Airway clearance techniques for individuals with an acute exacerbation of bronchiectasis: a randomised controlled trial

All participants will continue to receive usual care including medical therapy (including but not limited to antibiotics, corticosteroids, supplemental oxygen), nursing care, a walking program with the goal to return to previous level of function, and other allied health interventions as required. Participants will be randomly allocated by the chief investigator to one of three arms: Arm 1. Exercise with huffing and usual care Arm 2. The Active Cycle of Breathing Technique (ACBT), and usual care Arm 3. Oscillating-PEP therapy, and usual care All interventions will be supervised once daily by a physiotherapist whilst the participant is an inpatient, and participants requested to complete the intervention twice daily unsupervised whilst an inpatient, and unsupervised on discharge from hospital. Arm 1: Exercise with huffing Participants randomly assigned to arm 1 will complete a standardised exercise program based on over-ground walking in combination with directed huffing, with the goal of airway clearance. Participants will self-select their walking speed to a modified Borg scale level of 3-5 whilst maintaining acceptable blood oxygen saturation levels and heart rate range as determined by usual values or acceptable altered parameters prescribed by the participant’s treating respiratory physician. The goal will be to complete a total of 30 minutes/day, so whilst inpatients participants will be instructed to walk for 10 minutes, 3 times per day combined with a series of huffs at the end of the session. As outpatients, participants will maintain the goal of 30 minutes/day in combination with huffing. A huff involves breathing out with mild-moderate force to aid clearance of sputum from the lungs. Arm 2: Active cycle of breathing technique (ACBT) Participants will be positioned upright in a chair or sitting up in bed if unable to sit in a chair. The ACBT consists of three components which will be implemented: breathing control, thoracic expansion exercises and a huff. The cycle will involve: 1. Breathing control – participant to breathe at their usual rate and depth 2. Thoracic expansion – participant to breathe in slowly and deeply, pause for 1-2 seconds, breathe out fully but not forcefully. Repeated 2 to 3 times. 3. Return to breathing control as above 4. Thoracic expansion exercises as above repeated 2 – 3 times. 5. Return to breathing control as above 6. Huff – participant to take a slightly deeper breath than normal in, open mouth and keep it ‘O’ shaped, then breathe out more forcefully using abdominal muscles to assist. It should sound like a forced sigh. Participants to repeat 2 to 3 times with breathing control in between as needed. 7. Return to breathing control until ready to begin another cycle. The participant may cough if needed throughout the cycle. The participants will be instructed to complete a minimum of three cycles each session, or until the end points listed below. Arm 3: Oscillating PEP therapy The Oscillating -PEP therapy will use an Aerobika device. Participants will be positioned in forward lean sitting in a chair or sitting up in bed if unable to sit in a chair. The participant will complete 10 breaths, followed by a huff, and then a cough only if needed. This cycle will then be completed a minimum of three times or until the end points listed below. End Points The end points for all three arms will be: 1. Two non-productive cycles plus clear huff 2. Terminated by participant or physiotherapist for other reasons (such as participant fatigue, or the participant reporting subjectively feeling clear). 3. Productive cough remaining, or huff not clear, but session reached maximum time of 30 minutes. Participants will be recruited on admission to hospital and followed up for six months post discharge. Whilst they are inpatients, participants will be instructed by the ward physiotherapist to complete their allocated intervention three times daily, once supervised and twice independently. On discharge, participants will be instructed to continue their allocated technique twice daily. Compliance will be monitored through daily interviews (inpatient stay) and a weekly diary and monthly phone calls/email contact (upon discharge). The phone calls will collect information regarding adherence to ACT and clinical status in the previous month, including a change in cough/sputum, any hospital admissions or use of antibiotics. If participants are unable to be contacted via phone, they will also be contacted via email to minimise gaps in data.