Choosing an appropriate airway clearance (AC) routine
Despite lacking a robust evidence base, airway clearance techniques are standard treatment in people with bronchiectasis (TSANZ Bronchiectasis Guidelines). Available studies suggest that airway clearance techniques are beneficial, with improved QOL and exercise capacity and reduced cough and sputum volumes (Lee 2013, Lee 2008).
An appropriate AC program should be prescribed by a physiotherapist trained in airway clearance.
The choice of techniques will depend on:
Cause of bronchiectasis – stability of the airways
Location of the affected bronchi
Time since diagnosis
Quantity and nature of the sputum
Frequency of exacerbations
Co-morbidities eg pelvic floor weakness, gastroesophageal reflux
Spirometry
Age of the patient
Oxygen therapy required
Financial circumstances of the patient
Cognitive ability of the patient
Adherence to treatment
The AC technique should aim to:
Decrease exacerbations
Increase quality of life
Decrease shortness of breath
Minimise stress on the pelvic floor
Minimise energy expenditure
Some general guidelines:
Take time to educate patients about their condition
All patients should be taught the forced expiration technique
It is also beneficial for patients’ to be taught the active cycle of breathing technique as it is a portable technique, not requiring any equipment which can be used in any position
When choosing an appropriate airway clearance technique – think of physiology principles
Oscillating positive expiratory pressure therapy should be considered with tenacious sputum
Tenacious sputum may also benefit from nebulised saline – isotonic or hypertonic
Nebulised saline may also be beneficial in the presence of microbial isolates
Positive expiratory therapy should be considered for patients with unstable airways susceptible to collapse or airway collapse due to mucus plugs
Autogenic drainage should be considered for patients with stress incontinence and patients with large amounts of sputum
Ideally only teach one technique at a time
Patients should be instructed to minimise coughing unless the sputum is in the upper airways
Patients need to be educated that airway clearance is a technique to be done daily
Patients are more likely to adhere to an airway clearance routine if their preference is considered
As cough clearance is important in bronchiectasis, antitussive therapy, such as codeine, is relatively contraindicated.
See Airway Clearance Techniques section and AC videos for a full description of each technique.