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• Airway clearance adjuncts in COPD
  Nicholas S Hopkinson, Ruth Barker and Anthony A Laverty
  Published on: 12 September 2017
• Airway clearance technique prescription in COPD: unmet need or unclear data?
  Christian R Osadnik, Alethea Y Kavanagh
  Published on: 12 September 2017

• Published on: 12 September 2017

  Airway clearance adjuncts in COPD

  • Nicholas S Hopkinson, Reader in Respiratory Medicine Imperial College London
  • Other Contributors:
    • Ruth Barker, Research Physiotherapist
    • Anthony A Laverty, Research Fellow

  We thank the authors for their interest in our paper (1) which was designed, among other things, to be a statement of intent regarding the need to improve the evidence base concerning the use of adjunct devices for sputum clearance in patients with COPD.
  The authors reiterate some limitations of the data that we had outlined in our paper. In particular we are not able, using prescribing data, to capture other pathways through which patients may have obtained devices, including purchasing them from pharmacies. Direct patient surveys would address this as might company or pharmacy data on sales, if available. We did however present data on actual use of devices, reported by survey respondents, who were mostly in hospital practice, in the preceding year (Table 3). This confirms that use of devices for COPD patients was at an extremely low level and does not support the idea that a large amount of in hospital prescribing, not captured by prescription data, has been missed. We agree that some of the huge disparity with the use of mucolytic agents may reflect overuse of those medications. Nevertheless, the central point, that current extremely limited use of these devices in COPD patients seems at odds with the likely prevalence of patient phenotypes which are believed to benefit, stands.
  At present, this subject is largely ignored in clinical guidelines (2,3). Attention will be needed to address the limited evidence base and so feed into clinical guidelines and cli...

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  We thank the authors for their interest in our paper (1) which was designed, among other things, to be a statement of intent regarding the need to improve the evidence base concerning the use of adjunct devices for sputum clearance in patients with COPD.
  The authors reiterate some limitations of the data that we had outlined in our paper. In particular we are not able, using prescribing data, to capture other pathways through which patients may have obtained devices, including purchasing them from pharmacies. Direct patient surveys would address this as might company or pharmacy data on sales, if available. We did however present data on actual use of devices, reported by survey respondents, who were mostly in hospital practice, in the preceding year (Table 3). This confirms that use of devices for COPD patients was at an extremely low level and does not support the idea that a large amount of in hospital prescribing, not captured by prescription data, has been missed. We agree that some of the huge disparity with the use of mucolytic agents may reflect overuse of those medications. Nevertheless, the central point, that current extremely limited use of these devices in COPD patients seems at odds with the likely prevalence of patient phenotypes which are believed to benefit, stands.
  At present, this subject is largely ignored in clinical guidelines (2,3). Attention will be needed to address the limited evidence base and so feed into clinical guidelines and clinical practice.

  1. Barker R, Laverty AA, Hopkinson NS. Adjuncts for sputum clearance in COPD: clinical consensus versus actual use. BMJ Open Respiratory Research 2017;4(1) doi: 10.1136/bmjresp-2017-000226

  2. Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global Strategy for Diagnosis, Management, and Prevention of COPD: Updated 2017 2017:http://goldcopd.org/gold-2017-global-strategy-diagnosis-management-preve... accessed 24-3-17.

  3. Qaseem A, Wilt TJ, Weinberger SE, et al. Diagnosis and Management of Stable Chronic Obstructive Pulmonary Disease: A Clinical Practice Guideline Update from the American College of Physicians, American College of Chest Physicians, American Thoracic Society, and European Respiratory Society. Annals of Internal Medicine 2011;155(3):179-91. doi: 10.1059/0003-4819-155-3-201108020-00008

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  Conflict of Interest:
  None declared.

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• Published on: 12 September 2017

  Airway clearance technique prescription in COPD: unmet need or unclear data?

  • Christian R Osadnik, Physiotherapist / Research Fellow Monash University, Department of Physiotherapy, Australia; Monash Health, Monash Lung and Sleep, Australia.
  • Other Contributors:
    • Alethea Y Kavanagh, Physiotherapist

  It was interesting to review the findings of the study by Barker and colleagues [1] regarding airway clearance techniques (ACTs) for patients with chronic obstructive pulmonary disease (COPD). The authors suggest there may be a relative ‘under-prescription’ of simple adjunctive therapy options such as oscillatory positive expiratory pressure (OPEP) devices for the care of this patient group and reflect on the ability for ‘actual use’ registry data to inform research questions in this area. The data certainly show OPEP devices to be used less frequently and at significantly lower costs than prescription medications such as Tiotropium and Carbocisteine. This is not surprising, and is a likely accurate reflection of clinical practice.

  Identification of the most important clinical question(s) to arise from this data, however, appears quite challenging owing to significant limitations that may have been under-emphasised. The true incidence of OPEP device use amongst patients with COPD will certainly have been underestimated in the data obtained from the OpenPrescribing.net resource due to the ‘hidden’ market related to private or hospital-based device purchases. While this is acknowledged by the authorship team, we feel this may be more significant than that proposed. Our experience as clinical physiotherapists working in this area suggests a large proportion (if not the majority) of airway clearance therapy is the remit of physiotherapists working in cardiorespiratory...

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  It was interesting to review the findings of the study by Barker and colleagues [1] regarding airway clearance techniques (ACTs) for patients with chronic obstructive pulmonary disease (COPD). The authors suggest there may be a relative ‘under-prescription’ of simple adjunctive therapy options such as oscillatory positive expiratory pressure (OPEP) devices for the care of this patient group and reflect on the ability for ‘actual use’ registry data to inform research questions in this area. The data certainly show OPEP devices to be used less frequently and at significantly lower costs than prescription medications such as Tiotropium and Carbocisteine. This is not surprising, and is a likely accurate reflection of clinical practice.

  Identification of the most important clinical question(s) to arise from this data, however, appears quite challenging owing to significant limitations that may have been under-emphasised. The true incidence of OPEP device use amongst patients with COPD will certainly have been underestimated in the data obtained from the OpenPrescribing.net resource due to the ‘hidden’ market related to private or hospital-based device purchases. While this is acknowledged by the authorship team, we feel this may be more significant than that proposed. Our experience as clinical physiotherapists working in this area suggests a large proportion (if not the majority) of airway clearance therapy is the remit of physiotherapists working in cardiorespiratory medicine based primarily in (or outreached from) hospitals. This appears supported by the authors’ survey data responses, of which 72% of the 116 respondents stated they worked in hospitals. In these settings, ACTs are rarely formally ‘prescribed’ in medical registries, but rather implemented using existing resources, purchased privately or loaned / provided from the centre (as indicated in the survey instrument). Cost is a realistic barrier to OPEP device use, often resulting in education to substitute device use at home for cheaper, alternative means such as bottle-PEP (which could be performed at no cost). This would not appear on a prescription registry.

  OPEP devices may also be considered clinically indicated for certain patients, but this does not necessarily mean they are prescribed. Previous data from physiotherapists across the world demonstrates considerable variability regarding ACT prescription for this patient group, particularly during acute exacerbations. The most commonly used ACTs include the active cycle of breathing technique and deep breathing exercises in the United Kingdom, Australia, New Zealand [2-4], ‘conventional chest physiotherapy’ techniques (e.g. postural drainage, percussion, vibration) in Canada [5] and even physical exercise in Australia [4], despite scarce research examining this precise effect [6]. PEP device use did not feature prominently in any of these surveys, however its use is known to be widespread in countries such as Sweden.

  It is also unclear whether survey data (e.g. Table 2, Figure 1) represents opinion or actual practice patterns. Questions regarding ‘considerations’ or ‘recommendations’ may be quite different to treatment that a patient actually receives, particularly if the recommending therapist is different to the professional responsible for treatment ‘delivery’. And the survey responses, which represent only 12% of ACPRC members (and should therefore not be referred to as ‘clinical consensus’), may differ considerably from other members and/or the health professions represented in the prescription data. It would, of course, be interesting to know the extent of overlap between the two samples, however this is not likely to be possible. This uncertainty makes it challenging to comprehend the precise area in need of further research, particularly as it is possible the findings simply reflect differing views of two distinct health professions groups. For example, it is plausible the survey may primarily reflect opinions of physiotherapists but prescribing data that of general practitioners. If so, there remains a need to source more accurate information about OPEP prescription practices, potentially via closer examination of data originating from the therapists responsible for its implementation.

  Finally, as stated by the authors, we currently have very little clinical data upon which to base decisions regarding long-term ACTs for patients with COPD and chronic sputum production [7]. Further research is indeed required, but it is crucial that good judgment underpins decisions regarding the most relevant clinical question(s) to investigate. Identifying patients with stable COPD and chronic sputum production (in the absence of co-existing bronchiectasis, which reportedly occurs in up to 50% of COPD cases [8]) is not without challenge, with one previous physiological investigation of PEP therapy for this patient group observing a 43% exclusion rate of those screened due to a lack of regular sputum production [9].

  We feel some of the potential areas for future, clinically impactful research arising from this work may include identification of:
  i) The reasons underpinning the high use of mucolytic therapy in this patient group despite a lack of consensus recommendations in international COPD guidelines [10-12];
  ii) Patient acceptability regarding performance of long-term ACTs; and
  iii) Distinct clinical phenotypes who may benefit most from future, high quality clinical trials of ACTs.

  In conclusion, we congratulate Barker and colleagues for raising awareness of some of the challenging issues clinicians encounter when trying to deliver evidence-based care for patients with COPD and chronic sputum production. We encourage the issues to be further examined but implore a degree of caution when using inherently limited data as the foundation for future, clinically relevant research seeking to improve patient care.

  1. Barker R, Laverty AA, Hopkinson NS. Adjuncts for sputum clearance in COPD: clinical consensus versus actual use. BMJ Open Respiratory Research 2017;4(1) doi: 10.1136/bmjresp-2017-000226.
  2. Lee A, Button B, Denehy L. Current Australian and New Zealand physiotherapy practice in the management of patients with bronchiectasis and chronic obstructive pulmonary disease. New Zealand Journal of Physiotherapy 2008;36(2):49-58
  3. Yohannes AM, Connolly MJ. A national survey: percussion, vibration, shaking and active cycle breathing techniques used in patients with acute exacerbations of chronic obstructive pulmonary disease. Physiotherapy 2007;93(2):110-13
  4. Osadnik CR, McDonald CF, Holland AE. Airway clearance techniques in acute exacerbations of COPD: a survey of Australian physiotherapy practice. Physiotherapy 2013;99(2):101-6 doi: 10.1016/j.physio.2012.01.002.
  5. Harth L, Stuart J, Montgomery C, et al. Physical therapy practice patterns in acute exacerbations of chronic obstructive pulmonary disease. Can Respir J 2009;16(3):86-92
  6. Oldenburg FA, Jr., Dolovich MB, Montgomery JM, Newhouse MT. Effects of postural drainage, exercise, and cough on mucus clearance in chronic bronchitis. Am Rev Respir Dis 1979;120(4):739-45
  7. Osadnik CR, McDonald CF, Jones AP, Holland AE. Airway clearance techniques for chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2012(3):CD008328 doi: 10.1002/14651858.CD008328.pub2.
  8. Patel IS, Vlahos I, Wilkinson TM, et al. Bronchiectasis, exacerbation indices, and inflammation in chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2004;170(4):400-7 doi: 10.1164/rccm.200305-648OC200305-648OC.
  9. Osadnik C, Stuart-Andrews C, Ellis S, Thompson B, McDonald CF, Holland AE. Positive expiratory pressure via mask does not improve ventilation inhomogeneity more than huffing and coughing in individuals with stable chronic obstructive pulmonary disease and chronic sputum expectoration. Respiration 2014;87(1):38-44 doi: 10.1159/000348546.
  10. National Clinical Guideline Centre. Chronic obstructive pulmonary disease: management of chronic obstructive pulmonary disease in adults in primary and secondary care. 2010. http://guidance.nice.org.uk/CG101/Guidance/pdf/English (accessed 15/08/2017).
  11. Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global Strategy for the Diagnosis, Management and Prevention of COPD (2017 report). 2017. http://www.goldcopd.org/.
  12. Yang IA, Dabscheck E, George J, et al. The COPD-X Plan: Australian and New Zealand Guidelines for the management of Chronic Obstructive Pulmonary Disease 2017. Version 2.50, June 2017. 2017. http://www.copdx.org.au/.

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  Conflict of Interest:
  None declared.

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