European Respiratory Society statement on airway clearance techniques in adults with bronchiectasis

Abstract

Airway clearance techniques (ACTs) are part of the main management strategy for patients with bronchiectasis. Despite being a priority for patients, accessibility, implementation, and reporting of ACTs are variable in clinical settings and research studies. This European Respiratory Society statement summarises current knowledge about the ACTs in adults with bronchiectasis and makes recommendations to improve future evidence base. A task force of 14 experts and two patient representatives (10 countries) determined the scope of this statement through consensus and defined six questions. The questions were answered based on systematic searches of the literature.The statement provides a comprehensive review of the physiological rationale for ACTs in adults with bronchiectasis, and the mechanisms of action along with the advantages and disadvantages of each ACT. Evidence on the ACTs in clinical practice indicates that active cycle of breathing techniques, positive expiratory pressure devices and gravity assisted drainage technique are the most frequently used techniques, although there is limited evidence on the type of ACTs used in specific countries. A review of 30 randomised trials for the effectiveness of the ACTs shows that these interventions increase sputum clearance during or after treatment, reduce the impact of cough and the risk of exacerbations, and improve health-related quality of life. Furthermore, strategies for reducing the risk of bias in future studies are proposed. Finally, an exploration of patientś perceptions, barriers and enablers related to this treatment is also included to facilitate implementation and adherence to ACTs.

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

“…Impaired mucociliary clearance is one of the defining features of the clinical syndrome of bronchiectasis [ 1 , 2 ]. The most frequent symptoms that impact upon patients’ quality of life are cough and sputum production, commonly characterised by secretions with high viscoelasticity [ 3 – 5 ]. Chronic inflammation and infection in bronchiectasis result in excess mucus production through hyperplasia and metaplasia of goblets cells, reduced hydration of the airway surface liquid and impaired cilia beating [ 3 , 6 , 7 ].…”

“…Improving clearance of mucus from the airways is therefore recognised by international and national guidelines for bronchiectasis as a central component of management [ 9 – 11 ]. Airway clearance is, however, not supported by high-quality evidence [ 5 , 12 , 13 ]. The European Respiratory Society (ERS) guidelines in 2017 recommended using airway clearance management in symptomatic adult patients as a weak recommendation with a low quality of evidence due to a paucity of randomised studies [ 9 ].…”

“…The European Respiratory Society (ERS) guidelines in 2017 recommended using airway clearance management in symptomatic adult patients as a weak recommendation with a low quality of evidence due to a paucity of randomised studies [ 9 ]. The limited research into airway clearance techniques (ACTs), as well as the heterogeneity in the patient population, leads to diverse practice [ 5 ]. Access to healthcare is variable across Europe and worldwide, and therefore access to specialist respiratory physiotherapists and airway clearance management is also variable between different countries and within countries [ 5 , 14 , 15 ].…”

Objective sputum colour assessment and clinical outcomes in bronchiectasis: data from the European Bronchiectasis Registry (EMBARC)

“…Although the sputum colour chart was provided to all sites through the online data collection system, monitoring how this was used across so many sites is not feasible and variation in practice is inevitable. Sputum characteristics may vary by time of day, or depending on airway clearance techniques or other interventions [ 36 ]. Sputum cultures were not mandatory and so the analysis of sputum bacteria is limited by whether or not patients had sputum cultures performed for clinical reasons.…”

Eradication treatment forPseudomonas aeruginosainfection in adults with bronchiectasis: a systematic review and meta-analysis

“…Any explanation for the different effectiveness seen in bronchiectasis and cystic fibrosis would be speculative, but would include the lower frequency of sputum sampling in bronchiectasis, such that P. aeruginosa infection in people with bronchiectasis may represent previous undetected chronic infection. The older age and greater comorbidity of the patient population [ 32 – 34 ] in bronchiectasis and lower use of comedication such as macrolides, DNAse and other therapies including airway clearance may also be relevant [ 35 ].…”