Bronchiectasis is linked to several underlying causative agents and involves permanent airway damage, dilated bronchi, retained secretions, chronic infection, and persistent inflammation. But respiratory therapists have several airway clearance therapy options to treat the disease.
By Bill Pruitt, MBA, RRT, CPFT, FAARC
Airway clearance is essential to improving the health and well-being of patients who have bronchiectasis. This disease is linked to several underlying causative agents and involves permanent airway damage, dilated bronchi, retained secretions, chronic infection, and persistent inflammation. This article will review bronchiectasis and the airway clearance therapies available to the healthcare team as they care for these patients.
What is Bronchiectasis?
Bronchiectasis is a chronic condition of the lungs and particularly the airways. It was first described in 1819 by René Laënnec and was based on his assessment of auscultation in his patients and findings from post-mortem autopsies.1 Patients with bronchiectasis typically have a chronic, productive cough with viscid sputum and have thickened bronchial walls along with airway dilation on radiographs. Airways can also collapse easier despite the thickened walls – leading to air trapping and ineffective cough. Sputum produced in the airways is more tenacious and more concentrated compared to healthy controls and is produced most days of the week for months (or years). Bronchiectasis is often considered to be a syndrome and the end result of a number of different diseases.2-3 It is more commonly found in females than in males.1 An accurate diagnosis is dependent on chest imaging (CT scan) and the diagnosis is often delayed due to an incorrect diagnosis of some other condition (ie, chronic bronchitis, rhinosinusitis, etc).1
Two mechanisms are required in the development of bronchiectasis:4
- an infectious insult, and
- impaired drainage, airway obstruction, or a defect in host defense.
In the pathology of bronchiectasis, a vicious cycle of events starts with airway dilation and damage leading to retained secretions, chronic infection, persistent inflammation, and further airway damage.3 The retained secretions often lead to mucus plugging and provide a fertile area for infections to take hold. According to figures from 2017, some 350,000 to 500,000 adults in the US have bronchiectasis with a rapid increase in cases among those over 60 years of age.4 There are several diseases/conditions that cause bronchiectasis including post-infection, chronic obstructive pulmonary disease (COPD), rheumatic disorders, and immunodeficiency.4 Bronchiectasis is frequently identified as cases related to cystic fibrosis (CF) versus non-CF. Progressive decline in lung health is linked to frequent exacerbations and infections with P aeruginosa, Non-tuberculous mycobacteria, and Aspergillus fumigatus.
Airway Clearance—The First Line of Action
With the retained secretions that are thick and often copious, airway clearance is a primary therapy that is needed in bronchiectasis.3 Overall treatment goals should be to reduce symptoms, improve quality of life, preserve lung function, and reduce overall morbidity and mortality.1 There are many approaches to help clear secretions, involving inhaled medications, various breathing patterns, chest physiotherapy, and use of different devices.5 Inhaled medications include expectorants (ie, hypertonic saline), mucolytic agents (ie, N-acetylcysteine), anticholinergic mucoregulatory medications, bronchodilators, mucus clearing agents (ie, mannitol), and inhaled antibiotics (ie, tobramycin, gentamycin) for those with chronic infection.1,5 Research into the inhaled agents (other than antibiotics) has questioned the effectiveness of some of those mentioned and it is advisable to watch for further developments in this area. Breathing patterns such as active cycle of breathing technique (ACBT) and huff-coughing have been used most often, according to a published study from 2021.5 Deep breathing, sustained maximal inspiration, and ELTGOL (an active technique where the subject carries out slow expiration with the glottis open in a lateral decubitus position) also appeared in the listing of breathing pattern approaches. Chest physiotherapy techniques (CPT) include postural drainage, postural drainage with percussion, and manual chest wall vibration.5 Good coaching and patient cooperation/toleration are very important in using the breathing pattern and CPT approaches. Some of these therapies can be done by the patient alone, but others require assistance to the patient by a healthcare provider or family member.
Devices to Move Secretions
Non-pharmacologic approaches to clearing airway secretions using devices has been available for many years and many devices are available on the market. A fair amount of research has examined the effectiveness of the devices and the decision to use one versus the other depends on several factors. According to the UpToDate website regarding adults with bronchiectasis: “The choice of a technique or device should be based upon frequency and tenacity of phlegm, patient comfort, cost, and the patient’s ability to use the technique or device with minimal interference to their lifestyle and minimal detriment to coexisting medical conditions.”2
Mechanical Insufflation-Exsufflation (M I-E)
M I-E devices are primarily used for patients who have very weak respiratory muscles or a nervous system disease (ie, Duchenne muscular dystrophy, amyotrophic muscular dystrophy) that interferes with effective breathing and cough. The machine uses electricity and a blower unit to provide the therapy. The patient interface can be via a mouthpiece, face mask, or the device can be attached to an artificial airway. The machine forces air into the patient through a single-limb circuit to reach a set inspiratory pressure then rapidly removes air using negative pressure to generate a high expiratory flow which simulates a cough. Generally, during one session an inspiratory pressure of +30 cmH2O to +40 cmH2O and an expiratory pressure of -30 to -40 cmH2O is used in adults with 3 to 5 “breaths” given followed by a short rest. This is repeated until sufficient secretions have been expelled (or after several sessions – patient tolerance may also stop the therapy). Usually, two to four treatments are performed daily. Possible complications include abdominal distension, aggravation of gastroesophageal reflux, chest and abdomen discomfort, and pneumothorax, but these are rare according to the published research on the M I-E.6
Positive Expiratory Pressure (PEP)
PEP devices provide expiratory resistance during exhalation to splint the airways by increasing the diameter of the airways and reducing airway collapse. Inspiration through these devices is normal and without interference; the device applies “back-pressure” during exhalation. The splinting mechanism helps mobilize retained secretions. This is performed three to four times daily. This approach is simple and straight-forward but has been overshadowed by the addition of oscillations to the expiratory maneuver described in the next device.
Oscillatory PEP (OPEP)
OPEP devices also allow for normal inspiration and provide resistance during exhalation, like the PEP devices, but add an oscillation during the exhalation by very short occlusions of the airflow. Beyond the splinting effect of the positive expiratory pressure, the oscillations help thin and mechanically loosen secretions and aid the movement of mucus and mucus plugs toward the central airways to be expectorated. Therapy is usually performed three to four times daily.
These devices operate by either a mechanical (using an internal flap or a weighted ball) or acoustic mechanism (generating a sound that in doing so produces oscillations), and some are adjustable to provide variations in expiratory resistance or in oscillations. Some are gravity-dependent, meaning that the device must be oriented properly to obtain the desired oscillations. Several devices are designed to be used in conjunction with delivery of nebulized medications – however research has shown that doing so may reduce the delivered aerosol. All of these devices are fairly small and portable and need no power source or other attachments to operate.7
High-frequency Chest Wall Oscillation (HFCWO)
HFCWO devices utilize two different approaches to produce oscillations in the chest and airways: either an inflatable vest or a vest containing oscillating discs. The inflatable vest is attached to a compressor which generates short bursts of air into the vest to compress and release the chest wall. This device requires the patient to stay beside the compressor for therapy. The oscillating discs are battery operated and use magnets to produce a similar oscillating movement in the vest. Since this device is battery operated, the patient can be mobile. Both approaches produce airflow oscillations that can decrease the viscosity of the mucus (making secretions easier to move more centrally) and produces burst of airflow within the airways that have a shearing effect to move secretions. Therapy is usually performed three to four times daily.8
Intrapulmonary Percussive Ventilation (IPV)
IPV (also referred to as High Frequency Percussive Ventilation or HFPV) is a device that delivers pressure-limited, time-cycled, high frequency ventilation with small tidal volume breaths in conjunction with a nebulizer to provide either a medication or an isotonic aerosol to help remove secretions. The patient interface can be a face mask, mouthpiece, endotracheal airway. Therapy is usually performed three to four times daily. Research concerning the effectiveness of IPV is sparse. According to a review of IPV in COPD, cystic fibrosis, and bronchiectasis published in Respiratory Care journal from 2018, “The lack of evidence for IPV is due largely to the absence of standardized protocols and the difficulty of finding an outcome to evaluate the efficacy of the technique.” In the conclusion the authors stated, “The systematic use of IPV in different chronic obstructive airway diseases as an airway clearance technique is not supported by sufficiently strong evidence to recommend its routine use. However, IPV could offer some benefits in patients with COPD during exacerbation by improving gas exchange and by possibly reducing the length of hospital stay.”10
Bronchiectasis is a disease that cannot be cured but with the right support, patients can experience a better quality of life with fewer symptoms, fewer exacerbations, and reduced need for hospitalization. Research continues to evaluate the safety, effectiveness, and practicality of various treatments (both pharmaceutical and non-pharmaceutical). There are many ways to offer support and many therapeutic options, and an individualized approach is needed to ensure that the patient has what they need, can afford the therapies, is capable to perform what is in their care plan, and agreeable to cooperate with the plan of care. Therapies range from fairly low-cost and easy to perform to more costly approaches with higher technology. Being knowledgeable about what is available, the performance evaluations shown through research, and having insight into what is best for each patient is a key to providing the best patient care and preparing the best care plan for these patients.
Bill Pruitt, MBA, RRT, CPFT, FAARC, is a writer, lecturer, and consultant. He has over 40 years of experience in respiratory care, and has over 20 years teaching at the University of South Alabama in Cardiorespiratory Care. Now retired from teaching, he continues to provide guest lectures and write. For more info, contact [email protected].
- O’Donnell AE. Bronchiectasis—A Clinical Review. New England Journal of Medicine. 2022 Aug 11;387(6):533-45.
- UpToDate: Bronchiectasis in adults: Maintaining lung health. https://www.uptodate.com/contents/bronchiectasis-in-adults-maintaining-lung-health.
- Macfarlane L, Kumar K, Scoones T, Jones A, Loebinger MR, Lord R. Diagnosis and management of non-cystic fibrosis bronchiectasis. Clinical Medicine. 2021 Nov;21(6):e571.
- UpToDate: Clinical manifestations and diagnosis of bronchiectasis in adults. https://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-bronchiectasis-in-adults.
- Phillips J, Lee A, Pope R, Hing W. Physiotherapists’ use of airway clearance techniques during an acute exacerbation of bronchiectasis: a survey study. Archives of physiotherapy. 2021 Dec;11(1):1-1.
- Homnick DN. Mechanical insufflation-exsufflation for airway mucus clearance. Respiratory care. 2007 Oct 1;52(10):1296-307.
- Coppolo DP, Schloss J, Suggett JA, Mitchell JP. Non-Pharmaceutical Techniques for Obstructive Airway Clearance Focusing on the Role of Oscillating Positive Expiratory Pressure (OPEP): A Narrative Review. Pulmonary Therapy. 2021 Dec 3:1-41.
- Gorby H, Urribarri MC. When to Leverage High-Frequency Chest Wall Oscillation: A Rountable Discussion with Pulmonologists. . RT for Decision Makers in Respiratory Care. Oct. 2022.
- O’Neill K, O’Donnell AE, Bradley JM. Airway clearance, mucoactive therapies and pulmonary rehabilitation in bronchiectasis. Respirology. 2019 Mar;24(3):227-37.
- Reychler G, Debier E, Contal O, Audag N. Intrapulmonary percussive ventilation as an airway clearance technique in subjects with chronic obstructive airway diseases. Respiratory Care. 2018 May 1;63(5):620-31.