Traditional approaches to physiotherapy in bronchiectasis relied largely on postural drainage and chest percussion. Both of these strategies are now outdated in adults as they inhibit autonomous therapy and potentially exacerbate position-dependent gastro-oesophageal reflux. Chest percussion retains some benefit in paediatric management.
Positive expiratory pressure (PEP) strategies enhance and promote mucus clearance by preventing airway collapse through stenting the airways and increasing intrathoracic pressure distal to retained secretions. The simplest PEP therapy is bubble PEP, in which a patient exhales through a hose into a bottle containing 10 to 12 cm of water. An oscillating pressure is created by the movement of the column of water. Commercial PEP and oscillating PEP devices comprise a mask or mouthpiece with a one-way valve connected to either a small-exit orifice (PEP) or, more commonly, an adjustable expiratory resistor (oscillating PEP). Information about these devices is available online at http://bronchiectasis.com.au/physiotherapy/ techniques/oscillating-positive-expiratory-pressure-therapy. PEP therapy is generally performed once or twice daily, usually in combination with mucoactive treatments.
Airway clearance programs should be instituted in all patients with bronchiectasis who have daily sputum production and should be especially reinforced during periods of exacerbation. Occasionally, exercise can substitute for airway clearance; the likely contribution of a particular form of exercise to airway clearance is best assessed by a trained physiotherapist.
Antibiotics are central to the management of suppurative lung disease and are used in three different indications:
• to attempt eradication of new airway isolates
• to treat acute infection or exacerbation
• as a long-term maintenance for suppression of chronic colonisation.
Eradication of airway colonists
As mentioned previously, the microbial flora of the airway changes over time in patients with bronchiectasis. Strategies to eradicate new airway colonists appear useful in patients with CF bronchiectasis but evidence of benefit in those with non-CF bronchiectasis is still awaited.
Antibiotic strategies for the long-term suppression of microbial colonisation are now more flexible and may include intermittent or continuous use of a single oral agent, intermittent or continuous use of alternating oral agents and/or intermittent or continuous use of nebulised antibiotics. However, key to the development of an antibiotic strategy is the identification and nature of the airway colonisation. These strategies can be complex and protracted and are best developed by specialist respiratory units.
Antibiotic treatment of acute infection in the structurally damaged lung may need to be protracted. Home-treated patients may in some cases need antibiotic courses extended to one to two weeks, and hospital-treated patients may need seven to 14 days of intravenous antibiotic treatment. It is important to identify Pseudomonas colonisation, (present in about 30% of patients with bronchiectasis) because this infection will be largely unresponsive to beta-lactam monotherapy and may represent a risk for further deterioration in lung function. The use of long-term oral antibiotic treatment is inappropriate for most patients with bronchiectasis. It may be required in those suffering recurrent exacerbation, although only after confirming the adequacy of and adherence to airway clearance and mucoactive treatments.