Aloha everyone, thank you for joining us. I know it's the last day, but thank you for taking your time to attend this important session on airway clearance techniques and devices. We have a very good panelist today, including myself. I'm the Dean at Indra. I'm coming from Baylor College of Medicine, and I'm the chair of bronchiectasis section of the CHESS committee, so I'm very happy that CHESS gave us this opportunity to do this. And the next speaker is our Sanjay Devarajan, who is assistant professor. He's our director for the CF Center at Baylor, along with Dr. Tara Bartow there. David Vines is our professor and chairperson. You must have seen him in multiple sessions. He comes all the way from Illinois, Chicago. He's the Associate Dean of Clinical Integration and Interdisciplinary Initiatives at the College of Health Science at Rush. We also have Dr. Ramirez, Christina Ramirez, who is joining us as the assistant professor from the Division of Respiratory Care from UT San Antonio, and we're all happy to chair this session. We are gonna have audience response system, so please, if you'd like us to answer some of the questions, we give you a little bit brief of introduction of what these airway clearance techniques and devices are, and then we're gonna divide into four groups, and you'll be moving every 10 minutes, so that's the plan. The objectives of the session is to learn about different forms of airway clearance therapies, get some hands-on experience on these chest percussion, PEP devices, and the high-frequency chest wall oscillations. This is how the outline is gonna be. We're gonna talk for 12 minutes, and then we'll let you move every 10 minutes between four stations we have, and then we will wrap up with some questions and some challenges that we face. As we know, bronchiectasis is a clinical syndrome characterized by chronic cough, sputum production, in the presence of abnormal thickening, dilatation of the bronchial wall that we've seen on lung imaging, and there's a very good review from Dr. Annie O'Donnell. I highly recommend all of you to review this. It gives you all about the pathophysiology, causes, treatment, and what is important. As you can see, there's a vicious cycle of initial insult, which could be infection or injury, causing neutrophilic inflammation, releasing of proteases, which causes airway destruction and distortion, causing this bronchiectasis. You can see the airways are tethered out, filled with mucous secretions, and this clearance is poor, and that causes mucostasis, bacterial colonization, recurrent infections, and this cycle goes on. This is called the vicious vertex, and the role of neutrophilic inflammation, as we can see, patients with bronchiectasis have frequent exacerbations with neutrophilic inflammation, and these neutrophils are damaging the airways and causing airway destruction, and that cycle goes on. And this is a nice algorithm that I found at UT San Antonio, developed by my close friend Dr. Diego Maselli. He gives you what are the labs you should do, microbiology, PFTs, and what are the different things that you get at the interest of time. We're not gonna go into details, but this is something that I found very useful. If you look at the treatment approaches for bronchiectasis, obviously you have to treat the underlying cause, identify the infectious organism, use airway clearance techniques, which is what we're gonna do today. There's also importance of physical rehab and exercise. Macrolides, which are antibiotics, are useful in selected patients, and then we have to give antibiotics for frequent exacerbators. Again, from Dr. Anne McDonald, sorry, Donnell, you can see here that clearly airway clearance techniques are very useful in these patients. It improves endurances, improves mucus clearance, and reduces cough, and then you know there's always combination is better than unit one, so that's what we're gonna teach you today on all four of them. To start off with the first question, okay, what percentage of bronchiectasis patients are prescribed airway clearance? More than 90%, 80 to 90%, 70 to 80%, 60 to 70%, 50 to 60, 40 to 45, oh, sorry, 40 to 50. What do you think is the answer? How many patients with bronchiectasis are prescribed airway clearance techniques or device? I think we have more than 25 people. Okay, 30, good. All right, let's see the right answer. Actually, that is the right answer. It's only 40 to 50% patients are prescribed airway clearance techniques and devices. That's the right answer, the sixth one. The second question is what are the most important factors for prescribing right airway clearance device or technique? The rest is the best. PEP is perfect, cycle breathing is enough, patient preference, what's available in the office, insurance preference, or combination of above. I don't think that's a choice, but let's see what you will choose. I think we're plateauing at 35. Okay, let's see the answer. Patient preference is actually the right answer. So we have several devices, but if patient is not cooperative, no matter how good that device or technique is, they're not gonna use it, so that's the right answer. The next question, what is an important reason for non-adherence to airway clearance therapies? Is it the lack of education, affordability of devices, improper technique, it's time-consuming, or all of the above? Let's reveal the answers. Very good, all of the above, exactly. All of you got this right. I think this question, a patient with cystic fibrosis is receiving postural drainage and percussion of the right middle lung or middle lobe. What is the most appropriate patient position? One is, A, is you're prone with right shoulder elevation on pillows on the head on the same plane as the pelvis. Two is to supine on wedge with left shoulder elevation on pillows with head lower than the pelvis. Three is to supine on a wedge with the right shoulder elevated on pillows with the head lower than pelvis. Prone with the left shoulder elevation on pillows and head on the same plane as the pelvis. So the patient's problem is in the right middle lobe, and which position would be helpful for postural drainage? So I'm gonna ask Dr. Ramirez to come and see what the answer is and why she thinks it's the right answer. Okay. Thanks. Okay, the correct answer is, did you just have all of them? Yes, is the third one. So looks like the majority of you got it right. Breathing exercises such as controlled breathing techniques, diaphragmatic breathing, pursed lip breathing, huff coughing are all really important. What they can do is help improve lung function, they can increase oxygen exchange and decrease breathing difficulties. Diaphragmatic breathing is important to teach to your patients to make sure that you understand it's kind of belly breathing, putting a hand on the chest, a hand on the abdomen, making sure that when they inhale, that their belly is exhaling, and then whenever they're inhaling, they are exhaling, sorry, whenever they're exhaling, their belly's going back in. Pursed lip breathing is important to take a nice deep breath for two seconds in, and then exhale for about four seconds. And huff coughing is also very important with airway clearance, to make sure that they're mobilizing secretions, but we also want to help them control their huff coughing so it's not uncontrolled coughing. With breathing exercises when you're teaching patients, it's really important to individualize instruction to their strengths, needs, and abilities. Offer feedback and corrections as needed. Visual aids are helpful too. Diagrams and videos are very helpful for patients to understand step-by-step procedures. You really want to stress the importance of regular practice so they put it into their daily routine. Monitor the patient's progress and provide ongoing support. Empower them to really do it independently. Provide them with instructions. Like I said, step-by-step is very helpful, and reinforce the benefits of the breathing exercises. So postural drainage also goes hand-in-hand with breathing techniques. The frequency is typically two to three times a day before eating. And manual techniques that are typically used are percussion, vibration, and shaking. And these are all the different techniques we'll be practicing at one of the stations today. Okay, so next question. What is the minimal biocapacity in milliliters per kilogram needed to use a PEP device appropriately? 20, 15, 10, or five? I'm David Bynes, and I'm going to talk to you a little bit about laboratory PEP. Oh, very good. That is the correct answer. You need somewhere around 10 to 12 mLs per kilogram of volume is what's recommended to actually effectively use a PEP device. So we start talking about all these various techniques and start saying, hey, how do I choose what for my patient? This is certainly one in PEP therapy, whether your patient can actually take a deep enough inhalation to use it effectively. Probably a bigger problem if you think about it in acute care settings than it is in outpatient settings, but still something you would want to be able to evaluate or perhaps have them bring the device and demonstrate for you. So PEP therapy creates a positive expiratory pressure, and then the oscillations are added to it through the valve systems within the various devices. And as you can see, there are a lot of devices out there, and I just limited or listed a few here on the slide. But technically, how the technique works is the PEP therapy helps prevent the airway collapse, creating back pressure through pores of Kahn, canals of Lambert, communication between the alveoli that will allow the volume to move in behind the secretions. So after you do about 10 or so breaths, then of the device and the vibrations actually create shear forces that have been shown to help break the mucus apart. So it's a dual combination here, partly to try to get some volume behind the secretions. So thus, then the patients would be able to move them into larger airways and then generate effective cough flows to remove those secretions is thought around the technique there. And so PEP devices have the ability to change the resistance on them. And that, by changing that resistance, basically you're creating the amount of positive expiratory pressure they have and creates resistance as they begin to exhale. Part of that, though, you wanna be careful that they have about, let's say, a one-second inspiration, maybe four seconds of expiration, and they're able to use the device and vibration through that continuous period of time. And so if they're able to take enough volume and you can set enough resistance, then you would change it based on that to get a long exhalation from the patients there. There is, in theory, what's called an oscillatory index in a pretty recent paper that was published that looks at the amount of oscillatory flow and the flow amplitude, or the oscillations, the amount of hertz that's produced and the flow amplitude associated. And there is an argument in the paper that this would help with the mucus clearance versus one of a higher level of PEP. So that is currently, I wish I could tell you, here's the randomized control trial to demonstrate which of these devices is most effective and that this theory is right on and you want a high oscillatory index, but that's not available. It's all in theory and all of it is bench data driving some of what is thought to be here. So which is better, this big flow amplitude or higher PEP? It is really not known to today. So I would tell you, follow your patients. If one device doesn't work for them, perhaps you would change and pick a different device. And so as you can see, these are showing some of the ranges on the screens, but you wanna try to look at the companies and what they claim is mean PEPs, what is their mean oscillations and then make some decisions. But in this paper, as you can see, they test a lot of devices. There are a lot of devices out there that one could potentially choose. And so I will turn things over here to Sanjay and he will take over from there. All right, everyone, aloha. Thanks for coming here this morning to talk about mucus. We love nothing more than that. You wanna see? Here we go. All right, so which of the following statements is true about IPV? If you can pull out your phone and scan. How many votes do we have? So far, nine. I know we can do better than that. There we go. IPV being intrapulmonary percussive ventilation. All right, 25. That looks good. Let's take a look. Okay, so we've got a nice split there. Now, those are probably the two most likely answers, right? So if you chose answer C, you are correct. Now, I won't say this is a data-free zone, but it's data limited to be sure. And there was a kind of a meta-analysis, a study of studies looking at impact of IPV on inpatients, primarily geared at patients with obstructive lung disease from COPD. And it demonstrated they had a reduced to hospital length of stay, but interestingly, not a reduced ICU length of stay. There is a small RCT, which has demonstrated that, but it was a power. Its use is not contraindicated in patients with tracheostomy. This can be done in line. And it does impact gas exchange parameters, including PaO2 and PaCO2. So real quick, we're gonna talk about IPV as well as OLE, which is oscillation and lung expansion. And these are sort of parts of a continuum, if you will. So essentially what happens is that IPV really causes these shear forces in the airways that cause mucus basically to come off the walls and get to distal areas and improve airway clearance and recruitment. So these are both forms of chest physiotherapy. And it's a pressure limited, time cycle, high frequency ventilatory mode. And so what you get are these sort of juts of low volumes into the airway at relatively sturdy pressures. And these are sub, sort of sub, the volumes are subtitle volume. And what ends up happening when you do this is that you get a little bit of augmented ventilation, because you're able to augment the title volumes in particular. Because of those shear forces that IPV creates, you're able to get the mucus off those bronchiectatic dilated walls. And when you can do that, you can kind of recruit some of these areas where atelectasis is taking place. And that's the impact on oxygenation really comes from the improvement of mucus clearance and reversal of atelectasis. And the augmented ventilation created by these little bursts of low volume are what allow for the improvements in the ventilation. So how do these work? So you've got an IPV OLE device. So a session, an IPV session, how long should that last? Well, there's sort of differences of opinion on that, but somewhere in the realm of 10 to 30 minutes, because these patients got other places to be. The frequency of these sort of bursts are really gonna come in cycles per minute. And it's usually about 100 to 300 cycles per minute, 100 being quite low. There are some studies which have done it in the 500 and 600 upper range. And the pressures you're gonna see are primarily with peak inspiratory pressures less than 30. Although the device that we'll use in the back there on the hands-on, a lot of times the introductory or sort of the range that we'll set is 20 to 40. And so what do you do? So you've got this IPV device. You basically run it through a nebulizer system. And then you can actually run it sort of concurrently with a mucolytic hypertonic saline as sort of my weapon of choice. And what you can then do is basically connect that through something called a phazotron, which is part of the IPV setup. And really what this does is it uses this so-called sliding venturi phenomenon. And it basically creates this, it serves as an inspiratory and expiratory pressure valve, but it also is what gives you sort of these jets of pressure that the patient experiences. And you connect that to a mouthpiece, and then you find a random Hawaiian patient that you can use it on who might benefit, okay? And so this is how IPV sort of looks when it's sort of set up. This is actually publicly available on YouTube. This is a young lady with cystic fibrosis who wanted to capture her experience. Let me see if this thing works here. And there may be no audio, but that's okay. So what you're gonna see her do is you're gonna see her close her cheeks, and that's really to kind of allow the pressure to sort of be directed at the chest. And if you see her chest is kind of oscillating up and down, and she seems pretty happy with the whole setup, right? And this is something that has previously really only been available to sort of patients with neuromuscular disease. That's somewhere where the older data sets, small randomized trials, which demonstrated gas exchange improvements in neuromuscular disease. But this is sort of translated, especially in the inpatient setting, to patients with obstructive disease. But as you'll see, as we have in the machine in the back, this is actually commercially available for patients in the home setting as well. All right, so I will yield the rest of my time and bring Dharni back up to the stage to answer this question if you guys wanna answer this in the meantime. Thanks for being here. Yeah, so in the context of bronchiectasis, what is the mechanism of action of a high-frequency oscillatory device? So does the device employ the CPAP to assess mucus clearance? Or does the device create rapid low-amplitude pressure changes in the airways, which help to mobilize the secretions? Or does the device primarily dilates the bronchi to enhance mucus movement? The device uses sound waves to break down the thickened secretions? Or the device applies negative pressure to assist in direct suctioning of secretions? So which of the following is true for the mechanism of action for the high-frequency S-wall oscillation? All right, for the sake of time. That is the right answer. 90% of you got it right. It doesn't dilate the bronchi. It doesn't cause a CPAP effect. Or there's no sound waves to, you know, thicken or break down the secretions. And there's no negative pressure applied. That's right. So high-frequency chest-wall oscillation uses the positive and negative pressure changes to augment both peripheral and tracheal mucus movements towards the airway movement. So it helps with expelling of the secretions. The air pulses are transmitted to the chest, at the vest, sorry, to the vest, using a high-frequency oscillatory chest-wall compressions. During inflation, okay, during inflation, the pressure changes between five to 20 centimeters of water using a short burst of expiratory flow up to 1.6 liters per second. The device usually operates between two to 20 hertz. And you can see it mobilizes secretions by increasing the air fluid shear forces during expiration, enhances the ciliary beating, and changes the tenacity of the secretions, making them less thick and therefore easier to expectorate. The high-frequency chest-wall oscillation also allows the patients to receive treatment to larger portion of chest at the same time. And, you know, it can be done in sitting, or it can be, it minimizes the effect of reflux and other modified positions. This is one of the example of how it looks. Usually it is done in a session of 30 minutes, but every five minutes the person stops and uses the cough-assisted mechanisms, or cough mechanisms, and expels the secretions out. When do you not use it? When there's unstable neck injuries, or when patients are having big quotes under the vest, but I believe we can use a cushion to cover that. When the patients are having acute pulmonary embolism, or lung confusions, or having active hemoptysis, or they're unstable, they have rib fractures, not tipped fractures, rib fractures, or they have large pleural effusions or empyema. The disadvantage for the chest or the high-frequency oscillation they can be expensive, and you have to go through insurance to get, but if you have CF and valid bronchiectasis, maybe okay. Sometimes they're heavy and not portable, and they can be noisy, which sometimes kids, children may not like it, even adults for that matter, and then it kind of restricts your thoracic mobility, so that's a reason why people may not like it. There are evidence to show that improves both pulmonary function and quality of life with high-frequency chest wall oscillations. It is very safe in children, helps with sputum clearance, and some studies have said it's similar to pep therapy. Some studies have shown that it's less effective than airway clearance, and then there was a study from Dr. Bartow from Baylor where they did a retrospective analysis of almost 2,500 patients and analyzed these patients, and it did show they improved self-reported outcomes with initiation of this VAS devices by decreasing the number of hospitalizations, antibiotic use, and also subjective experience of airway clearance. There was another study done at UAB which showed, I think, there's about 250 patients. There's also observation with respective cohort study where they showed that using chest wall VAS devices will keep your lungs stable. Lung functions are stable at the end of one year, does decrease your hospitalizations, and thus kind of reduces your antibiotic usage as well, so there has been some data to show that it does effectively work. Now this is the infographic that we developed as a part of the chest, and we're gonna go on to the hands-on training. We're not sure how many people will come, but we have four stations, so we're gonna have an airway clearance station, we have a pep station there, and we have the IPV and the VAS. If you can divide yourself into four of you, and every 10 minutes we're gonna move to each station so you will learn on each of these, and we have representatives to help us teach this as well. We are not promoting any device today. I just wanna give a disclosure, but we are very fortunate that some of the representatives have come to explore these devices. We are not recommending one or the other, but we are just showing you what is available out there. And then I'm gonna give you a QR code so you can download this infographic, but we're gonna stay here and move from station. So if you can all divide into four groups in any fashion, and then come here, this is table one, that's table two, table three at the back, and table four up here, so you can experience what these airway clearance techniques and devices are all about. Thank you. So I hope you all got some hands-on experience on different techniques and devices. I do have some resources for you, like the infographic I showed you to share, so you can use the QR code to download that. And there is an excellent website on the Australian site called the Brontoectasis Toolbox, which gives you all about all different techniques and devices that we talked about today. So it's a valuable resource to have. We really thank you for taking your time to come today to learn on this session. I hope you learned something. And if there's any questions, please reach out to us and we'll be happy to answer. The last thing is I wanted to say that it's a multidisciplinary effort. It's not just the physician that's important here. It's physician, respiratory therapist, and even people that can help house, home health care, or whoever. In terms of family education, it's very important for these patients so they can use the right devices and techniques. Thank you again. And thank you for joining us. Thank you.

airway clearance techniques

devices

bronchiectasis

mechanisms of action

patient preference

non-adherence