A review of physiotherapy practice for people with bronchiectasis

To the Editor:

People with bronchiectasis experience chronic productive cough and acute exacerbations, which are linked to poorer quality of life and a higher rate of disease progression. The clinical guidelines for bronchiectasis management recommend physiotherapy [1, 2]. These guidelines advise the prescription of airway clearance techniques (ACTs) to improve sputum clearance and reduce symptoms [1, 2]. Mucoactive agents may be cautiously considered when required [1, 2]. Individuals with reduced exercise tolerance are recommended to engage in pulmonary rehabilitation or undertake exercise or physical activity [1,2]. Surveys of physiotherapy management for people with bronchiectasis have described commonly applied ACTs [3, 4] but have not alluded to technique combinations, a strategy considered a key approach towards personalising therapy [3–5]. Other audits have highlighted that ACTs were applied in only 49% and 52% of people with bronchiectasis in Europe and Australia respectively, reflecting a potential underuse of this therapeutic approach [6, 7]. Low referral rates to pulmonary rehabilitation have been noted [3, 7], and the prescription of exercise and physical activity beyond pulmonary rehabilitation is unknown [3].

It is acknowledged that comorbidities are common in people with bronchiectasis [1, 2]. Gastro-oesophageal reflux disease (GORD) may increase exacerbation risk [8]. Stress urinary incontinence has been linked to reduced quality of life [9]. Chronic rhinosinusitis is associated with greater disease severity and poorer HRQOL [10]. Those with bronchiectasis may be at an increased risk of cardiovascular disease, independent of established cardiovascular risk factors or comorbidities [11]. Finally, musculoskeletal disorders including osteoarthritis or osteoporosis have been noted in bronchiectasis, and may account for joint stiffness and pain [12].

These comorbidities may influence the ACT or exercise prescription, or require specific physiotherapy to alleviate symptoms. However, there is no understanding of how frequently these comorbidities are assessed by physiotherapists and what clinical modifications are incorporated to manage these comorbidities. This audit sought to explore the current physiotherapy practice for ACTs, pulmonary rehabilitation and physiotherapy approaches for comorbidity management in people with bronchiectasis within a private healthcare facility.

For a 12-month period (June 2018–2019), an audit of 56 participants diagnosed with bronchiectasis who received outpatient physiotherapy at Cabrini Health, Melbourne, Australia during this time frame was conducted. There were no exclusions for data incompleteness. Assessment of current symptoms, clinical status and presence of comorbidities were extracted from a single occasion of service (the initial consultation). The ACT routine, recommendations for exercise prescription (including pulmonary rehabilitation referral) and management strategies for comorbidities were extracted from medical records by a single investigator using an a priori template. Approval was obtained from the Cabrini Health Human Research Ethics Committee.

The mean±sd age of participants was 76±11 years with a median of 2 (interquartile range 1–4) exacerbations in the year preceding the initial consultation. All were referred by respiratory physicians. During this timeframe, 96% (n=54) were referred for ACTs, while one participant was referred for haemoptysis and one for exercise prescription. With regards to clinical review, chest status assessment incorporated history and status of cough and sputum production, breathlessness, and existing ACT or exercise routine, if applicable. A valid measure of exercise tolerance, lower limb strength or functional mobility was completed in 33% of participants; tools included the 6-min walk test (2%), 10-m walk test (3%) and sit-to-stand test (18%). Shortness of breath was assessed in 86% of participants, with a self-reported description applied in 94%. Upper airway symptoms (rhinosinusitis) were assessed in 39% of participants, incontinence was assessed in 9%, GORD was assessed in 88% and musculoskeletal pain was assessed in 32%.

All participants were instructed in ACTs by a clinically experienced physiotherapist. 12 participants (21%) used a single technique, 36% used two techniques and 43% used three or more techniques, with proportions of use and common combinations outlined in table 1. Treatment approaches for extrapulmonary symptoms were documented for 23% of participants. Thoracic and shoulder mobility exercises were prescribed for pain or postural dysfunction. A mix of suggestions to address GORD, including nonprescription medications, physical modalities, and advice for timing of ACTs and oral intake, were prescribed. Treatment for rhinosinusitis consisted of sinus rinsing and upper airway humidification or nebulisation. Techniques to counter breathing dysfunction were prescribed in a small number of participants.

19 participants (29%) were referred to pulmonary rehabilitation while 57% were recommended to undertake other exercise, including walking (63%), exercise bike (9%), yoga (4%), dancing, golf or Pilates (each 2%). A small proportion of participants (11%) were recommended a combination of physical activities.

We found a mix of ACTs were applied and prescribing a combination of ACTs was the most common approach. This strategy is considered an acceptable method, personalising ACT while considering physiological parameters, symptoms and patient preference [5]. The frequent selection of the active cycle of breathing technique (ACBT), oscillating positive expiratory pressure (PEP) therapy and exercise in isolation or combination in this study aligns with practice recommendations [1] and surveys [3, 13]. While there is evidence supporting the role of ACBT and oscillating PEP therapy in bronchiectasis [1, 2], the effect of exercise as an ACT is unclear. Despite this, the application of exercise as an ACT within this audit and a survey conducted in 2016 [13] highlight the need to establish the benefits of this technique in bronchiectasis. The caution in guidelines related to inhaled saline therapy is predominantly restricted to hypertonic saline [1, 2]. It was not consistently clear from this audit whether hypertonic or isotonic saline was prescribed. However, its regular use is supported by the suggestion to consider a trial of mucoactive therapy for individuals experiencing difficulty in secretion clearance [1, 2].

Formal appraisal of exercise tolerance or exertional breathlessness was limited. However, only a single session of physiotherapy was audited and with time constraints, prioritisation of assessment and treatment are necessary. The encouragement of individuals to engage in different forms of exercise aligns with clinical guidelines [1, 2]. However, with a mix of exercise modes, the intensity of this exercise is likely to be variable. Incorporating a regular, validated measure of exercise capacity within a clinical review provides the opportunity for specific exercise prescription. Only a small proportion were referred to pulmonary rehabilitation. Pulmonary rehabilitation guidelines indicate the inclusion of those with bronchiectasis with symptoms of breathlessness [14]. The predominant use of subjective descriptions of breathlessness over objective measures may limit the understanding of symptom behaviour and the extent to which exercise intolerance is present. This, together with the high portion of individuals prescribed walking as a main form of exercise, may account for the low referral rate.

Enquiry regarding comorbidities was largely variable but is likely to be influenced by patients’ clinical presentation and assessment priorities. The range of treatment applied aligns with physiotherapy approaches for these comorbidities in individuals with cystic fibrosis [15]. This audit provides some guidance regarding what approaches require further investigation to determine their therapeutic worth and provide advice for physiotherapy treatments in the future.

In conclusion, combinations of ACTs were applied for people with bronchiectasis, together with recommendations for exercise. Future research could examine the effect of exercise as an ACT in people with bronchiectasis, including the impact on patient-reported outcomes, and explore the clinical benefits of physiotherapy-directed advice or treatment for managing comorbidities.