Making airway clearance successful

Personalising airway clearance in chronic suppurative lung diseases: a scoping review

Background

Personalised airway clearance techniques are commonly recommended to augment mucus clearance in chronic suppurative lung diseases. It is unclear what current literature tells us about how airway clearance regimens should be personalised. This scoping review explores current research on airway clearance technique in chronic suppurative lung diseases, to establish the extent and type of guidance in this area, identify knowledge gaps and determine the factors which physiotherapists should consider when personalising airway clearance regimens.

Methods

Systematic searching of online databases (MEDLINE, EMBASE, CINAHL, PEDro, Cochrane, Web of Science) was used to identify full-text publications in the last 25 years that described methods of personalising airway clearance techniques in chronic suppurative lung diseases. Items from the TIDieR framework provided a priori categories which were modified based on the initial data to develop a "Best-fit" framework for data charting. The findings were subsequently transformed into a personalisation model.

Results

A broad range of publications were identified, most commonly general review papers (44%). The items identified were grouped into seven personalisation factors: physical, psychosocial, airway clearance technique (ACT) type, procedures, dosage, response and provider. As only two divergent models of ACT personalisation were found, the personalisation factors identified were then used to develop a model for physiotherapists.

Conclusions

The personalisation of airway clearance regimens is widely discussed in the current literature, which provides a range of factors that should be considered. This review summarises the current literature, organising findings into a proposed airway clearance personalisation model, to provide clarity in this field.

Airway clearance and exercise for people with cystic fibrosis: Balancing longevity with life

Airway clearance has been an integral part of cystic fibrosis (CF) care for almost as long as CF has been identified as a condition. From diagnosis as a neonate through to end-of-life care, airway clearance is an everyday aspect of life, adding a considerable treatment burden to the lives of people with CF. There are many different techniques used for airway clearance which have evolved over time with an aim to improve effectiveness, support adherence and, more recently, to consider the impact of burden. A popular thought is whether airway clearance could be replaced by exercise. With new precision therapies in the form of CFTR modulators available, the CF landscape is rapidly changing, raising the question of whether certain treatments are needed at all. Depending on factors such as CFTR mutation, age, and pre-existing lung damage before starting a CFTR modulator, individuals with CF may need different levels of intensity and type of maintenance treatment. Precision medicine is likely to lead to the need for increased precision and individualized management around other maintenance therapies such as airway clearance.

ECFS best practice guidelines: the 2018 revision

Developments in managing CF continue to drive dramatic improvements in survival. As newborn screening rolls-out across Europe, CF centres are increasingly caring for cohorts of patients who have minimal lung disease on diagnosis. With the introduction of mutation-specific therapies and the prospect of truly personalised medicine, patients have the potential to enjoy good quality of life in adulthood with ever-increasing life expectancy. The landmark Standards of Care published in 2005 set out what high quality CF care is and how it can be delivered throughout Europe. This underwent a fundamental re-write in 2014, resulting in three documents; center framework, quality management and best practice guidelines. This document is a revision of the latter, updating standards for best practice in key aspects of CF care, in the context of a fast-moving and dynamic field. In continuing to give a broad overview of the standards expected for newborn screening, diagnosis, preventative treatment of lung disease, nutrition, complications, transplant/end of life care and psychological support, this consensus on best practice is expected to prove useful to clinical teams both in countries where CF care is developing and those with established CF centres. The document is an ECFS product and endorsed by the CF Network in ERN LUNG and CF Europe.

Autogenic Drainage in Children With Cystic Fibrosis

PURPOSE

Airway clearance is an essential part of the management of cystic fibrosis (CF) as it facilitates clearance of viscous pulmonary secretions. This review aimed to determine the effect of autogenic drainage (AD) and assisted autogenic drainage (AAD) compared with no, sham, or other types of airway clearance in children with CF.

SUMMARY OF KEY POINTS

Two pediatric randomized cross-over trials were identified on the use of AD in children with CF; no studies were available on the use of AAD. In one study AD had a positive influence on the Huang score, and is preferred over postural drainage in this population.

CONCLUSIONS AND RECOMMENDATIONS

We could not determine the efficacy of AD and AAD in children with CF. We recommend the implementation of pediatric-specific randomized controlled trials with adequate sample sizes, appropriate clinical outcome measures, and analysis of adverse effects.

Comparing airways clearance techniques in chronic obstructive pulmonary disease and bronchiectasis: positive expiratory pressure or temporary positive expiratory pressure? A retrospective study

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Patients with chronic hypersecretion (CH) of tracheobronchial mucus are a clinical challenge. They have an impaired quality of life, frequent exacerbations, and hospitalizations with need of antibiotics and other type of expensive treatments.

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Chest physical therapy evolved along the last decades and new techniques are currently used to help patients clear the airways efficiently. Among these airway clearance techniques (ACTs), the use of positive expiratory pressure (PEP) is considered one of the most effective.

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We report the retrospective evaluation of 162 patients with CH due to chronic obstructive pulmonary disease or bronchiectasis undergoing ACT in our Pulmonary Rehabilitation Department. They were treated either with PEP or with a new PEP device called UNIKO^®, which applies PEP in a temporary manner (TPEP).

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Comparing the two groups of patients, both treatments (i.e., PEP and TPEP) were followed by great improvements in physiological parameters of spirometry and gas exchange. However, subdividing patients, it was evident that TPEP had better effects than PEP in patients with emphysema and in patients on long-term oxygen treatment, while PEP was superior at least in some parameters in patients on mechanical ventilation.

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This study, albeit retrospective and calling for controlled clinical trials, suggests that different ACTs can be applied in different populations of patients.

Background

Airway clearance techniques include positive expiratory pressure, commonly used in our clinical practice, and a recently introduced temporary positive expiratory pressure device called UNIKO^®. It is unclear which one provides the best benefit to patients.

Objectives

The aim of this observational 4-year study was to retrospectively compare the efficacy of and specific indications for temporary positive expiratory pressure compared to positive expiratory pressure in a standard rehabilitation program.

Method

We retrospectively collected data from 162 subjects (107 males, mean age 70 ± 9 years, 97 with primary diagnosis of chronic obstructive pulmonary disease, 65 with bronchiectasis), 51 treated with temporary positive expiratory pressure and 111 with positive expiratory pressure.

Results

Subjects showed significant improvement in ratio of partial pressure arterial oxygen and fraction of inspired oxygen (p < 0.001), forced vital capacity, forced expiratory volume in one second, peak expiratory flow, arterial oxygen saturation, and partial pressure arterial oxygen with no significant difference between positive expiratory pressure and temporary positive expiratory pressure groups apart from forced expiratory flow, which increased only in the positive expiratory pressure group. Evaluating specific subgroups, temporary positive expiratory pressure was more effective than positive expiratory pressure in improving gas transfer in subjects with emphysema and in those on oxygen therapy, as the effective supplement oxygen flow decreased significantly (p = 0.034 and 0.046 respectively for temporary positive expiratory pressure vs. positive expiratory pressure). In subjects on mechanical ventilation, positive expiratory pressure was superior to temporary positive expiratory pressure in increasing forced expiratory flow (p = 0.018).

Conclusion

The physiological parameters of both groups improved significantly and similarly. Subgroup analysis suggests that temporary positive expiratory pressure could provide some advantage to subjects with emphysema and those on oxygen therapy, while positive expiratory pressure would benefit patients on mechanical ventilation. Randomized clinical trials are necessary to confirm our preliminary results indicating that different subgroups/phenotypes can benefit more from one type of treatment.

European Cystic Fibrosis Society Standards of Care: Best Practice guidelines

Specialised CF care has led to a dramatic improvement in survival in CF: in the last four decades, well above what was seen in the general population over the same period. With the implementation of newborn screening in many European countries, centres are increasingly caring for a cohort of patients who have minimal lung disease at diagnosis and therefore have the potential to enjoy an excellent quality of life and an even greater life expectancy than was seen previously. To allow high quality care to be delivered throughout Europe, a landmark document was published in 2005 that sets standards of care. Our current document builds on this work, setting standards for best practice in key aspects of CF care. The objective of our document is to give a broad overview of the standards expected for screening, diagnosis, pre-emptive treatment of lung disease, nutrition, complications, transplant/end of life care and psychological support. For comprehensive details of clinical care of CF, references to the most up to date European Consensus Statements, Guidelines or Position Papers are provided in Table 1. We hope that this best practice document will be useful to clinical teams both in countries where CF care is developing and those with established CF centres.

Time invested in the global respiratory care of cystic fibrosis paediatrics patients

INTRODUCTION

Respiratory therapy is a keystone of the treatment for cystic fibrosis (CF) lung disease, but it is time consuming.

OBJECTIVES

We aimed to assess the total time spent on respiratory therapy, including chest physiotherapy (CPT) and physical activity (PA), as well as inhalation therapy (IT) and maintenance of materials (MM) to rationalise and optimise treatment.

METHODS

A cross-sectional prospective study in a paediatric CF cohort. A questionnaire was developed to look at the time spent on respiratory care over 3 months. Enrolled in this study are all CF patients aged from 6 to 16 years (the exclusion criterion was lung transplantation).

RESULTS

Of the 40 enrolled patients, 22 participated (13 boys and 9 girls), with a mean age of 11 years. The patients spent approximately 19.46 h per week (standard deviation ± 7.53, 8.00-35.25 h) on therapy: CPT (30.58%), IT (15.11%), PA (50%) and MM (4.32%), without statistical significance between sexes.

CONCLUSION

In our cohort, CF patients spent an average of nearly 20 h a week in respiratory therapy, within a wide range of between 8 h to almost 36 h a week. PA consumes almost half of the time. Physicians have to take into consideration the burden of the treatment, to optimise the therapy.

Adherence to the medical regimen: clinical implications of new findings

PURPOSE OF REVIEW

Treatment nonadherence is a common problem, yet adherence to treatments is important for the successful management of cystic fibrosis (CF). Previous work has concentrated on rates of adherence in children and adults using self-report questionnaires. Recent studies have employed new measurement methods and evaluated various treatment components. It is important to understand the factors that impede and facilitate adherence in order that research and clinical practice can improve adherence rates.

RECENT FINDINGS

There is a high perceived treatment burden in CF. Rates of adherence vary according to the treatment and the measurement method. Reasons for nonadherence are numerous. Even with technology designed to reduce treatment time, adherence to nebulized antibiotics is still poor. Nonadherence is a particular issue in adolescence and there is evidence that girls are less adherent than boys, leading to poorer lung function. Patients who have a cohesive and balanced family life may be better able to incorporate CF treatments. Treatment beliefs and the perception of treatment effectiveness are important determinants of adherence.

SUMMARY

Research needs to move forward to understand how to help patients to improve their adherence and to assist healthcare professionals in supporting them. There is a consensus that tailored interventions are essential. In addition, it is important to understand adherence behaviours over time in order to recognize specific periods during a person's life when adherence is more difficult to achieve.

Trajectories of adherence to airway clearance therapy for patients with cystic fibrosis

OBJECTIVE

Although cross-sectional studies have demonstrated poor adherence to airway clearance therapy (ACT) for patients with cystic fibrosis (CF), no studies have identified longitudinal patterns of adherence. The objective was to characterize and identify predictors of ACT adherence trajectories for individuals with CF.

METHODS

Secondary data analyses were conducted for a randomized clinical trial examining differences in three ACTs. Participants (n = 153; M = 14.3 years, 55% male, 86% Caucasian, baseline FEV(1)% predicted: M = 86.7)/primary caregivers completed Daily Phone Diaries, an empirically supported adherence measure, every 4 months.

RESULTS

Group-based trajectory modeling revealed the best-fitting solution was a three-group model: low-adherence (14%), medium-adherence (49%), and high-adherence (37%) groups. ACT type was the only significant predictor of adherence trajectories.

DISCUSSION

Three trajectories of adherence to ACT for patients with CF were found. With the identification of trajectories, adherence interventions can be targeted for the subgroup at highest risk in order to prevent poor health outcomes.

Psychological factors affecting disease activity in children and adolescents with cystic fibrosis: medical adherence as a mediator

PURPOSE OF REVIEW

It is likely that nonadherence to treatment is one mediator of the effect of psychological factors on disease activity and course of cystic fibrosis. Nonadherence is a significant problem for patients with the disease. This review assesses adherence to multiple treatment components in cystic fibrosis and identifies factors associated with poor adherence. Based on this assessment, strategies aimed at enhancing adherence will be discussed.

RECENT FINDINGS

Adherence to treatment occurs less than 50% of the time in patients with cystic fibrosis, indicating poor adherence, which is particularly common in adolescents. Factors associated with poor adherence include psychiatric, psychological and emotional factors; family issues; and treatment-related problems. Recently, more information is being gathered regarding processes related to poor adherence.

SUMMARY

Psychological factors affecting physical conditions frequently occur in children with cystic fibrosis. Therefore, patients need to be routinely screened for coexisting psychosocial issues and treatment adherence problems. Adherence needs to be examined according to the specific treatment component, and with an understanding of factors that make adherence difficult for patients and families. This will enable healthcare teams to target individualized strategies to counteract nonadherence, with emphasis on the role of psychological and psychosocial factors.