Lee Annemarie L, Burge Angela, Holland Anne E
School of Physiotherapy, The University of Melbourne, Carlton, Australia.
Cochrane Database Syst Rev. 2013 May 31(5):CD008351. doi: 10.1002/14651858.CD008351.pub2.
People with non-cystic fibrosis bronchiectasis commonly experience chronic cough and sputum production and these features may be associated with progressive decline in clinical status. Airway clearance techniques (ACTs) are often prescribed to facilitate expectoration of sputum from the lungs, but the efficacy of these techniques in a stable clinical state or during an acute exacerbation of bronchiectasis is unclear.
Primary: to determine the effects of ACTs on the rate of acute exacerbations, incidence of hospitalisation and health-related quality of life in individuals with acute and stable bronchiectasis.Secondary: to determine whether a) ACTs are safe for individuals with acute and stable bronchiectasis and b) ACTs have beneficial effects on physiology and symptoms in individuals with acute and stable bronchiectasis.
We searched the Cochrane Airways Group Specialised Register of trials from inception to October 2012, PEDro in October 2012 and handsearched relevant journals.
Randomised controlled parallel and cross-over trials that compared an ACT to no treatment, sham ACT or directed coughing in participants with bronchiectasis.
We used standard methodological procedures expected by The Cochrane Collaboration.
Five studies involving 51 participants met the inclusion criteria of the review, all of which were cross-over design. Four studies were on adults with stable bronchiectasis, and the other study was on clinically stable children with bronchiectasis. Three studies were single treatment sessions, two were longer-term studies. The interventions varied and some control groups received a sham intervention while others were inactive. The methodological quality of the studies was variable and the studies were not able to blind participants and personal. Heterogeneity between studies precluded these data from meta-analysis and the review was therefore narrative.One study on 20 adults comparing an airway oscillatory device with no treatment found no significant difference in the number of exacerbations at 12 weeks (low-quality evidence). No data were available to assess the impact of ACTs on the time to exacerbation, duration of, incidence of hospitalisation or total number of hospitalised days. The same study reported clinically significant improvements in health-related quality of life in both disease-specific and cough-related measures. While based on a small number of participants and the data were skewed, the median difference in the change in total St George's Respiratory Questionnaire (SGRQ) score over three months in this study was 8.5 units (P value = 0.005 (Wilcoxon), low-quality evidence). Two studies reported mean increases in volume of sputum expectorated with airway oscillatory devices in the short term of 8.4 mL (95% CI 3.4 to 13.4 mL) and in the long term of 3 mL (P value = 0.02), with no significant effect on lung function. One study reported an immediate reduction in pulmonary hyperinflation in adults with non-positive expiratory pressure (PEP) ACTs (difference in functional residual capacity (FRC) of 19%, P value < 0.05) and with airway oscillatory devices (difference in FRC of 30%, P value < 0.05) compared to no ACTs. A similar decrease in pulmonary hyperinflation (difference in FRC of 6%) was found in children using an airway oscillatory device for 3 months compared to sham therapy. No studies reported on the effects of gas exchange, people's symptoms or antibiotic usage.
AUTHORS' CONCLUSIONS: ACTs appear to be safe for individuals (adults and children) with stable bronchiectasis, where there may be improvements in sputum expectoration, selected measures of lung function and health-related quality of life. The role of these techniques in people with an acute exacerbation of bronchiectasis is unknown. In view of the chronic nature of bronchiectasis, more data are needed to establish the clinical value of ACTs over the short and long term on patient-important outcomes, including symptoms, on physiological outcomes which may clarify the rationale for each technique and on long-term parameters that impact on disease progression in individuals with stable bronchiectasis. This is necessary in order to provide further guidance of specific ACT prescription for people with bronchiectasis. It may also be important to establish the comparative effect of different types of ACTs in people with bronchiectasis.
非囊性纤维化支气管扩张症患者常经历慢性咳嗽和咳痰，这些特征可能与临床状况的逐渐恶化有关。气道廓清技术（ACTs）常被用于促进痰液从肺部咳出，但这些技术在支气管扩张症稳定期或急性加重期的疗效尚不清楚。
主要目的：确定气道廓清技术对急性和稳定期支气管扩张症患者急性加重率、住院率及健康相关生活质量的影响。次要目的：确定a）气道廓清技术对急性和稳定期支气管扩张症患者是否安全，以及b）气道廓清技术对急性和稳定期支气管扩张症患者的生理和症状是否有有益影响。
我们检索了Cochrane Airways Group专业试验注册库（从建库至2012年10月）、2012年10月的PEDro数据库，并手工检索了相关期刊。
随机对照平行试验和交叉试验，比较气道廓清技术与无治疗、假气道廓清技术或指导咳嗽在支气管扩张症患者中的效果。
我们采用了Cochrane协作网期望的标准方法程序。
五项涉及51名参与者的研究符合本综述的纳入标准，均为交叉设计。四项研究针对稳定期支气管扩张症成人患者，另一项研究针对临床稳定的支气管扩张症儿童患者。三项研究为单次治疗，两项为长期研究。干预措施各不相同，一些对照组接受假干预，而另一些则无干预。研究的方法学质量参差不齐，且研究无法使参与者和研究者设盲。研究间的异质性使得这些数据无法进行荟萃分析，因此本综述采用叙述性总结。一项针对20名成人的研究比较了气道振荡装置与无治疗，发现12周时急性加重次数无显著差异（低质量证据）。无数据可用于评估气道廓清技术对急性加重时间、急性加重持续时间、住院率或住院总天数的影响。同一研究报告，在疾病特异性和咳嗽相关测量方面，健康相关生活质量有临床显著改善。虽然基于少数参与者且数据有偏态，但本研究中三个月内圣乔治呼吸问卷（SGRQ）总分变化的中位数差异为8.5分（P值=0.005（Wilcoxon），低质量证据）。两项研究报告，使用气道振荡装置短期内痰量平均增加8.4 mL（95% CI 3.4至13.4 mL），长期增加3 mL（P值=0.02），对肺功能无显著影响。一项研究报告，与无气道廓清技术相比，非呼气末正压（PEP）气道廓清技术使成人肺过度充气立即减轻（功能残气量（FRC）差异为19%，P值<0.05），气道振荡装置使FRC差异为30%（P值<0.05）。与假治疗相比，使用气道振荡装置3个月的儿童肺过度充气也有类似程度的减轻（FRC差异为6%）。没有研究报告气体交换、患者症状或抗生素使用情况的影响。
气道廓清技术对稳定期支气管扩张症患者（成人和儿童）似乎是安全的，可能会改善痰液咳出、部分肺功能指标及健康相关生活质量。这些技术在支气管扩张症急性加重患者中的作用尚不清楚。鉴于支气管扩张症的慢性性质，需要更多数据来确定气道廓清技术在短期和长期对患者重要结局（包括症状）、可能阐明每种技术原理的生理结局以及影响稳定期支气管扩张症患者疾病进展的长期参数的临床价值。这对于为支气管扩张症患者提供特定气道廓清技术处方的进一步指导是必要的。确定不同类型气道廓清技术在支气管扩张症患者中的比较效果可能也很重要。
