Advanced Physiotherapist Paul McCallion shares his expertise in airway clearance and the role physiotherapists have in the treatment of Bronchiectasis patients.
What can physiotherapists do for patients with bronchiectasis?
Physiotherapists have a key role in the management of patients with bronchiectasis. We provide education, offer lifestyle management, prescribe airway clearance techniques, assess breathing patterns, promote physical activity, prescribe exercise and if needed advice on continence management. Many physiotherapists will also lead or facilitate pulmonary rehabilitation classes. These can help improve exercise capacity, quality of life and anxiety and depression in bronchiectasis.
How has the role of physiotherapy evolved in bronchiectasis management?
Historically physiotherapists were only involved in the provision of airway clearance techniques. Up until the 1990’s this mainly involved manual techniques such as percussions and vibrations to the chest wall with gravity assisted drainage, depending on the locations of the patient’s bronchiectasis. Most physiotherapists involved in caring for patients with bronchiectasis will offer a wider range of airway clearance techniques.
Airway clearance is still considered the most important role of physiotherapists in bronchiectasis management. However, some physiotherapists now have advanced clinical skills which allow a more comprehensive consultation. Physiotherapists can train to be independent non-medical prescribers, perform nebuliser trials (e.g. hypertonic saline or an inhaled antibiotic), request bloods, sputum tests, chest x-rays and high-resolution CT chest scans to facilitate a comprehensive assessment and treatment for patients. This also supports the increasing workload with wider bronchiectasis multi-disciplinary teams.
What are the benefits of doing airway clearance?
Airway clearance is considered the cornerstone of bronchiectasis management - it plays an important role in disrupting the ‘viscous vortex’ of bronchiectasis. People with bronchiectasis who perform regular airway clearance are less likely to have chest infections and many will have an improved quality of life.
Many patients produce excess mucus which can get stuck in the airways. Coughing alone is not enough to clear mucus, especially mucus which is ‘trapped’ in the lower airways of the lung. Airway clearance involves different mechanisms depending on the technique used. Techniques will typically involve ventilation (getting air behind mucus plugs) of the lungs, modulation of the expiratory breath (quicker breath out than in) or with adjuncts such as oscillatory positive expiratory pressure (OPEP), creating sheering forces (via device oscillations) to break bonds the mucus has with the airways. These allow more effective mucus clearance from the lungs.
What has changed with airway clearance over the last 10 years?
There has been a growing market for airway clearance adjuncts such as PEP (positive expiratory pressure) and OPEP devices. These have been more widely advertised and available off-prescription. Availability of these devices have allowed a greater choice of airway clearance technique for physiotherapists to choose from.
There has been more research investigating the mechanisms of specific airway clearance techniques which have allowed the personalisation of airway clearance for patients. There have also been some improvements in the quality of studies using airway clearance techniques as interventions. For example, a study using a technique called “L’Expiration Lente Totale Glotte Ouverte en décubitus Latéral” or ELTGOL, which is less utilised in the UK, demonstrated a reduction in exacerbations over 12 months compared to a placebo group.
There has been developments in many self-management and educational (manual and digital) techniques for airway clearance. This has transformed the availability of credible information to support patients.
Below are some bronchiectasis and airway clearance technique resources:
How can research into airway clearance impact patient care?
There are many different airway clearance techniques available worldwide, unlike some pharmacological products there are no well designed randomised controlled trials to suggest one airway clearance technique is superior to another. Additionally, the main reason why patients do not perform airway clearance is due to the clinician (for example, a doctor or consultant) not recommending it (data from the European Multicentre Bronchiectasis Audit and Research Collaboration). Conducting meaningful research in airway clearance will help create more robust evidence for its use. This may lead to wider promotion and adoption across the UK, Europe and wider. Research can also help physiotherapists support patients on how to choose an airway clearance technique they prefer best, or most suited to their lifestyle. This could improve adherence and support better patient outcomes.