Speaker's Highlight

• Don Sin University of British Columbia, St. Paul Hospital (Canada)
  Kenneth R. Chapman Toronto General Hospital Research Institute (Canada)
• Parameswaran Nair McMaster University (Canada)
  Carolyn Calfee UCSF (U.S.A.)
• Gregory P. Downey University of Colorado School of Medicine (U.S.A.)
  David A. Schwartz University of Colorado School of Medicine (U.S.A.)
• Neil Schluger Tuberculosis Control Branch, California Department of Public Health (U.S.A.)
  Nick Kim Critical Care & Sleep Medicine, University of California San Diego (U.S.A.)
• Nicola Hananiah Baylor College of Medicine (U.S.A.)
  Jae-Joon Yim Seoul National University College of Medicine (Republic of Korea)
• Koichiro Asano Tokai University School of Medicine (Japan)
  Diahn-Warng Perng Taipei Veterans General Hospital (Taiwan)
• Konstantinos Kostikas University of Ioannina (Greece)
  Karin Klooster University Medical Center Groningen (Kingdom of the Netherlands)

• Bronchiectasis Care: Advances in Airway Clearance Techniques

  Bronchiectasis is a chronic respiratory condition in which permanently widened airways struggle to move mucus effectively. Retained secretions can obstruct airflow, encourage bacterial growth, worsen breathlessness, and increase the risk of recurrent exacerbations. Airway clearance is therefore a central part of long-term management, alongside infection control, exercise, vaccination, and treatment of underlying causes.

  Modern bronchiectasis care has moved beyond prescribing one technique for everyone. Clinicians increasingly match airway clearance methods to sputum volume, cough strength, fatigue, lung function, coexisting disease, and the person’s daily routine. The best approach is practical, repeatable, and reviewed as symptoms change.

  Research presented through respiratory medicine organizations such as APSR and KATRD continues to shape clinical education and collaboration. Advances in airway clearance techniques are especially valuable because small improvements in secretion removal can support exercise tolerance, reduce treatment burden, and improve confidence in self-management.

  Why Airway Clearance Matters

  Healthy airways use mucus transport and ciliary movement to remove inhaled particles. In bronchiectasis, structural damage impairs this process, while inflammation often increases mucus production and changes its thickness. Some people produce large amounts of sputum; others have difficulty expectorating even modest secretions because of weak cough or severe fatigue.

  Effective clearance can reduce airway obstruction and help patients recognize changes in sputum color, volume, or consistency. This information is clinically useful because a sudden change may signal an exacerbation requiring assessment. Airway clearance does not replace antibiotics, anti-inflammatory treatment, or management of the underlying cause, but it supports the wider care plan.

  A respiratory physiotherapist should assess technique and reassess it periodically. Instruction may include breathing control, thoracic expansion, huffing, supported coughing, posture, and the safe use of a device. Poor technique can increase fatigue or trigger wheezing, while an individualized routine can make treatment more sustainable.

  Established Techniques And Newer Options

  The active cycle of breathing techniques combines relaxed breathing, deep breaths, and forced expiratory maneuvers known as huffs. It requires no equipment and can be adapted for home use, during an exacerbation, or alongside other methods. Patients should avoid forceful, repeated coughing that causes airway collapse, chest pain, dizziness, or exhaustion.

  Positive expiratory pressure devices create resistance during exhalation. This may help splint open smaller airways and move mucus toward larger airways, where it can be expelled. Oscillating devices add rapid pressure changes that may loosen secretions. Selection depends on comfort, portability, breathing pattern, and the person’s ability to clean and maintain the device.

  Nebulized saline, particularly hypertonic saline in selected patients, may hydrate airway secretions and make sputum easier to clear. Bronchodilator use before inhaled saline can be considered when bronchospasm is a concern. Each treatment should be introduced under clinical guidance, since irritation, coughing, or wheezing can occur.

  Approach	Useful features	Practical considerations
  Active cycle of breathing	Equipment-free and adaptable	Requires coaching and regular practice
  Positive expiratory pressure	Portable and simple for many users	Correct exhalation pressure is important
  Oscillating PEP	Combines resistance with vibration	Device choice and cleaning affect adherence
  Nebulized saline	May loosen thick sputum	Can provoke cough or bronchospasm
  Postural drainage	Uses gravity to assist secretion movement	May be unsuitable with reflux or certain comorbidities
  Manual or mechanical percussion	Can support people with weak clearance	Often requires a trained caregiver or specialist device

  Choosing A Personalized Routine

  The most suitable method is often determined by a short clinical trial rather than a single test. A physiotherapist may observe sputum production, breathing control, oxygen saturation, fatigue, and cough effectiveness before recommending a sequence. The routine may involve a device, breathing exercises, saline, or a combination of approaches.

  Timing also matters. Some patients clear mucus more effectively after waking, while others benefit from a session before exercise or inhaled medication. During an exacerbation, the schedule may need temporary adjustment. A written plan should explain when to pause, when to seek help, and how to respond to increased breathlessness or blood in sputum.

  Adherence improves when airway clearance fits into ordinary life. Compact devices can help people continue treatment while traveling, and shorter sessions may be preferable to an ambitious routine that is quickly abandoned. Tracking sputum, symptoms, and session frequency can help the care team identify what is working.

  Supporting Exercise And Pulmonary Function

  Physical activity can complement airway clearance by increasing ventilation and supporting cough effectiveness. Walking, cycling, strength training, and pulmonary rehabilitation may improve exercise capacity and reduce deconditioning. Exercise should be prescribed according to functional status, oxygen needs, cardiovascular risk, and exacerbation history.

  Some patients clear more sputum during or after activity, which can be useful when exercise is coordinated with huffing or a device session. However, breathlessness should be distinguished from dangerous symptoms such as chest pain, fainting, severe wheezing, or oxygen levels below the patient’s agreed target.

  Pulmonary rehabilitation also provides education in pacing, breathing strategies, nutrition, and self-management. These components address the wider effects of chronic respiratory disease and can make airway clearance less physically demanding.

  Managing Special Clinical Needs

  People with severe airflow limitation may need longer rest periods, bronchodilator treatment, or a gentler technique. Those with frequent exacerbations may require a personalized rescue plan, sputum cultures, vaccination review, and evaluation for contributing conditions such as immunodeficiency, aspiration, allergic bronchopulmonary aspergillosis, or primary ciliary dyskinesia.

  Hemoptysis requires particular caution. Small streaks of blood can occur with inflamed airways, but increasing or heavy bleeding needs urgent medical assessment. Postural drainage positions may be inappropriate for people with significant reflux, recent surgery, unstable cardiovascular disease, or musculoskeletal limitations.

  Children and older adults may need adapted instruction, caregiver participation, and age-appropriate equipment. People with cognitive, visual, or dexterity limitations may benefit from simplified steps, written prompts, demonstrations, and follow-up visits to confirm safe use.

  Building Better Care Through Education And Research

  Airway clearance is most effective when it is integrated into a broader multidisciplinary pathway. Respiratory physicians, physiotherapists, nurses, pharmacists, microbiology teams, and primary care clinicians can coordinate medication use, sputum monitoring, rehabilitation, and exacerbation prevention. Regular review is important because a technique that worked during one stage of disease may become tiring or less effective later.

  Education should include device hygiene. Reusable equipment needs cleaning, drying, and replacement according to manufacturer and clinical guidance. Nebulizers require careful handling to limit contamination. Patients should also understand the purpose of each treatment so that airway clearance does not become a confusing collection of disconnected tasks.

  Clinical innovation depends on training and investigation. Professionals developing respiratory research or educational projects can review APSR awards and grants for opportunities that support collaboration and knowledge development. Better studies are still needed to compare devices, define meaningful outcomes, and understand which approaches work best for different bronchiectasis phenotypes.

  Practical Recommendations For Daily Care

  A consistent routine should be adjusted around symptoms, work, sleep, and personal priorities. The following principles can help make airway clearance safer and more manageable:

  • Learn at least one equipment-free method, such as breathing control with huffing, from a respiratory physiotherapist.
  • Use a prescribed PEP or oscillating device with the correct technique and a clear cleaning routine.
  • Consider exercise or pulmonary rehabilitation to improve ventilation, strength, and treatment tolerance.
  • Record changes in sputum, breathlessness, fatigue, and blood so that deterioration can be reported promptly.
  • Review the plan after exacerbations, medication changes, declining function, or difficulty maintaining adherence.

  Effective bronchiectasis management is built through repeated, informed practice rather than a single intervention. A respiratory clinician can assess airway clearance, identify barriers, and help create a routine that fits the individual’s lungs and lifestyle. Arrange a review with a bronchiectasis specialist or respiratory physiotherapist to refine the technique and establish a clear plan for stable periods and flare-ups.

  Richard Russell Nuffield Department of Clinical Medicine, University of Oxford (United Kingdom)
• Mona Bafadhel King’s College London (United Kingdom)
  David Jackson Guy’s and St Thomas’ Hospital, King’s College London (United Kingdom)
• James Chalmers University of Dundee (United Kingdom)
  David Price University of Aberdeen (United Kingdom)