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Physiotherapy for large airway collapse: an ABC approach

Lizzie J.F. Grillo, Georgie M. Housley, Sidhu Gangadharan, Adnan Majid, James H. Hull
ERJ Open Research 2022 8: 00510-2021; DOI: 10.1183/23120541.00510-2021
Lizzie J.F. Grillo
1Royal Brompton and Harefield Hospitals, London, UK
2National Heart and Lung Institute, Imperial College, London, UK
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  • ORCID record for Lizzie J.F. Grillo
  • For correspondence: l.grillo@rbht.nhs.uk
Georgie M. Housley
1Royal Brompton and Harefield Hospitals, London, UK
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Sidhu Gangadharan
3Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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  • ORCID record for Sidhu Gangadharan
Adnan Majid
3Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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James H. Hull
1Royal Brompton and Harefield Hospitals, London, UK
2National Heart and Lung Institute, Imperial College, London, UK
4Institute of Sport, Exercise and Health, UCL, London, UK
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Figures

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  • FIGURE 1
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    FIGURE 1

    Flow-limiting segment in large airway collapse (LAC). a) Airway with LAC. The flow-limiting segment is limiting the expiratory airflow and/or creating unwanted turbulent airflow due to the invagination of the airway influenced by the equal pressure point theory and wave speed theory. Ppl: pleural pressure; Palv: alveolar pressure. b) Normal airway. The equal pressure point (EPP) is kept proximal and promotes movement of expiratory airflow to enhance sputum clearance.

  • FIGURE 2
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    FIGURE 2

    Dynamic movements of equal pressure points in different examples of airway physiology. EPP: equal pressure point; FET: forced expiration technique; FLS: flow-limited segment.

  • FIGURE 3
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    FIGURE 3

    The Active Cycle of Breathing Technique.

  • FIGURE 4
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    FIGURE 4

    Visual representation of the physiological mechanism behind the positive expiratory pressure (PEP).

  • FIGURE 5
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    FIGURE 5

    Positive expiratory pressure (PEP) Mask (PEP/RMT© Henleys Medical Supplies, Welwyn Garden City, UK).

Tables

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  • TABLE 1

    Subjective and objective physiotherapy assessment for a patient with large airway collapse (LAC)

    Subjective: Patient's description/reportObjective: Physiotherapist's observations/measurements
    A: Airways
    NASAL SYMPTOMS
    Blocked or runny nose
    Sinus pain
    Post-nasal drip
    Altered sense of smell
    AIRWAY CLEARANCE
    Technique completed
    Frequency and length of Rx
    Efficacy
    % adherence
    COUGH
    Effectiveness/ease of clearance
    Triggers
    Dry/rattling/productive
    Feeling of airway closure
    SPUTUM
    Colour/consistency
    24-h volume
    NASAL SYMPTOMS
    Quality of secretions
    Throat clearing
    AIRWAY CLEARANCE
    Observed technique
    Impact of airway closure on clearance
    Observed effectiveness
    COUGH
    Nature/sound,
    e.g. barking/honking sound
    SPUTUM
    Viscosity/colour of sputum
    Microbiology
    B: Breathing
    BREATHLESSNESS
    Symptoms
    Triggers
    Recovery techniques
    VOICE/UA
    Voice changes, e.g. husky/strained/lost voice
    Closure/discomfort in throat
    BREATHING PATTERN
    Awareness of breathing pattern
    BREATHLESSNESS
    Work of breathing
    Upper limb fixation
    Accessory muscle use
    SpO2
    Auscultation
    VOICE/UA
    Audible upper airway sounds
    Quality
    BREATHING PATTERN
    Completion of BPAT score
    -Upper chest versus lower chest
    -Nose–mouth breathing
    -Flow/air hunger/RR/rhythm
    C: Capacity for exercise
    EXERCISE ABILITY
    Frequency of exercise
    Intensity of exercise
    Time spent on exercise
    Type of exercise
    Symptoms with exercise
    -cough/airway closure
    General physical activity levels
    Barriers to exercise
    Use of oxygen/NIV/CPAP for exercise
    EXERCISE TESTING
    6MWT
    1 min STS
    Ax with and without CPAP/NIV
    Cough/SOB/WOB/SpO2
    Breathing pattern changes during exercise
    UA SYMPTOMS
    Observed adaptations to breathing
    Audible airway collapse
    Other Ax
    SLEEP
    Quality/duration
    Epworth sleep score
    NIV/CPAP history +/− use
    OUTCOME MEASURES
    VAS: ease of clearance/airway closure
    Dyspnoea-12
    BPAT
    MRC grading
    Leicester cough questionnaire (LCQ)

    Rx: treatment; SpO2: oxygen saturation measured by pulse oximetry; Ax: assessment; UA: upper airway; NIV: noninvasive ventilation; CPAP: continuous positive airways pressure; RR: respiratory rate; SOB: shortness of breath; 6MWT: 6-min walk test; 1 min STS: 1-min sit-to-stand test; BPAT: breathing pattern assessment tool; WOB: work of breathing; VAS: visual analogue scale; MRC: Medical Research Council.

    • TABLE 2

      Airway clearance techniques and evidence

      ACTPhysiological principlesEvidencePragmatic approach in LAC
      ACBTFlexible three phase cyclical technique of breathing control, TEE and FET
      Enhances tidal volumes, collateral ventilation and expiratory airflow
      Modification for use in LAC to ensure FET is optimised
      Physiological background [32]
      Bronchiectasis [34]
      Cystic fibrosis [25]
      No direct evidence
      • Clinical experience in LAC demonstrates that caution may be required in FET to ensure balance of airway calibre with creation of equal pressure points
      PEPA flow-regulated technique that has three effects: to increase lung volume (functional residual capacity and tidal volume (VT)), to reduce hyperinflation and to improve airway clearance. Positive pressure is then achieved by augmenting expiratory flow against this resistancePhysiological background [35]
      COPD [39]
      Cystic fibrosis [38]
      TBM (improve expiratory airflow) [40]
      No direct evidence
      • Use in LAC to reduce airway closure during expiration and modify FET
      • Caution to prevent airway collapse but not to cause limitation to expiratory airflow
      OPEPPEP is applied by blowing out against a variable resistance that produces an oscillation in flow
      Individuals breathe out to expiratory reserve volume (ERV) enabling a modulation of both pressure and flow
      Physiological background [22]
      Bronchiectasis [42]
      Cystic fibrosis [45]
      COPD [43]
      No direct evidence
      • Use in LAC with caution as oscillations may cause airway collapse and irritation in some patients
      • If used comfortably, may have similar benefits to OPEP
      HFCWOPatient wears an inflatable vest attached to a machine that creates positive and negative pressure changes through high-frequency air pulses at a set pressure and frequency. Displacement of the airway walls additionally disengages secretions, enhancing airflow and ciliary beatingPhysiological background [22]
      Bronchiectasis [47]
      Cystic fibrosis [49, 50]
      COPD [48]
      No direct evidence
      • Clinical experience suggests this technique must be combined with FET (with relevant principles discussed for patients with LAC)
      CPAPCreates a “pneumatic splint”, helping to prevent dynamic airways collapse as flow and effort increasePaediatric TBM [51]Extrapolation of knowledge from paediatric TBM although caution required as different conditions
      • Clinical expertise/extrapolation of knowledge from use of PEP/high PEP
      • Caution required as underlying pathology may be different

      ACT: airway clearance technique; ACBT: Active Cycle of Breathing Technique; TEE: thoracic expansion exercise; FET: two forced expiration technique; LAC: large airway collapse; TBM: tracheobronchomalacia; PEP: positive expiratory pressure; OPEP: oscillating expiratory pressure; HFCWO: high-frequency chest wall oscillation; CPAP: continuous positive airway pressure.

      Supplementary Materials

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      • Supplementary Material

        Please note: supplementary material is not edited by the Editorial Office, and is uploaded as it has been supplied by the author.

        Supplementary material 00510-2021.SUPPLEMENT

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      Physiotherapy for large airway collapse: an ABC approach
      Lizzie J.F. Grillo, Georgie M. Housley, Sidhu Gangadharan, Adnan Majid, James H. Hull
      ERJ Open Research Jan 2022, 8 (1) 00510-2021; DOI: 10.1183/23120541.00510-2021

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      Physiotherapy for large airway collapse: an ABC approach
      Lizzie J.F. Grillo, Georgie M. Housley, Sidhu Gangadharan, Adnan Majid, James H. Hull
      ERJ Open Research Jan 2022, 8 (1) 00510-2021; DOI: 10.1183/23120541.00510-2021
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      • Article
        • Abstract
        • Abstract
        • Introduction
        • Understanding the pathophysiology of LAC
        • Models to understand pathophysiology of LAC
        • Approach to physiotherapy assessment in LAC
        • The ABC model of physiotherapy assessment
        • Limitations
        • Conclusion
        • Supplementary material
        • Acknowledgements
        • Footnotes
        • References
      • Figures & Data
      • Info & Metrics
      • PDF

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