This week’s Pulm PEEPs Pearls episode is a focused discussion between Furf and Monty about non-pharmacologic techniques for airway clearance in the non-Cystic Fibrosis bronchiectasis population. This is a focused, high-yield discussion of the key points about airway clearance, including practical tips and a discussion of the evidence.

This episode was prepared in conjunction with George Doumat MD. Goerge is an internal medicine resident at UT Southwestern and joined us for a Pulm PEEPs – BMJ Thorax journal club episode. He is now acting as a Pulm PEEPs Editor for the Pulm PEEPs Pearls series.

Key Learning Points

1) Why airway clearance matters in non-CF bronchiectasis

Non-CF bronchiectasis is defined by irreversible bronchial dilation with impaired mucociliary clearance, leading to mucus retention.
Retained sputum drives the classic vicious cycle: mucus → infection → neutrophilic inflammation → airway damage → worse clearance.
Airway clearance techniques (ACTs) are meant to interrupt this cycle, primarily by improving mucus mobilization and symptom control.

2) What ACTs are trying to achieve clinically

Main benefits are:
- More effective sputum clearance
- Reduced cough/dyspnea burden
- Improved activity tolerance and quality of life
Effects on spirometry are usually small.
Exacerbation reduction is possible, but evidence is mixed—some longer-term data suggest benefit for specific techniques.

3) The main ACT “families” and when to use them

Breathing-based techniques (device-free, flexible)

ACBT (Active Cycle of Breathing Technique): breath control → deep breaths with holds → huffing.
- Pros: portable, adaptable, good first-line option.
- Key requirement: teaching/coaching to get technique right.
Autogenic drainage: controlled breathing at different lung volumes to move mucus from peripheral → central airways.
- Pros: no device, can work well once learned.
- Cons: more technically demanding, needs training and practice.

PEP / Oscillatory PEP (stents airways + “vibrates” mucus loose)

PEP: back-pressure helps prevent small airway collapse during exhalation; often paired with huff/cough.
Oscillatory PEP (Flutter/Acapella/Aerobika): adds oscillation that many patients find easy and satisfying to use.
- Good fit for: people who benefit from airway stenting, want something portable, and prefer a device.

Mechanical/manual techniques (help when patient can’t self-clear well)

HFCWO (“the vest”): external chest wall oscillation; helpful for high sputum volumes, dexterity limits, or difficulty coordinating breathing maneuvers.
Postural drainage/percussion/vibration: caregiver/therapist-assisted options; still useful but consider:
- GERD/reflux risk with certain positions
- Hemoptysis risk with vigorous techniques

4) How to choose the “right” technique (the practical framework)

There is no one-size-fits-all. Match the tool to the patient:

Sputum burden (volume/viscosity)
Strength, coordination, cognition, dexterity
Comorbidities (GERD, hemoptysis history, severe obstruction/airway collapse)
Lifestyle + portability (what they’ll actually do)
Cost/access and availability of respiratory therapy/physio support

A key mindset from the script: this is not a lifetime contract—reassess and adjust over time with shared decision-making.

5) Evidence takeaways (what improves, what doesn’t)

ACTs reliably improve sputum expectoration and often symptoms/QoL.
QoL/cough scores (e.g., SGRQ, LCQ) tend to improve modestly, particularly with oscillatory PEP and some vest studies.
Lung function: typically minimal change; occasional short-term FEV₁ benefit is reported in some vest trials.
Exacerbations: mixed overall; the script highlights a longer-term RCT of ELTGOL showing fewer exacerbations at 12 months vs placebo exercises.
Safety: generally excellent; main cautions are hemoptysis and reflux (depending on technique/positioning).

6) Special population pearls

Hemoptysis / fragile airways: start with gentle breathing-based ACTs (ACBT, controlled huffing); avoid overly vigorous oscillatory/manual methods if concerned.
Severe obstruction or early airway collapse: PEP/oscillatory PEP can help by keeping small airways open on exhalation.
Mobility/coordination barriers: consider HFCWO vest or simple oscillatory PEP devices to enable daily adherence.
During exacerbations: keep it simple—1–2 reliable techniques, prioritize daily consistency, and re-check technique.

7) The “real” bottom line

Start with simple, self-manageable options (often ACBT ± PEP).
The “best” ACT is the one the patient will do consistently.
Reassess technique and fit over time; education and demonstration are part of the therapy.

References and Further Reading

Lee AL et al., “Airway clearance techniques for bronchiectasis,” Cochrane Database Syst Rev. 2015; PMC7175838. PMID: 26591003.

Athanazio RA et al., “Airway Clearance Techniques in Bronchiectasis,” Front Med (Lausanne). 2020; PMC7674976. PMID: 33251032.

Iacono R et al., “Mucociliary clearance techniques for treating non-cystic fibrosis bronchiectasis,” Eur Rev Med Pharmacol Sci. 2015; PMID: 26078380.

Polverino E et al., “European Respiratory Society statement on airway clearance techniques in bronchiectasis,” Eur Respir J. 2023; PMID: 37142337.

Doumat G, Aksamit TR, Kanj AN. Bronchiectasis: A clinical review of inflammation. Respir Med. 2025 Aug;244:108179. doi: 10.1016/j.rmed.2025.108179. Epub 2025 May 25. PMID: 40425105.

114. Pulm PEEPs Pearls: Airway Clearance Techniques in Non-CF Bronchiectasis

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