Management of bronchiectasis is crucial in helping to prevent or reduce exacerbations and to maintain quality of life. However, when excessive mucus buildup does occur, patients have several options to clear the airways.
By Phyllis Hanlon
According to the American Lung Association (ALA), bronchiectasis, which occurs in fewer than 200,000 Americans annually, is a chronic, long-term condition in which the patient loses the ability to naturally clear mucus and secretions and can lead to persistent destruction of the airways. Management of the disease is crucial in helping to prevent or reduce exacerbations and to maintain quality of life. However, when excessive mucus buildup does occur, patients have several options to clear the airways.
In 2015, authors from Canada published results from a search of the Cochrane Airways Group Specialized Registry of trials and relevant journals on patients with non-cystic fibrosis bronchiectasis to determine the efficacy of airway clearance techniques (ACT) in a stable clinical state or during acute exacerbations.1
The techniques used in these trials included airway oscillatory devices, high frequency chest wall oscillation (HFCWO) and positive expiratory pressure (PEP). The authors concluded, “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.” However, outcomes when using these techniques in acute bronchiectasis exacerbations were inconclusive.
The Thoracic Society of Australia and New Zealand (TSANZ) noted that airway clearance techniques in patients with bronchiectasis could be beneficial in improving quality of life and capacity for exercise as well as in reducing cough and sputum, despite a lack of robust evidence.
TSANZ indicated that, regardless of device selection, the goal of the ACT is to decrease exacerbations and shortness of breath; minimize stress on the pelvic floor; reduce energy expenditure; and improve quality of life. Furthermore, the organization recommends a six-month review of the ACT program to determine whether goals are being met or if the regimen should be changed.
Cause Determines Treatment
Joseph Khabbaza, MD, staff physician, respiratory department, pulmonologist, Cleveland Clinic, explained that confirming a bronchiectasis diagnosis and the underlying cause is key to creating a personalized treatment plan; the disease might stem any one of multiple causes from infection to immune diseases/deficiencies.
“You also need to be aware of rare conditions, like primary ciliary dyskinesia or something else that leads to a different prognosis. Most commonly, simple acid reflux from the stomach can cause bronchiectasis. In that case, the treatment plan would be different,” Khabbaza said.
Some environmental factors could also be responsible for the development of bronchiectasis, Khabbaza asserted. He reported that nontuberculosis mycobacteria (NTF) is present in water and soil; in people with a predisposition or high risk, exposure could lead to the development of a lung condition.
“Most of us would be able to cough up bacterium out of the airway. Patients with bronchiectasis don’t clear [mucus] like we do, so it can fall down into the airways and cause more bronchiectasis,” he said.
Khabbaza pointed out that, once underlying factors have been identified, healthcare providers must understand the patient and what they will tolerate before prescribing a clearance technique. “No regimen has been found to be superior than another. The most effective one is whatever the patient will use,” he said.
Multiple Device Options
A nebulizer breathing treatment can deliver medication down deep into the lung and will make mucus and sputum more moist and easy to move, according to Khabbaza. “The flutter valve or Acapella is more common. This is a plastic device the patient blows into. It puts positive pressure back into the airway, shakes up mucus and clears it out,” he said.
Percussion and postural drainage is another technique that helps drain mucus out from the lung. “Older, thinner frail patients will not do well with this technique,” Khabbaza said, noting that the process can be fatiguing.
The market supports several types of mechanical vest; this device creates oscillating waves and vibrations to loosen up mucus, according to Khabbaza. “This works well but the patient may not tolerate it. It can be time-consuming and more physically uncomfortable. You need to find something the patient will tolerate.”
Patient age and stage of disease should factor into any decisions regarding a treatment plan. “Older patients can’t tolerate more vigorous devices,” said Khabbaza, emphasizing that early diagnosis can benefit the patient. “In various stages, the disease is often missed since the symptoms and presentations are subtle. If you can catch it earlier, the patient is more likely to quickly respond to nebulized treatments for airway clearance. They might do well with Acapella or a hypertonic saline nebulizer.”
Patients who continue to have trouble clearing the airways would add vest therapy or other types of treatment. “Regardless of severity of disease, you should start with easier techniques and then, step up, based on response or lack thereof,” said Khabbaza.
For patients with advanced disease, mechanical ventilation might be prescribed for inpatients and noninvasive ventilation for outpatients. In some cases, combination therapies, tailored to what the patient can tolerate or is willing to do, could be the best treatment option.
Hospital Combination Therapy
Andy Reding, vice president and general manager, Respiratory Health, Hillrom, noted that hospitalized patients with bronchiectasis might receive treatment with the MetaNeb System, which delivers Oscillation Lung Expansion, or OLE, therapy. The MetaNeb System provides three therapies in one device: Continuous Positive Expiratory Pressure mode (CPEP) for lung expansion, Continuous High Frequency Oscillation (CHFO) mode for secretion mobilization, and aerosolized humidification and/or medication in both CPEP and CHFO modes.
During the CPEP mode, airways are opened to get air behind secretions and aerosols moisten thickened secretions. During the CHFO mode, high-frequency oscillation loosens and breaks up secretions, while creating a faster expiratory flow to move secretions upward. Treatment alternates between CPEP and CHFO modes for approximately 10 minutes. Patients receive this type of treatment based on physician order. While the frequency varies, Reding indicated that two to four times a day is a common regimen.
Hospitalized bronchiectasis patients may receive treatments with The Vest System, which provides HFCWO therapy to aid in the mobilization of retained secretions. This therapy consists of an inflatable garment connected to an air pulse generator that inflates and deflates the garment, gently compressing and releasing the chest wall to create airflow within the lungs to help thin and shear secretions from the wall of the airways. Faster expiratory airflow is created to move secretions upward where they can be more easily coughed out. Therapy two to four times a day is a common regimen, Reding reported.
“This therapy has been used for over 30 years and is commonly used in the hospital. Single-patient-use garments meant for the length of a patient’s hospital stay are discarded after the patient leaves the hospital, so there is no worry of cross contamination,” he said.
HFCWO therapy with The Vest System is available for bronchiectasis patients who require ACT at home. The only difference is that permanent washable and dryable garments are used at home, where treatments are commonly done two times per day.
Mobile HFCWO therapy is also available to patients at home with the battery-operated Monarch Airway Clearance System. The garment contains eight oscillating pulmonary discs (PODS) that generate airflow to help thin and mobilize secretions. “While the Monarch System is great for those who value mobility, it’s not for every patient,” Reding explained. “The device has to be the right fit for the patient since the POD technology makes it heavier than traditional HFCWO therapy. Frail or elderly patients with bronchiectasis might not tolerate a garment that weighs about 13 pounds. But patients with greater mobility might find the Monarch System allows them to move about freely during therapy to perform chores and everyday activities, while still getting their treatments done.”
Another HFCWO device that can be effective in helping patients clear the airways is the Philips InCourage, vest therapy that delivers pulsating air to an inflatable vest or band, resulting in a rhythmic inflation and deflation of the garment against the patient’s chest. “These brief, intense thumps to the chest, similar to the compressions that occur in manual chest physiotherapy, help loosen and thin mucus so it can be mobilized and expelled by the patient, offering a safe, effective, non-invasive airway clearance method,” said Dave Myers, director, Global Product Marketing Ventilation and Airway Clearance at Philips Respironics.
The InCourage system features triangle waveform technology, which research shows can clear up to 20% more mucus than competing technology,2 according to Myers. This therapy may also be more comfortable since the duration of peak pressure is shorter than sine wave technology, he added.2-3
Myers cited research that indicates patients who use HFCWO daily may experience fewer unscheduled visits to healthcare providers, reduced hospitalizations due to respiratory complications, decreased respiratory medication use, lower incidence of pneumonia and a better quality of life.4
Patients of all ages and at all stages of disease can safely use InCourage, according to Myers. However, the system “should not be used on patients who have a head and/or neck injury that has not yet been stabilized or who have an active hemorrhage with hemodynamic instability,” he cautioned.
Licensed respiratory therapists and registered nurses provide in-home training on how to use the device and also assist patients in completing their first therapy cycle and provide ongoing support to encourage compliance, Myers said.
To foster compliance and positive outcomes, RespirTech created a bronchiectasis patient outcomes program. “After 12 months of Philips InCourage vest therapy, patients in the program reported a 62% decrease in yearly hospitalizations; 62% of patients said the ability to clear their lungs was ‘good-excellent’; 43% of patients rated their respiratory health as ‘good-excellent’; and 14% of patients reported decreased antibiotic use.”
Khabbaza emphasized that diagnosing and creating an effective treatment plan for a patient with bronchiectasis is “…time intensive and takes a lot of work on the patient’s end.” He cited challenges around compliance, effective communication with physicians and getting buy-in from the patient. “A very important part of an airway clearance regimen is simply being physically active, getting 150 minutes a week of activity,” he asserted.
Phyllis Hanlon is a contributing writer to RT. For more information, contact [email protected].
- Lee AL, Burge AT, Holland AE. “Airway clearance techniques for bronchiectasis.” Cochrane Database System Review. 2015 Nov 23;(11):CD008351. doi: 10.1002/14651858.CD008351.pub3.
- Milla CE, Hansen LG, Weber A, Warwick WJ. “High-Frequency chest compression: effect of the third generation compression waveform.” Biomed Instrum Technol 2004; 38:322-328.
- Milla CE, Hansen LG, Warwick WJ. “Different frequencies should be prescribed different high frequency chest compression machines.”
- Giarraffa P, Berger KI, Chaikin AA, Axelrod FB, Davey C, Becker B. “Assessing efficacy of high frequency chest wall oscillation in patients with familial dysautonomia.” CHEST 2005;128:3377-3381.