Acapella versus 'usual airway clearance' during acute exacerbation in bronchiectasis: a randomized crossover trial

Bronchiectasis management in adults: state of the art and future directions

Formerly regarded as a rare disease, bronchiectasis is increasingly recognised. A renewed interest in this disease has led to significant progress in bronchiectasis research. Randomised clinical trials (RCTs) have demonstrated the benefits of airway clearance techniques, inhaled antibiotics and long-term macrolide therapy in bronchiectasis patients. However, the heterogeneity of bronchiectasis remains one of the most challenging aspects of management. Phenotypes and endotypes of bronchiectasis have been identified to help find "treatable traits" and partially overcome disease complexity. The goals of therapy for bronchiectasis are to reduce the symptom burden, improve quality of life, reduce exacerbations and prevent disease progression. We review the pharmacological and non-pharmacological treatments that can improve mucociliary clearance, reduce airway inflammation and tackle airway infection, the key pathophysiological features of bronchiectasis. There are also promising treatments in development for the management of bronchiectasis, including novel anti-inflammatory therapies. This review provides a critical update on the management of bronchiectasis focusing on treatable traits and recent RCTs.

Remote Voice Therapy With an Oscillatory Positive Expiratory Pressure Device in Subjects With Vocal Fatigue: A Randomized Controlled Trial

PURPOSE

The present study aimed at assessing the efficacy of remote voice therapy (telepractice) implemented with Shaker Medic Plus device in subjects with vocal fatigue.

METHOD

Thirty-six participants were initially enrolled in this study. Twenty-four participants with vocal fatigue were finally randomly assigned to one of two treatment groups: (a) voice treatment with Shaker Medic Plus device plus vocal hygiene program (n = 12) and (b) voice treatment with water resistance therapy (WRT) plus vocal hygiene program (n = 12). Laryngoscopic assessment was conducted on all subjects. Before and after voice therapy, participants underwent (a) self-assessment of voice: Vocal Fatigue Index and Vocal Tract Discomfort Scale and (b) instrumental assessment with aerodynamic, acoustic, and electroglottographic measures. The treatment period included six voice therapy sessions within 6 weeks. Each session lasted 30 min. For both groups, exercises consisted of a sequence of nine phonatory tasks performed with Shaker Medic Plus (experimental group) and WRT (control group). Comparisons for all variables were performed between the experimental group and control group.

RESULTS

Significant improvements were found for self-reported variables when comparing pre- and postmeasures for both groups. No significant differences were found when comparing groups. No significant main effects or interactions were observed for any of the observed instrumental variables.

CONCLUSIONS

Remote physiologic voice therapy with Shaker Medic Plus device and water resistance therapy seem to be both effective to improve voice in subjects diagnosed with vocal fatigue. No differences should be expected between these therapeutic protocols when treating patients with vocal fatigue. Moreover, both are effective at reducing tiredness of voice, voice avoidance, physical discomfort associated with voicing, subjective perception of sensory discomfort in throat, and reduction of physical, emotional, and functional impact of voice problems.

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.

Effectiveness of Acapella along with institutional based chest physiotherapy techniques on pulmonary functions and airway clearance in post-operative CABG patients

BACKGROUND

Patients undergoing Coronary Artery Bypass Graft (CABG) surgery often develop pulmonary complications in the early post-operative period as result of decreased lung function and impaired cough. Conventional physiotherapy in early post-operative period aims at increasing lung volumes and airway clearance.

OBJECTIVE

This study aimed to determine the effectiveness of the addition of Acapella to conventional chest physiotherapy in improving lung volumes and secretion clearance in early post-operative CABG patients.

METHODS

Twenty patients of both genders (40-70 years) who had undergone CABG and were in Phase I of Cardiac Rehabilitation were involved in this pilot randomized control trial (9 control, 11 experimental). Post-surgery intervention commenced on post-operative day 2 (POD 2) and continued till POD 6. Patients in the control group were given conventional physiotherapy that included breathing exercises, incentive spirometry and manual techniques. Patient in the experimental group used an Acapella device along with the conventional intervention. Outcome measures considered were pulmonary function parameters (FVC, FEV1 & PEFR) and amount of sputum expectorated.

RESULTS

A significant increase in lung volumes was observed in both the groups on POD 6 as compared to POD 2 (both < 0 . 01 ). However, the increase was significantly greater on POD 6 in experimental group than the control group [mean difference (95% CI) FVC: 0.44 L (0.24-0.63), FEV1: 0.43 L (0.19-0.66), PEFR: 0.86 L/s (0.57-1.14)]. The amount of sputum expectoration significantly greater in the experimental group as compared to the control group [2.71 mL (0.53-4.90)].

CONCLUSION

The addition of Acapella enhanced the effect conventional physiotherapy in improving lung volumes and airway clearance in the early post-operative period for CABG patients.

Efficacy of Voice Therapy With Acapella Choice ® Device in Subjects With Vocal Fatigue Delivered Via Telepractice

PURPOSE

The present study aimed at assessing the effectiveness of remote voice therapy (telepractice) implemented with Acapella Choice device in subjects with vocal fatigue.

METHODS

Thirty participants with vocal fatigue were randomly assigned to one of two treatment groups: (1) voice treatment with acapella Choice device plus vocal hygiene program (n=15), and (2) voice treatment with Water resistance therapy plus vocal hygiene program (n=15). Laryngoscopic assessment was conducted in all subjects to confirm diagnosis. Before and after voice therapy, participants underwent self-assessment of voice. Vocal Fatigue Index (VFI), Voice Handicap Index (VHI), and Vocal tract discomfort scale (VTDS) were used. Treatment period included six voice therapy sessions within 3 weeks, with a frequency of two therapy sessions per week. Each session lasted 30 minutes. For both groups, exercises consisted of a sequence of nine phonatory tasks performed with Acapella Choice (experimental group) and WRT (control group). Comparison for all variables were performed between experimental group and control group.

RESULTS

Significant improvements were found when comparing Pre and Post measures for both groups. No significant differences were found when comparing Acapella Choice group and WRT group.

CONCLUSION

Remote physiologic voice therapy with Acapella Choice device and water resistance therapy seem to be both effective to improve voice in subjects diagnosed with vocal fatigue. No differences should be expected between these therapeutic protocols when treating patients with vocal fatigue. Moreover, both are effective at reducing tiredness of voice, voice avoidance, physical discomfort associated with voicing, subjective perception of sensory discomfort in throat, and reduction of physical, emotional, and functional impact of voice problems.

Physical Activity and Screen Time Practices of Family Child Care Providers: Do They Meet Best Practice Guidelines?

Background: Child care settings significantly influence children's physical activity (PA) and screen time (ST) behaviors, yet less research has been conducted in family child care homes (FCCHs) than in child care centers. While a few studies have measured family child care providers' (FCCPs') PA practices, none have used observation to assess which specific evidence-based, best practice guidelines FCCPs met or did not meet, and no previous studies have included Latinx providers. This article examines FCCPs' adherence to PA and ST best practice guidelines using primarily observational methods with diverse FCCPs (including Latinx). Methods: We examined baseline data from a cluster randomized trial including surveys and observational data collected at the FCCH to assess whether providers met specific PA and ST best practices from the Nutrition and Physical Activity Self-Assessment for Child Care (NAP SACC) and the American Academy of Pediatrics. Results: Providers completed a telephone survey and participated in two full-day observations (n = 127; 72% Hispanic). Overall, only 4 of 14 PA and ST best practices were met by >50% of providers including: leading a planned PA class more than once a week; no ST during meal or snack; not modeling sedentary behavior; and providing families with information about children's ST. Best practices least likely to be met (<20% of providers) include: providing children with >60 minutes of outdoor play daily; providing children with >45 minutes of adult-led PA each day; participating in outdoor PA with children; participating in indoor PA with children; prompting and praising children for being active; and talking with children informally about the importance of PA. Conclusions: While FCCPs engage in some positive PA and ST practices, many providers do not meet best practice guidelines. There is a need for more research about how to overcome providers' personal and environmental barriers for meeting these guidelines as well as interventions and supports to overcome these barriers. Clinical Trial Registration Number NCT0245645.

Mealtime Environment and Feeding Practices in Urban Family Child Care Homes in the United States

Background: Family Child Care Homes (FCCHs) are the second-largest childcare option in the US. Given that young children are increasingly becoming overweight and obese, it is vital to understand the FCCH mealtime environment. There is much interest in examining the impact of the Child and Adult Care Food Program (CACFP), a federal initiative to support healthy nutrition, by providing cash reimbursements to eligible childcare providers to purchase nutritious foods. This study examines the association among the FCCH provider characteristics, the mealtime environment, and the quality of foods offered to 2-5-year-old children in urban FCCHs and examines the quality of the mealtime environment and foods offered by CACFP participation. Methods: A cross-sectional design with a proportionate stratified random sample of urban FCCHs by the CACFP participation status was used. Data were collected by telephone using the Nutrition and Physical Activity Self-Assessment for Child Care survey. Results: A total of 91 licensed FCCHs (69 CACFP, 22 non-CACFP) participated. FCCH providers with formal nutrition training met significantly more of the quality standards for foods offered than providers without nutrition training (β = 0.22, p = 0.034). The mealtime environment was not related to any FCCH provider characteristics. CACFP-participating FCCH providers had a healthier mealtime environment (β = 0.326, p = 0.002) than non-CACFP FCCHs. Conclusions: Findings suggest that nutrition training and CACFP participation contribute to the quality of nutrition-related practices in the FCCH. We recommend more research on strengthening the quality of foods provided in FCCHs and the possible impact on childhood obesity.

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.

Non-Pharmaceutical Techniques for Obstructive Airway Clearance Focusing on the Role of Oscillating Positive Expiratory Pressure (OPEP): A Narrative Review

Mucus secretion in the lungs is a natural process that protects the airways from inhaled insoluble particle accumulation by capture and removal via the mucociliary escalator. Diseases such as cystic fibrosis (CF) and associated bronchiectasis, as well as chronic obstructive pulmonary disease (COPD), result in mucus layer thickening, associated with high viscosity in CF, which can eventually lead to complete airway obstruction. These processes severely impair the delivery of inhaled medications to obstructed regions of the lungs, resulting in poorly controlled disease with associated increased morbidity and mortality. This narrative review article focuses on the use of non-pharmacological airway clearance therapies (ACTs) that promote mechanical movement from the obstructed airway. Particular attention is given to the evolving application of oscillating positive expiratory pressure (OPEP) therapy via a variety of devices. Advice is provided as to the features that appear to be the most effective at mucus mobilization.

Tissue Mobilization During Double Source of Vibration Semioccluded Vocal Tract Exercises: A Neck and Face Surface Acceleration Study

Purpose This study primarily aimed at observing the possible tissue mobilization on facial, neck, and chest tissues caused by different double source of vibration semioccluded vocal tract exercises (DSV-SOVTEs). Another goal was to inspect the degree of self-perceived sensation of a massage-like sensation. Method Fifty-five participants engaged in a set of several DSV-SOVTEs: (a) phonation with a silicone tube submerged 2 and 8 cm below water surface, (b) Acapella Choice device, (c) lip trills, and (d) tongue trills. A self-perceived massage-like sensation was also assessed. All exercises were performed at three loudness levels. Tissue mobilization signal was captured by four accelerometers placed in four different body regions: (a) over the cheek, (b) over the neck, (c) over the thyroid cartilage, and (d) over the suprasternal notch. Results There is a differential effect of all DSV-SOVTEs on tissue mobilization. All four observed dependent variables from tissue oscillation modulation (frequency, amplitude, jitter, and shimmer) showed significant three-way interactions. In general, amplitude and frequency of tissue oscillation modulation increases with loudness. A self-perceived massage-like sensation showed highly significant differences between DSV-SOVTEs. Conclusions All DSV-SOVTEs do mobilize tissues. Type of exercise, loudness level, and body region produce an effect on all tissue oscillation variables. Acapella device produces the largest amplitude of vibration, lowest frequency, and more regular oscillation of tissue. Water resistance therapy showed the most irregular tissue oscillation. Control of these variables is likely to be relevant to obtain the best outcomes in patients.

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.

Comparison of conventional chest physiotherapy and oscillatory positive expiratory pressure therapy in primary ciliary dyskinesia

BACKGROUND

Chest physiotherapy (CP) is a recommended treatment modality in primary ciliary dyskinesia (PCD).

OBJECTIVE

Primary aim was to compare the efficacy and safety of the conventional chest physiotherapy (CCP) and oscillatory positive expiratory pressure therapy (OPEPT). Secondary aims were to compare the exacerbation rate, time until the first exacerbation, patient compliance and comfort between the two CP methods.

METHODS

This is a 6 month randomized, controlled crossover trial. Patients >6 years of age with PCD were randomized into two groups, first group was assigned to OPEPT (Acapella®) for 3 months while second group was assigned to CCP. Groups were crossed over to the other modality after a 15-day washout period. Pulmonary function tests (PFTs) and compliance were monitored by monthly clinic visits.

RESULTS

There was a significant increase in FEV₁ , FEF_25-75 , and PEF values (p = .018, p = .020, and p = .016, respectively) in the OPEPT group and in FVC values (p = .007) in CCP group compared to baseline. However PFT increase at 3rd month was not superior to each other with both physiotherapy methods. Median acute pulmonary exacerbation rate and time period until the first exacerbation were similar in both groups (p = .821, p = .092, respectively). Comfort and effectiveness of OPEPT was higher than CCP according to patients (p = .029 and p = .042, respectively). There were no adverse effects with either therapy.

CONCLUSIONS

OPEPT was as effective as CCP in PCD patients. OPEPT was more comfortable and effective than CCP according to patients. OPEPT might be an efficient alternative method for airway cleareance in PCD patients.

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.

Comparing the Effect of Incentive Spirometry with Acapella on Blood Gases in Physiotherapy After Coronary Artery Bypass Graft

Objective

To compare the effect of incentive spirometry with Acapella (Smiths Medical Inc, Carlsbad, California) in physiotherapy after coronary artery bypass surgery.

Methods

A randomized controlled trial comparing incentive spirometry with Acapella was conducted in the intensive care unit of Chaudhary Pervaiz Elahi Institute of Cardiology (CPEIC) Multan. The study began from December 2017 to August 2019 after getting approval from the ethical committee of the hospital. Informed written consent was taken from all 270 patients who were included in the study. Patients who underwent coronary artery bypass graft (CABG) were divided into two groups by the lottery method. The primary end-point of the study was to check the blood gases on Day 3 after the procedure at room air and compare it with the baseline and with blood gases immediately after the procedure. SPSS 23 (IBM Corp., Armonk, NY) was used to analyze the data of this study. For qualitative variables in data such as gender, place of living, patients with any comorbidities, and education status were statistically analyzed in percentage and frequencies. For numerical variables, such as age, body mass index, blood gases values, distance covered in a six-minute walk test, and spirometry values were analyzed and statistically measured as mean and standard deviation. A P-value of less than .05 was considered significant.

Results

The mean partial pressure of oxygen (PaO2) of incentive spirometry was 58.1±2.31 and 67.2±3.24 after extubation and after three days, respectively. While the PaO2 of Acapella was 56.3±3.43 and 66.4±3.54 after extubation and after three days, respectively. The mean PCO2 of incentive spirometry was 41.4±3.26 and 36.1±2.11 after extubation and after three days, respectively. While the partial pressure of carbon dioxide (PCO2) of Acapella was 39.4±2.55 and 37.5±3.58 after extubation and after three days, respectively. The differences were statistically significant at p-value ≤0.05.

Conclusion

It was concluded that both Acapella and incentive spirometry treatment after coronary artery bypass graft improved blood gases.

The Efficacy of Therapeutic Respiratory Muscle Training Interventions in People with Bronchiectasis: A Systematic Review and Meta-Analysis

Background: Respiratory muscle dysfunction is an important health problem with high morbidity and mortality and associated costs in patients with bronchiectasis (BC). The aim of this study was to analyse the effects of therapeutic respiratory muscle training (RMT) interventions on improving sputum clearance, ventilator function, muscle strength and functional capacity in BC. Methods: Systematic review and meta-analysis were conducted following PRISMA guidelines. Two independent investigators searched using several electronic databases. The methodological quality of nine studies was assessed using the PEDro scale. Study selection/eligibility criteria: The following were included: randomised controlled trials, randomised crossover trials and pilot studies of patients with BC that used the intervention as RMT (inspiratory/expiratory) and evaluations of respiratory muscle strength (maximal expiratory pressure/maximal inspiratory pressure). This systematic review was registered in PROSPERO (CRD42017075101). Nine studies were included, five of which obtained an A recommendation grade, three with B, and one with C. Study quality was poor to good (mean PEDro Score of 6.375 out of 10). Studies had small sample sizes (8–98). Results show improvements on PImax in favour of therapeutic respiratory muscle training intervention (MD = 6.08; 95% CI = 1.38, 10.77; p < 0.01; I² = 92%). However, high heterogeneity was identified on meta-analysis.

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,

Nutrition-Related Practices of Family Child Care Providers and Differences by Ethnicity

BACKGROUND

Child care settings play an important role in shaping children's eating behaviors; yet few studies have included family child care homes (FCCHs). We examined provider-reported nutrition-related practices in FCCHs and observed adherence to nutrition guidelines from the Nutrition and Physical Activity Self-Assessment for Child Care (NAP SACC), exploring differences by provider ethnicity.

METHODS

We assessed baseline data from a cluster-randomized trial, including surveys with FCCH providers and observational data collected at the FCCH. We examined provider-reported nutrition-related practices and if providers met NAP SACC guidelines using observational data. Differences by ethnicity were assessed using chi-square and multivariate log-linear analysis adjusting for education.

RESULTS

Providers completed a telephone survey (n = 166, 100% female and 72% Hispanic) and participated in 2 full-day observations (n = 119). Many providers reported engaging in positive nutrition-related practices. Significant differences by ethnicity included the following: Hispanic providers less likely to report feeding practices that were responsive to children's self-regulation, but also less likely to report eating and drinking unhealthy foods/beverages in front of children and having screens on during meals and more likely to report seeking nutrition trainings. Using observational data, only 10 of 26 NAP SACC practices were met by >60% of providers. Few ethnic differences in meeting guidelines were found (7 of 26 practices).

CONCLUSIONS

While providers engage in some positive nutrition practices, improvement is needed to ensure that all providers actually meet evidence-based guidelines. Ethnic differences in certain practices underscore the need for culturally relevant trainings.

TRIAL REGISTRATION NUMBER

NCT02452645.

[Can Perioperative Oscillating Positive Expiratory Pressure Practice Enhance Recovery in Lung Cancer Patients Undergoing Thorascopic Lobectomy?]

背景与目的

振动正压呼气（oscillatory positive expiratory pressure, OPEP）训练是一种通过正压呼气装置（acapella）进行的呼吸训练。OPEP在慢性阻塞性肺疾病、支气管扩张症、肺囊肿等疾病的临床价值已经得到广泛探讨，但其在肺癌手术患者围术期的应用价值尚有待探索。本研究旨在探索围术期进行振动正压呼气训练对胸腔镜肺癌患者术后并发症发生率、肺功能、生活质量的影响。

方法

前瞻性收集2017年9月15日-2018年1月15日四川大学华西医院胸外科单个医疗组行胸腔镜肺叶切除的原发性非小细胞癌患者69例，随机分成实验组（35例）和对照组（34例）。实验组（acapella group, AG）围手术期采用振动正压呼气训练，对照组（control group, CG）进行常规围术期处理。对比分析两组在术后并发症发生率、肺功能、生活质量方面的差异。

结果

术后肺部并发症和肺不张在AG（2.9%, 0.0%）显著低于CG（20.6%, 14.7%）（P=0.03, P=0.03）；平均住院日和术后住院日在AG（10.86±5.64, 5.09±4.55）d显著短于CG（14.41±4.58, 7.59±3.21）d（P=0.01, P=0.01）；住院药物费用在AG（4, 413.60±1, 772.35）￥显著低于CG（6, 490.35±3, 367.66）￥（P=0.01）。出院当日第1秒用力呼气容积（forced expiratory volume in the first second, FEV₁）和呼气峰流速（peak expiratory flow, PEF）在AG[(1.50±0.32) L, (252.06±75.27) L/min]显著高于CG[(1.34±0.19) L, (216.94±49.72) L/min]（P=0.03, P=0.03）。

结论

肺癌患者围手术期使用振动正压呼气训练有助于降低肺部并发症，同时能够加速患者康复。

A Pilot Study Assessing the Therapeutic Potential of a Vibratory Positive Expiratory Pressure Device (Acapella Choice) in the Treatment of Voice Disorders

INTRODUCTION

Semioccluded vocal tract exercises (SOVTEs) can involve a single source of vibration (eg, vocal folds in the straw exercise) or a dual source of vibration (eg, vocal folds and water bubbling in tube phonation) in the vocal tract. Oftentimes, this secondary source of vibration causes large oscillations in intraoral pressure and has been likened to a "massage effect." This study assesses the implementation of a positive expiratory pressure device (Acapella Choice) as a possible alternative SOVTE, which presents a secondary source of vibration without the need of a water container.

METHODS

Twenty-two normophonic participants underwent acoustic, electroglottographic, and aerodynamic assessment before, during, and after phonation with two different established SOTVEs (silicone tube in water and straw in air) in addition to Acapella Choice.

RESULTS

Acapella Choice produced the largest peak-to-peak amplitudes of intraoral pressure oscillation. Straw in air produced the largest static intraoral pressure. Straw in air and Acapella Choice presented significantly larger ranges of static pressures than tube in water phonation. Post-exercise condition showed a statistically larger sound pressure level for Acapella Choice.

CONCLUSIONS

Positive expiratory pressure devices, such as Acapella Choice, may be a promising alternative to established SOVTEs as it promotes large oscillatory pressures in the vocal tract without the need for a water container. This exercise also produces larger sound pressure level with no significant changes in glottic contact quotient, indicating improved vocal economy.

Examining Nutrition and Physical Activity Policies and Practices in Maryland's Child Care Centers

BACKGROUND

Child care settings provide opportunities for obesity prevention by implementing nutrition/physical activity best practices. This study examines how center policies, provider training, family education, and center demographics relate to best practices for nutrition/physical activity in Maryland's child care centers.

METHODS

A survey, including minor modifications to The Nutrition and Physical Activity Self-Assessment for Child Care (Go NAP SACC), was sent by e-mail to center directors statewide. Best practice sum scores (dependent variable) were calculated, including physical activity (17 items), feeding environment (18 items), and food served (19 items). Adjusted regression models analyzed the number of nutrition/physical activity policies, provider training topics, and family education opportunities related to best practice scores.

RESULTS

Response rate was 40% (n = 610/1506) with 69% independent centers (vs. organization sponsored), 19% with Child and Adult Care Food Program (CACFP enrolled), and 50.2% centers with majority (≥70%) Caucasian children and 16.8% centers with majority African American children. Centers reported 40.8% of physical activity best practices, 52.0% of feeding environment best practices, and 51.6% of food served best practices. Centers reported (mean) 7.9 of 16 nutrition/physical activity-relevant policies, 6.9 of 13 provider training topics, and 4.4 of 8 family education opportunities. Regression models yielded associations with best practices: policies and provider training with feeding environment (B = 0.26, p < 0.001; B = 0.26, p = 0.001, respectively); policies with foods served (B = 0.22, p = 0.002); and policies, provider training, and feeding environment with physical activity (B = 0.19, p = 0.001; B = 0.24, p = 0.010; B = 0.38, p < 0.001).

CONCLUSIONS

Nutrition/physical activity best practices in child care are supported by specific policies, provider training, and family education activities.

Exacerbation of Bronchiectasis

Please check the hierarchy of the sections and correct if necessary.

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.

A new method for enhanced expectoration of sputum by vibratory stimulation of the cervical trachea

BACKGROUND

Expectoration of sputum can be difficult for patients with respiratory conditions such as chronic obstructive pulmonary disease, chronic bronchitis, or bronchiectasis because of the effects of decreased pulmonary function, respiratory muscle fatigue, altered sputum properties, and impaired ciliary function. We developed a new method for the vibratory stimulation of the cervical trachea and this study aimed to compare it with the Acapella (a current oscillation device) method.

METHODS

Patients with chronic productive cough and difficulty with expectoration were recruited for the study. The tracheal vibration and Acapella methods were applied for 4 weeks each, according to a crossover design with an intervening 4-week washout period. To perform the tracheal vibration method, an electronic artificial larynx (Yourtone®) was applied to the cervical trachea for up to 5minutes. Patient preference for the two devices was determined from the performance scores recorded for each device and by using a visual analogue scale.

RESULTS

Twelve patients were recruited in the study. According to the performance scores assigned by the subjects, the tracheal vibration method was effective in 9 patients, while the Acapella method was effective in 10 patients. Both methods were effective in 8 patients, among whom the tracheal vibration method was more effective in 5 patients. Both methods were found to be ineffective in 1 patient.

CONCLUSIONS

The tracheal vibration method may be effective at removing central airway sputum and does not require repeated forced expiratory effort, which can otherwise cause exhaustion in patients with decreased lung function. Further investigation is required to confirm its use as a new oscillation technique.

Pulmonary exacerbation in adults with bronchiectasis: a consensus definition for clinical research

There is a need for a clear definition of exacerbations used in clinical trials in patients with bronchiectasis. An expert conference was convened to develop a consensus definition of an exacerbation for use in clinical research.

A systematic review of exacerbation definitions used in clinical trials from January 2000 until December 2015 and involving adults with bronchiectasis was conducted. A Delphi process followed by a round-table meeting involving bronchiectasis experts was organised to reach a consensus definition. These experts came from Europe (representing the European Multicentre Bronchiectasis Research Collaboration), North America (representing the US Bronchiectasis Research Registry/COPD Foundation), Australasia and South Africa.

The definition was unanimously approved by the working group as: a person with bronchiectasis with a deterioration in three or more of the following key symptoms for at least 48 h: cough; sputum volume and/or consistency; sputum purulence; breathlessness and/or exercise tolerance; fatigue and/or malaise; haemoptysis AND a clinician determines that a change in bronchiectasis treatment is required.

The working group proposes the use of this consensus-based definition for bronchiectasis exacerbation in future clinical research involving adults with bronchiectasis.

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.

Are Mealtime Best Practice Guidelines for Child Care Centers Associated with Energy, Vegetable, and Fruit Intake?

BACKGROUND

Mealtime best practices for obesity prevention in child care have been developed from experimental studies and expert opinion. Our objective was to describe adherence to best practices in child care centers and to evaluate the association between mealtime practices and children's dietary intake.

METHODS

We conducted an observational study of 349 preschoolers, ages 36 to 72 months, from 30 child care centers in Cincinnati, Ohio (November 2009 to January 2011). Trained observers recorded providers' behaviors related to six mealtime best practice recommendations and documented children's intake (n = 60 group lunches). General linear mixed models were used to evaluate the association between practice use and children's total energy (caloric consumption) and fruit and vegetable consumption.

RESULTS

Adherence to individual mealtime best practices was variable (0%-77%). Staff sitting with children at lunch was associated with lower energy intake and higher vegetable intake. Staff eating some of the same foods was associated with higher energy intake and higher vegetable intake. Staff encouraging children to try new/less-favorite foods more than once was associated with lower fruit intake. Staff having general conversations with children (not addressed in recommendations) was associated with lower vegetable intake. Family-style meal service, staff talking about healthy foods, and staff helping children assess hunger before seconds were not significantly associated with intake.

CONCLUSIONS

Few mealtime best practices were associated with dietary intake. Given the number of meals children consume in child care and the prevalence of childhood obesity, efforts to identify mealtime practices that improve children's dietary intake are crucial for obesity prevention.

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.

Prolonged antibiotics for non-cystic fibrosis bronchiectasis in children and adults

BACKGROUND

The vicious cycle hypothesis for bronchiectasis predicts that bacterial colonisation of the respiratory tract perpetuates inflammatory change. This damages the mucociliary escalator, preventing bacterial clearance and allowing persistence of pro-inflammatory mediators. Conventional treatment with physiotherapy and intermittent antibiotics is believed to improve the condition of people with bronchiectasis, although no conclusive data show that these interventions influence the natural history of the condition. Various strategies have been tried to interrupt this cycle of infection and inflammation, including prolonging antibiotic treatment with the goal of allowing the airway mucosa to heal.

OBJECTIVES

To determine the benefits of prolonged antibiotic therapy in the treatment of patients with bronchiectasis.

SEARCH METHODS

We searched the Cochrane Airways Group Trials Register and reference lists of identified articles. Searches were current as of February 2014.

SELECTION CRITERIA

Randomised trials examining the use of prolonged antibiotic therapy (for four or more weeks) in the treatment of bronchiectasis compared with placebo or usual care.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data. We contacted study authors to ask for missing information.

MAIN RESULTS

Eighteen trials met the inclusion criteria, randomly assigning a total of 1157 participants. Antibiotics were given for between four weeks and 83 weeks. Limited meta-analysis was possible because of the diversity of outcomes reported in these trials. Based on the number of participants with at least one exacerbation, the meta-analysis showed significant effects in favour of the intervention (odds ratio (OR) 0.31, 95% confidence interval (CI) 0.19 to 0.52; P value < 0.00001), with events occurring in 271 per 1000 people in the intervention arm (95% CI 126 to 385) and in 546 per 1000 in the control population, based on evidence of moderate quality. A non-statistically significant reduction in hospitalisation favoured the use of prolonged antibiotics with a moderate quality grade of supporting evidence (37 per 1000 in the intervention arm (95% CI 13 to 96) and 87 per 1000 in control (OR 0.40, 95% CI 0.14 to 1.11; P value = 0.08). Drug resistance developed in 36 of 220 participants taking antibiotics compared with 10 of 211 participants given placebo or standard therapy (OR 3.48, 95% CI 1.20 to 10.07; P value = 0.02), translating to natural frequencies of 155 per 1000 in the intervention arm (95% CI 59 to 346) and 50 per 1000 in the control arm. The intervention was well tolerated with no overall significant difference in withdrawal between treatment and placebo groups (OR 0.91, 95% CI 0.56 to 1.49). Diarrhoea was commonly reported as an adverse event, particularly with an oral intervention.

AUTHORS' CONCLUSIONS

Available evidence shows benefit associated with use of prolonged antibiotics in the treatment of patients with bronchiectasis, at least halving the odds of exacerbation (with 275 fewer exacerbations per every 1000 people treated in the antibiotic arm compared with the control arm) and hospitalisation (50 fewer hospitalisations per 1000 people in the antibiotic arm compared with the control arm). However, the risk of emerging drug resistance is increased more than threefold. This review is limited by diversity of trials and by evidence of moderate to low quality. Further randomised controlled trials with adequate power and standardised end points are required.

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.

Childhood Obesity Research Demonstration project: cross-site evaluation methods

INTRODUCTION

The Childhood Obesity Research Demonstration (CORD) project links public health and primary care interventions in three projects described in detail in accompanying articles in this issue of Childhood Obesity. This article describes a comprehensive evaluation plan to determine the extent to which the CORD model is associated with changes in behavior, body weight, BMI, quality of life, and healthcare satisfaction in children 2-12 years of age.

DESIGN/METHODS

The CORD Evaluation Center (EC-CORD) will analyze the pooled data from three independent demonstration projects that each integrate public health and primary care childhood obesity interventions. An extensive set of common measures at the family, facility, and community levels were defined by consensus among the CORD projects and EC-CORD. Process evaluation will assess reach, dose delivered, and fidelity of intervention components. Impact evaluation will use a mixed linear models approach to account for heterogeneity among project-site populations and interventions. Sustainability evaluation will assess the potential for replicability, continuation of benefits beyond the funding period, institutionalization of the intervention activities, and community capacity to support ongoing program delivery. Finally, cost analyses will assess how much benefit can potentially be gained per dollar invested in programs based on the CORD model.

CONCLUSIONS

The keys to combining and analyzing data across multiple projects include the CORD model framework and common measures for the behavioral and health outcomes along with important covariates at the individual, setting, and community levels. The overall objective of the comprehensive evaluation will develop evidence-based recommendations for replicating and disseminating community-wide, integrated public health and primary care programs based on the CORD model.

Positive expiratory pressure - Common clinical applications and physiological effects

Breathing out against resistance, in order to achieve positive expiratory pressure (PEP), is applied by many patient groups. Pursed lips breathing and a variety of devices can be used to create the resistance giving the increased expiratory pressure. Effects on pulmonary outcomes have been discussed in several publications, but the expected underlying physiology of the effect is seldom discussed. The aim of this article is to describe the purpose, performance, clinical application and underlying physiology of PEP when it is used to increase lung volumes, decrease hyperinflation or improve airway clearance. In clinical practice, the instruction how to use an expiratory resistance is of major importance since it varies. Different breathing patterns during PEP increase or reduce expiratory flow, result in movement of EPP centrally or peripherally and can increase or decrease lung volume. It is therefore necessary to give the right instructions to obtain the desired effects. As the different PEP techniques are being used by diverse patient groups it is not possible to give standard instructions. Based on the information given in this article the instructions have to be adjusted to give the optimal effect. There is no consensus regarding optimal treatment frequency and number of cycles included in each treatment session and must also be individualized. In future research, more precise descriptions are needed about physiological aims and specific instructions of how the treatments have been performed to assure as good treatment quality as possible and to be able to evaluate and compare treatment effects.

Mucolytics for bronchiectasis

BACKGROUND

Bronchiectasis is predominantly an acquired disease process that represents the end stage of a variety of unrelated pulmonary insults. It is defined as persistent irreversible dilatation and distortion of medium-sized bronchi. It has been suggested that with widespread use of high-resolution computed tomography, more bronchiectasis diagnoses are being made. Patients diagnosed with bronchiectasis frequently have difficulty expectorating sputum. Sputum therefore is retained in the lungs and may become infected, leading to further lung damage. Mucolytic agents target hypersecretion or changed physiochemical properties of sputum to make it easier to clear. One drug, recombinant human DNase, breaks down the DNA that is released at the site of infection by neutrophils.Mucus clearance along with antimicrobial therapy remains an integral part of bronchiectasis management. Chest physiotherapy along with mucolytic agents is commonly used in practice without clear supportive evidence.

OBJECTIVES

To determine whether ingested or inhaled mucolytics are effective in the treatment of patients with bronchiectasis.

SEARCH METHODS

We searched the Cochrane Airways Group Specialised Register and reference lists of relevant articles. We contacted experts in the field and drug companies. Searches were current as of June 2013.

SELECTION CRITERIA

Randomised trials of mucolytic treatment in people with bronchiectasis but not cystic fibrosis.

DATA COLLECTION AND ANALYSIS

Data extraction was performed independently by two review authors. Study authors were contacted for confirmation.

MAIN RESULTS

Four trials (with a combined total of 528 adult participants) were included, but almost none of the data from these studies could be aggregated in a meta-analysis.One trial (with 88 participants) compared bromhexine versus placebo. Compared with placebo, high doses of bromhexine with antibiotics eased difficulty in expectoration (mean difference (MD) -0.53, 95% confidence interval (CI) -0.81 to -0.25 at 16 days); the quality of the evidence was rated as low. A reduction in sputum production was noted with bromhexine (MD -21.5%, 95% CI -38.9 to -4.1 at day 16); again the quality of the evidence was rated as low. No significant differences between bromhexine and placebo were observed with respect to reported adverse events (odds ratio (OR) 2.93; 95% CI 0.12 to 73.97), and again the quality of the evidence was rated as low.In a single small, blinded but not placebo-controlled trial of older (> 55 years) participants with stable bronchiectasis and mucus hypersecretion, erdosteine combined with physiotherapy over a 15-day period improved spirometry and sputum purulence more effectively compared with physiotherapy alone. The spirometric improvement was small (MD 200 mL in forced expiratory volume in one second (FEV1) and 300 mL in forced vital capacity (FVC)) and was apparent only at day 15, not at earlier time points.The remaining two studies (with a combined total of 410 participants) compared recombinant human DNase (RhDNase) versus placebo. These two studies were very different (one was a two-week study of 61 participants, and the other ran for 24 weeks and included 349 participants), and the opportunity for combining data from the two studies was very limited. Compared with placebo, recombinant human DNase showed no difference in FEV1 or FVC in the smaller study but showed a significant negative effect on FEV1 in the larger and longer study. For reported adverse events, no significant differences between recombinant human DNase and placebo were noted. In all of the above comparisons of recombinant human DNase versus placebo, the quality of the evidence was judged to be low.

AUTHORS' CONCLUSIONS

Given the harmful effects of recombinant human DNase in one trial and no evidence of benefit, this drug should be avoided in non-cystic fibrosis bronchiectasis, except in the context of clinical trials. Evidence is insufficient to permit evaluation of the routine use of other mucolytics for bronchiectasis. High doses of bromhexine coupled with antibiotics may help with sputum production and clearance, but long-term data and robust clinical outcomes are lacking. Similarly, erdosteine may be a useful adjunct to physiotherapy in stable patients with mucus hypersecretion, but robust longer-term trials are required.Generally, clinical trials in children on the use of various mucolytic agents are lacking. As the number of agents available on the market, such as RhDNase, acetylcysteine and bromhexine, is increasing, improvement of the evidence base is needed.

Phase 3 randomized study of the efficacy and safety of inhaled dry powder mannitol for the symptomatic treatment of non-cystic fibrosis bronchiectasis

BACKGROUND

Inhaled dry powder mannitol enhanced mucus clearance and improved quality of life over 2 weeks in non-cystic fibrosis bronchiectasis. This study's objective was to investigate the efficacy and safety of dry powder mannitol over 12 weeks.

METHODS

Patients with bronchiectasis confirmed by high-resolution CT (HRCT) scan, aged 15 to 80 years, with FEV1≥50% predicted and ≥1 L participated in a randomized, placebo-controlled, double-blind study. Patients with a negative mannitol provocation test were randomized to inhale 320 mg mannitol (n=231) or placebo (n=112) bid for 12 weeks. To further assess safety, the same mannitol dose/frequency was administered to a patient subset in an open-label extension over 52 weeks. Primary end points were changes from baseline at 12 weeks in 24-h sputum weight and St. George's Respiratory Questionnaire (SGRQ) score.

RESULTS

There was a significant difference of 4.3 g in terms of change in sputum weight over 12 weeks (95% CI, 1.64-7.00; P=.002) between mannitol and placebo; however, this was largely driven by a decrease in sputum weight in the placebo group. This was associated, in turn, with more antibiotic use in the placebo group (50 of 112 [45%]) than in the inhaled mannitol group (85 of 231 [37%]). There was no statistical difference between the groups (P=.304) in total SGRQ score (mannitol, -3.4 points [95% CI, -4.81 to -1.94] vs placebo, -2.1 points [95% CI, -4.12 to -0.09]). In a subgroup study (n=82), patients receiving mannitol showed less small airway mucus plugging on HRCT scan at 12 weeks compared with patients receiving placebo (P=.048). Compliance rates were high, and mannitol was well tolerated with adverse events similar to those of placebo.

CONCLUSION

Because the difference in sputum weights appears to be associated with increased antibiotic use in the placebo group, a larger controlled study is now required to investigate the long-term mannitol effect on pulmonary exacerbations and antibiotic use.

TRIAL REGISTRY

ClinicalTrials.gov; No.: NCT0027753; URL: www.clinicaltrials.gov.

Nutritional quality of meals compared to snacks in child care

BACKGROUND

Most young children are in child care. Previous studies suggest that children may receive insufficient vegetables, and foods and beverages with added sugars, fats, and sodium in these settings. None have compared the nutritional quality of meals to snacks.

METHODS

Directors from 258 full-day child-care centers in two urban counties of southwestern Ohio were surveyed via telephone in the fall of 2009 about their nutrition practices, and asked to provide a current menu. Lunch and afternoon snack menus were categorized according to average weekly frequency for fruits, vegetables, lean meats, juice (100%), and sweet or salty foods served. Frequencies were compared by meal occasion (lunch vs. snack) using the Fisher exact test.

RESULTS

Most (60%) directors reported serving 2% milk to children ≥3 years; 31% served whole milk. Menu analysis demonstrated the composition of lunches differed from snacks (p<0.0001) in all food categories. A total of 87% centers rarely (<1 time per week) listed nonstarchy vegetables for snacks, but 67% of centers included them at lunch ≥3 times per week. Juice (100%) was on snack menus >2 times per week in 37% centers, but in only 1 center as a regular component of lunch. Similarly, 87% centers listed sweet and salty foods at snack ≥3 times per week, but rarely at lunch.

CONCLUSIONS

Despite efforts to improve children's diets in child care, meals-and particularly snacks-still lack whole fruits and nonstarchy vegetables and contain added sugars and fats. Snacks represent a missed opportunity to improve the nutritional quality of foods served in childcare.

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.

Nutrition practices and mealtime environments of North Carolina child care centers

BACKGROUND

The majority of children in the United States attend out-of-home child care. However, little is known about the nutritional quality of foods served and the mealtime environments.

METHODS

We assessed 96 child care centers over one full day using a researcher-administered structured observation and document review. We focused on eight nutrition domains: (1) fruits and vegetables, (2) whole grains, (3) high-sugar, high-salt, and high-fat foods, (4) beverages, (5) food availability and service, (6) staff behaviors, (7) training and education, and (8) policies. We computed daily means and frequencies for each domain.

RESULTS

Seventy-five percent of centers participated in the Child and Adult Care Food Program, indicating they served low-income children. Centers enrolled 66 children on average; 60% were white, 28% were black, 4% were Native American, and 8% identified as mixed race. On the day of observation, seven centers did not serve a fruit and 15 did not serve a vegetable. Eighty centers served a high-sugar or high-salt food and 84 did not serve any whole grains. Five centers did not provide water indoors to children, 22 served juice twice, and 50 served whole milk. Seventeen centers had a vending machine on site visible to parents and children. Overall, children were served excessive juice, high-sugar and high-salt snack foods, and too much whole milk.

CONCLUSIONS

Centers had room for improvement and could strive to serve more nutritious foods and create healthier mealtime environments for children.

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.

A pilot study of the impact of high-frequency chest wall oscillation in chronic obstructive pulmonary disease patients with mucus hypersecretion

Introduction

Chronic obstructive pulmonary disease (COPD) patients with mucus hypersecretion tend to demonstrate increased frequency of infective exacerbations and a steeper slope of decline in lung function. Enhanced mucociliary clearance with high-frequency chest wall oscillation (HFCWO) devices previously used in cystic fibrosis and bronchiectasis patients may offer the opportunity for community-based, self-managed therapy to improve quality of life and lung function.

Study design and methods

A randomized controlled crossover pilot study of HFCWO compared with conventional treatment was conducted in 22 patients with moderate to severe COPD and mucus hypersecretion. Patients spent 4 weeks using an HFCWO (SmartVest^®) device and 4 weeks in a conventional phase with a 2-week washout. Eleven patients started with HFCWO and changed to conventional treatment, whereas the other eleven patients started conventional treatment and crossed over to HFCWO.

Results

The patients were elderly with a mean age of 71 (standard deviation [SD] 10) years and were at the upper end of the normal range of body mass index (25 [SD 4.2] kg/m²). The majority of patients had moderate to severe COPD with a mean percentage predicted forced expiratory volume in 1 second of 41 (SD 15.6) and percentage predicted forced vital capacity of 73 (SD 17.7). Baseline sputum production was negatively correlated to lung function and positively to St George’s Respiratory Questionnaire. Symptom scores and St George’s Respiratory Questionnaire symptom dimension improved significantly (−8, P < 0.05). Sputum production showed a declining trend in the HFCWO phase, although not reaching statistical significance. The HFCWO device was well tolerated with good reported compliance.

Conclusion

This pilot study demonstrated that patients with advanced COPD and mucus hypersecretion at increased risk of declining lung function tolerated the HFCWO treatment well, leading to improvement in quality of life and reduced symptoms.

Mechanical analysis of an oscillatory positive expiratory pressure device used in respiratory rehabilitation

This article aims to characterize the mechanical behavior of the Acapella Blue, a respiratory rehabilitation device designed to aid sputum clearance. In this scope, the present study initially describes in detail the peak-to-peak oscillation amplitude (App) and peak frequency (fp) behavior, as well as positive pressure level (Ppl), in the flow range more comonly found in practice. The parameters were evaluated in all 5 adjustment levels of the equipment in intervals of 50 mL/s. The device characterization has shown fp up to 23 Hz, App from 0.2 to 2.8 cmH(2)O and Ppl ranging from 1.2 to 13.5 cmH(2)O. The studied device may produce oscillation in the ranges of ciliary movements and respiratory system resonance frequency of patients with respiratory diseases. Data obtained in this work may help to optimize the use of the Acapella Blue device in respiratory rehabilitation. Suggestions for the practical use of the device are also presented.

Bronchiectasis: new findings in the pathogenesis and treatment of this disease

PURPOSE OF REVIEW

Bronchiectasis is an under-appreciated cause of chronic lung disease in the USA. We highlight developments in diagnosis and treatment of this debilitating disease.

RECENT FINDINGS

A possible link between gastroesophageal reflux and development of nontuberculous mycobacterial lung disease was highlighted. Reflux is more common in patients with nontuberculous mycobacterial lung disease, and among those with established bronchiectasis more extensive disease was observed in those patients who also had reflux. Long-term mortality in bronchiectasis was significantly associated with age, lower body mass index, dyspnea, lack of vaccination, hypoxemia, hypercapnia, and other functional parameters. In a large, randomized clinical trial, addition of inhaled tobramycin to ciprofloxacin for acute exacerbations of Pseudomonas infection produced microbiologic improvement correlating with clinical outcomes but not overall improvement. A review noted that five macrolide trials reported reduced sputum volume, improved lung function, and better symptom control. Finally, articles suggested benefit from inhaled hyperosmolar agents (e.g. hypertonic saline and inhaled mannitol).

SUMMARY

The possible link between gastroesophageal reflux and nontuberculous mycobacterial lung disease, and the microbiology and resistance patterns of bacteria observed in these patients were clarified. A large study of inhaled tobramycin for exacerbations was inconclusive, but macrolide therapy and hyperosmolar agents hold promise.