Personalising airway clearance in chronic lung disease

This review describes a framework for providing a personalised approach to selecting the most appropriate airway clearance technique (ACT) for the individual patient. It is based on a synthesis of the physiological evidence that supports the modulation of ventilation and expiratory airflow as a means of assisting airway clearance. By possessing a strong understanding of the physiological basis for ACTs, it will enable clinicians to decide which ACT best aligns with the individual patient’s pathology in diseases with anatomical bronchiectasis and mucus hyper-secretion. The physiological underpinning of postural drainage is that by placing a patient in various positions, gravity enhances mobilisation of secretions. Newer ACTs are based on two other physiological premises: the ability to ventilate behind obstructed regions of the lung; and the capacity to achieve the minimum expiratory airflow bias necessary to mobilise secretions. After reviewing each ACT to determine if it utilises both ventilation and expiratory flow, these physiological concepts are assessed against the clinical evidence to provide a mechanism for the effectiveness of each ACT. This paper provides the clinical rationale necessary to determine the most appropriate ACT for each patient, thereby improving care.