“Ben, Ben! You’ll never guess, I only managed to take the wife out for dinner the other night, didn’t I?! It was lovely, and we’ve booked to go again with friends of ours this week!”
Brian could not wait to tell me this as he arrived at Pulmonary Rehab that Tuesday afternoon. Eight weeks prior, Brian (63, diagnosed with COPD) had attended my COPD outpatient clinic and reported that his excessive sputum production and retention was so severe, that he and his wife had ceased to socialise in public due to Brian’s anxiety for others to witness him expectorating frequently. This was the first time that Brian had proactively reported an improvement in his perceived quality of life since I had prescribed a regime of Airway Clearance Techniques (ACTs) at his last out-patient appointment.
ACTs – How may they help my patients?
ACTs are a series of breathing manoeuvres often prescribed by a Respiratory Physiotherapist in a secondary care setting. The manoeuvres cause air turbulence within the airway and mobilise secretions to relieve sputum retention. ACTs are recommended by NICE in COPD patients with excessive sputum production 1, and also by BTS for adult patients diagnosed with bronchiectasis 2. It is known that sputum retention is a symptom commonly associated with respiratory disease of varying pathophysiology, including COPD, pulmonary fibrosis, bronchiectasis, cystic fibrosis and asthma to name a few. It can also manifest itself when respiratory decline is secondary to neuromuscular disease such as in motor neurone disease, or muscular dystrophy. Characteristics of sputum retention reported by our patients often include a frequent desire to expectorate, difficulty expectorating, chronic cough, chest discomfort, shortness of breath, and embarrassment and social isolation associated with their symptoms being visible to others.
On taking Brian’s history in clinic, it was apparent that his frequent desire to expectorate and his difficulty in doing so was having a profound impact on his quality of life. So much so, that his schedule, appointments, and social life were planned to avoid the periods where his symptoms were at their worst. Brian did not leave the house before 10:30am as he described having a near constant period of coughing an hour after waking. He was expectorating throughout the day, often three to four times an hour, requiring such violent episodes of coughing these would often trigger the gag reflex or result in vomiting. Brian, this pleasant, 63-year-old gentleman was visibly close to tears as he told me of the impact his symptoms were having on his daily life.
The Practice of Airway Clearance Techniques
ACTs aim to reduce this symptom burden and consists of varying manoeuvres predominantly focussed on the Active Cycle of Breathing Technique (ACBT). This cycle of breathing manoeuvres within the ACBT is often practiced as follows 3;
Breathing Control – often practiced with the patient voluntarily slowing their rate of breathing and focussing on a relaxed inhalation through the nose and exhaling gently from the mouth.
Deep breathing/maximal inhalation – the patient maximally inhales followed by a gentle exhalation. This is repeated 3-5 times, depending on what is right for the patient.
Short/Long huff – a huff is commonly instructed as a short, sharp open-mouthed exhalation, or can be extended to a long open-mouthed exhalation whereby the patient exhales until a cough is spontaneously induced. A clinician may describe this to the patient as attempting to forcibly steam up a window with their breath.
Cough – if a cough is not induced spontaneously following the huff, the patient then voluntarily coughs and attempts to expectorate any sputum.
This cycle is then repeated over a matter of minutes until the patient expectorates to the point of feeling relief, or to where it is obvious there is not an immediate need to expectorate.
Over the course of a thirty-minute clinic slot Brian and I practiced this regime. After observing successful application within that appointment, with Brian expectorating on demand with much greater ease, I prescribed Brian his own version of the ACBT. Our strategy to specifically address his anxiety around being in public was to time his airway clearance with visiting the bathroom so his intermittent absence in social situations appeared to others as a normal visit to the toilet. Brian was also part of our Pulmonary Rehab cohort which would further benefit his secretion clearance. We know the air turbulence within the airway that we are trying to invoke with ACBT also occurs involuntarily with aerobic exercise.
What improvements can my patients expect to see?
In a 2011 review of twenty-six studies in COPD,2 studies looked at ACBT and provide encouragement in showing ACBT increases FVC, PEF, arterial oxygenation and exercise performance. The ACBT was particularly effective if performed, in the horizontal position, in COPD patients who produced more than 20g of sputum daily. Patients reported reduced breathlessness and a preference to performing the techniques in this position. Furthermore, in another study, when radioactive tracers were used to assess the movement of inhaled radio particles in sputum, ACTs showed an enhance mucociliary clearance and reduced cough difficulty. 4
A 2012 meta-analysis of the efficacy of ACBT in respiratory conditions, characterised by chronic sputum production, found ACBT significantly increased expectoration in 1 hour sputum wet weight versus a control 3. Further benefits are outlined in a 2015 Cochrane review of 6 studies on ACTs in bronchiectasis. In one study, over 3 months, a clinically meaningful benefit to quality of life was observed. This was defined by a median reduction in St George’s Respiratory Questionnaire score of 7.5 points.5 Furthermore, in two studies, reductions in pulmonary hyperinflation occurred with regular use of ACTs. Those patient with residual volumes above expected normal ranges experienced a decrease in residual capacity of 19%.5
There has been no clear difference in specific variations of ACBT with and without adjunct therapy. However, it is encouraging that suitably qualified clinician-led ACTs may be beneficial for secretion clearance, improved quality of life, and decreased pulmonary hyperinflation compared to not engaging in any airway clearance techniques. It would seem the improved quality of life scores are consistent with the anecdotal evidence reported by patients. Certainly, in Brian’s case, he cited his perceived improvement in symptoms being characterised by a sense of increased control of his symptoms, and empowerment born out of the ability to spontaneously relieve his own symptoms as required without need for apparatus or pharmacological intervention.
Making it all worthwhile
Observing Brian grow from the anxious and tearful gentleman he was in clinic, to the confident and rejoicing man we saw in Pulmonary Rehab was a remarkable piece of anecdotal evidence for our team. One of my fondest memories during my time as a respiratory physiotherapist will always be writing that week’s Pulmonary Rehab diaries, while over-hearing Brian remark to one of his peers, “If you’re coughing that stuff up like I was, you need to go and see Ben, it’s magic what he’s done for me!”
Chronic obstructive pulmonary disease in over 16s: diagnosis and management | Guidance | NICE [Internet]. Nice.org.uk. 2019 [cited 12 April 2019].
Hill A, Sullivan A, Chalmers J. British Th 1. Hill A, Sullivan A, Chalmers J. British Thoracic Society guideline for bronchiectasis in adults. BMJ Open Respiratory Research. 2018;5(000348).
Lewis L, Williams M, Olds T. The active cycle of breathing technique: A systematic review and meta-analysis. Respiratory Medicine. 2012;106(2).
Ides K, Vissers D, De Backer L, Leemans G, De Backer W. Airway Clearance in COPD: Need for a Breath of Fresh Air? A Systematic Review. COPD: Journal of Chronic Obstructive Pulmonary Disease. 2011;8:3,196-205.
Lee A, Burge A, Holland A. Airway clearance techniques for bronchiectasis. Cochrane Database of Systematic Reviews. 2015;(11).
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