This blog post was written by Dr. Ashwin Basavaraj, who serves as Pulmonologist at NYU Langone Health, Assistant Professor in the Department of Medicine at NYU Grossman School of Medicine, Section Chief of Pulmonary, Critical Care and Sleep Medicine at Bellevue Hospital, and Associate Director of the Bronchiectasis Program at NYU.

Airway clearance techniques (ACTs) are important management strategies in the care of patients with bronchiectasis and non-tuberculous mycobacterial (NTM) lung disease. ACTs may help bring up mucus that often times are difficult to clear from large airways. This may, in turn, help reduce inflammation, and improve symptoms and quality of life. ACTs include the use of instrumental techniques, such as positive expiratory pressure devices and high frequency chest wall oscillation vests, and various manual techniques, such as manual chest physical therapy, chest percussion, postural drainage, and active cycle breathing techniques.

Although ACTs are widely recommended by guidelines and expert opinion, high-quality research studies on the utility of ACTs are lacking. Moreover, reports suggest that ACTs are under-utilized by patients, and rates of adherence are not high. Further studies are needed comparing the effectiveness of different ACTs, as no one technique has shown to be superior to another.

In our study, we sought to analyze clinical outcomes in patients with productive cough and bronchiectasis, utilizing the United States Bronchiectasis and NTM Research Registry. Patients were divided into three groups: 1. Patients that did not use ACTs at their baseline visit and at one-year follow-up visit (no ACT use), 2. Those that used ACTs at both baseline and one-year follow up (continuous use), and 3. Those that used ACTs either at baseline or at one-year follow-up (intermittent users). Patients in the Registry were seen clinically from 2008-2019.

There were about 905 patients in this study. The patients were predominantly middle-aged, Caucasian, and female. We found that those patients who utilized ACTs continuously or intermittently were more likely to experience a bronchiectasis exacerbation, or to be hospitalized for a pulmonary illness in the prior two years, compared to those that did not use ACTs. Moreover, those who utilized ACTs continuously had increased odds of developing a bronchiectasis exacerbation, compared to those not using ACTs. Patients with Pseudomonas Aeruginosa, a bacteria that has shown to be associated with worsening symptoms, quality of life, and higher rates of exacerbations in patients with bronchiectasis, were more likely to use ACTs. There was no change in pulmonary function at one-year follow-up for those that used ACTs. Fifty-nine percent of patients with bronchiectasis and productive cough utilized ACTs at their baseline visit; more than half of the patients (58%) did not continue to use them at their one-year follow-up visit.

The results of this study highlight again the under-utilization of ACTs in patients with bronchiectasis and productive cough, as well as the reduced rates of adherence (continued long-term use). Many patients are already burdened by the time it takes to perform all their necessary treatments on a daily basis, and may not have the time to use ACTs. They may also feel that the ACTs are not working, or they may not be prescribed ACTs by their physician due to lack of provider awareness. The study also highlights that those who use ACTs are more likely to be a sicker bronchiectasis population. Patients who used ACTs were more likely to have experienced an exacerbation of their bronchiectasis, or had increased odds of developing an exacerbation. This may be because those who use ACTs are more symptomatic, and want better control of their symptoms. They may also be more likely to be prescribed ACTs by their providers when they are sick. Those with Pseudomonas Aeruginosa, were also more likely to use ACTs, possibly because of increased clinical symptoms associated with the bacteria. Further studies are needed to determine which patients benefit the most from ACTs, and to determine ways to improve accessibility and adherence to ACTs.

The results of this study were published in CHEST® and can be accessed here.