A randomized evaluation of the acute efficacy, acceptability and tolerability of Flutter and active cycle of breathing with and without postural drainage in non-cystic fibrosis bronchiectasis

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).

Evaluation of outcome reporting in clinical trials of physiotherapy in bronchiectasis: The first stage of core outcome set development

INTRODUCTION

The aim of this study is to explore outcomes currently reported in physiotherapy trials for bronchiectasis and investigate the level of consistency in outcome reporting. This mapping of outcomes will be used to inform the development of a core outcome set (COS) for physiotherapy research in bronchiectasis. Outcomes reported in randomised clinical trials (RCTs) and RCT protocols were reviewed and evaluated. We included trials with physiotherapy as the main intervention, including pulmonary rehabilitation, exercise prescription, airway clearance, positive expiratory pressure devices, breathing training, self-management plans, and home exercise program. Medline, CINAHL, Scopus, Cochrane Central Register of Controlled Trials (CENTRAL), and the physiotherapy evidence database (PEDro) were searched from inception using a prespecified search strategy. Records including adult patients with bronchiectasis were included. Outcomes were listed verbatim and categorised into domains based on a pre-specified system, frequency of reporting and sources of variation were inspected.

RESULTS

Of 2158 abstracts screened, 37 trials (1202 participants) and 17 trial protocols were identified. Eighteen different physiotherapy techniques were investigated. A total of 331 outcomes were reported. No single outcome was reported by all trials. The most reported outcomes were lung function (27 trials, 50%), health related quality of life (26 trials, 48.1%), and dyspnoea (18 trials, 33.3%). A list of 104 unique outcomes covering 23 domains was created. Trials focus on physiological outcomes, mainly those related to respiratory system functions. Outcomes related to functioning and life impact are often neglected.

CONCLUSION

Outcome reporting in physiotherapy research for bronchiectasis was found to be inconsistent in terms of choosing and defining outcomes. Developing a core outcome set in this area of research is needed to facilitate aggregation of future trial results in systematic reviews that will in turn inform the strength of evidence for the effectiveness of physiotherapy. Outcome choice should include all stakeholders, including patients.

TRIAL REGISTRATION

This study is registered in the PROSPERO registry under the number CRD42021266247.

The effectiveness of the active cycle of breathing technique in patients with chronic respiratory diseases: A systematic review

BACKGROUND

Active cycle breathing technique (ACBT), which includes cycle of breathing control, thoracic expansion exercises and forced expiratory technique (FET), appears to have beneficial effects in patients with a variety of respiratory diseases. This systematic review provides an update on the new related studies, expanding the evidence base through the last 12 years and specifically evaluating the effectiveness of ACBT on pulmonary function-related outcome variables in patients with chronic respiratory diseases.

METHODS

MEDLINE/Pubmed, PEDro, and Cochrane Library for Randomized Controlled Trials were searched between September 2008 and December 2021, in continuance of a previous systematic review, to identify randomized clinical trials and/or crossover studies comparing ACBT to other respiratory treatment techniques in patients with chronic obstructive pulmonary diseases, cystic fibrosis, or bronchiectasis.

RESULTS

Eleven studies were included and the quality of most of them was moderate to good. The outcomes most frequently assessed were forced expiratory volume in 1 s (FEV₁), sputum wet weight, forced vital capacity (FVC), and peak expiratory flow rate. Secondary outcomes were quality of life and dyspnea. Various comparators were identified and most of them assessed the ACBT as an effective method in comparison with other respiratory treatment modalities. Most studies revealed that ACBT/FET had at least an equally beneficial short-term effect on sputum wet weight, FEV₁ and FVC compared to other treatment methods.

CONCLUSION

The results of this updating review reinforced the data of a previous systematic review regarding the beneficial impact of ACBT for the short-term improvement in respiratory tract secretions clearance and pulmonary function. ACBT is effective in increasing the expectorated sputum volume, in reducing viscoelasticity of the secretion and in relieving symptoms such as dyspnea.

Physiotherapy for large airway collapse: an ABC approach

Large airway collapse (LAC) describes the phenomenon of excessive, abnormal, inward movement of the large airways (i.e. trachea and/or main bronchi and/or bronchus intermedius) occurring during the expiratory phase of the respiratory cycle. It is an increasingly well-recognised problem and a prevalent comorbidity in other chronic respiratory conditions (e.g. COPD and asthma). LAC is associated with pervasive respiratory features such as a barking cough, exertional dyspnoea and an increased propensity to lower respiratory tract infection. These symptoms are unpleasant, and patients are often limited in their daily life and their function. The pathophysiology of this condition impairs airway clearance and can cause breathlessness and exercise intolerance, due to a loss of airway patency during expiratory flow. Dysfunctional adaptations to breathing and coughing may further amplify symptoms. This article provides, for the first time, clinically focused physiotherapeutic intervention advice based on our understanding of the pathophysiology of LAC, to support conservative management. It uses the available evidence from LAC, transferable evidence from other conditions and knowledge based on clinical experience. It proposes a practical "ABC model" to ensure physiotherapy assessment and treatments are centred around optimising three key clinical areas: Airways, including airway clearance and cough; Breathing, including breathlessness and breathing pattern; and Capacity for exercise, including an assessment of functional exercise ability.

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.

A multidisciplinary approach to the management of nontuberculous mycobacterial lung disease: a clinical perspective

INTRODUCTION

Management of nontuberculous mycobacterial lung disease (NTM-LD) can be encumbered by difficult diagnostic criteria and complex treatment decisions. As prevalence of this debilitating, often refractory, progressive lung disease increases globally, management must evolve beyond antimicrobials to encompass holistic and customized treatments coordinated by practitioners across various specialties.

AREAS COVERED

This review aims to complement the recently updated NTM-LD treatment guidelines and expand current approaches to diagnosis, treatment, and disease management in a multidisciplinary dimension. The foundation of effective long-term management of NTM-LD is awareness of diagnostic criteria, individual patient risk factors, and the importance of managing underlying pulmonary and nonpulmonary comorbidities. The value of adopting all available pharmacological and nonpharmacological treatment modalities with a patient-centered approach to address the needs of long-term patient care cannot be minimized.

EXPERT OPINION

This section, while acknowledging the limited advances in understanding of NTM-LD and the availability of newer diagnostic and therapeutic tools over the last decade, underscores the need for a programmatic approach to this chronic, debilitating pulmonary infection. This will not only lead to more comprehensive patient care with better outcomes, but will also inspire and activate robust networks of research and public health initiatives in this field.

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.

Scaling the Need, Benefits, and Risks Associated with COVID-19 Acute and Postacute Care Rehabilitation: A Review

Coronavirus is an RNA virus, which attacks the respiratory system causing complications including severe respiratory distress and pneumonia and many other symptoms. Recently, a novel coronavirus (COVID-19) outbreak emerged in Wuhan, which caused a significant number of infections in China and resulted in a global pandemic. The main aim of this study is to review and summarize the evidence regarding the supportive role of physical rehabilitation techniques in managing COVID-19-associated pneumonia. In this review, we also emphasize the use of rehabilitation techniques in the management of pneumonia in COVID-19-infected patients. Based on the evidence presented, we conclude that certain physical rehabilitation techniques and modalities could be of great support in the management of COVID-19-associated pneumonia. The safety of staff and patients when applying rehabilitation intervention requires attention. The combination of physical rehabilitation and medical treatment would result in improved treatment outcomes, faster recovery, and shorter hospital stay. Many rehabilitation techniques are safe and feasible and can be easily incorporated into the management protocol of COVID-19 victims. Decisions of early rehabilitation induction should be based on the patient's medical condition and tolerability.

Measuring airway clearance outcomes in bronchiectasis: a review

While airway clearance techniques (ACTs) are recommended for individuals with bronchiectasis, many trials have demonstrated inconsistent benefits or failed to reach their primary outcome. This review determined the most common clinical and patient-reported outcome measures used to evaluate the efficacy of ACTs in bronchiectasis. A literature search of five databases using relevant keywords and filtering for studies published in English, up until the end of August 2019, was completed. Studies included randomised controlled trials, using crossover or any other trial design, and abstracts. Studies were included where the control was placebo, no intervention, standard care, usual care or an active comparator. Adults with bronchiectasis not related to cystic fibrosis were included. Extracted data comprised study authors, design, duration, intervention, outcome measures and results. The search identified 27 published studies and one abstract. The most common clinical outcome measures were sputum volume (n=23), lung function (n=17) and pulse oximetry (n=9). The most common patient-reported outcomes were health-related quality of life (measured with St George's Respiratory Questionnaire, n=4), cough-related quality of life (measured with Leicester Cough Questionnaire, n=4) and dyspnoea (measured with Borg/modified Borg scale, n=8). Sputum volume, lung function, dyspnoea and health- and cough-related quality of life appear to be the most common clinical and patient-reported measures of airway clearance treatment efficacy.

Therapeutic pulmonary telerehabilitation protocol for patients affected by COVID-19, confined to their homes: study protocol for a randomized controlled trial

Background

In December 2019, 27 cases of pneumonia, of unknown cause, were identified in the province of Hubei (China). The WHO declared the situation as a Public Health Emergency of International Concern, and it was finally declared a global pandemic on March 11, 2020. The Spanish Government obliges the entire population to remain confined to their homes, with the exception of essential basic services, to stop the spread of COVID-19. Home isolation implies a notable physical deconditioning. Telerehabilitation methods have reported positive experiences, and we propose to study in affected patients of COVID-19, due to the general house confinement of the entire Spanish population.

Methods

Patients will be recruited in the regions of Andalusia, Murcia, and Valencia (Spain). Patients will remain confined to their homes, and there, they will carry out their assigned exercise program, which will be controlled telematically. Evaluators will attend to carry out all measurements at the beginning, during, and end of the study, telematically controlled. The patients will be randomly divided into three groups, two of them will perform a home exercise program (breathing exercises or non-specific exercises for muscle toning) and the third group will perform sedentary activities, using mental activation techniques, and will act as a sham group. We will evaluate respiratory variables and other variables of the physical state through physical tests, effort, and perceived fatigue. The data will be statistically analyzed, and the hypotheses will be tested between the groups, using the SPSS software, v.24, considering a 95% confidence interval.

Discussion

We will analyze the results, in terms of the level of fatigue and perceived exertion, physical health, and maintenance of respiratory activity of two types of exercise programs, toning and respiratory, applied in patients affected by COVID-19 during the period of home confinement. We intend to investigate a field not previously studied, such as the repercussion of carrying out a toning and respiratory exercise program in these patients, in historical circumstances that no one had previously observed in Spain, since the general population has never been forced to remain confined in their homes, due to a pandemic infection, by a coronavirus (COVID-19). Observing the effects that these two home exercise programs could produce in patients infected with COVID-19, we will try to better analyze and understand the mechanisms that are associated with the worsening of breathing in this type of patient.

Trial registration

Brazilian Clinical Trial Registry RBR-6m69fc. Registered on March 31, 2020.

Nonpharmacological treatment for patients with nontuberculous mycobacterial lung disease

Patients with nontuberculous mycobacterial lung disease (NTM-LD) often have significant exercise intolerance and poorer health-related quality of life (HRQL). The goals of treatment for NTM-LD should include reducing the severity of symptoms, improving HRQL, and reducing acute exacerbations. Nonpharmacological treatment, including pulmonary rehabilitation program and optimal nutritional strategy, should be one part of treatment for NTM-LD. A pulmonary rehabilitation (PR) program can comprise education, airway clearance techniques instruction, exercise training program, and inspiratory muscle training (IMT). Airway clearance techniques can improve the volume of sputum expectorated, cough symptom, breathlessness, and HRQL. Exercise training can improve exercise capacity and HRQL, and reduce acute exacerbations and dyspnea. Clinical benefits of IMT remain controversial but high-intensity IMT has been shown to be effective in increasing respiratory muscle strength with concurrent improvement of HRQL and exercise capacity. Body weight and muscle mass loss are common in patients with NTM-LD. An adequate protein and caloric diet combined with antioxidant nutrients might be the most appropriate dietary strategy. Comprehensive treatment for NTM-LD should include the combination of both pharmacological and nonpharmacological treatments. The management programs should be tailored to the individual's condition.

Respiratory physical therapy techniques recommended for patients with cystic fibrosis treated in specialized centers

BACKGROUND

Respiratory therapy is a part of the treatment of patients with cystic fibrosis (CF). However, there is no information about the main factors influencing the recommendation of the use of different techniques or devices by physical therapists from different specialized centers.

OBJECTIVE

To determine the respiratory therapy techniques recommended for the treatment of patients with CF seen in specialized treatment centers in Brazil.

METHODS

This is a descriptive study including a sample of Brazilian CF specialized treatment centers. Data on demographics, spirometric variables, and recommended respiratory therapy treatment techniques were collected.

RESULTS

Twelve specialized treatment centers with a total of 974 patients were included (13.5±11.3 years old and FEV₁ (%) 75.7±27.9). The most recommended techniques were huffing (61.1% of patients), high frequency oral oscillation (HFOO) (52.0%), and positive expiratory pressure (PEP) (45.3%). Most often, recommendation was to perform treatment once (54.8% of patients) or twice (34%) a day. There was great variability in the recommendation among the different states. When data were separated by age, there was a predominance of performing conventional and manual techniques in infants and preschool children. There were no significant variations according to pulmonary function. Based on the literature, techniques based on volume, huffing, and PEP were most prevalently performed in international centers.

CONCLUSION

The most recommended treatment techniques for patients with CF in Brazil are huffing, HFOO, and PEP, followed by volume-based techniques. There were geographical variations in the preferred treatment techniques, as well as based on patient age, but not based on the level of pulmonary function.

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.

Diagnosis and management of bronchiectasis

KEY POINTS Following a diagnosis of bronchiectasis, it is important to investigate for an underlying cause. Goals of management are to suppress airway infection and inflammation, to improve symptoms and health-related quality of life. There are now validated scoring tools to help assess disease severity, which can help to stratify management. Good evidence supports the use of both exercise training and long-term macrolide therapy in long-term disease management.

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.

The Bronchiectasis Toolbox-A Comprehensive Website for the Management of People with Bronchiectasis

While the health burden of bronchiectasis is increasing worldwide, medical and physiotherapy treatment strategies have progressed significantly over the past decade. For this reason, clinicians require readily accessible current evidence based information on the management of this condition. E-learning is a suitable educational forum for the development and maintenance of professional skills, however a comprehensive, evidence based, multidisciplinary website for bronchiectasis was not available. The Bronchiectasis Toolbox at www.bronchiectasis.com.au was developed by a team of clinicians in Australia and New Zealand with extensive experience in bronchiectasis. The content of this website, based on national and international guidelines, is presented under the headings: 'Bronchiectasis', 'Assessment', 'Physiotherapy', 'Indigenous', 'Paediatrics', and 'Resources'. Through a blend of multimedia resources, this website provides information to consolidate the knowledge and practical skills for health professionals caring for people with this condition. After launching in 2015 the website has received 64,549 hits from over 100 countries and the videos have been viewed 10,205 times in 89 countries. The Bronchiectasis Toolbox is a comprehensive multidisciplinary resource accessible to health professionals worldwide who manage people with bronchiectasis and is a unique solution to an educational need. Regular updates will ensure that the website continues to be relevant.

Airway-Clearance Techniques in Children and Adolescents with Chronic Suppurative Lung Disease and Bronchiectasis

Common symptoms of chronic suppurative lung disease or bronchiectasis in children and adolescents are chronic cough with sputum production, retention of excess secretions in dilated airways, and a history of recurrent infections. Clinical management includes the prescription of airway-clearance techniques (ACTs) to facilitate mucociliary clearance, optimize sputum expectoration, relieve symptoms, and improve well-being. A wide range of ACTs are available for selection, and these strategies may be applied in isolation or in combination. The choice of technique will depend in part on the age of the child, their clinical state, and factors which may influence treatment adherence. While the evidence base for ACTs in children and adolescent with these conditions is not robust, the current available evidence in addition to clinical expertise provides guidance for technique prescription and clinical effect. An overview of the most commonly applied ACTs, including their physiological rationale and discussion of factors influencing prescription in children and adolescents is outlined in this review.

Respiratory manifestations and management in children with Common Variable Immunodeficiency

Common variable immunodeficiency is an antibody deficiency that usually presents in childhood with recurrent sino-pulmonary infections. Diagnostic delay is frequent and thus respiratory morbidity is common, ranging from recurrent suppurative bronchitis to bronchiectasis. Immunoglobulin replacement therapy is the mainstay of treatment, whilst prophylactic antibiotic therapy and muco-ciliary clearance are additional treatment options. This review examines the diagnosis and management of respiratory issues in children with CVID.

Pediatric bronchiectasis: No longer an orphan disease

Bronchiectasis is described classically as a chronic pulmonary disorder characterized by a persistent productive cough and irreversible dilatation of one or more bronchi. However, in children unable to expectorate, cough may instead be wet and intermittent and bronchial dilatation reversible in the early stages. Although still considered an orphan disease, it is being recognized increasingly as causing significant morbidity and mortality in children and adults in both affluent and developing countries. While bronchiectasis has multiple etiologies, the final common pathway involves a complex interplay between the host, respiratory pathogens and environmental factors. These interactions lead to a vicious cycle of repeated infections, airway inflammation and tissue remodelling resulting in impaired airway clearance, destruction of structural elements within the bronchial wall causing them to become dilated and small airway obstruction. In this review, the current knowledge of the epidemiology, pathobiology, clinical features, and management of bronchiectasis in children are summarized. Recent evidence has emerged to improve our understanding of this heterogeneous disease including the role of viruses, and how antibiotics, novel drugs, antiviral agents, and vaccines might be used. Importantly, the management is no longer dependent upon extrapolating from the cystic fibrosis experience. Nevertheless, substantial information gaps remain in determining the underlying disease mechanisms that initiate and sustain the pathophysiological pathways leading to bronchiectasis. National and international collaborations, standardizing definitions of clinical and research end points, and exploring novel primary prevention strategies are needed if further progress is to be made in understanding, treating and even preventing this often life-limiting disease.

[Manual airway clearance techniques in adults and adolescents: What level of evidence?]

BACKGROUND

The aim of this systematic literature review was to grade the levels of evidence of the most widely used manual airway clearance techniques.

METHODS

A literature search was conducted over the period 1995-2014 from the Medline, PEDro, ScienceDirect, Cochrane Library, REEDOC and kinedoc databases, with the following keywords: "postural drainage", "manual vibrations", "manual chest percussion", "directed cough", "increased expiratory flow", "ELTGOL", "autogenic drainage" and "active cycle of breathing technique".

RESULTS

Two-hundred and fifty-six articles were identified. After removing duplicates and reading the titles and abstracts, 63 articles were selected, including 9 systematic reviews. This work highlights the lack of useful scientific data and the difficulty of determining levels of evidence for manual airway clearance techniques. Techniques were assessed principally with patients with sputum production (cystic fibrosis, DDB, COPD, etc.). It also shows the limited pertinence of outcome measures to quantify congestion and hence the efficacy of airway clearance techniques.

CONCLUSION

The 1994 consensus conference summary table classifying airway clearance techniques according to physical mechanism provides an interesting tool for assessment, grouping together techniques having identical mechanisms of action. From the findings of the present systematic review, it appears that only ELTGOL, autogenic drainage and ACBT present levels of evidence "B". All other techniques have lower levels of evidence.

LEVEL OF EVIDENCE

II.

Using Cystic Fibrosis Therapies for Non-Cystic Fibrosis Bronchiectasis

Non-cystic fibrosis bronchiectasis (NCFB) is an increasingly prevalent disease that places a significant burden on patients and health systems globally. Although many of the therapies used to treat NCFB were originally developed as cystic fibrosis (CF) therapies, not all of them have been demonstrated to be efficacious in NCFB and some may even be harmful. This article explores the evidence for which therapeutic strategies used to treat CF have been translated into the care of NCFB. The conclusion is that therapies for adult NCFB cannot be simply extrapolated from CF clinical trials, and in some instances, doing so may actually result in harm.

Airway clearance techniques for bronchiectasis

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.

Interventions for bronchiectasis: an overview of Cochrane systematic reviews

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.

Causes of chronic productive cough: An approach to management

A chronic 'productive' or 'wet' cough is a common presenting complaint for patients attending the adult respiratory clinic. Most reviews and guidelines suggest that the causes of a productive cough are the same as those of a non-productive cough and as such the same diagnostic pathway should be followed. We suggest a different diagnostic approach for patients with a productive cough, focussing on the conditions that are the most likely causes of this problem. This review is intended to briefly summarise the epidemiology, clinical features, pathophysiology and treatment of a number of conditions which are often associated with chronic productive cough to aid decision making when encountering a patient with this often distressing symptom. The conditions discussed include bronchiectasis, chronic bronchitis, asthma, eosinophilic bronchitis and immunodeficiency. We also propose an adult version of the paediatric diagnosis of protracted bacterial bronchitis (PBB) in patients with idiopathic chronic productive cough who appear to respond well to low dose macrolide therapy.

Mucociliary clearance techniques for treating non-cystic fibrosis bronchiectasis: Is there evidence?

Non-cystic fibrosis bronchiectasis (nCFb) is an acquired condition of variable etiology. An impaired mucociliary clearance seems to be one of the mechanisms behind nCFb, and treatment involves antibiotics, mucoactive agents, and airway clearance techniques (ACTs). Traditional ACTs have four components: postural drainage, percussion, vibration of the chest wall, and coughing. Reviewing the international medical literature on the use of ACTs for patients with nCFb from 1989 to the present day, we retrieved 93 articles, of which 35 met our selection criteria for this analysis. We reviewed active cycle of breathing techniques (ACBT), forced expiration techniques (FET), autogenic drainage, postural drainage, oscillating positive expiratory pressure (OPep), high frequency chest wall oscillation (HFCWO), and exercise or pulmonary rehabilitation. Overall, ACTs appear to be safe for individuals (adults and children) with stable bronchiectasis; where there may be improvements in sputum expectoration, selected measures of lung function, and health-related quality of life. Unfortunately, there is a lack of RCTs in nCFb patients, especially in children. Moreover, none of the studies describes long-term effects of ACTs. It should be noted that a single intervention might not reflect the longer-term outcome and there is no evidence to recommend or contest any type of ACTs in nCFb management. Multicenter RCTs are necessary to evaluate the different techniques of ACTs especially in children with nCFb.

The effects of oscillating positive expiratory pressure therapy in adults with stable non-cystic fibrosis bronchiectasis: A systematic review

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.

Airway clearance techniques for bronchiectasis

BACKGROUND

People with non-cystic fibrosis bronchiectasis commonly experience chronic cough and sputum production and these features may be associated with progressive decline in clinical 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 the effects of ACTs on the rate of acute exacerbations, incidence of hospitalisation and health-related quality of life in individuals with acute and stable bronchiectasis.Secondary: to determine whether a) ACTs are safe for individuals with acute and stable bronchiectasis and b) 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 October 2012, PEDro in October 2012 and handsearched relevant journals.

SELECTION CRITERIA

Randomised controlled parallel and cross-over trials that compared an ACT to no treatment, sham ACT or directed coughing in participants with bronchiectasis.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by The Cochrane Collaboration.

MAIN RESULTS

Five studies involving 51 participants met the inclusion criteria of the review, all of which were cross-over design. Four studies were on adults with stable bronchiectasis, and the other study was on clinically stable children with bronchiectasis. Three studies were single treatment sessions, two were longer-term studies. The interventions varied and some control groups received a sham intervention while others were inactive. The methodological quality of the studies was variable and the studies were not able to blind participants and personal. Heterogeneity between studies precluded these data from meta-analysis and the review was therefore narrative.One study on 20 adults comparing an airway oscillatory device with no treatment found no significant difference in the number of exacerbations at 12 weeks (low-quality evidence). No data were available to assess the impact of ACTs on the time to exacerbation, duration of, incidence of hospitalisation or total number of hospitalised days. The same study reported clinically significant improvements in health-related quality of life in both disease-specific and cough-related measures. While based on a small number of participants and the data were skewed, the median difference in the change in total St George's Respiratory Questionnaire (SGRQ) score over three months in this study was 8.5 units (P value = 0.005 (Wilcoxon), low-quality evidence). Two studies reported mean increases in volume of sputum expectorated with airway oscillatory devices in the short term of 8.4 mL (95% CI 3.4 to 13.4 mL) and in the long term of 3 mL (P value = 0.02), with no significant effect on lung function. One study reported an immediate reduction in pulmonary hyperinflation in adults with non-positive expiratory pressure (PEP) ACTs (difference in functional residual capacity (FRC) of 19%, P value < 0.05) and with airway oscillatory devices (difference in FRC of 30%, P value < 0.05) compared to no ACTs. A similar decrease in pulmonary hyperinflation (difference in FRC of 6%) was found in children using an airway oscillatory device for 3 months compared to sham therapy. No studies reported on the effects of gas exchange, people's symptoms or antibiotic usage.

AUTHORS' CONCLUSIONS

ACTs appear to be safe for individuals (adults and children) with stable bronchiectasis, where there may be improvements in sputum expectoration, selected measures of lung function and health-related quality of life. The role of these techniques in people with an acute exacerbation of bronchiectasis is unknown. In view of the chronic nature of bronchiectasis, more data are needed to establish the clinical value of ACTs over the short and long term on patient-important outcomes, including symptoms, on physiological outcomes which may clarify the rationale for each technique and on long-term parameters that impact on disease progression in individuals with stable bronchiectasis. This is necessary in order to provide further guidance of specific ACT prescription for people with bronchiectasis. It may also be important to establish the comparative effect of different types of ACTs in people with bronchiectasis.

Effectiveness of treatment with high-frequency chest wall oscillation in patients with bronchiectasis

Background

High-frequency airway clearance (HFCWC) assist devices generate either positive or negative trans-respiratory pressure excursions to produce high-frequency, small-volume oscillations in the airways.

HFCWC can lead to changes in volume of 15–57 ml and in flow up to 1.6 L/s, which generate minimal coughing to mobilize secretions. The typical treatment lasts 20–30 minutes, and consists of short periods of compression at different frequencies, separated by coughing.

The aim of this study was to find the more efficacious treatment in patients with bronchiectasis: traditional techniques of chest physiotherapy (CPT) versus high frequency oscillation of the chest wall in patients with bronchiectasis.

Methods

37 patients were enrolled. Seven of them were excluded. Computer randomization divided the patients into three groups:

– 10 patients treated with HFCWO by using the Vest® Airway Clearance System;

– 10 patients treated with traditional techniques of air way clearance (PEP bottle, PEP mask, ELTGOL, vibratory positive expiratory pressure);

– 10 patients received medical therapy only (control group).

To be eligible for enrollment, participants had to be between 18 and 85 years old and have a diagnosis of bronchiectasis, confirmed on high resolution computed tomography. Exclusion criteria: lack of informed consent, signs of exacerbation, cystic fibrosis. Before the treatment, each patient had blood tests, sputum volume and cell count, pulmonary function tests and on the quality of life inventories (MMRC, CAT, BCSS). The results were processed through the covariance analysis, performed with the R-Project statistical program. It has been considered a positive result p <005.

Results

Both treatments (traditional CPT and HFCWO) showed a significant improvement in some biochemical and functional respiratory tests as well as in the quality of life compared to the control group. The use of HFCWO compared to CPT also produced a significant improvement in blood inflammation parameter C-RP (p ≤0.019), parameters of lung functionality associated with bronchial obstruction (FVC, FEV1) (p ≤0.006 and p ≤0.001), and in the dyspnea. Improvement in quality of life scales was noted. (BCSS, CAT) (both p ≤0.001). No significant changes of total cell counts in sputum samples were observed in the two groups. In the HFCWO group a significant reduction of neutrophils percentage (p≤0.002) and a significant increase of macrophages percentage (p ≤0.012).

Conclusions

The HFCWO technique provides an improvement both in pulmonary function and quality of life related parameters in patients with chronic hypersecretive disease. Since those patients need daily airway clearance, this treatment should be included among the principal options in chest physiotherapy. The study was registered as ChiCTR-TRC-12002134 at http://www.chictr.org.

Chest physiotherapy techniques in bronchiectasis

Bronchiectasis is a persistent and progressive condition characterized by inflammation and infection causing damage that potentiates impaired mucociliary clearance. The rationale for promoting airway clearance is so that purulent secretions are removed from the airways, ameliorating the inflammation and improving control of symptoms such as cough and sputum plugging. Physiotherapists aim to teach patients one of a variety of airway clearance techniques to regularly perform as part of their daily management.

Bronchiectasis: new approaches to diagnosis and management

Non-cystic fibrosis (CF) bronchiectasis is a common, potentially serious, condition. Further investigations should be performed in an attempt to identify the underlying cause because it may lead to a change in therapy and have significant prognostic implications. MRI is being investigated as a radiation free alternative to high-resolution CT scan of the chest. Many of the treatment recommendations for non-CF bronchiectasis have not been studied in randomized controlled trials but have been extrapolated from the management recommendations for CF. Studies are beginning to inform decisions regarding the management of non-CF bronchiectasis, and an understanding of the best treatment options is beginning to emerge.

The active cycle of breathing technique: a systematic review and meta-analysis

QUESTION

What is the best available research evidence (volume, quality, consistency, generalisability) for the active cycle of breathing technique (ACBT)?

DESIGN

Systematic review with meta-analysis.

PARTICIPANTS

Participants with respiratory conditions characterised by chronic sputum production.

INTERVENTION

The active cycle of breathing or forced expiratory technique. COMPARATOR: All comparators including control conditions.

OUTCOME MEASURES

All outcomes providing continuous data.

RESULTS

Twenty-four studies were included. Ten comparators were identified with the most common being conventional chest physiotherapy, positive expiratory pressure and a control. The outcomes most frequently assessed were sputum wet weight (n = 17), forced vital capacity (n = 12) and forced expiratory volume in 1 s (n = 12). Meta-analysis was completed on the primary outcome of sputum wet weight. The standardised mean difference (SMD, random effects) showed an increase in sputum wet weight during and up to 1 h post ACBT compared to conventional physiotherapy (SMD 0.32, 95%CI 0.05-0.59), external oscillatory devices (0.75, 0.48-1.02), and control (0.24, 0.02-0.46).

CONCLUSION

The overall body of evidence was classified as good (good volume, quality and consistency, excellent generalisability). High level, variable risk of bias research evidence favours ACBT over most alternatives for short-term improvements in secretion clearance.

[Treatment of non-cystic fibrosis bronchiectasis]

Bronchiectasis is currently growing in importance due to both the increase in the number of diagnoses made as well as the negative impact that its presence has on the baseline disease that generates it. A fundamental aspect in these patients is the colonization and infection of the bronchial mucous by potentially pathogenic microorganisms (PPM), which are the cause in most cases of the start of the chronic inflammatory process that results in the destruction and dilatation of the bronchial tree that is characteristic in these patients. The treatment of the colonization and chronic bronchial infection in these patients should be based on prolonged antibiotic therapy in its different presentations. Lately, the inhaled form is becoming especially prominent due to its high efficacy and limited production of important adverse effects. However, one must not overlook the fact that the management of patients with bronchiectasis should be multidisciplinary and multidimensional. In addition to antibiotic treatment, the collaboration of different medical and surgical specialties is essential for the management of the exacerbations, nutritional aspects, respiratory physiotherapy, muscle rehabilitation, complications, inflammation and bronchial hyperreactivity and the hypersecretion that characterizes these patients.

[Etiology and evolution of bronchiectasis in women]

INTRODUCTION

Although considered as an orphan disease in the developed countries, bronchiectasis are frequent in our country as in all emerging ones. They are most common in women and they represent a frequent cause for consultation and hospitalization in pulmonology departments.

PATIENTS AND METHODS

To determine the etiology and prognosis of the bronchectasies in women, a retrospective study was performed including 200 patients.

RESULTS

The mean age was 55.60 years. The diagnosis of bronchiectasis was confirmed in all patients. Bronchiectasis were post-tuberculosis in 56.5% of cases and primitive in 29.5% of cases. The systemic diseases, in particular the rheumatoid polyarthritis represented 3% of cases. The infectious complications and the chronic respiratory failure were more frequent in patients with primitive bronchiectasis than those with secondary bronchiectasis. However this difference was statistically significant only for the chronic respiratory failure.

CONCLUSION

The bronchiectasis remains frequent in women in our country, as a sequel of pulmonary tuberculosis more than primitive forms. Bronchiectasis secondary to systemic diseases, although rare, must be known.