Bronchiectasis is a chronic lung condition that results in permanent and abnormal widening of the bronchi. This condition can lead to recurrent infections and respiratory symptoms such as cough, sputum production, and shortness of breath. While there is no cure for bronchiectasis, several treatment options can help manage the symptoms and improve the quality of life for people with this condition.
One of the key components of bronchiectasis management is airway clearance techniques. These techniques aim to remove excess mucus and secretions from the airways, which can help prevent infections and improve lung function. Here you will find information on airway clearance in bronchiectasis.
Chest Physiotherapy
CPT is a type of airway clearance technique that involves manually percussing or vibrating the chest wall to help loosen and mobilize mucus in the lungs.
There are different ways to perform CPT, but some common techniques include:
Manual percussion: this involves tapping the chest wall rhythmically with cupped hands to help loosen mucus in the lungs.
Vibrating vest: this is a vest that vibrates at high frequency to help loosen mucus in the lungs.
Oscillatory positive expiratory pressure (OPEP) devices: these devices use a one-way valve to create positive pressure during exhalation, which helps to keep the airways open and promote mucus clearance.
Active Cycle of Breathing Techniques (ACBT)
Airway clearance techniques (ACTs) are essential in the management of bronchiectasis. One of the most commonly used ACTs is Active Cycle of Breathing Techniques (ACBT). ACBT is a simple and effective technique that can be performed by patients themselves or with the help of a trained physiotherapist. In this article, we will discuss ACBT in detail and its effectiveness in bronchiectasis management.
What is ACBT?
ACBT is a series of breathing exercises that aims to loosen and clear mucus from the airways. The technique involves three distinct phases:
Breathing Control: In this phase, the patient is asked to breathe slowly and deeply, with an emphasis on diaphragmatic breathing. The patient is encouraged to take a deep breath in through the nose, hold it for a few seconds, and then breathe out slowly through pursed lips.
Thoracic Expansion Exercise: In this phase, the patient is asked to take a deep breath in, hold it for a few seconds, and then cough to loosen any mucus in the airways. The patient then takes two to three normal breaths before repeating the process.
Forced Expiratory Technique: In this phase, the patient is asked to take a deep breath in and then breathe out forcefully and rapidly through an open mouth, huffing like they are blowing out a candle. This helps to move mucus up towards the mouth, where it can be expectorated or swallowed.
How does ACBT work in bronchiectasis?
In bronchiectasis, mucus accumulates in the airways due to impaired mucociliary clearance. This can lead to chronic infection and inflammation, which can cause further damage to the airways. Airway clearance techniques like ACBT aim to improve mucociliary clearance by physically moving mucus out of the airways. This is why airway clearance is very important.
ACBT works by combining breathing control, thoracic expansion exercises, and forced expiratory techniques to mobilize and clear mucus from the airways. The slow, deep breathing in the breathing control phase helps to open up the airways and improve oxygenation. The thoracic expansion exercises help to loosen mucus, while the forced expiratory techniques move the mucus up towards the mouth.
The huffing technique used in ACBT is particularly effective in bronchiectasis. Unlike coughing, which can be harsh and cause further damage to the airways, huffing is a gentler way of clearing mucus. The huffing technique also allows the patient to control the force of the expiratory effort, which is particularly useful for patients with fragile airways.
ACBT is also effective in reducing breathlessness and improving exercise tolerance in patients with bronchiectasis. By improving mucociliary clearance, ACBT can reduce airway obstruction, which in turn can lead to better lung function and exercise tolerance.
How often should ACBT be performed?
The frequency of ACBT sessions depends on the severity of the bronchiectasis and the patient’s individual needs. In general, ACBT should be performed at least twice a day for 20-30 minutes each session. However, patients with severe bronchiectasis may need to perform ACBT more frequently.
ACBT should be performed on an empty stomach or at least two hours after a meal. Patients should also be in a comfortable position, either sitting or lying down. A physiotherapist can guide patients on the correct technique and the appropriate frequency and duration of ACBT sessions.
What are Huffs?
Huffing is a type of coughing technique used in airway clearance. Unlike a regular cough, which is forceful and sharp, huffing is a gentler and more controlled technique that uses a combination of breath control and abdominal muscle contraction to move mucus up and out of the airways. Instead of coughing hard, a person takes a deep breath and then exhales slowly and steadily while making a “huff” sound with their throat. This creates a positive pressure in the lungs that can help move mucus up towards the throat, where it can be spit out or swallowed.
How are Huffs Performed?
To perform huffing, follow these steps:
- Sit up straight or lean forward slightly in a comfortable position.
- Take a deep breath in through the nose.
- Close the mouth and exhale slowly and steadily through the mouth while making a “huff” sound with the throat. The huff should be short and sharp, like a forced whisper, but not forceful like a regular cough.
- After the huff, take a few normal breaths to rest, and then repeat the process.
- It’s important to remember to avoid bearing down or holding your breath during the huff, as this can increase pressure in the chest and make it harder to move mucus out of the airways.
When to Use Huffs?
Huffing is often used in combination with other airway clearance techniques, such as postural drainage and percussion, to help loosen and move mucus out of the lungs. It’s also a good technique to use when you feel a cough coming on but don’t want to cough hard or expel a lot of mucus. Huffing can help to clear small amounts of mucus from the airways and prevent it from building up and causing further breathing difficulties.
Postural Drainage
What is Postural Drainage?
Postural drainage is a technique used to help clear the lungs of mucus by positioning the body in specific ways that allow gravity to help move the mucus towards the mouth, where it can be coughed up and expelled. This technique is often used in conjunction with other ACTs, such as percussion and vibration, to help dislodge and mobilize the mucus.
The aim of postural drainage is to position the body so that gravity helps to move mucus from the affected areas of the lungs towards the larger airways where it can be more easily cleared. There are several different positions that can be used for postural drainage, and the most appropriate position will depend on the location of the bronchiectasis and the severity of the condition.
How is Postural Drainage Performed?
Postural drainage is performed by positioning the body in a specific way, which allows gravity to help move the mucus towards the mouth. The most common positions used for postural drainage are:
- Trendelenburg Position: In this position, the patient lies on their back with their head tilted downwards at a 45-degree angle. This position is used to drain the lower lobes of the lungs.
- Fowler’s Position: In this position, the patient sits upright at a 45-degree angle. This position is used to drain the upper lobes of the lungs.
- Left Lateral Position: In this position, the patient lies on their left side with their head tilted downwards at a 30-degree angle. This position is used to drain the left lung.
- Right Lateral Position: In this position, the patient lies on their right side with their head tilted downwards at a 30-degree angle. This position is used to drain the right lung.
The duration of postural drainage will depend on the severity of the bronchiectasis and the amount of mucus present in the lungs. Typically, each position is held for 10-15 minutes, and the process is repeated several times a day.
Positive Pressure Devices
What are positive pressure devices?
Positive pressure devices are devices that help clear mucus from the lungs by providing positive pressure to the airways. Positive pressure refers to the application of pressure that is greater than the atmospheric pressure, which can help to expand the airways and promote the movement of mucus.
Positive pressure devices come in several forms, including:
- Intrapulmonary percussive ventilation (IPV) devices: These devices deliver bursts of air into the lungs at high frequencies, creating a vibration that can help loosen and dislodge mucus.
- High-frequency chest wall oscillation (HFCWO) devices: These devices consist of an inflatable vest that is attached to an air pulse generator. The vest inflates and deflates rapidly, creating a vibration that can help loosen mucus.
- Oscillatory positive expiratory pressure (OPEP) devices: These devices use a combination of positive expiratory pressure and oscillations to help move mucus out of the lungs.
How do positive pressure devices work?
Positive pressure devices work by delivering a burst of air into the lungs, which can help to expand the airways and loosen mucus. The oscillations or vibrations created by the devices can also help to break up mucus, making it easier to cough up.
Positive pressure devices are usually used in combination with other airway clearance techniques, such as postural drainage, to help move mucus out of the lungs. They can be used by patients with mild to severe bronchiectasis and are often recommended for patients who have difficulty performing other airway clearance techniques.
Mucolytics
Mucolytics are a class of medications that are commonly used in the treatment of non-cystic fibrosis (non-CF) bronchiectasis. These medications help to break down and thin the mucus in the airways, making it easier to cough up and clear.
Hypertonic saline and mannitol are two of the most commonly used mucolytics in the treatment of non-CF bronchiectasis. Hypertonic saline is a saltwater solution that is more concentrated than normal saline. When inhaled, hypertonic saline draws water into the airways, making the mucus thinner and easier to clear. Mannitol is a sugar alcohol that works in a similar way to hypertonic saline, drawing water into the airways and helping to break down and thin the mucus.
Carbocysteine and N-acetylcysteine (NAC) are two other mucolytics that are commonly used in the treatment of non-CF bronchiectasis. Carbocysteine is an amino acid derivative that works by breaking down the bonds between the proteins in mucus, making it easier to cough up and clear. NAC is a type of antioxidant that helps to break down and thin the mucus in the airways. It also has anti-inflammatory properties, which can help to reduce inflammation in the airways and improve breathing.
While mucolytics can be effective in the treatment of non-CF bronchiectasis, they are not without potential side effects. Some common side effects of hypertonic saline and mannitol include coughing, wheezing, and chest tightness. Carbocysteine and NAC can also cause side effects, such as nausea, vomiting, and diarrhea. It is important to discuss any potential side effects with your healthcare provider before starting a new medication.
Combination therapy
Combination therapy, which involves using multiple airway clearance techniques and/or mucolytics together, may be more effective than using one treatment alone. For example, a combination of CPT and inhaled mucolytics has been shown to be more effective than either treatment alone in improving lung function and reducing exacerbations in people with bronchiectasis.
It is important to work with a specialist in bronchiectasis and as well as a specialist chest physiotherapist to determine the most appropriate airway clearance techniques and medications for each individual with bronchiectasis. A personalised treatment plan can be established that takes into account the severity of the condition, the person’s overall health, and any other medical conditions they may have.