Breaking the Vicious Cycle of Bronchiectasis: The Role of Airway Clearance Therapy
My name is Dr. Alan Barker. I’m a professor of Respiratory Medicine at Oregon Health and Science University in Portland Oregon. I’ve been on the faculty and in clinical practice for 41 years. I have been involved in clinical research including rare lung diseases most notably bronchiectasis.
Bronchiectasis is a chronic disease. It starts with a patient who has had recurrent respiratory tract infections, a chronic cough usually accompanied by sputum production without coughing and then the so-called gold standard or key is a chest image usually one of these high resolution CTs. That shows the findings of bronchiectasis. That is the damage airways that are dilated or larger than they should be and often filled with mucus or certainly show the thickened walls of inflammation. The HRCT has become such a good microscope into the small airways where this disease begins and evolves, that it will be seen virtually all the time on an HRCT.
The bronchiectasis patient is elderly or at least a senior citizen age and they often are dealing with other chronic diseases trying to deal with another one makes them particularly difficult in clearing out the mucus and inflammatory debris that is accompanying bronchiectasis. Secondarily they have frequent setbacks or as we call them exacerbations. They end up in emergency departments on average of two to three times a year. They have hospitalizations at anywhere from one to four to five times a year. These are often not short hospitalizations. In the United States the COPD Foundation and other sources estimate that there’s probably somewhere in the order of 20 to 24 million individuals affected by chronic obstructive pulmonary disease.
In addition we’ve learned over the past five to eight years that they probably have bronchiectasis as defined by this gold standard test of the HRCT. We’re using this chest imaging tool more and more in our COPD population and as we do more of these studies we’re finding that as many as 20 to 25 percent of a large COPD population have bronchiectasis. With management should be able and is able to make lives more comfortable for these people. The vicious cycle of infection, inflammation, reduced host defense is part of the issue why this is a chronic disease. But each of our treatments are focused on each of these elements of that cycle in an attempt to reduce infectious episodes, keep the inflammation down and bolster the host defense.
First we need to pay attention to infection with the use of antibiotics. But the most important part in these patients is getting it out, getting the infection out, getting the possibly toxic mucus out. In many individuals, cough is just not effective. So we need to rely on physical measures and that leads us to a discussion of airway clearance or bronchial hygiene. We have a variety of techniques that have been used and the direction has evolved through the years.
Some patients find more effective the so-called high frequency chest wall oscillation devices of which there’s two main modalities. The pneumatic or bladder type device has been available for almost 30 years. The device requires attach tubing you provide the pneumatic compression. It involves a vest that usually needs assistance to be applied and needs of course electricity to power the device. And I would say fortunately the field has improved vastly.
There is a second device available that operates on a very different principle. It operates on a mechanical oscillatory technique. Advantages include its portability. A patient can be and is encouraged to be more mobile and the number of oscillations can be dialed for comfort in the areas for directed mechanical oscillation can be adjusted for those areas that need more attention. In summary the management of bronchiectasis returns us to the vicious cycle in interrupting that cycle. Airway clearance is crucial during the acute stages of an exacerbation in the hospital and to be followed during home management as well, daily if not more often. Following a management strategy are the keys to living a relatively healthy and reasonable life with bronchiectasis.