Respiratory physiotherapy in the bronchiectasis guidelines: is there a loud voice we are yet to hear?

Abstract

]. Bronchiectasis is a chronic respiratory disease of airway dilatation, where patients typically suffer from respiratory infections, fatigue, sputum, cough, dyspnoea and poor quality of life [1, 2]. This condition has received increased interest over the past years, with important developments in establishing national and international patient registries [3-5], randomised controlled trials of new treatments [6-8] and disease-specific health status questionnaires, such as the Bronchiectasis Health Questionnaire and the Quality of Life Questionnaire-Bronchiectasis [9, 10]. A number of new treatment approaches have been proposed including long term antibiotic therapies and immune modulating drugs [6, 7, 11, 12]. Nevertheless the area of bronchiectasis care that has received the least attention during this period is the aspect of management that most healthcare professionals caring for bronchiectasis agree is the most important: airway clearance and exercise [13, 14]. The evidence base for respiratory physiotherapy has not advanced at the same pace as other aspects of bronchiectasis care [15]. To assist clinical decision-making, bronchiectasis guidelines synthesise, evaluate the evidence and provide recommendations for clinical practice, and a number of clinical guidelines in bronchiectasis have been published since 2008 (table 1). Although usually similar, guidelines can present some variability in their recommendations even for the same topic [16-21]. This is particularly the case for physiotherapy, because of the limited evidence on which to base guideline recommendations. The purpose of this editorial is to discuss the current state of play worldwide with regard to airway clearance and pulmonary rehabilitation and suggest the need to prioritise research into these topics.

Measuring airway clearance outcomes in bronchiectasis: a review

“…International guidelines over the past decade have also emphasised the need for high-quality evidence to support ACTs in bronchiectasis [1,20,29,132]. A recent editorial has issued a "call for action" for increased awareness and research into ACTs in bronchiectasis and the need for establishing clinically important outcomes [133]. The European Respiratory Society guidelines also confirmed the nine most important Patient/problem, Intervention, Comparison, Outcome (PICO) topics agreed between clinicians and patients, with respiratory physiotherapy considered one of the most important [20].…”

“…Research challenges include the personalisation of ACTs, study blinding and placebo effects. Study designs including active comparators, clusters based on endotypes or phenotypes, or stepped-wedge implementation trials are alternative approaches that require consideration for future studies [133]. Adding to the confusion, there is currently no validated respiratory exacerbation prediction tool and there have been varying definitions of respiratory exacerbations in airway clearance studies [46,59].…”

ERS International Congress 2020 Virtual: highlights from the Allied Respiratory Professionals Assembly

“…In conclusion, there was low quality of evidence about the effectiveness of ACTs in chronic respiratory diseases [43]. The most prevalent methodological issues were difficulties in adherence and compliance in long-term investigations, ethical problems, lack of blinding, poor study design, poorly defined or misinterpreted techniques and lack of selecting appropriate outcome measurements.…”

“…As a key message, clinical practice about ACTs is mainly guided by physiology rationale and short-term benefits. There is an urgent need to take an action and perform high quality research on the long-term effectiveness of ACTs [43].…”

Counting the cost of bronchiectasis

“…Strategies to prevent exacerbations will ultimately reduce economic burden. Currently, a multidisciplinary approach has been proposed, including treating underlying conditions, vaccination, optimizing airway clearance, 9 prescribing chronic macrolide therapy or additional therapies based on identified treatable traits, 10,11 including potentially inhaled antibiotics in patients with high bacterial load, mucoactive agents in patients with high daily symptom burden as well as inhaled corticosteroid in patients with elevated blood eosinophil counts. Unfortunately, despite evidence‐based guidelines having been available for many years, guideline adherence is poor globally and it is highly likely that much of the burden of the disease could be alleviated by raising the overall quality of care.…”