Positive expiratory pressure therapy versus other airway clearance techniques for bronchiectasis

Efficacy of an oscillating positive expiratory pressure device in patients with Mycobacterium avium complex pulmonary disease

Patients with Mycobacterium avium complex pulmonary disease (MAC-PD) often suffer from chronic symptoms such as sputum production, which reduces quality of life. Oscillatory positive expiratory pressure (OPEP) devices are used in physiotherapy to promote the clearance of respiratory secretions. We report two cases of improved lung function and improved scores on the Leicester Cough Questionnaire (LCQ) and the Breathlessness, Cough and Sputum Scale (BCSS) after the use of OPEP in patients with MAC-PD where treatment with guideline-based therapy, including amikacin liposome inhalation suspension, had proved ineffective for symptoms. Use of OPEP might maximize the efficacy of therapy and thereby improves outcomes in patients with MAC-PD. It is important to use both guideline-based therapy and OPEP, especially in patients whose health-related quality of life is affected by sputum symptoms. Further prospective studies are warranted to assess the benefit of adding OPEP to guidelines concerning therapy for patients with MAC-PD and sputum symptoms.

Airway clearance management in people with bronchiectasis: data from the European Bronchiectasis Registry (EMBARC)

BACKGROUND

International guidelines recommend airway clearance management as one of the important pillars of bronchiectasis treatment. However, the extent to which airway clearance is used for people with bronchiectasis in Europe is unclear. The aim of the study was to identify the use of airway clearance management in patients with bronchiectasis across different countries and factors influencing airway clearance use.

METHODS

This was a prospective observational study using data from the European Multicentre Bronchiectasis Audit and Research Collaboration (EMBARC) Registry between January 2015 and April 2022. Prespecified options for airway clearance management were recorded, including airway clearance techniques, devices and use of mucoactive drugs.

RESULTS

16 723 people with bronchiectasis from 28 countries were included in the study. The mean age was 67 years (interquartile range 57-74 years, range 18-100 years) and 61% were female. 72% of the participants reported daily sputum expectoration and 52% (95% CI 51-53%) of all participants reported using regular airway clearance management. Active cycle of breathing technique was used by 28% of the participants and airway clearance devices by 16% of participants. The frequency of airway clearance management and techniques used varied significantly between different countries. Participants who used airway clearance management had greater disease severity and worse symptoms, including a higher daily sputum volume, compared to those who did not use it regularly. Mucoactive drugs were also more likely to be used in participants with more severe disease. Access to specialist respiratory physiotherapy was low throughout Europe, but particularly low in Eastern Europe.

CONCLUSIONS

Only a half of people with bronchiectasis in Europe use airway clearance management. Use of and access to devices, mucoactive drugs and specialist chest physiotherapy appears to be limited in many European countries.

Incremental Load Respiratory Muscle Training Improves Respiratory Muscle Strength and Pulmonary Function in Children with Bronchiectasis

Methods

Participants underwent respiratory muscle training for 24 weeks. The main results were changes in respiratory muscle strength and pulmonary function indices (forced expiratory volume in 1 s (FEV1), forced vital capacity (FVC), FEV1/FVC, peak expiratory flow rate (PEF), forced expiratory flow 25-75% (FEF25-75%), and maximal midexpiratory flow 75/25 (MMEF75/25)) before, 12 weeks after, and 24 weeks after the intervention. The secondary outcomes were changes in the exercise load and work rate, exercise work, Leicester Cough Questionnaire (LCQ) scale, and Fatigue Severity Scale (FSS).

Results

Compared with before the intervention, after 24 weeks of respiratory muscle training, the maximal inspiratory pressure (MIP) and maximal expiratory pressure (MEP) were significantly enhanced (P < 0.05), while FVC, FEV1, and PEF were significantly increased (P < 0.01). FEF25-75 and MMEF75/25 values showed significant improvement compared to those before training (P < 0.05). The exercise loading, work, and exercise work rate of expiratory muscle training were significantly improved compared to those before intervention (P < 0.05). The LCQ score increased significantly (P <  0.001), and the FSS score decreased significantly (P <  0.001).

Conclusion

Incremental load respiratory muscle training effectively improved children's lung function over the long term, improved the strength of their inspiratory and expiratory muscles, and improved their quality of life.

Effect of post-extubation high-flow nasal cannula combined with respiratory training versus conventional oxygen therapy on postoperative pulmonary complications in patients after major abdominal surgery: protocol for a single-centre randomized controlled trial

BACKGROUND

Nearly 234 million patients undergo surgery each year, and 1.3 million among them develop complications. Patients undergoing major upper abdominal surgery (operation time > 2 h) have a really high incidence of postoperative pulmonary complications (PPCs). The occurrence of PPCs seriously affects the outcomes of patients. High-flow nasal cannula (HFNC) is as effective as noninvasive ventilation (NIV) in preventing postoperative hypoxaemia and respiratory failure. Respiratory training using positive expiratory pressure (PEP) Acapella (Choice) has been shown to help patients with rapid recovery from postoperative atelectasis. However, no relevant randomized controlled studies have been conducted to clarify the effect of HFNC combined with respiratory training in the prevention of PPCs. This study aims to investigate whether the use of HFNC combined with respiratory training could reduce the incidence of PPCs within 7 days after major upper abdominal surgery compared to that with conventional oxygen therapy (COT).

METHODS

This is a randomized controlled single-centre trial. A total of 328 patients who undergo major abdominal surgery will be included. Subjects who fulfil the eligible criteria will be randomly assigned into the combination treatment group (Group A) or COT group (Group B) after extubation. The interventions will begin within 30 min of extubation. Patients in Group A will receive HFNC for at least 48 h and respiratory training three times a day for at least 72 h. Patients in Group B will receive oxygen therapy through a nasal catheter or mask for at least 48 h. Our primary endpoint is the incidence of PPCs within 7 days, and the secondary outcome measures include 28-day mortality, reintubation rate, length of hospital stay, and all-cause mortality within 1 year.

DISCUSSION

This trial would help provide evidence on the effectivity of applying HFNC combined with respiratory training for the prevention of PPCs in patients undergoing major upper abdominal surgery. The objective of this study is to determine the optimal treatment approach to improve the prognosis of patients undergoing surgery.

TRIAL REGISTRATION

ChiCTR2100047146. Registered on 8 June 2021. Retrospectively registered.

Evaluation of safety and efficacy of inhaled ambroxol in hospitalized adult patients with mucopurulent sputum and expectoration difficulty

Background

Ambroxol is a widely used mucoactive drug in sputum clearance of respiratory diseases taken orally and by injection. However, there is a paucity of evidence for inhaled ambroxol in sputum clearance.

Methods

This study performed a multicenter, randomized, double-blind, placebo-controlled, phase 3 trial at 19 centers in China. Hospitalized adult patients with mucopurulent sputum and expectoration difficulty were recruited. Patients were randomized by 1:1 to receive inhalation of either ambroxol hydrochloride solution 3 mL (22.5 mg) + 0.9% sodium chloride 3 mL or 0.9% sodium chloride 6 mL twice daily for 5 days, with an interval of more than 6 h. The primary efficacy endpoint was the absolute change in the sputum property score after treatment compared to the baseline in the intention-to-treat population.

Results

Between 10 April 2018 and 23 November 2020, 316 patients were recruited and assessed for eligibility, of whom 138 who received inhaled ambroxol and 134 who received a placebo were included. Patients who received inhaled ambroxol had a significantly greater decrease in the sputum property score compared with patients who received inhalation of placebo (difference: -0.29; 95% CI: -0.53 to -0.05; p = 0.0215). Compared with the placebo, inhaled ambroxol also significantly reduced more expectoration volume in 24 h (difference: -0.18; 95% CI: -0.34 to -0.03; p  = 0.0166). There was no significant difference in the proportion of adverse events between the two groups, and no deaths were reported.

Discussion

In hospitalized adult patients with mucopurulent sputum and expectoration difficulty, inhaled ambroxol was safe and effective for sputum clearance compared with a placebo.

Clinical trial registration

[https://www.chictr.org.cn/showproj.html?proj=184677], Chinese Clinical Trial Registry [ChiCTR2200066348].

Effectiveness of the use of an oscillating positive expiratory pressure device in bronchiectasis with frequent exacerbations: a single-arm pilot study

Impaired airway clearance in patients with non-cystic fibrosis bronchiectasis causes frequent bacterial infection, chronic inflammation, and progressive tissue destruction. We aimed to evaluate whether an oscillating positive expiratory pressure (OPEP) device could allow effective sputum expectoration and prevent acute exacerbations in patients with bronchiectasis who had frequent acute exacerbations. This open-label, single-arm, prospective study included 17 patients who experienced three or more acute exacerbations in the past year. We evaluated the prevention of acute exacerbations, subjective symptom improvement, and change in sputum amount during the use of the Aerobika (Trudell Medical International, London, ON) OPEP device twice daily for 6  months. Of all enrolled patients, only two acute exacerbations occurred during the study period, indicating a significant decrease compared with the number of acute exacerbations before the device use (p < 0.001). Additionally, Bronchiectasis Health Questionnaire score changed from 58.7 to 66.6, showing significant improvement over the treatment period (p < 0.001). The largest sputum volume was observed 3  months after OPEP device use (baseline: 10 ml, 3rd month 25 ml, p = 0.325). There were no major adverse events related to the use of OPEP devices. Twice-daily physiotherapy with OPEP device in patients with bronchiectasis who have frequent exacerbations may facilitate symptomatic improvement and prevention of acute exacerbations without serious adverse events.

Active cycle of breathing technique versus oscillating PEP therapy versus walking with huffing during an acute exacerbation of bronchiectasis: a randomised, controlled trial protocol

BACKGROUND

Airway clearance techniques (ACTs) for individuals with bronchiectasis are routinely prescribed in clinical practice and recommended by international guidelines, especially during an acute exacerbation. However, there is limited evidence of the efficacy of these techniques during an exacerbation to improve sputum expectoration, health-related quality-of-life (HRQOL) or exercise tolerance. The primary aim of this study is to compare the effects of the active cycle of breathing technique (ACBT), oscillating positive expiratory pressure (O-PEP) therapy, and walking with huffing on sputum expectoration for adults hospitalised with an acute exacerbation of bronchiectasis. Secondary aims are to compare the effects of these interventions on HRQOL, health status, exacerbation rates and hospital admissions in a six-month period following hospital discharge.

METHODS

This multi-centre randomised controlled trial will recruit adults with an acute exacerbation of bronchiectasis requiring hospital admission. Participants will be randomised to receive one of three interventions: ACBT, O-PEP therapy, and walking with huffing. Outcome measures including sputum volume during and 1-h post ACT session, and 24-h sputum, as well as health status, HRQOL and exercise capacity will be completed during inpatient stay on day 2 and day 6 of admission, and within 24 h of hospital discharge. Time to first exacerbation, and time to first hospitalisation will be monitored via monthly phone calls for six months post hospital discharge. Health status and HRQOL will be assessed after discharge at two and six months, and exercise capacity will be assessed at six months post hospital discharge.

DISCUSSION

Despite recommendations regarding the importance of ACT for individuals with bronchiectasis during an acute exacerbation, there is a gap in the literature regarding effectiveness of ACT when undertaken by individuals in this clinical state. This study will add to the evidence base regarding the effectiveness of commonly implemented ACTs during a hospital admission with an exacerbation of bronchiectasis. Additionally, it will contribute to knowledge of the long term effects on important and patient-centred outcomes, including incidence of future exacerbations, and HRQOL, which has not been previously established. Trial registration Registered on the Australian and New Zealand Clinical Trials Registry (ACTRN12621000428864).

[The use of oscillatory respiratory therapy with positive expiratory pressure (PEP-therapy) to restore the functional state of the lungs in patients after cardiac surgery]

Postoperative pulmonary complications in cardiac surgery patients occur in 10-35% of cases, depending on differences in their definition, patient characteristics and type of surgical intervention, most of them are associated with ineffective coughing and evacuation of bronchial secretions.

OBJECTIVE

To determine the effectiveness of stimulating the evacuation of bronchial secretions with the help of oscillating PEP therapy carried out during the first three days.

MATERIAL AND METHODS

A randomized prospective study of 60 adult patients after elective cardiac surgery was performed (Clinical Trials.gov. protocol number NCT05159401). Oscillatory PEP-therapy was performed in 30 patients using Acapella DHGreen device (SmithMedicalASD, USA) 10-12 hours after tracheal extubation 3 times a day for 3 days after surgery. The control group (30 patients). The inclusion criteria: age over 18 years, spontaneous breathing after tracheal extubation, clear consciousness and productive contact with the patient, the ability to maintain adequate gas exchange on the low-flow oxygen inhalation, adequate analgesia (<2 points of VAS). Exclusion criteria: the need for re-intubation and mechanical ventilation, non-invasive mask ventilation, high-flow oxygen therapy, acute cerebrovascular accident, ongoing bleeding, cardiac insufficiency (inotropic index >10), shocks syndrome of various etiologies, the use of any extracorporeal support, any neuromuscular disorders, pneumothorax, hydro-or hemothorax. Before each session and 20 minutes after its end, when breathing air, blood oxygen saturation was recorded using a pulse oximeter (SpO2), the maximum inspiratory capacity (MIC) was measured using a Coach-2 incentive spirometer from SmithsMedical and spirometry with a portable ultrasonic spirometer Spiro Scout (Schiller, Switzerland). For the purposes of this work, the total index of the spirometry maximum inspiratory capacity (SMIC) was used - the sum of the respiratory volume and the reserve volume of inspiration in ml.

RESULTS

Difficulties in evacuation of sputum were noted in 90% of patients. Three-day sessions of oscillating PEP- therapy are accompanied by a significant improvement in the passage of sputum, as evidenced by a 3-fold increase in the number of patients with productive cough. The increase in MIC in the main group was 46.9% and 21.3%, respectively (p=0.042), and the number of patients with values greater than MICo. 1500 ml increased from 23.3% to 7.6% (p<0.001). The effectiveness of oscillatory PEP-therapy is confirmed by a 7-fold decrease in the frequency of radiological changes in the lungs at the end of sessions (p<0.001), while in the control group the frequency of their occurrence practically did not change and remained at a high level. The total number of patients with respiratory insufficiency (SpO2≤92%) decreased by 8.6 times after completion of all PEP- therapy sessions (p=0.001), however, without statistically significant difference with the control group.

CONCLUSIONS

Oscillatory PEP- therapy in cardiac surgery patients has a positive effect on sputum passage, ventilation parameters and oxygenating lung function. The procedure was well tolerated and there were no complications associated with it.

Dyspnea: a map of Cochrane evidence relevant to rehabilitation for people with post COVID-19 condition

INTRODUCTION

Rehabilitation focuses on impairments, activity limitations and participation restrictions being informed by the underlying health condition. In the current absence of direct "evidence on" rehabilitation interventions for people with post COVID-19 condition (PCC), we can search and synthesize the indirect "evidence relevant to" coming from interventions effective on the symptoms of PCC in other health conditions. The World Health Organization (WHO) required this information to inform expert teams and provide specific recommendations in their Guidelines. With this overview of reviews with mapping we aimed to synthesize in a map the Cochrane evidence relevant to rehabilitation for dyspnea due to PCC.

EVIDENCE ACQUISITION

We searched the last five years' Cochrane Systematic Review (CSRs) using the terms "dyspnea" and its synonyms in the Cochrane Library. We extracted and summarized all the available evidence using a map. We grouped the included CSRs for health conditions and interventions, indicating the effect and the quality of evidence.

EVIDENCE SYNTHESIS

We found 371 CSRs published between 2016 and 2021 and included 15 in this overview. We found eight studies on chronic obstructive pulmonary disease, two on cancer, and one for bronchiectasis, chronic respiratory disease, cystic fibrosis, idiopathic pulmonary fibrosis and interstitial lung disease. Effective interventions included pulmonary rehabilitation, also in combination with exercise training, non-invasive ventilation, upper limb training and multicomponent integrated interventions, with very low- to moderate-quality evidence.

CONCLUSIONS

These results are the first step of indirect evidence to generate helpful hypotheses for clinical practice and future research on dyspnea in adults with PCC. They served as the basis for one recommendation on treatments for dyspnea as a PCC symptom published in the current WHO Guidelines for clinical practice.

Fatigue, post-exertional malaise and orthostatic intolerance: a map of Cochrane evidence relevant to rehabilitation for people with post COVID-19 condition

INTRODUCTION

Rehabilitation focuses on impairments, activity limitations and participation restrictions being informed by the underlying health condition. In the current absence of direct "evidence on" rehabilitation interventions for people with post-COVID-19 condition (PCC), we can search and synthesize the indirect "evidence relevant to" coming from interventions effective for the symptoms of PCC in other health conditions. The World Health Organization (WHO) required this information to inform expert teams and provide specific recommendations in their Guidelines. With this overview of reviews with mapping, we aimed to synthesize in a map the Cochrane evidence relevant to rehabilitation for fatigue, post-exertional malaise and orthostatic intolerance due to PCC.

EVIDENCE ACQUISITION

We searched the last five years' Cochrane Systematic Review (CSRs) using the terms "fatigue," "orthostatic intolerance," "rehabilitation" and their synonyms in the Cochrane Library. We extracted and summarized the available evidence using a map. We grouped the included CSRs for health conditions and interventions, indicating the effect and the quality of evidence.

EVIDENCE SYNTHESIS

Out of 1397 CSRs published between 2016 and 2021, we included 32 for fatigue and 4 for exercise intolerance. They provided data from 13 health conditions, with cancer (11 studies), chronic obstructive pulmonary disease (7 studies), fibromyalgia (4 studies), and cystic fibrosis (3 studies) being the most studied. Effective interventions for fatigue included exercise training and physical activities, telerehabilitation and multicomponent and educational interventions. Effective interventions for exercise intolerance included combined aerobic/anaerobic training and integrated disease rehabilitation management. The overall quality of evidence was low to very low and moderate in very few cases. We did not identify CSRs that specifically addressed post-exertional malaise or orthostatic intolerance.

CONCLUSIONS

These results are the first step of indirect evidence able to generate helpful hypotheses for clinical practice and future research. They served as the basis for the three recommendations on treatments for these PCC symptoms published in the current WHO Guidelines for clinical practice.

Non-Cystic Fibrosis Bronchiectasis in Pediatric Age: A Case Series in a Metropolitan Area of Northern Italy

Non-cystic fibrosis bronchiectasis is an emergent disease characterized by endobronchial suppuration, dilated airways with neutrophilic inflammation and chronic wet cough due to recurrent lower airway infections. A regular clinical follow-up and adequate management of exacerbations are essential to reduce symptoms and the worsening of lung injury. We report a retrospective study comprising 15 children and adolescents with NCFB followed in our hospital center of pediatric pulmonology. We retrospectively analyzed the main comorbidities associated with the presence of NCFB, the radiological aspect associated with the different etiologies and the therapeutic approach used. We also emphasized the importance of an effective preventive strategy to reduce and prevent pulmonary exacerbations.

Bronchiectasis in African children: Challenges and barriers to care

Bronchiectasis (BE) is a chronic condition affecting the bronchial tree. It is characterized by the dilatation of large and medium-sized airways, secondary to damage of the underlying bronchial wall structural elements and accompanied by the clinical picture of recurrent or persistent cough. Despite an increased awareness of childhood BE, there is still a paucity of data on the epidemiology, pathophysiological phenotypes, diagnosis, management, and outcomes in Africa where the prevalence is mostly unmeasured, and likely to be higher than high-income countries. Diagnostic pathways and management principles have largely been extrapolated from approaches in adults and children in high-income countries or from data in children with cystic fibrosis. Here we provide an overview of pediatric BE in Africa, highlighting risk factors, diagnostic and management challenges, need for a global approach to addressing key research gaps, and recommendations for practitioners working in Africa.

Assessment of the microbial load of airway clearance devices used by a cohort of children with cystic fibrosis

Background

Positive expiratory pressure (PEP) devices are an important element of the management of cystic fibrosis, and of other respiratory diseases. Whereas there have been reports in the literature of contamination of airway clearance devices and their surfaces by microbial pathogens, there is little evidence available regarding such contamination and its contribution to respiratory infection.

Aim

To establish whether pathogenic bacteria can contaminate PEP devices in the context of normal cleaning and maintenance practices.

Methods

Patients' home-use clearance devices were brought to a routine clinic appointment and collected for microbiology sampling and analysis. The patients were provided with replacement devices. Nineteen such devices were collected from 17 patients, reflecting use of multiple devices by some patients. Swabs were taken and cultured from each patient's used device, the patient's airway, as well as from new unopened and unused devices that acted as controls.

Results

Seven of 19 devices (37%) tested positive for presence of pathogenic bacteria. Device-cleaning methods varied among patients and non-sterilization methods were found to be ineffective at removing pathogens. Microbial species found on the devices did not correlate with those identified from airway swabs.

Conclusion

This study demonstrates the presence of pathogens on positive expiratory pressure devices. The potential for transmission of these pathogens to the patient's airway and the risk of infection remains unclear and requires further study.

The Deteriorating Patient: Therapies Including Lung Transplantation

In this review paper, we discuss the characteristics that define severe bronchiectasis and which may lead to deterioration of noncystic fibrosis bronchiectasis. These characteristics were used to establish the current severity scores: bronchiectasis severity index (BSI), FACED, and E-FACED (exacerbation frequency, forced expiratory volume in 1 second, age, colonization, extension and dyspnea score). They can be used to predict mortality, exacerbation rate, hospital admission, and quality of life. Furthermore, there are different treatable traits that contribute to severe bronchiectasis and clinical deterioration. When present, they can be a target of the treatment to stabilize bronchiectasis.One of the first steps in treatment management of bronchiectasis is evaluation of compliance to already prescribed therapy. Several factors can contribute to treatment adherence, but to date no real interventions have been published to ameliorate this phenomenon. In the second step, treatment in deteriorating patients with bronchiectasis should be guided by the predominant symptoms, for example, cough, sputum, difficulty expectoration, exacerbation rate, or physical impairment. In the third step, we evaluate treatable traits that could influence disease severity in the deteriorating patient. Finally, in patients who are difficult to treat despite maximum medical treatment, eligibility for surgery (when disease is localized), should be considered. In case of end-stage disease, the evaluation for lung transplantation should be performed. Noninvasive ventilation can serve as a bridge to lung transplantation in patients with respiratory failure.

Airway Clearance Techniques: The Right Choice for the Right Patient

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.

The effect of vibrating positive expiratory pressure therapy on refractory Mycoplasma pneumoniae pneumonia prognosis in children

BACKGROUND

It is well documented that vibration techniques and positive expiratory pressure (PEP) can improve airway clearance, however, few clinical trials have studied the efficacy of vibrating PEP therapy on refractory Mycoplasma pneumoniae (M. pneumoniae) pneumonia (RMPP) in children. This study aimed to explore using vibrating PEP therapy in children with RMPP.

METHODS

Sixty participants in the remission stage of RMPP were recruited into this randomized study and divided into two groups. The Acapella group (n=30) used the Acapella^® Choice twice daily for 2 months to clear their airways. The control group (n=30) used traditional chest percussion or postural drainage to mediate sputum expectoration. The groups administered their respective treatments at home and were followed up weekly. Participants kept a record of their treatment and condition in a daily log. The primary outcome of this study was the resolution of chest images, and the secondary outcome was the sputum period.

RESULTS

There was no significant difference in sex or age distribution between the two groups. There were no significant differences at baseline between the groups in the location of their lesions (P=0.11). After 2 months of treatment, there was a better resolution of chest images in the Acapella group (P=0.00) compared with the control group. Additionally, the mean sputum period was significantly shorter for the Acapella group than for the control group (Acapella: 7.97±1.54 days; control: 11.90±1.64 days; P=0.00).

CONCLUSIONS

Vibrating PEP therapy is an effective therapy for children with RMPP, both in airway clearance and the resolution of lung abnormalities.

Physiotherapists' use of airway clearance techniques during an acute exacerbation of bronchiectasis: a survey study

BACKGROUND

Airway clearance techniques are recommended for individuals with bronchiectasis both in stable state and during an acute exacerbation, however the current use of airway clearance techniques in the management of individuals during an acute exacerbation is unclear. The aims of this study were to establish what current physiotherapy clinical practice comprises for adults and paediatrics during an acute exacerbation of bronchiectasis; identify physiotherapist's perceptions of the effectiveness of airway clearance techniques and identify what factors influence their treatment decisions in this population.

METHODS

An anonymous online survey was distributed to the members of the Australian Physiotherapy Association and Physiotherapy New Zealand between August 2016 and April 2017.

RESULTS

The survey was accessed by 130 physiotherapists and 121 of those deemed themselves eligible and consented to participate. Most participants (89%) reported prescribing airway clearance techniques for 81-100% of individuals during an acute exacerbation of bronchiectasis. The most commonly used airway clearance techniques with adults were huffing (92%), exercise (89%) and the active cycle of breathing technique (89%). The techniques perceived most effective for adults were physical exercise (100%), oscillating positive expiratory pressure devices (97%), directed huffing (95%) the active cycle of breathing technique (90%) and positive expiratory pressure (90%). The most commonly used airway clearance techniques for paediatric patients were: newborn-3 years - percussion (85%) and modified postural drainage (85%); 4-10 years - huffing (100%) and exercise (85%); 11-18 years - huffing (92%) and exercise (77%), active cycle of breathing technique (77%) and positive expiratory pressure therapy (77%). The techniques perceived most effective for paediatric patients were directed huffing (100%), percussion (100%) and positive expiratory pressure via a mask or mouthpiece (93%). The most commonly reported factors influencing choice of technique were patient clinical presentation (72%) and the presence/absence of contra-indications (72%).

CONCLUSION

This survey demonstrates that airway clearance techniques are routinely used as part of physiotherapy management of individuals experiencing an acute exacerbation of bronchiectasis, and that choice of technique and perceived effectiveness varies depending on the age of the patient.

Preference for Aggressive End-of-Life Care among Advanced Cancer Patients in Wuhan, China: A Cross-Sectional Study

Life-sustaining treatments (LSTs) and end-of-life (EOL) care’s goal for prolonging one’s life are defined as aggressive EOL care among critically ill patients. They have limited effects and add unnecessary financial burden to advanced cancer patients. A questionnaire survey was conducted to collect information on demographics, disease conditions, preference for LSTs, and goal of EOL care among advanced cancer patients of comprehensive grade-A tertiary hospitals in Wuhan, mainland China. Most patients preferred to accept LSTs when they were in a critical condition, including cardiopulmonary resuscitation (89.9%), mechanical ventilation support (85.7%), nasogastric tube feeding (84.1%), blood transfusion (89.8%), general surgery (87.5%), and hemodialysis (85.8%). Most (88%) preferred prolonging life as the goal of EOL care. Logistic regression showed common influencing factors were participants who completed junior high/high school or below and were financially adequate had higher reference for aggressive EOL care. Patients whose physician had accurately disclosed prognosis; however, showed a decrease trend for aggressive EOL care. Most advanced cancer patients preferred to accept aggressive EOL care. Discussions about prognosis disclosure among physicians and patients should be improved. Education about LSTs’ limitations and comfort-oriented care’s benefits should be promoted among the advanced cancer patients in mainland China.

Analogy between classical Yoga/Zen breathing and modern clinical respiratory therapy

Anesthesiologists and intensivists are modern-day professionals who provide appropriate respiratory care, vital for patient survival. Recently, anesthesiologists have increasingly focused their attention on the type of spontaneous breathing made by non-intubated patients with pulmonary disease cared for in an intensive care unit, and also patients with chronic pain receiving cognitive behavioral therapy. Prior to our modern understanding of respiratory physiology, Zen meditators recognized that breathing has a significant impact on a person’s mental state and general physical well-being. Examples of this knowledge regarding respiration include the beneficial effects of deep inhalation and slow exhalation on anxiety and general wellness. The classical literature has noted many suggestions for breathing and its psycho-physical effects. In the present review, we examine the effect of classical breathing methods and find an analogy between typical Yoga/Zen breathing and modern clinical respiratory therapy. Evidence is increasing about historical breathing and related meditation techniques that may be effective in modern clinical practice, especially in the field of anesthesiology, such as in improving respiratory function and reducing chronic pain. Clarification of the detailed mechanisms involved is anticipated.

Airway Clearance Techniques in Bronchiectasis: Analysis From the United States Bronchiectasis and Non-TB Mycobacteria Research Registry

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.

Infection prevention and chronic disease management in cystic fibrosis and noncystic fibrosis bronchiectasis

Bronchiectasis is a chronic lung disease (CLD) characterized by irreversible bronchial dilatation noted on computed tomography associated with chronic cough, ongoing viscid sputum production, and recurrent pulmonary infections. Patients with bronchiectasis can be classified into two groups: those with cystic fibrosis and those without cystic fibrosis. Individuals with either cystic fibrosis related bronchiectasis (CFRB) or noncystic fibrosis related bronchiectasis (NCFRB) experience continuous airway inflammation and suffer airway architectural changes that foster the acquisition of a unique polymicrobial community. The presence of microorganisms increases airway inflammation, triggers pulmonary exacerbations (PEx), reduces quality of life (QOL), and, in some cases, is an independent risk factor for increased mortality. As there is no cure for either condition, prevention and control of infection is paramount. Such an undertaking incorporates patient/family and healthcare team education, immunoprophylaxis, microorganism source control, antimicrobial chemoprophylaxis, organism eradication, daily pulmonary disease management, and, in some cases, thoracic surgery. This review is a summary of recommendations aimed to thwart patient acquisition of pathologic organisms, and those therapies known to mitigate the effects of chronic airway infection. A thorough discussion of airway clearance techniques and treatment of or screening for nontuberculous mycobacteria (NTM) is beyond the scope of this discussion.

A novel device combining acoustic vibration with oscillating expiratory pressure for the treatment of nasal congestion

BACKGROUND

Chronic nasal congestion affects 20% of the population with significant impact on quality of life. This study investigated the simultaneous administration of nasal acoustic vibration and oscillating expiratory pressure for the treatment of nasal congestion.

METHODS

Patients with chronic nasal congestion but without fixed anatomic obstruction participated in a prospective clinical study applying simultaneous acoustic vibrations and positive expiratory pressure to the nasal cavity twice daily over 5 weeks. Safety was assessed by rhinoscopy and patient questionnaires. Efficacy was assessed using peak nasal inspiratory flow (PNIF), visual analogue scale (VAS) of nasal symptoms, Total Nasal Symptom Score (TNSS), Nasal Obstruction and Septoplasty Effectiveness (NOSE) score, and the 22-item Sino-Nasal Outcome Test (SNOT-22).

RESULTS

Forty patients (mean age 39 years, 65% female) completed the study with no adverse effects. At the 2 week follow-up, PNIF improved by 25.0 L/min (31% increase from baseline, p < 0.001). At the 5 week follow-up, nasal congestion VAS improved from mean ± SD of 5.8 ± 2.4 to 2.6 ± 2.3, TNSS improved from 7.2 ± 3.5 to 3.5 ± 3.1, NOSE improved from 50.4 ± 19.9 to 23.3 ± 17.2, and SNOT-22 improved from 31.7 ± 20.3 to 14.2 ± 12.7, all p < 0.001. Eighty percent of patients would use the device again and 87.5% would recommend to others.

CONCLUSION

Simultaneous administration of acoustic vibration and oscillating expiratory pressure appears to be a safe treatment for chronic nasal congestion. Results from this initial study are promising with regard to efficacy but will require further study.

Contemporary management of bronchiectasis in children

Introduction: Bronchiectasis is increasingly recognized as a major cause of morbidity and mortality worldwide. It affects children of all ethnicities and socioeconomic backgrounds and represents a far greater burden than cystic fibrosis (CF). Bronchiectasis often begins in childhood and the radiological changes can be reversed, when mild, with optimal management. As there are limited pediatric studies in this field, current treatment approaches in children are based largely upon adult and/or CF studies. The recent establishment of bronchiectasis registries will improve understanding of pediatric bronchiectasis and increase capacity for large-scale research studies in the future. Areas covered: This review summarizes the current management of bronchiectasis in children and highlights important knowledge gaps and areas for future research. Current treatment approaches are based largely on consensus guidelines from international experts in the field. Studies were identified through searching Medline via the Ovid interface and Pubmed using the search terms 'bronchiectasis' and 'children' or 'pediatric' and 'management' or 'treatments'. Expert opinion: Bronchiectasis is heterogeneous in nature and a one-size-fits-all approach has limitations. Future research should focus on advancing our understanding of the aetiopathogenesis of bronchiectasis. This approach will facilitate development of targetted therapeutic interventions to slow, halt or even reverse bronchiectasis in childhood.

Brazilian consensus on non-cystic fibrosis bronchiectasis

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.

Bronchiectasis and cough: An old relationship in need of renewed attention

Bronchiectasis is an increasingly recognised respiratory condition with limited therapeutic options and a complex spectrum of clinical manifestations that invariably includes chronic cough. As the primary presentation of bronchiectasis in most cases, chronic cough and its mechanistic underpinnings are of central importance but remain poorly understood in this setting. Bronchiectasis is also increasingly identified as an underlying cause of chronic cough highlighting the interrelationship between the two conditions that share overlapping clinical features. Several therapeutic approaches have illustrated positive effects on bronchiectasis-associated cough, however, more focused treatment of heterogeneous cough subtypes may yield better outcomes for patients. A current challenge is the identification of bronchiectasis and cough endophenotypes that may allow improved patient stratification and more targeted therapeutic matching of the right treatment to the right patient. Here we discuss the complex disease phenotypes of bronchiectasis and their interrelationship with cough while considering current and emerging treatment options. We discuss some key cough promoters in bronchiectasis including infection, allergy and immune dysfunction.

Non Cystic Fibrosis Bronchiectasis-new clinical approach, management of treatment and pulmonary rehabilitation

Abstract Non-Cystic Fibrosis Bronchiectasis (NCFB) are characterised by abnormal, permanently damaged and dilated bronchi due to the innapropiate clearence of various microorganisms and recurrent chronic infections.The diagnosis is suggested by the clinical presentation and is confirmed by multiple investigations. There are some comorbidities associated with bronhciectasis, such as chronic obstructive pulmonary disease (COPD), cardiovascular disorders, gastro-esophageal reflux disease (GERD), psychological illnesses, pulmonary hypertension, obstructive apnea syndrome(OSA). The condition has a substantial socioeconomic impact because it requests a multidisciplinary management and periods of exacerbations are common. The aims of the management of bronchiectasis are to reduce symptoms (such as sputum volume and purulence, cough and dyspnea), reduce the frequency and severity of exacerbations, preserve lung function and improve health-related quality of life. The multidisciplinary approach of bronchiectasis patients require along with the medical treatment, a specific plan of nonphamarcological strategies, including balneological intervention. There are a lot of techniques improving the airway clearence, such as: active cycle of breathing techniques (which include breathing control, thoracic expansion exercises, forced expiratory technique), oscilatting possitive expiratory pressure, autogenic drainage, gravity-assisted-positioning, modified postural drainage. Together with specific medication, these techniques can diminuate symptoms and improve the quality of life. Key words: NCFB, airway clearence, physiotherapy,

Airway clearance techniques for cystic fibrosis: an overview of Cochrane systematic reviews

BACKGROUND

Cystic fibrosis is a life-limiting genetic condition in which thick mucus builds up in the lungs, leading to infections, inflammation, and eventually, deterioration in lung function. To clear their lungs of mucus, people with cystic fibrosis perform airway clearance techniques daily. There are various airway clearance techniques, which differ in terms of the need for assistance or equipment, and cost.

OBJECTIVES

To summarise the evidence from Cochrane Reviews on the effectiveness and safety of various airway clearance techniques in people with cystic fibrosis.

METHODS

For this overview, we included Cochrane Reviews of randomised or quasi-randomised controlled trials (including cross-over trials) that evaluated an airway clearance technique (conventional chest physiotherapy, positive expiratory pressure (PEP) therapy, high-pressure PEP therapy, active cycle of breathing techniques, autogenic drainage, airway oscillating devices, external high frequency chest compression devices and exercise) in people with cystic fibrosis.We searched the Cochrane Database of Systematic Reviews on 29 November 2018.Two review authors independently evaluated reviews for eligibility. One review author extracted data from included reviews and a second author checked the data for accuracy. Two review authors independently graded the quality of reviews using the ROBIS tool. We used the GRADE approach for assessing the overall strength of the evidence for each primary outcome (forced expiratory volume in one second (FEV1), individual preference and quality of life).

MAIN RESULTS

We included six Cochrane Reviews, one of which compared any type of chest physiotherapy with no chest physiotherapy or coughing alone and the remaining five reviews included head-to-head comparisons of different airway clearance techniques. All the reviews were considered to have a low risk of bias. However, the individual trials included in the reviews often did not report sufficient information to adequately assess risk of bias. Many trials did not sufficiently report on outcome measures and had a high risk of reporting bias.We are unable to draw definitive conclusions for comparisons of airway clearance techniques in terms of FEV1, except for reporting no difference between PEP therapy and oscillating devices after six months of treatment, mean difference -1.43% predicted (95% confidence interval -5.72 to 2.87); the quality of the body of evidence was graded as moderate. The quality of the body of evidence comparing different airway clearance techniques for other outcomes was either low or very low.

AUTHORS' CONCLUSIONS

There is little evidence to support the use of one airway clearance technique over another. People with cystic fibrosis should choose the airway clearance technique that best meets their needs, after considering comfort, convenience, flexibility, practicality, cost, or some other factor. More long-term, high-quality randomised controlled trials comparing airway clearance techniques among people with cystic fibrosis are needed.

[Advances in respiratory assessment and treatment in children undergoing invasive mechanical ventilation]

The widespread use of mechanical ventilation technology has contributed to the successful treatment of many children with respiratory failure. At the same time, forced ventilation and changes in normal respiratory physiology and mechanics may lead to respiratory dysfunction and decreased airway clearance ability. Therefore, how to perform a comprehensive and accurate respiratory function assessment, conduct appropriate respiratory function rehabilitation, perform extubation as soon as possible, and shorten the duration of mechanical ventilation based on the children's own physiological characteristics, is a focus of the research on effective weaning from mechanical ventilation in children with severe conditions. This article reviews the advances in the respiratory function assessment and treatment methods in children undergoing invasive mechanical ventilation.

Respiratory care in familial dysautonomia: Systematic review and expert consensus recommendations

BACKGROUND

Familial dysautonomia (Riley-Day syndrome, hereditary sensory autonomic neuropathy type-III) is a rare genetic disease caused by impaired development of sensory and afferent autonomic nerves. As a consequence, patients develop neurogenic dysphagia with frequent aspiration, chronic lung disease, and chemoreflex failure leading to severe sleep disordered breathing. The purpose of these guidelines is to provide recommendations for the diagnosis and treatment of respiratory disorders in familial dysautonomia.

METHODS

We performed a systematic review to summarize the evidence related to our questions. When evidence was not sufficient, we used data from the New York University Familial Dysautonomia Patient Registry, a database containing ongoing prospective comprehensive clinical data from 670 cases. The evidence was summarized and discussed by a multidisciplinary panel of experts. Evidence-based and expert recommendations were then formulated, written, and graded using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system.

RESULTS

Recommendations were formulated for or against specific diagnostic tests and clinical interventions. Diagnostic tests reviewed included radiological evaluation, dysphagia evaluation, gastroesophageal evaluation, bronchoscopy and bronchoalveolar lavage, pulmonary function tests, laryngoscopy and polysomnography. Clinical interventions and therapies reviewed included prevention and management of aspiration, airway mucus clearance and chest physical therapy, viral respiratory infections, precautions during high altitude or air-flight travel, non-invasive ventilation during sleep, antibiotic therapy, steroid therapy, oxygen therapy, gastrostomy tube placement, Nissen fundoplication surgery, scoliosis surgery, tracheostomy and lung lobectomy.

CONCLUSIONS

Expert recommendations for the diagnosis and management of respiratory disease in patients with familial dysautonomia are provided. Frequent reassessment and updating will be needed.

The Efficacy of Flutter® and Active Cycle of Breathing Techniques in Patients with Bronchiectasis: A Prospective, Randomized, Comparative Study

OBJECTIVES

The objective of the study was to compare the efficacy of an oscillating positive expiratory device and the active cycle of breathing techniques (ACBT) in patients with bronchiectasis.

MATERIALS AND METHODS

A home-based study that lasted for 4 weeks was designed to compare the oscillating physiotherapy device Flutter^® and the ACBT in 40 patients, who were randomly assigned into two groups containing 20 patients each. The effect of the two methods of physiotherapy on sputum production, pulmonary functions, and the quality of life was compared.

RESULTS

The results of the present study indicate that both the methods were associated with a reduced number of patients complaining of cough and fatigue and increased sputum production (p=0.000, p=0.004, and p=0.002, respectively). In addition, statistically significant reductions were determined by the Medical Research Council and Borg Dyspnea scores (p=0.001 and 0.002, respectively). The Flutter® device caused a more significant effect on the perception of dyspnea. Overall, there was an improvement in the physical sub-scale of the Short Form (SF)-36 Quality of Life Questionnaire scores of 36 patients who completed the study (p=0.001). During the physiotherapy period, no changes in pulmonary functions were observed. Exacerbations were recorded in 3 patients in the ACBT group and in 1 patient in the Flutter® group.

CONCLUSION

The Flutter® device and ACBT represent effective home-based physiotherapeutic methods. The Flutter® device appears to be more effective with regard to sputum production.

Positive expiratory pressure therapy versus other airway clearance techniques for bronchiectasis

BACKGROUND

People with bronchiectasis experience chronic cough and sputum production and require the prescription of airway clearance techniques (ACTs). A common type of ACT prescribed is positive expiratory pressure (PEP) therapy. A previous review has suggested that ACTs including PEP therapy are beneficial compared to no treatment in people with bronchiectasis. However, the efficacy of PEP therapy in a stable clinical state or during an acute exacerbation compared to other ACTs in bronchiectasis is unknown.

OBJECTIVES

The primary aim of this review was to determine the effects of PEP therapy compared with other ACTs on health-related quality of life (HRQOL), rate of acute exacerbations, and incidence of hospitalisation in individuals with stable or an acute exacerbation of bronchiectasis.Secondary aims included determining the effects of PEP therapy upon physiological outcomes and clinical signs and symptoms compared with other ACTs in individuals with stable or an acute exacerbation of bronchiectasis.

SEARCH METHODS

We searched the Cochrane Airways Group Specialised Register of Trials, PEDro and clinical trials registries from inception to February 2017 and we handsearched relevant journals.

SELECTION CRITERIA

Randomised controlled parallel and cross-over trials that compared PEP therapy versus other ACTs in participants with bronchiectasis.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures as outlined by Cochrane.

MAIN RESULTS

Nine studies involving 213 participants met the inclusion criteria, of which seven were cross-over in design. All studies included adults with bronchiectasis, with eight including participants in a stable clinical state and one including participants experiencing an acute exacerbation. Eight studies used oscillatory PEP therapy, using either a Flutter or Acapella device and one study used Minimal PEP therapy. The comparison intervention differed between studies. The methodological quality of studies was poor, with cross-over studies including suboptimal or no washout period, and a lack of blinding of participants, therapists or personnel for outcome measure assessment in most studies. Clinical heterogeneity between studies limited meta-analysis.Daily use of oscillatory PEP therapy for four weeks was associated with improved general health according to the Short-Form 36 questionnaire compared to the active cycle of breathing technique (ACBT). When applied for three sessions over one week, minimal PEP therapy resulted in similar improvement in cough-related quality of life as autogenic drainage (AD) and L'expiration Lente Totale Glotte Ouverte en Decubitus Lateral (ELTGOL). Oscillatory PEP therapy twice daily for four weeks had similar effects on disease-specific HRQOL (MD -0.09, 95% CI -0.37 to 0.19; low-quality evidence). Data were not available to determine the incidence of hospitalisation or rate of exacerbation in clinically stable participants.Two studies of a single session comparison of oscillatory PEP therapy and gravity-assisted drainage (GAD) with ACBT had contrasting findings. One study found a similar sputum weight produced with both techniques (SMD 0.54g (-0.38 to 1.46; 20 participants); the other found greater sputum expectoration with GAD and ACBT (SMD 5.6 g (95% CI 2.91 to 8.29: 36 participants). There was no difference in sputum weight yielded between oscillatory PEP therapy and ACBT with GAD when applied daily for four weeks or during an acute exacerbation. Although a single session of oscillatory PEP therapy was associated with less sputum compared to AD (median difference 3.1 g (95% CI 1.5 to 4.8 g; one study, 31 participants), no difference between oscillatory PEP therapy and seated ACBT was evident. PEP therapy had a similar effect on dynamic and static measures of lung volumes and gas exchange as all other ACTs. A single session of oscillatory PEP therapy (Flutter) generated a similar level of fatigue as ACBT with GAD, but greater fatigue was noted with oscillatory PEP therapy compared to ACBT alone. The degree of breathlessness experienced with PEP therapy did not differ from other techniques. Among studies exploring adverse events, only one study reported nausea with use of oscillatory PEP therapy.

AUTHORS' CONCLUSIONS

PEP therapy appears to have similar effects on HRQOL, symptoms of breathlessness, sputum expectoration, and lung volumes compared to other ACTs when prescribed within a stable clinical state or during an acute exacerbation. The number of studies and the overall quality of the evidence were both low. In view of the chronic nature of bronchiectasis, additional information is needed to establish the long-term clinical effects of PEP therapy over other ACTs for outcomes that are important to people with bronchiectasis and on clinical parameters which impact on disease progression and patient morbidity in individuals with stable bronchiectasis. In addition, the role of PEP therapy during an acute exacerbation requires further exploration. This information is necessary to provide further guidance for prescription of PEP therapy for people with bronchiectasis.