras Pneumol 2019; 45:e20190122. [PMID: 31411280 PMCID: PMC6733718 DOI: 10.1590/1806-3713/e20190122] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 05/16/2019] [Indexed: 12/16/2022] Open
Abstract
Bronchiectasis is a condition that has been increasingly diagnosed by chest HRCT. In the literature, bronchiectasis is divided into bronchiectasis secondary to cystic fibrosis and bronchiectasis not associated with cystic fibrosis, which is termed non-cystic fibrosis bronchiectasis. Many causes can lead to the development of bronchiectasis, and patients usually have chronic airway symptoms, recurrent infections, and CT abnormalities consistent with the condition. The first international guideline on the diagnosis and treatment of non-cystic fibrosis bronchiectasis was published in 2010. In Brazil, this is the first review document aimed at systematizing the knowledge that has been accumulated on the subject to date. Because there is insufficient evidence on which to base recommendations for various treatment topics, here the decision was made to prepare an expert consensus document. The Brazilian Thoracic Association Committee on Respiratory Infections summoned 10 pulmonologists with expertise in bronchiectasis in Brazil to conduct a critical assessment of the available scientific evidence and international guidelines, as well as to identify aspects that are relevant to the understanding of the heterogeneity of bronchiectasis and to its diagnostic and therapeutic management. Five broad topics were established (pathophysiology, diagnosis, monitoring of stable patients, treatment of stable patients, and management of exacerbations). After this subdivision, the topics were distributed among the authors, who conducted a nonsystematic review of the literature, giving priority to major publications in the specific areas, including original articles, review articles, and systematic reviews. The authors reviewed and commented on all topics, producing a single final document that was approved by consensus.
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Affiliation(s)
- Mônica Corso Pereira
- . Departamento de Clínica Médica, Faculdade de Ciências Médicas, Universidade Estadual de Campinas - UNICAMP - Campinas (SP) Brasil
| | - Rodrigo Abensur Athanazio
- . Divisão de Pneumologia, Instituto do Coração - InCor - Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | - Paulo de Tarso Roth Dalcin
- . Departamento de Medicina Interna, Universidade Federal do Rio Grande do Sul, Porto Alegre (RS) Brasil
- . Serviço de Pneumologia, Hospital de Clínicas de Porto Alegre, Porto Alegre (RS) Brasil
| | | | - Mauro Gomes
- . Faculdade de Ciências Médicas da Santa Casa de São Paulo, São Paulo (SP) Brasil
- . Equipe de Pneumologia, Hospital Samaritano, São Paulo (SP) Brasil
| | | | | | - Ilma Aparecida Paschoal
- . Departamento de Clínica Médica, Faculdade de Ciências Médicas, Universidade Estadual de Campinas - UNICAMP - Campinas (SP) Brasil
| | - Samia Zahi Rached
- . Divisão de Pneumologia, Instituto do Coração - InCor - Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | - Rosemeri Maurici
- . Programa de Pós-Graduação em Ciências Médicas, Universidade Federal de Santa Catarina, Florianópolis (SC) Brasil
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Bardin PG, Rangaswamy J, Yo SW. Managing comorbid conditions in severe asthma. Med J Aust 2019; 209:S11-S17. [PMID: 30453867 DOI: 10.5694/mja18.00196] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 11/20/2018] [Indexed: 12/26/2022]
Abstract
Asthma care has increasingly focused on personalised management for severe asthma, and recognition of the role and importance of comorbid conditions has increased. Severe asthma can be crippling; associated comorbid conditions often play a key role in the significant disease morbidity and frequently contribute to a severe and difficult-to-treat asthma phenotype. Comorbid conditions can be broadly grouped as being either airway-related or airway-unrelated. Airway-related comorbid conditions with the greatest impact are allergic rhinitis, chronic rhinosinusitis, vocal cord dysfunction, lung fungal sensitisation and underlying structural lung disease. The most important airway-unrelated comorbid conditions are obesity, obstructive sleep apnoea, gastro-oesophageal reflux disease and anxiety and depression. A diagnostic and management algorithm for comorbid conditions in severe asthma is outlined. It concentrates initially on the group with common comorbid conditions that can be managed in primary care. If asthma remains troublesome, emphasis can shift to identifying uncommon and more complex factors. The algorithm allows for personalised diagnostic and management pathways to be implemented. Personalised diagnosis and management of comorbid conditions are essential to achieving effective and improved outcomes for patients with severe asthma.
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Affiliation(s)
- Philip G Bardin
- Monash Lung and Sleep, Monash Hospital and University, Melbourne, VIC
| | | | - Shaun W Yo
- Monash Lung and Sleep, Monash Hospital and University, Melbourne, VIC
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Li W, Qin Z, Gao J, Jiang Z, Chai Y, Guan L, Chen Y. Azithromycin or erythromycin? Macrolides for non-cystic fibrosis bronchiectasis in adults: A systematic review and adjusted indirect treatment comparison. Chron Respir Dis 2018; 16:1479972318790269. [PMID: 30101613 PMCID: PMC6302979 DOI: 10.1177/1479972318790269] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Non-cystic fibrosis (non-CF) bronchiectasis is a condition characterized by an
airway inflammatory response to bacterial pathogens. Frequent exacerbations have
a major influence on the quality of life. Macrolide antibiotics have not only
antibacterial but also immune-regulation effects. It is proved that macrolides
have a benefit in preventing exacerbations. However, it is still uncertain
whether azithromycin or erythromycin is more effective and safe. The purpose of
this study was to answer the following question: Which kind of macrolide
antibiotic is more effective and safe in preventing non-CF bronchiectasis
exacerbation? We conducted a systematic review to identify randomized clinical
trials published up to May 2017 that reported on macrolides for non-CF
bronchiectasis and an adjusted indirect treatment comparison (AITC) between
macrolides to evaluate their efficacy and safety. The direct comparison
meta-analysis found that macrolides decreased the rate of exacerbation of non-CF
bronchiectasis (risk ratio (RR) = 0.45; 95% confidence interval (CI) 0.36–0.55)
with heterogeneity (I2 = 63.7%, p = 0.064). The AITC showed that
azithromycin had a significantly lower bronchiectasis exacerbation rate than
erythromycin (RR = 0.35; 95% CI: 0.403–0.947). Azithromycin increased the risk
of diarrhea and abnormal pain. This meta-analysis suggested that long-term
treatment with macrolides significantly reduced the incidence of non-CF
bronchiectasis exacerbation. Moreover, azithromycin is more efficient than
roxithromycin and erythromycin in preventing exacerbation.
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Affiliation(s)
- Wen Li
- 1 Department of Preclinical Medicine, Guiyang University of Chinese Medicine, Guiyang, Guizhou, China
| | - Zhong Qin
- 1 Department of Preclinical Medicine, Guiyang University of Chinese Medicine, Guiyang, Guizhou, China
| | - Jie Gao
- 1 Department of Preclinical Medicine, Guiyang University of Chinese Medicine, Guiyang, Guizhou, China
| | - Zhibin Jiang
- 2 Department of Pharmacy, Guiyang University of Chinese Medicine, Guiyang, Guizhou, China
| | - Yihui Chai
- 1 Department of Preclinical Medicine, Guiyang University of Chinese Medicine, Guiyang, Guizhou, China
| | - Liancheng Guan
- 1 Department of Preclinical Medicine, Guiyang University of Chinese Medicine, Guiyang, Guizhou, China
| | - Yunzhi Chen
- 1 Department of Preclinical Medicine, Guiyang University of Chinese Medicine, Guiyang, Guizhou, China
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Benscoter DT. Bronchiectasis, Chronic Suppurative Lung Disease and Protracted Bacterial Bronchitis. Curr Probl Pediatr Adolesc Health Care 2018; 48:119-123. [PMID: 29602647 DOI: 10.1016/j.cppeds.2018.03.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Bronchiectasis is a structural airway disease characterized by dilated bronchi and bronchioles due to severe or recurrent lower airways inflammation. Bronchiectasis can occur as a result of chronic pulmonary aspiration. Bronchiectasis may also be associated with a wide variety of systemic diseases, which should be considered in the differential diagnosis. Children with bronchiectasis typically have a chronic or recurrent productive cough and carry a significant burden of disease with a considerable impact on quality of life. The diagnosis of bronchiectasis is made by high-resolution chest computerized tomography. Aggressive management of bronchiectasis is necessary to reduce the daily symptom burden and frequency of exacerbations. Chronic suppurative lung disease may be a precursor to bronchiectasis, only lacking the defining radiographic features of bronchiectasis. Children with chronic suppurative lung disease may have the same symptoms as children with bronchiectasis and should be treated similarly. Protracted bacterial bronchitis is defined as a cough lasting at least four weeks that responds to antibiotic therapy. Protracted bacterial bronchitis may occur following a viral respiratory tract infection. Protracted bacterial bronchitis can be treated with a prolonged course of empiric antibiotics. Further evaluation is necessary if a child with suspected protracted bacterial bronchitis does not adequately respond to antibiotics as chronic suppurative lung disease or bronchiectasis must be considered.
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Affiliation(s)
- Dan T Benscoter
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH.
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Howlett BM, Coleman GC, Hoffman RH, Lustig MR, King JG, Marsland DW. Selected Disorders of the Respiratory System. Fam Med 2017. [PMCID: PMC7121868 DOI: 10.1007/978-3-319-04414-9_93] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Respiration and gas exchange require coordination between the chest wall, lungs, central nervous system, and pulmonary circulation. A disruption within any one of these systems or a change in the relationship between systems can result in impairments of ventilation, perfusion, or gas exchange. These disruptions can result in debilitating acute and chronic respiratory disorders. This chapter discusses the etiology, epidemiology, clinical presentation, diagnostic criteria, management, and notable public health implications of respiratory system disorders not addressed in prior chapters. Topic areas covered include acute respiratory distress syndrome (ARDS), pulmonary hypertension, pneumothorax, pleural effusion, interstitial lung disease, bronchiectasis, atelectasis, and pulmonary sarcoidosis.
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Khoo JK, Venning V, Wong C, Jayaram L. Bronchiectasis in the Last Five Years: New Developments. J Clin Med 2016; 5:jcm5120115. [PMID: 27941638 PMCID: PMC5184788 DOI: 10.3390/jcm5120115] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Revised: 11/24/2016] [Accepted: 11/25/2016] [Indexed: 12/31/2022] Open
Abstract
Bronchiectasis, a chronic lung disease characterised by cough and purulent sputum, recurrent infections, and airway damage, is associated with considerable morbidity and mortality. To date, treatment options have been limited to physiotherapy to clear sputum and antibiotics to treat acute infections. Over the last decade, there has been significant progress in understanding the epidemiology, pathophysiology, and microbiology of this disorder. Over the last five years, methods of assessing severity have been developed, the role of macrolide antibiotic therapy in reducing exacerbations cemented, and inhaled antibiotic therapies show promise in the treatment of chronic Pseudomonas aeruginosa infection. Novel therapies are currently undergoing Phase 1 and 2 trials. This review aims to address the major developments within the field of bronchiectasis over this time.
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Affiliation(s)
- Jun Keng Khoo
- Department of Respiratory Medicine, Western Health, Melbourne 3011, VIC, Australia.
| | - Victoria Venning
- Department of Respiratory Medicine, Prince of Wales, Sydney 2031, NSW, Australia.
| | - Conroy Wong
- Department of Respiratory Medicine, Middlemore Hospital, Auckland 2025, New Zealand.
| | - Lata Jayaram
- Department of Respiratory Medicine, Western Health, Melbourne 3011, VIC, Australia.
- Melbourne Medical School Western Precinct, The University of Melbourne, Melbourne 3021, VIC, Australia.
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What Does the Cochrane Collaboration Say about the Effectiveness of Chest Physiotherapy in Respiratory Conditions? Physiother Can 2016; 67:393. [PMID: 27504040 DOI: 10.3138/ptc.67.4.cochrane] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Abstract
BACKGROUND Chest physiotherapy is widely used in people with cystic fibrosis in order to clear mucus from the airways. This is an updated version of previously published reviews. OBJECTIVES To determine the effectiveness and acceptability of chest physiotherapy compared to no treatment or spontaneous cough alone to improve mucus clearance in cystic fibrosis. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register which comprises references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings.Date of the most recent search of the Group's Cystic Fibrosis Trials Register: 02 June 2015. SELECTION CRITERIA Randomised or quasi-randomised clinical studies in which a form of chest physiotherapy (airway clearance technique) were taken for consideration in people with cystic fibrosis compared with either no physiotherapy treatment or spontaneous cough alone. DATA COLLECTION AND ANALYSIS Both authors independently assessed study eligibility, extracted data and assessed the risk of bias in the included studies. There was heterogeneity in the published outcomes, with variable reporting which meant pooling of the data for meta-analysis was not possible. MAIN RESULTS The searches identified 157 studies, of which eight cross-over studies (data from 96 participants) met the inclusion criteria. There were differences between studies in the way that interventions were delivered, with several of the intervention groups combining more than one treatment modality. One included study looked at autogenic drainage, six considered conventional chest physiotherapy, three considered oscillating positive expiratory pressure, seven considered positive expiratory pressure and one considered high pressure positive expiratory pressure. Of the eight studies, six were single-treatment studies and in two, the treatment intervention was performed over two consecutive days (once daily in one, twice daily in the other). This enormous heterogeneity in the treatment interventions prevented any meta-analyses from being performed. Blinding of participants, caregivers or clinicians in airway clearance studies is impossible; therefore this was not considered as a high risk of bias in the included studies. Lack of protocol data made assessment of risk of bias unclear for the majority of other criteria.Four studies, involving 28 participants, reported a higher amount of expectorated secretions during chest physiotherapy as compared to a control. One study, involving 18 participants, reported no significant differences in sputum weight. In five studies radioactive tracer clearance was used as an outcome variable. In three of these (28 participants) it was reported that chest physiotherapy, including coughing, increased radioactive tracer clearance as compared to the control period. One study (12 participants) reported increased radioactive tracer clearance associated with all interventions compared to control, although this was only reported to have reached significance for postural drainage with percussion and vibrations; and the remaining study (eight participants) reported no significant difference in radioactive tracer clearance between chest physiotherapy, without coughing, compared to the control period. Three studies, involving 42 participants reported no significant effect on pulmonary function variables following intervention; but one further study did report significant improvement in pulmonary function following the intervention in some of the treatment groups. AUTHORS' CONCLUSIONS The results of this review show that airway clearance techniques have short-term effects in the terms of increasing mucus transport. No evidence was found on which to draw conclusions concerning the long-term effects.
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Affiliation(s)
- Louise Warnock
- Oxford Centre for Respiratory Medicine, The Churchill HospitalOxford Adult Cystic Fibrosis CentreOld RoadHeadingtonOxfordUKOX3 7LJ
| | - Alison Gates
- Oxford Centre for Respiratory Medicine, The Churchill HospitalOxford Adult Cystic Fibrosis CentreOld RoadHeadingtonOxfordUKOX3 7LJ
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Abstract
BACKGROUND People with non-cystic fibrosis bronchiectasis commonly experience chronic cough and sputum production, features that may be associated with progressive decline in clinical and functional status. Airway clearance techniques (ACTs) are often prescribed to facilitate expectoration of sputum from the lungs, but the efficacy of these techniques in a stable clinical state or during an acute exacerbation of bronchiectasis is unclear. OBJECTIVES Primary: to determine effects of ACTs on rates of acute exacerbation, incidence of hospitalisation and health-related quality of life (HRQoL) in individuals with acute and stable bronchiectasis. Secondary: to determine whether:• ACTs are safe for individuals with acute and stable bronchiectasis; and• ACTs have beneficial effects on physiology and symptoms in individuals with acute and stable bronchiectasis. SEARCH METHODS We searched the Cochrane Airways Group Specialised Register of trials from inception to November 2015 and PEDro in March 2015, and we handsearched relevant journals. SELECTION CRITERIA Randomised controlled parallel and cross-over trials that compared an ACT versus no treatment, sham ACT or directed coughing in participants with bronchiectasis. DATA COLLECTION AND ANALYSIS We used standard methodological procedures as expected by The Cochrane Collaboration. MAIN RESULTS Seven studies involving 105 participants met the inclusion criteria of this review, six of which were cross-over in design. Six studies included adults with stable bronchiectasis; the other study examined clinically stable children with bronchiectasis. Three studies provided single treatment sessions, two lasted 15 to 21 days and two were longer-term studies. Interventions varied; some control groups received a sham intervention and others were inactive. The methodological quality of these studies was variable, with most studies failing to use concealed allocation for group assignment and with absence of blinding of participants and personnel for outcome measure assessment. Heterogeneity between studies precluded inclusion of these data in the meta-analysis; the review is therefore narrative.One study including 20 adults that compared an airway oscillatory device versus no treatment found no significant difference in the number of exacerbations at 12 weeks (low-quality evidence). Data were not available for assessment of the impact of ACTs on time to exacerbation, duration or incidence of hospitalisation or total number of hospitalised days. The same study reported clinically significant improvements in HRQoL on both disease-specific and cough-related measures. The median difference in the change in total St George's Respiratory Questionnaire (SGRQ) score over three months in this study was 7.5 units (P value = 0.005 (Wilcoxon)). Treatment consisting of high-frequency chest wall oscillation (HFCWO) or a mix of ACTs prescribed for 15 days significantly improved HRQoL when compared with no treatment (low-quality evidence). Two studies reported mean increases in sputum expectoration with airway oscillatory devices in the short term of 8.4 mL (95% confidence interval (CI) 3.4 to 13.4 mL) and in the long term of 3 mL (P value = 0.02). HFCWO improved forced expiratory volume in one second (FEV1) by 156 mL and forced vital capacity (FVC) by 229.1 mL when applied for 15 days, but other types of ACTs showed no effect on dynamic lung volumes. Two studies reported a reduction in pulmonary hyperinflation among adults with non-positive expiratory pressure (PEP) ACTs (difference in functional residual capacity (FRC) of 19%, P value < 0.05; difference in total lung capacity (TLC) of 703 mL, P value = 0.02) and with airway oscillatory devices (difference in FRC of 30%, P value < 0.05) compared with no ACTs. Low-quality evidence suggests that ACTs (HFCWO, airway oscillatory devices or a mix of ACTs) reduce symptoms of breathlessness and cough and improve ease of sputum expectoration compared with no treatment (P value < 0.05). ACTs had no effect on gas exchange, and no studies reported effects of antibiotic usage. Among studies exploring airway oscillating devices, investigators reported no adverse events. AUTHORS' CONCLUSIONS ACTs appear to be safe for individuals (adults and children) with stable bronchiectasis and may account for improvements in sputum expectoration, selected measures of lung function, symptoms and HRQoL. The role of these techniques in acute exacerbation of bronchiectasis is unknown. In view of the chronic nature of bronchiectasis, additional data are needed to establish the short-term and long-term clinical value of ACTs for patient-important outcomes and for long-term clinical parameters that impact disease progression in individuals with stable bronchiectasis, allowing further guidance on prescription of specific ACTs for people with bronchiectasis.
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Affiliation(s)
- Annemarie L Lee
- West Park Healthcare Centre82 Buttonwood AveTorontoONCanadaM6M 2J5
- Austin HospitalInstitute for Breathing and SleepCommercial RoadHeidelbergAustralia
| | - Angela T Burge
- Alfred HealthDepartment of PhysiotherapyCommercial RoadMelbourneVictoriaAustralia3004
- La Trobe UniversityDepartment of PhysiotherapyMelbourneAustralia
| | - Anne E Holland
- Austin HospitalInstitute for Breathing and SleepCommercial RoadHeidelbergAustralia
- Alfred HealthDepartment of PhysiotherapyCommercial RoadMelbourneVictoriaAustralia3004
- La Trobe UniversityDepartment of PhysiotherapyMelbourneAustralia
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McCullough A, Thomas ET, Ryan C, Bradley JM, O'Neill B, Elborn S, Hughes C. Interventions for enhancing adherence to treatment in adults with bronchiectasis. Cochrane Database Syst Rev 2015; 2015:CD011023. [PMID: 26576499 PMCID: PMC6483476 DOI: 10.1002/14651858.cd011023.pub2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND Bronchiectasis is characterised by a widening of the airways, leading to excess mucus production and recurrent infection. It is more prevalent in women and those in middle age. Many patients with bronchiectasis do not adhere to treatments (medications, exercise and airway clearance) prescribed for their condition. The best methods to change these adherence behaviours have not been identified. OBJECTIVES To assess the effects of interventions to enhance adherence to any aspect of treatment in adults with bronchiectasis in terms of adherence and health outcomes, such as pulmonary exacerbations, health-related quality of life and healthcare costs. SEARCH METHODS We searched the Cochrane Airways Group Specialised Register (CAGR), which contains trial reports identified through systematic searches of CENTRAL, MEDLINE, EMBASE, CINAHL, AMED and PsycINFO, from inception to October 2015. SELECTION CRITERIA We planned to include randomised controlled trials (RCTs) of adults with bronchiectasis that compared any intervention aimed at enhancing adherence versus no intervention, usual care or another adherence intervention. We excluded studies of those who had bronchiectasis due to cystic fibrosis. DATA COLLECTION AND ANALYSIS Two review authors (AMcC and ET) independently screened titles, abstracts and full-texts of identified studies. MAIN RESULTS Searches retrieved 36 studies reported in 37 articles; no eligible studies were identified. AUTHORS' CONCLUSIONS We did not identify any studies that assessed the effect of interventions to enhance adherence to treatment in bronchiectasis. Adequately powered, well-designed trials of adherence interventions for bronchiectasis are needed.
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Affiliation(s)
- Amanda McCullough
- Bond UniversityCentre for Research in Evidence‐Based Practice (CREBP)Gold CoastQueenslandAustralia
| | - Elizabeth T Thomas
- Bond UniversityCentre for Research in Evidence‐Based Practice (CREBP)Gold CoastQueenslandAustralia
| | - Cristin Ryan
- Royal College of Surgeons in IrelandSchool of Pharmacy111 St Stephen’s GreenDublin 2Ireland
| | - Judy M Bradley
- Queen's University BelfastThe Wellcome Trust‐Wolfson Northern Ireland Clinical Research Facility U FloorBelfast City HospitalLisburn RoadBelfastNorthern IrelandUKBT9 7AB
- Belfast Health and Social Care TrustDepartment of Respiratory MedicineLisburn RoadBelfastUKBT9 7AB
| | - Brenda O'Neill
- Ulster UniversityCentre for Health and Rehabilitation Technologies (CHaRT), Institute of Nursing and Health ResearchNewtownabbeyNorthern IrelandUK
| | - Stuart Elborn
- Belfast Health and Social Care TrustDepartment of Respiratory MedicineLisburn RoadBelfastUKBT9 7AB
- Queen's University BelfastCentre for Infection and ImmunityHealth Sciences Building97 Lisburn RoadBelfastNorthern IrelandUKBT9 7BL
| | - Carmel Hughes
- Queen's University BelfastSchool of Pharmacy97 Lisburn RoadBelfastNorthern IrelandUKBT9 7BL
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Griffith DE, Adjemian J, Brown-Elliott BA, Philley JV, Prevots DR, Gaston C, Olivier KN, Wallace RJ. Semiquantitative Culture Analysis during Therapy for Mycobacterium avium Complex Lung Disease. Am J Respir Crit Care Med 2015; 192:754-60. [PMID: 26068042 PMCID: PMC4595680 DOI: 10.1164/rccm.201503-0444oc] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Accepted: 06/10/2015] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Microbiologically based criteria such as sputum culture conversion to negative have traditionally been used to define treatment success for mycobacterial diseases. There are, however, limited data regarding whether nontuberculous mycobacterial sputum culture conversion or semiquantitative culture analysis correlates with subjective or nonmicrobiologic objective indices of treatment response. OBJECTIVES To determine whether a semiquantitative mycobacterial culture scale correlated with clinical disease status and was predictive of long-term sputum mycobacterial culture conversion to negative in a cohort of patients with nodular/bronchiectatic Mycobacterium avium complex lung disease undergoing therapy. METHODS One hundred and eighty patients undergoing standard macrolide-based therapy for M. avium complex lung disease were monitored at standard frequent intervals with symptomatic, radiographic, and microbiologic data collected, including semiquantitative mycobacterial culture analysis. Analyses were used to evaluate clinical and microbiologic predictors of long-term sputum conversion to culture negative. MEASUREMENTS AND MAIN RESULTS After 12 months of therapy, 148 (82%) patients had sputum conversion to culture negative. Baseline semiquantitative sputum culture scores did not differ between patients with sputum conversion and those without. The change in sputum culture semiquantitative score from baseline to Month 3 was highly predictive of subsequent sputum long-term conversion status indicative of treatment success, as was improvement in cough, and especially early radiographic improvement. CONCLUSIONS Early semiquantitative sputum agar plate culture results can be used to predict symptomatic and radiographic improvement as well as long-term sputum culture conversion to negative in this population. We suggest that semiquantitative sputum culture scores can be a useful tool for evaluating new nontuberculous mycobacterial lung disease therapies.
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Affiliation(s)
| | - Jennifer Adjemian
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
- United States Public Health Service Commissioned Corps, Rockville, Maryland; and
| | | | | | - D. Rebecca Prevots
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
| | | | - Kenneth N. Olivier
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
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15
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Welsh EJ, Evans DJ, Fowler SJ, Spencer S. Interventions for bronchiectasis: an overview of Cochrane systematic reviews. Cochrane Database Syst Rev 2015; 2015:CD010337. [PMID: 26171905 PMCID: PMC7086475 DOI: 10.1002/14651858.cd010337.pub2] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Bronchiectasis is a chronic respiratory disease characterised by abnormal dilatation of the bronchi, and presents typically with a chronic productive cough (or chronic wet cough in children) and recurrent infective exacerbations. It significantly impacts daily activities and quality of life, and can lead to recurrent hospitalisations, severe lung function impairment, respiratory failure and even death. OBJECTIVES To provide an overview of the efficacy and safety of interventions for adults and children with bronchiectasis from Cochrane reviews.To identify gaps in the evidence base that will inform recommendations for new research and reviews, and to summarise information on reported outcomes and make recommendations for the reporting of standard outcomes in future trials and reviews. METHODS We included Cochrane reviews of non-cystic fibrosis (CF) bronchiectasis. We searched the Cochrane Database of Systematic Reviews. The search is current to 11 February 2015. We also identified trials that were potentially eligible for, but not currently included in, published reviews to make recommendations for new Cochrane reviews. We assessed the quality of included reviews using the AMSTAR criteria. We presented an evidence synthesis of data from reviews alongside an evidence map of clinical trials and guideline data. The primary outcomes were exacerbations, lung function and quality of life. MAIN RESULTS We included 21 reviews but extracted data from, and rated the quality of, only nine reviews that reported results for people with bronchiectasis alone. Of the reviews with no usable data, two reviews included studies with mixed clinical populations where data were not reported separately for people with bronchiectasis and 10 reviews did not contain any trials. Of the 40 studies included across the nine reviews, three (number of participants nine to 34) included children. The studies ranged from single session to year-long studies. Each review included from one to 11 trials and 28 (70%) trials in the overview included 40 or fewer participants. The total number of participants included in reviews ranged from 40 to 1040. The age range of adult participants was from 36 to 73 years and children ranged from six to 16 years. The proportion of male participants ranged from 21% to 72%. Where reported, mean baseline forced expiratory volume in one second (FEV1) ranged from 1.17 L to 1.66 L and from 47% to 88% predicted. Most of the reviews had search dates older than two years.We have summarised the published evidence as outlined in Cochrane reviews, but it was not possible to draw definitive conclusions. There was inconclusive evidence on the use of long-term antibiotics and nebulised hypertonic saline for reducing exacerbation frequency and evidence that human deoxyribonuclease (RhDNase) increases exacerbation frequency. Improvements in lung function were reported for inhaled corticosteroids (ICS) though this was small and not clinically relevant. Evidence of benefit for hyperosmolar agents and mucolytics was inconclusive. There was limited evidence of improvements in quality of life with airway clearance techniques and physical therapy but evidence of benefit for hyperosmolar agents was inconclusive. Secondary outcomes were not clearly reported in all trials in the included reviews. Improvements in dyspnoea, wheeze and cough-free days were reported for small trials of ICS and LABA (long-acting beta2-agonsts)/ICS and cough reduction was also reported for a small bromhexine trial. Reduction in sputum production was reported for long-term antibiotics and airway clearance techniques but evidence of benefit for hyperosmolar agents was inconclusive.Adverse events were included as outcomes in seven reviews. The review of long-term (four weeks to one year) prophylactic courses of antibiotics reported significantly more cases of wheeze (Peto odd ratio (OR) 8.56, 95% confidence intervals (CI) 1.63 to 44.93), dyspnoea (12 versus three, P value = 0.01) and chest pain (seven versus zero, P value = 0.01) from the same trial (74 participants) but no differences in occurrence of diarrhoea, rash or number of withdrawals. In the review of mucolytics versus placebo, relevant outcomes were not reported for erdosteine comparisons and no significant adverse effects were reported for bromhexine, though adverse events were associated with RhDNase (OR 28.19, 95% CI 3.77 to 210.85, 1 study). Of the remaining five reviews, adverse events were not reported in the single trials included in the ICS review or the physical therapy review and the impact of adverse events in the single trial included in the inhaled LABA/ICS combination versus ICS review were unclear. The reviews of short-term courses of antibiotics and inhaled hyperosmolar agents reported no significant differences in occurrence of adverse events. Fewer admissions to hospital were reported for long-term antibiotics, but this outcome was not reported in all reviews. No reviews reported differences in mortality, but again this outcome was not included in all reviews.We did not explicitly include antibiotic resistance as an outcome in the review, but this was unclear in the Cochrane reviews and evidence from other trials should be considered.We rated all reviews as high quality (AMSTAR), though opportunities for improved reporting (e.g. summary of findings and GRADE evaluation of the evidence) were identified for inclusion in future updates of the reviews. However, the majority of trials were not high quality and confidence in the effects of treatments, therefore, requires additional evidence from larger and more methodologically robust trials. We evaluated the overall coverage of important topics in bronchiectasis by mapping the quality of the current evidence base against published guidelines and identifying high priority areas for new research on; use of short-course and long-term antibiotics, ICS and oral corticosteroids, inhaled hyperosmolars, mucolytics, and use of airway clearance techniques. AUTHORS' CONCLUSIONS This overview clearly points to significant opportunities for further research aimed at improving outcomes for people with bronchiectasis. We have highlighted important endpoints for studies (particularly exacerbations, quality of life and lung function), and areas of clinical practice that are in most urgent need of evidence-based support (including long-term antibiotics, ICSs and mucolytics).As the evidence is confined to small trials of short duration, it is not currently possible to assess the balance between the benefits and potential harms of treatments for bronchiectasis.
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Affiliation(s)
- Emma J Welsh
- St George's, University of LondonPopulation Health Research InstituteCranmer TerraceLondonUKSW17 0RE
| | - David J Evans
- Hemel Hempstead HospitalThoracic MedicineHillfield RoadHemel HempsteadHertsUKHP2 4AD
- Harefield HospitalHill End RoadHarefieldUKUB9 6JH
| | - Stephen J Fowler
- University Hospital of South ManchesterUniversity of Manchester, NIHR Respiratory and Allergy Clinical Research FacilityManchesterUK
- Lancashire Teaching Hospitals NHS Foundation TrustPrestonUK
| | - Sally Spencer
- Lancaster UniversityFaculty of Health and MedicineBailriggLancasterLancashireUKLA1 4YD
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16
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Lee AL, Burge A, Holland AE. Positive expiratory pressure therapy versus other airway clearance techniques for bronchiectasis. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2015. [DOI: 10.1002/14651858.cd011699] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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17
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El-Tahan MR. Pulmonary Hypertension and Noncardiac Surgery: Implications for the Anesthesiologist--Additional Considerations. J Cardiothorac Vasc Anesth 2015; 29:e49-50. [PMID: 25869909 DOI: 10.1053/j.jvca.2015.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2014] [Indexed: 11/11/2022]
Affiliation(s)
- Mohamed R El-Tahan
- Department of Anaesthesia and Surgical ICU King Fahd Hospital of the University of Dammam, Al Khubar Saudi Arabia
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18
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Selected Disorders of the Respiratory System. Fam Med 2015. [DOI: 10.1007/978-1-4939-0779-3_93-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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19
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Lee AL, Williamson HC, Lorensini S, Spencer LM. The effects of oscillating positive expiratory pressure therapy in adults with stable non-cystic fibrosis bronchiectasis: A systematic review. Chron Respir Dis 2014; 12:36-46. [PMID: 25518845 DOI: 10.1177/1479972314562407] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Airway clearance techniques (ACTs) are recommended for patients with stable non-cystic fibrosis (non-CF) bronchiectasis, but the efficacy of oscillating positive expiratory pressure (PEP) therapy compared to other techniques has not been reviewed. A systematic review of studies was conducted in stable patients comparing the effect of oscillating PEP therapy to other ACTs or a control condition. Data were extracted related to sputum expectoration, lung function, gas exchange, quality of life (QOL), symptoms, and exacerbation rate. Seven studies were included with a total of 146 patients, with a mean (SD) PEDro score of 7(1). Oscillating PEP therapy enhanced sputum expectoration compared to no treatment, but has equivalent benefits as the active cycle of breathing technique with gravity-assisted drainage (mean difference [95% CI] -2.8 g [-8.8 to 3.2 g]). Oscillating PEP has a similar effect as other ACTs on dynamic lung volumes, gas exchange and breathlessness. Use of oscillating PEP improved disease-specific QOL (p < 0.001) and cough-related QOL (p < 0.002) compared to no treatment but did not reduce exacerbation rate. In conclusion, in stable non-CF bronchiectasis, oscillating PEP therapy is associated with improvement in sputum expectoration and QOL compared to no treatment. Compared to other ACTs, the effect upon sputum expectoration, lung function, gas exchange, and symptoms are equivalent.
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Affiliation(s)
- Annemarie L Lee
- Physiotherapy, Alfred Health, Melbourne, Australia Institute for Breathing and Sleep, Austin Health, Heidelberg, Australia
| | | | - Sarah Lorensini
- Physiotherapy, Adelaide Community Healthcare Alliance Health, Ashford, Australia
| | - Lissa M Spencer
- Physiotherapy, Royal Prince Alfred Hospital, Camperdown, NSW, Australia Discipline of Physiotherapy, Faculty of Health Sciences, University of Sydney, NSW, Australia
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Daniels MLA, Noone PG. Genetics, diagnosis, and future treatment strategies for primary ciliary dyskinesia. Expert Opin Orphan Drugs 2014; 3:31-44. [PMID: 26998415 DOI: 10.1517/21678707.2015.989212] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Primary ciliary dyskinesia (PCD) is a genetically heterogeneous recessive disorder resulting in chronic oto-sino-pulmonary disease. While PCD is estimated to occur in 1 in 20,000 individuals, fewer than 1,000 patients in the US have a well-established diagnosis. AREAS COVERED We provide an overview of the clinical manifestations of PCD, describe the evolution of diagnostic methods, and critique the literature on management of PCD. EXPERT OPINION Although interest in clinical studies in non-CF bronchiectasis has increased in recent years, some of whom enroll patients with PCD, the literature regarding therapy for PCD as a distinct entity is lacking, as the numbers are small, and there have been no sub-analyses published. However, with improved screening and diagnostic methods, the development of clinical and research consortiums, and actively enrolling registries of PCD patients, the environment is conducive to perform longitudinal studies of disease course and therapeutic studies to alter that course.
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Affiliation(s)
- M Leigh Anne Daniels
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina, Chapel Hill, NC 27599, USA
| | - Peadar G Noone
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina, Chapel Hill, NC 27599, USA
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21
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Warnock L, Gates A, van der Schans CP. Chest physiotherapy compared to no chest physiotherapy for cystic fibrosis. Cochrane Database Syst Rev 2013:CD001401. [PMID: 24006212 DOI: 10.1002/14651858.cd001401.pub2] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Chest physiotherapy is widely used in people with cystic fibrosis in order to clear mucus from the airways. OBJECTIVES To determine the effectiveness and acceptability of chest physiotherapy compared to no treatment or spontaneous cough alone to improve mucus clearance in cystic fibrosis. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register which comprises references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings.Date of the most recent search of the Group's Cystic Fibrosis Trials Register: 04 February 2013. SELECTION CRITERIA Randomised or quasi-randomised clinical studies in which a form of chest physiotherapy (airway clearance technique) were taken for consideration in people with cystic fibrosis compared with either no physiotherapy treatment or spontaneous cough alone. DATA COLLECTION AND ANALYSIS Both authors independently assessed study eligibility, extracted data and assessed study quality. There was heterogeneity in the published outcomes, with variable reporting which meant pooling of the data for meta-analysis was not possible. MAIN RESULTS The searches identified 144 studies, of which eight cross-over studies (data from 96 participants) met the inclusion criteria. There were differences between studies in the way that interventions were delivered, with several of the intervention groups combining more than one treatment modality. One included study looked at autogenic drainage, six considered conventional chest physiotherapy, three considered oscillating positive expiratory pressure, seven considered positive expiratory pressure and one considered high pressure positive expiratory pressure. Of the eight studies, six were single-treatment studies and in two, the treatment intervention was performed over two consecutive days (once daily in one, twice daily in the other). This enormous heterogeneity in the treatment interventions prevented any meta-analyses from being performed.Four studies, involving 28 participants, reported a higher amount of expectorated secretions during chest physiotherapy as compared to a control. One study, involving 18 participants, reported no significant differences in sputum weight. In five studies radioactive tracer clearance was used as an outcome variable. In three of these (28 participants) it was reported that chest physiotherapy, including coughing, increased radioactive tracer clearance as compared to the control period. One study (12 participants) reported increased radioactive tracer clearance associated with all interventions compared to control, although this was only reported to have reached significance for postural drainage with percussion and vibrations; and the remaining study (eight participants) reported no significant difference in radioactive tracer clearance between chest physiotherapy, without coughing, compared to the control period. Three studies, involving 42 participants reported no significant effect on pulmonary function variables following intervention; but one further study did report significant improvement in pulmonary function following the intervention in some of the treatment groups. AUTHORS' CONCLUSIONS The results of this review show that airway clearance techniques have short-term effects in the terms of increasing mucus transport. No evidence was found on which to draw conclusions concerning the long-term effects.
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Affiliation(s)
- Louise Warnock
- Oxford Adult Cystic Fibrosis Centre, Oxford Centre for Respiratory Medicine, The Churchill Hospital, Old Road, Headington, Oxford, UK, OX3 7LJ
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Montella S, Mollica C, Finocchi A, Pession A, Pietrogrande MC, Trizzino A, Ranucci G, Maglione M, Giardino G, Salvatore M, Santamaria F, Pignata C. Non invasive assessment of lung disease in ataxia telangiectasia by high-field magnetic resonance imaging. J Clin Immunol 2013; 33:1185-91. [PMID: 23975689 DOI: 10.1007/s10875-013-9933-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2013] [Accepted: 08/08/2013] [Indexed: 12/18/2022]
Abstract
PURPOSE A sensitive imaging technique that assesses ataxia telangiectasia (AT) lung disease without ionizing radiation is highly desirable. We designed a study to evaluate lung changes using magnetic resonance imaging (MRI), and to investigate the relationships among severity and extent of pulmonary abnormalities and clinical, microbiological and functional data in children and young adults with AT. METHODS Fifteen AT patients (age, 11.3 years; range, 6-31) underwent 3.0-T MRI, spirometry, and deep throat or sputum culture. Images were scored using a modified Helbich score. RESULTS Although only 8 patients (53 %) had recurrent/chronic respiratory symptoms, MRI identified lung abnormalities in all. Bronchiectasis, peribronchial thickening, mucous plugging, and collapse/consolidation were present in 60 %, 87 %, 67 %, and 13 % of cases, respectively, with no difference between subjects with or without respiratory symptoms. No difference in changes of specific scores was found between the two groups, but the total MRI score was higher in patients with respiratory symptoms (6.5 versus 5, respectively; p = 0.02). Total or specific MRI scores were not associated with patients' age. Of all scores, only mucous plugging subscore appeared significantly related to FEV1 (r = 0.7, p = 0.04) and FEF25-75% (r = 0.9, p = 0.001). MRI scores from patients with positive (n = 5) or negative (n = 10) sputum culture were not significantly different. CONCLUSIONS MRI is valuable in the assessment of extent and severity of pulmonary changes in children and adults with AT. It represents an helpful tool for the longitudinal evaluation of patients and may be also used as an outcome surrogate to track the effects of medications.
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Affiliation(s)
- Silvia Montella
- Department of Translational Medical Sciences, "Federico II" University, Via Pansini 5, 80131, Naples, Italy
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