Under-diagnosis of Bronchiectasis Hinders Treatment
Bronchiectasis is a condition affecting the airways in the lungs that causes cough, increased mucus production, and recurrent lung infections.¹ The symptoms are caused by abnormal widening of the airways of the lung, also known as bronchi. The cells lining the airways become inflamed and swollen. These damaged airways can no longer effectively clear mucus and bacteria from the lung. Over time, excess mucus accumulates in the airways and provides a breeding ground for bacteria that produce recurrent infections. Mucus build-up can cause a vicious cycle of inflammation and infection, leading to further damaged airways. This can lead to flare-ups of cough, mucus production, and shortness of breath.² The two main types of bronchiectasis are cystic fibrosis bronchiectasis and non-cystic fibrosis bronchiectasis. For the remainder of this article the focus will be on non-cystic fibrosis bronchiectasis.
Bronchiectasis is caused by one or more infections introduced into the lungs. The most common symptoms are persistent cough and production of excess mucus. Each lung infection can make the bronchiectasis worse. Therefore, early diagnosis and treatment of bronchiectasis is very important. Treatments can help reduce coughing, discomfort, and mucus production, but this condition is incurable.
The recognized causes of bronchiectasis include post-infection, Chronic Obstructive Pulmonary Disease (COPD), primary ciliary dyskinesia, allergic bronchopulmonary aspergillosis, NTM infections, immune deficiencies, and connective tissue diseases.³ Despite extensive testing 53% of patients may have no identifiable cause and the diagnosis of idiopathic bronchiectasis remains common.³
Bronchiectasis affects 500,000 people in the U.S. with 70,000 new cases diagnosed annually⁴. The risk of developing bronchiectasis increases with age, and it is more common in women.
Studies indicate that 42% of COPD patients may have bronchiectasis.⁵ The common symptoms and clinical overlap between COPD, asthma and bronchiectasis can make diagnosis difficult and lead to diagnostic errors.⁶
Often developing gradually, symptoms of bronchiectasis may not appear for months or even years after the predisposing event or events. These symptoms typically are chronic cough, chest congestion and sputum production. Patients also often have a history of respiratory infections.
Some of the signs and symptoms of a bronchiectasis exacerbation are the same as those of acute bronchitis and COPD, making them hard to differentiate. Diagnosing bronchiectasis can therefore be tricky because it often presents like COPD but won’t respond to COPD therapy.
A bronchiectasis exacerbation can include cough, breathlessness, sputum volume/consistency, fatigue, sputum purulence.¹ But not all bronchiectasis exacerbations are the same. Each likely has independent biological mechanisms including infection, inflammation and mucus production which likely requires a specific targeted therapeutic approach.⁷
Symptoms alone do not confirm a bronchiectasis diagnosis. A high-resolution computerized tomography (HRCT) scan is required to confirm the presence of bronchiectasis. Bronchiectasis is a common and important cause of respiratory disease realized with the widespread availability of HRCT.⁸ Is HRCT widespread? If it is widespread is it being utilized? One reason bronchiectasis is underestimated is because of a lack of health care resources, like a CT scan, or the inadequate use of the CT scan for diagnosis.⁶
Treatment approaches to manage symptoms for people with bronchiectasis can include a) the use of breathing exercises and medical devices to help loosen and clear mucus from the lungs, b) the use of oral and inhaled medications that help clear mucus from the lungs, and c) the use of antibiotics to treat lung infections.
Effective mucus clearance is essential for lung health, and airway disease is a consistent consequence of poor clearance⁹ Expert consensus opinion is that regular airway clearance therapy should be performed for all clinically significant bronchiectasis patients.¹ Airway clearance therapy is considered a cornerstone of therapy for people with bronchiectasis and is aimed at minimizing the effects of airway obstruction, infection, and inflammation in these lung diseases. Airway clearance therapy is recommended for not just people with bronchiectasis but any individual whose ability to mobilize and clear airway secretions is compromised. Patients with a daily, productive cough should be utilizing airway clearance therapy daily to help prevent future infections or hospitalizations.
Airway clearance techniques are intended to reduce obstructive secretions, which can include issues like air-flow obstruction, respiratory infection, dyspnea, fatigue, and reduced quality of life.¹⁰ These techniques include both mucus-mobilizing techniques and assisted cough techniques.
Studies recommend that airway clearance techniques be used as the primary method of mobilizing secretions from the middle and small airways to the larger airways. Then, effective coughing can be used to clear secretions from the larger airways, thereby preserving the integrity of the larger airways.⁹
The goal of airway clearance therapy is to provide a preventative treatment option for at-risk pulmonary patients that results in reduced, recurring hospitalizations and better overall health. ¹¹’¹²
Due to the range of techniques, it is important to personalize airway clearance therapy for everyday living with the aim of providing the best health and therapy adherence.
High-frequency chest wall oscillation (HFCWO) therapy is a highly recommended and effective form of airway clearance therapy. HFCWO, also referred to as vest therapy, applies high-frequency vibration to loosen and mobilize mucus. HFCWO vest therapy has been shown to produce an improvement in lung function, quality of life, and reduction of symptoms compared to traditional chest physiotherapy.¹³
AffloVest Mobile Mechanical HFCWO vest therapy is the first battery-operated, mobile during use, HFCWO therapy that allows patients to receive state-of-the-art airway clearance therapy on the go.
AffloVest therapy is specifically engineered to mimic the gold standard of manual chest physical therapy, streamline treatment, enhance airway clearance, help mobilize lung secretions, and promote treatment adherence. With no bulky tubes and generators as found in other HFCWO therapies, the AffloVest can be utilized in any postural position to help improve secretion mobilization. A recent retrospective study showed the initiation of AffloVest therapy reduced antibiotic usage, emergency visits and hospitalizations. On average after 6 months of AffloVest therapy patients achieved an 87.3% reduction in antibiotic usage and 82.4% reduction in emergency visits.¹⁴
AffloVest is designed to increase therapy adherence through mobility during use, which can provide more consistent therapy compliance and an improved quality of life.
AffloVest requires a doctor’s prescription for treatment by High Frequency Chest Wall Oscillation (HFCWO). The AffloVest has received the FDA’s 510k clearance for U.S. market availability, and is approved for Medicare, Medicaid, and private health insurance reimbursement under the Healthcare Common Procedure Coding System(HCPCS) code E0483 – High Frequency Chest Wall Oscillation. The AffloVest is also available through the U.S Department of Veterans Affairs/Tricare. Patients must qualify to meet insurance eligibility requirements.
1. O’Donnell, A. Medical Management of Bronchiectasis. Journal of Thoracic Disease. 2018; 10(Suppl 28):S3428-S3435.
2. American Lung Association: https://www.lung.org/lung-health-and-diseases/lung-disease-lookup/bronchiectasis/
3. Contarini, M. et al. Bronchiectasis: A Case-Based Approach to Investigation and Management. European Respiratory Rev 2018; 27:1800016.
4. Weycker D, Hansen GL, Seifer FD. Prevalence and incidence of noncystic fibrosis bronchiectasis among US adults in 2013. Chron Respir Dis 2017; 14:377.
5. Kosmas, E. et al. Bronchiectasis in Patients with COPD: An Irrelevant Imaging Finding or a Clinically Important Phenotype? CHEST. 2016; 150(4):894A.
6. Aksamit, T. et al. Bronchiectasis and Chronic Airway Disease: It is not just about Asthma and COPD. CHEST. October 2018.
7. Burgel, P. et al. Can’t Stop the Feeling: Symptoms as the Key to Trial Success in Bronchiectasis. American Journal of Respiratory and Critical Care. 2020; 201(12).
8. King, P. The Pathophysiology of Bronchiectasis. International Journal of COPD. 2009; 4:411-419.
9. McIlwaine, M. et al. Personalizing Airway Clearance in Chronic Lung Disease. European Respiratory Review. 2017; 26.
10. Andrews, J. et al. Nonpharmacologic Airway Clearance Techniques in Hospitalized Patients: A Systematic Review. Respiratory Care. 2013; 58(12) 2160-2186.
11. O’Neill, K. et al. Airway Clearance, Mucoactive Therapies and Pulmonary Rehabilitation in Bronchiectasis. Respirology 2019; 24(3):227-237.
12. McShane, P et al. Concise Clinical Review: Non-Cystic Fibrosis Bronchiectasis. Am J Respir Crit Care Med 2013; 188(6):647-656.
13. Nicolini, A. et al., Effectiveness of treatment with high-frequency chest wall oscillation in patients with bronchiectasis. BMC Pulmonary Medicine. 2013;13:21
14. Foley, B. et al. Reduction in Antibiotic Use, Emergency Visits and Hospitalizations in COPD and Bronchiectasis Patients after Initiating AffloVest HFCWO Therapy. RT Magazine. January/February 2021.