Airway Clearance Therapy Research Articles

The Short Term Influence of Chest Physiotherapy on Lung Function Parameters in Children With Cystic Fibrosis and Primary Ciliary Dyskinesia.

Airway clearance therapy (ACT) is one of the cornerstone treatment modalities to improve mucociliary clearance for patients with bronchiectasis. The progression of lung disease in patients with bronchiectasis can be evaluated by spirometry and multiple breath washout (MBW) and it is advised to monitor these on a regular basis. However, the short term effect of ACT on spirometry and MBW parameters is insufficiently clear and this variability may impact standardization. For cystic fibrosis (CF), available literature refutes a short time effect on spirometry and MBW parameters in children, however, for primary ciliary dyskinesia (PCD) no data are available. We performed a single-center, prospective cross-over study to evaluate the short term effect of a single ACT session using positive expiratory pressure mask on forced expiratory volume in 1 s (FEV1) and lung clearance index (LCI), derived from MBW, compared to no ACT (control) in pediatric patients with CF and PCD. A total of 31 children were included: 14 with PCD and 17 with CF. For the whole group, there was no difference in median change of FEV1 pp between the treatment and the control group (p 0.969), nor in median change of LCI (p 0.294). For the CF subgroup, the mean change in FEV1 pp with ACT was −1.4% (range −9 to + 5) versus −0.2% (range −6 to + 5) for no ACT (p 0.271), the mean change in LCI with ACT was + 0.10 (range −0.7 to + 1.2) versus + 0.17 (range −0.5 to + 2.8) for no ACT (p 0.814). In the PCD subgroup, the mean change in FEV1 pp with ACT was + 1.0 (range −7 to + 8) versus −0.3 (range −6 to + 5) for no ACT (p 0.293) and the mean change in LCI with ACT was −0.46 (range −3.7 to + 0.9) versus −0.11 (range −1.4 to + 1.3) for no ACT (p 0.178). There was no difference between PCD and CF for change in FEV1 pp after ACT (p = 0.208), nor for LCI (p = 0.095). In this small group of pediatric patients, no significant short-term effect of chest physiotherapy on FEV1 pp nor LCI in PCD and CF values nor variability was documented.

Comparison of Airway Clearance Therapies for Cystic Fibrosis: A Cochrane Review Summary With Commentary.

Several methods exist for airway clearance therapy in people with cystic fibrosis including both devices and techniques. Some of the common modalities include conventional chest physical therapy (CPT), active cycle of breathing, autogenic drainage, positive expiratory pressure (PEP) therapy, high-

Effects of Pulmonary Rehabilitation on Systemic Inflammation and Exercise Capacity in Bronchiectasis: A Randomized Controlled Trial.

Bronchiectasis is a chronic condition that is becoming a global health concern. To examine the effects of pulmonary rehabilitation (PR) on systemic inflammation, exercise capacity, and quality of life in participants with bronchiectasis. Participants were randomized to receive PR (outpatient, three weekly sessions for 3 months) or control intervention (usual care + airway clearance therapy + breathing exercises). Data on laboratory (fibrinogen level) and patient-centered outcomes such as physical fitness [6-min walk test (6MWT)] and quality of life were collected. A total of 41 participants were evaluated (20 in the intervention group and 21 in the control group). The magnitude of change between baseline and the end of study was greater in the PR group than in the control group-the 6MWT distance increased by a mean of 54m (54 vs 12m; p < 0.01), fibrinogen showed a significant reduction (fibrinogen -92.8 versus -47.1mg/dl; p < 0.01), and quality of life improved according to Saint George's Respiratory Questionnaire (SGRQ) (-7.5 vs 3.2; p < 0.01), which exceeded the minimal clinically important difference of 4 points. PR effectively improved physical fitness, quality of life, and the degree of systemic inflammation, as reflected by changes in 6 MWT, fibrinogen levels and SGRQ scores. This study supports the inclusion of people with bronchiectasis in supervised PR programs.

Role of inhaled antibiotics in children and adolescents with cystic fibrosis: Experience from the tertiary care center

Introduction:Cystic fibrosis (CF) remains under-diagnosed in Pakistan. CF population has increased tendency for Pseudomonas aeruginosa (Pa) infection and it is one of the leading causes of mortality. Utilizing inhaled antibiotics (IAs) for the treatment of Pa infection has been well established in the literature. There is limited data available on CF in Pakistan, especially regarding the efficacy of IAs. The aim of this study is to investigate the role of IAs on Pa infection in children and adolescents with CF.Methodology:CF patients enrolled between January 2012 and December 2019 were selected as part of this retrospective cohort study. CF patients from 2 to 18 years of age who cultured Pa on any respiratory sample and who had never been Pa-free in at least two sputum cultures in the previous 12 months were included. Patients were divided into an IA group and a noninhaled antibiotic (NIA) group based on the treatment they received. Follow-up was done between 3 and 6 months posttherapy on Pseudomonas growth in the sputum. The number of pulmonary exacerbations were documented for 6 months follow-up.Results:Eighty-one children with CF were enrolled during the study period, of which 39 were in the IA group and 42 were in the NIA group. There was no significant difference in their demographics and initial clinical characteristics. The mean pulmonary exacerbations after 6 months were lower in the IA group as compared to the NIA group (1.102 ± 0.50 vs. 2.45 ± 0.89: P = 0.001). Follow-up between 3 and 6 months showed greater Pseudomonas colonization in the IA group versus the NIA group (53.84% vs. 92.85%: P = 0.001).Conclusion:IAs in combination with airway clearance therapy and oral or IV antibiotics are an effective regimen for children with CF.

Cystic Fibrosis: A Review Article

Cystic Fibrosis is considered one of the most common autosomal recessive diseases that is associated with a decrease in the length of age in a Caucasian population. Also, it is considered as one of the most common life-shortening diseases in the white population in the United States. Cystic fibrosis affects around 30,000 people in the United States and more than 80,000 people worldwide. The incidence rate of this disease is 1 out of 3,500 births per year in the white population in the United States, while the incidence rate of the person becoming a carrier is 1:25 in the Caucasian population, the incidence of the disease is 1:2,500. The main cause for this disease is the mutation in Fibrosis Transmembrane Conductance Regulator (CFTR) gene. This disease is considered a life-threatening genetic disease that causes a buildup of thick, viscous mucus secretions in organ systems. Cystic Fibrosis is considered a multiple system disease, but in most cases, the disease gets worse and mortality increases because of respiratory manifestations such as bronchiectasis. Also, pancreatic damage in children is followed by severe wasting, malabsorption, and mortality is one of the recorded observations in children. This article aims to provide a brief introduction and the clinical picture of the disease, Etiology, Pathophysiology, Epidemiology, Nutrition, Prevention, and good practice management advice. Keywords: Cystic Fibrosis, Bronchiectasis, Review Article, Airway Clearance Therapy, Fibrosis Transmembrane Conductance Regulator gene.

Influence of Comorbidities and Airway Clearance on Mortality and Outcomes of Patients With Severe Bronchiectasis Exacerbations in Taiwan.

Bronchiectasis is characterized by systemic inflammation and multiple comorbidities. This study aimed to investigate the clinical outcomes based on the bronchiectasis etiology comorbidity index (BACI) score in patients hospitalized for severe bronchiectasis exacerbations. We included non-cystic fibrosis patients hospitalized for severe bronchiectasis exacerbations between January 2008 and December 2016 from the Chang Gung Research Database (CGRD) cohort. The main outcome was the 1-year mortality rate after severe exacerbations. We used the Cox regression model to assess the risk factors of 1-year mortality. Of 1,235 patients who were hospitalized for severe bronchiectasis exacerbations, 641 were in the BACI < 6 group and 594 in the BACI ≥ 6 group. The BACI ≥ 6 group had more previous exacerbations and a lower FEV1. Pseudomonas aeruginosa (19.1%) was the most common bacterium, followed by Klebsiella pneumoniae (7.5%). Overall, 11.8% of patients had respiratory failure and the hospital mortality was 3.0%. After discharge, compared to the BACI < 6 group, the BACI ≥ 6 group had a significantly higher cumulative incidence of respiratory failure and mortality in a 1-year follow-up. The risk factors for 1-year mortality in a multivariate analysis include age [hazard ratio (HR) 4.38, p = 0.01], being male (HR 4.38, p = 0.01), and systemic corticosteroid usage (HR 6.35, p = 0.001), while airway clearance therapy (ACT) (HR 0.50, p = 0.010) was associated with a lower mortality risk. An increased risk of respiratory failure and mortality in a 1-year follow-up after severe exacerbations was observed in bronchiectasis patients with multimorbidities, particularly older age patients, male patients, and patients with a history of systemic corticosteroid use. ACT could effectively improve the risk for 1-year mortality.

REAL-WORLD OUTCOMES IN VETERANS USING HIGH FREQUENCY CHEST WALL OSCILLATION FOR AIRWAY CLEARANCE

TOPIC: Obstructive Lung Diseases TYPE: Original Investigations PURPOSE: Veterans have a high COPD prevalence compared to the civilian population. In COPD, excess sputum production and accumulation in the lungs is a commonly reported symptom. Several neuromuscular disorders are also known to present the clinician with airway clearance management challenges. High Frequency Chest Wall Oscillation (HFCWO) therapy is a noninvasive airway clearance therapy that directly addresses the issues associated with excess sputum production. There is limited information regarding outcomes of HFCWO therapy within the veteran population. To address this evidence gap, we established an ongoing VA outcomes program to better understand patient-reported outcomes in the veteran population receiving HFCWO therapy. METHODS: Self-reported hospitalization patterns and metrics of airway clearance from veterans were assessed before and after initiation of HFCWO therapy in a data set drawn from the HFCWO Outcomes Registry (HFCWO-OR). Variables collected included demographics, hospitalizations, and respiratory symptoms. The study was comprised of patients with a blended mix of diagnoses (e.g., COPD, bronchiectasis, and various neuromuscular disorders) who received the Philips InCourage vest therapy system. RESULTS: 323 veterans met inclusion criteria in this retrospective analysis. In the 12-month interval prior to initiating HFCWO therapy, the number of patients who reported zero hospitalizations was 46.4% (149/321), compared with 75.0% (21/28) of patients who reported zero hospitalizations in the subsequent 12 months (p=0.005). Conversely, 20.9% (67/321) of patients reported three or more hospitalizations in the prior 12 months, compared with only 3.6% (1/28) in the subsequent 12 months (p=0.001). There was an overall 66.3% reduction in the annualized hospitalization rate after 12 months (0.357 hospitalizations/patient/year at 12 months, compared to 1.059 hospitalizations/patient/year prior to initiating vest therapy) (p=0.001). Those patients who subjectively rated their "overall respiratory health" as good, very good, or excellent increased from 10.5% (34/323) upon initiation of therapy to 60.7% (17/28) within 12 months (p=0.0002). Those who rated the "ability to clear your lungs" as good, very good, or excellent increased from 8.4% (27/322) to 67.9% (19/28) within 12 months. (p<.0001). CONCLUSIONS: Our analysis indicates that outcomes in a veteran population, as measured by the number of self-reported hospitalizations, respiratory health, and the ability to clear secretions, improved substantially after the initiation of HFCWO therapy. These improvements were sustained for at least one year and provide valuable insights into the value of HFCWO in the population served by the VA health system. CLINICAL IMPLICATIONS: In a veteran population, positive outcomes are associated with the use of high frequency chest wall oscillation. DISCLOSURES: Consultant relationship with Respirtech Technologies Please note: $5001 - $20000 by Tara Barto, source=Web Response, value=Consulting fee No relevant relationships by Sarah Daignault, source=Web Response Employee relationship with RespirTech Please note: 2015-Present Added 04/16/2021 by Gary Hansen, source=Web Response, value=Salary Employee relationship with RespirTech, A Philips Company Please note: 2019 - present Added 04/16/2021 by PRITESH PANDYA, source=Web Response, value=Salary No relevant relationships by Frederic Seifer, source=Web Response

COVID-19 pandemic restrictions continuously impact on physical activity in adults with cystic fibrosis.

We have recently reported reduced physical activity (PA) in people with cystic fibrosis (pwCF) with and without lung transplantation (LTX) during a 6-week stringent lockdown in Switzerland. This follow-up study explores the impact of coronavirus-2019 disease (COVID-19) related pandemic restrictions on individuals' therapy regimens and health-related aspects in pwCF. We conducted a cross-sectional web-based national survey in Spring 2021. The survey included questions on daily PA, airway clearance and inhalation therapy, questions on COVID-19-compatible symptoms, diagnostic tests and vaccination status, and enquired health-related aspects covering the pandemic period between March 2020 to April 2021. 193 individuals with CF (53% female; 25% LTX recipients) participated. Among pwCF, 10 reported COVID-19 (n = 2 LTX recipients), two subjects were hospitalized, no invasive ventilation required, no deaths. The clinical course was generally mild. Overall, 46% reported less PA during the pandemic, mostly due to closed fitness facilities (85%), lack of motivation (34%), and changes in daily structures (21%). In contrast, 32/193 (17%) pwCF were able to increase their PA levels: 12 (38%) and 11 (34%) reported undertaking home-based training and outdoor activities more frequently; 6 (19%) reported an increase in routine PA, and another 3 (9%) started new activities. Among pwCF without LTX, 5% and 4% reported to undertake less airway clearance and inhalation therapy, respectively. Our study reveals unfavorable consequences of COVID-19 pandemic restrictions on PA of pwCF with unknown long-term consequences for their overall physical fitness and lung health. Strategies to overcome this undesirable situation are needed; increased uptake of telehealth PA programs and virtual exercise classes to promote PA participation might be one promising approach along with vaccination of pwCF and their close contacts.

Bronchoscopic airway clearance therapy for acute exacerbations of bronchiectasis.

BackgroundPersistent cough and large amounts of purulent sputum affects many bronchiectasis patients. No studies have evaluated the efficacy and safety of bronchoscopic airway clearance therapy and bronchoalveolar lavage (B-ACT) for non-cystic fibrosis bronchiectasis patients with acute exacerbation.MethodsA randomised controlled trial was conducted to explore the efficacy and safety of B-ACT among 189 bronchiectasis inpatients from February 1, 2018 to February 28, 2019. The primary outcome was the time to first acute exacerbation. Secondary outcomes included changes of health-related scores, length of hospital stay, hospitalization expenses and incidences of adverse events.FindingsB-ACT therapy significantly prolonged the median days to first acute exacerbation when compared with control group (198 vs 168 days, HR 0·555 (0·322-0·958), p=0·012; effect size(r)= 0·94). Further analysis showed that B-ACT therapy was more beneficial for these patients with severe disease and greater symptoms. COPD Assessment Test (CAT) scores improved significantly on the third day (5·45 vs 4·85, 0·60 (0·09-1·11), p=0·023), and Leicester Cough Questionnaire (LCQ) scores improved obviously on the third and seventh days (1·53 vs 1·23, 0·30 (0·05-0·55), p=0·044; 1·66 vs 1·32, 0·34 (0·08-0·60), p=0·022; respectively) after B-ACT therapy. Adverse events associated with B-ACT were mostly transient and mild. Differences of the lengths of hospital stay and hospitalization expenses in both group was not significant.InterpretationB-ACT therapy significantly prolonged the time to first acute exacerbation after discharge, highlighting the importance of B-ACT therapy focused on symptom improvements in preventing exacerbation.FundingNational Natural Science Foundation of China.Trial registryClinicalTrials.gov; No.:NCT03643302; URL: www.clinicaltrials.gov.

Airway Clearance Therapy in Cystic Fibrosis Patients Insights from a Clinician Providing Cystic Fibrosis Care.

Cystic fibrosis (CF) is a genetic disease characterized by an accumulation of thick layers of mucus, leading to airway obstruction and air trapping. Poorly cleared mucus leads to frequent respiratory infections that produce chronic cough and dyspnea. The presence of infected mucus induces progressive inflammation. The resulting damage anatomically distorts airways leading to development of bronchiectasis. Bronchiectasis is irreversible and results in progressive respiratory function decline over time. Impaired mucociliary clearance together with tenacious mucus makes expectoration with cough alone problematic. Clinicians providing effective care for CF patients must have knowledge of the wide variety of treatment options currently available. Knowledge of these techniques will enable clinicians to prescribe airway clearance therapy (ACT) where necessary and provide treating physicians the ability to adapt to changing patient treatments as necessary. Training programs frequently do not provide in-depth knowledge of ACT technologies in CF patients resulting in knowledge gaps once physicians are in practice. This paper reviews strategies for ACT. It is specifically targeted for clinicians who frequently provide care for patients with CF.

A short-term evaluation of a prototype disposable Oscillating Positive Expiratory Pressure (OPEP) device in a cohort of children with cystic fibrosis

BackgroundOscillating Positive Expiratory Pressure (OPEP) devices are important adjuncts to airway clearance therapy in patients with cystic fibrosis (CF). Current devices are typically reusable and require daily, or often more frequent, cleaning to prevent risk of infection by acting as reservoirs of potentially pathogenic organisms. In response, a daily disposable OPEP device, the UL-OPEP, was developed to mitigate the risk of contamination and eliminate the burdensome need for cleaning devices.MethodsA convenience sample of 36 participants, all current OPEP device users, was recruited from a paediatric CF service. For one month, participants replaced their current OPEP device with a novel daily disposable device. Assessment included pre- and post-intervention lung function by spirometry, as well as Lung Clearance Index. Quality of life was assessed using the Cystic Fibrosis Questionnaire – Revised, while user experience was evaluated with a post-study survey.Results31 participants completed the study: 18 males; median age 10 years, range 4–16 years. Lung function (mean difference ± SD, %FEV1 = 1.69 ± 11.93; %FVC = 0.58 ± 10.04; FEV1: FVC = 0.01 ± 0.09), LCI (mean difference ± SD, 0.08 ± 1.13), six-minute walk test, and CFQ-R were unchanged post-intervention. Participant-reported experiences of the device were predominantly positive.ConclusionsThe disposable OPEP device maintained patients’ lung function during short term use (≤ 1 month), and was the subject of positive feedback regarding functionality while reducing the risk of airway contamination associated with ineffective cleaning.RegistrationThe study was approved as a Clinical Investigation by the Irish Health Products Regulatory Authority (CRN-2209025-CI0085).

Exercise training for bronchiectasis.

Exercise training for bronchiectasis.

EPS1.03 Recommended shielding against COVID-19 impacts physical activity levels and adherence to airway clearance therapy in patients with cystic fibrosis

Background: Physical activity and physiotherapy are recommended as components of the cystic fibrosis (CF) treatment regimen. Objectives: To assess the impact of the lockdown during the second wave of the COVID-19 pandemic on daily airway clearance and physical activity levels among patients with CF. Methods: A telephone-based survey on adherence to physiotherapy and physical exercise was conducted among CF patients attending our CF Unit during the “second wave of the pandemic” (November 2020–January 2021). Results: A total of 120 patients were included, mean (StDev) age 13.8 (8.1) years, mean baseline FEV1 pp 101.0 (24.7) %. Before the lockdown, 79.5% of the patients reported performing physiotherapy daily, 8.2% reported performing physiotherapy 2–4 times per week, and 12.3% of the patients reported performing no physiotherapy at all. Most of the CF patients (69%) did not change the frequency of their daily physiotherapy practice during the COVID-19 pandemic. Moreover, 49.2% of the CF patients performed assisted airway clearance by having a physiotherapist visiting their home once a week through a home care program. Only 6.3% of them increased, 33.7% stopped, and 60% did not change the frequency of assisted physiotherapy during the study period. Concerning physical exercise, before the COVID-19 pandemic, 81% of the CF patients reported performing regular exercise. During the quarantine period, 58.4% of the patients needed to change the type of exercise, while 29% reported increasing the frequency, and 48% performed less exercise than before. Conclusions: Strict lockdown measures affected patients’ physical activity levels and their daily airway clearance practice. It is of vital importance to monitor CF patients and give incentives to maintain/increase the adherence to exercise and physiotherapy during such difficult circumstances.

Global Attitudes of Health Care Providers About Aerosolized Airway Clearance Therapy in Bronchiectasis Patients During the Coronavirus Disease 2019 Pandemic.

McShane PJ, Philley JV, Prieto DA, Aksamit TR. Global attitudes of health care providers about aerosolized airway clearance therapy in bronchiectasis patients during the coronavirus disease 2019 pandemic.

Pulmonary rehabilitation following the 2019 novel Coronavirus infection

Abstract The treatment of an infectious disease is only one step to a cure and, in many cases, infectious diseases can lead to short-and long-term impairments, including physical, cognitive and psycho-emotional complications. In this paper, we perform a literature review to identify the appropriate rehabilitation interventions for responding to COVID-19 consequences, taking into consideration the current standards for pulmonary rehabilitation and the COVID-19 literature which has been developed during the pandemic’s evolution. Pulmonary, neurological, cardiac, musculoskeletal, nutritional, cognitive and psychological disabilities, as well as dysphasia, have been observed among patients who recovered after needing time in the intensive care unit (ICU), related either directly to COVID-19 or critical care treatments. Some have also been reported in patients who were asymptomatic or recovered from a mild or moderate form of the disease. Patients who still have dyspnea, exercise intolerance and fatigue, are unable to conduct activities of daily living and/or have difficulty in managing or coping with their disease, despite optimised pharmacological therapy, are most likely to benefit from pulmonary rehabilitation. Contraindications should be considered during patient selection. Rehabilitation prescription should be individually tailored, based on patient assessment and outcome measurements. Pulmonary rehabilitation interventions may involve airway clearance therapy, breathing exercises, mobilisation and strength training, flexibility training, balance training, neuromuscular electrical stimulation (NMES), activities of daily living, aerobic training, dysphagia management, nutrition therapy, cognitive training and psychological support. Medical management of comorbidities and patient-family education are key factors for achieving optimal gains from pulmonary rehabilitation.

Effects of music therapy as an adjunct to chest physiotherapy in children with cystic fibrosis: A randomized controlled trial

Airway clearance therapy (ACT) is considered an important approach to improve airway clearance in children with cystic fibrosis (CF). Daily ACT administration requires substantial commitments of time and energy that complicate ACT and reduce its benefits. It is crucial to establish ACT as a positive routine. Music therapy (MT) is an aspect of integrative strategies to ameliorate the psycho-emotional consequences of chronic diseases, and a MT intervention could help children with CF between the ages of 2 and 17 develop a positive response. The aim of this randomized controlled trial was to evaluate the effects of specifically composed and recorded instrumental music as an adjunct to ACT. We compared the use of specifically composed music (Treated Group, TG), music that the patient liked (Placebo Group, PG), and no music (Control Group, CG) during the usual ACT routine in children with CF aged from 2 to 17. The primary outcomes, i.e., enjoyment and perception of time, were evaluated via validated questionnaires. The secondary outcome, i.e., efficiency, was evaluated in terms of avoided healthcare resources. Enjoyment increased after the use of the specifically composed music (children +0.9 units/parents +1.7 units; p<0.05) compared to enjoyment with no music (0 units) and familiar music (+0.5 units). Perception of time was 11.1 min (±3.9) less than the actual time in the TG (p<0.05), 3.9 min (±4.2) more than the actual time in the PG and unchanged in the CG. The potential cost saving related to respiratory exacerbations was €6,704.87, while the cost increased to €33,524.35 in the CG and to €13,409.74 in the PG. In conclusion, the specifically composed, played and compiled instrumental recorded music is an effective adjunct to ACT to establish a positive response and is an efficient option in terms of avoided costs.Trial registered as ISRCTN11161411. ISRCTN registry (www.isrctn.com).

CLINICAL OUTCOMES AND HEALTHCARE RESOURCE UTILIZATION IN ADULT HIGH-RISK PATIENTS WITH NONCYSTIC FIBROSIS BRONCHIECTASIS USING HIGH FREQUENCY CHEST WALL OSCILLATION AND POSITIVE EXPIRATORY PRESSURE THERAPY

SESSION TITLE: Obstructive Lung Disease Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: October 18-21, 2020 PURPOSE: In current clinical practice, airway clearance therapy is important in the overall management of patients with bronchiectasis. We aimed to compare healthcare resource utilization (HCRU) and costs among adults with high risk bronchiectasis after initiation of high frequency chest wall oscillation (HFCWO) and positive expiratory pressure (PEP) therapy. METHODS: A pre-post analysis of two mutually exclusive cohorts was conducted using the PharMetrics Health Plan Claims Database. Adult patients with Non-CF bronchiectasis, a high-risk Bronchiectasis Aetiology and Comorbidity Index (BACI) score of >6, and a claim for HFCWO or PEP between 2009 - 2018 were included. Clinical outcomes, HCRU and costs were measured in the 12-months pre- and post-index periods in each cohort. Comparisons to baseline data were conducted using McNemar’s test for categorical and Wilcoxon signed-rank test for continuous variables. RESULTS: In the HFCWO cohort (N=147), the mean age was 56.4 years (SD=14); 64% were females. COPD (88%) and asthma (72%) were common comorbidities. At one-year follow-up from initiation of HFCWO therapy, there was a statistically significant reduction in mean all-cause (22%, P=0.04) and disease-specific hospitalizations, (73%, P=0.01) compared to baseline. All-cause and disease-specific bronchoscopies reduced by 69% (P<0.0001) and 75% (P<0.001), respectively. Chest X-ray use reduced by 25% (P<0.001) and 38% (P=0.02), respectively. Disease-specific laboratory use decreased by 31% (P<0.01). Oral and IV antibiotics use reduced by 8% (P=0.03) and 63% (P=0.01), respectively. Pulmonologist visits reduced by 11% (P<0.01). Disease-specific ED visits trended down. All-cause inpatient costs decreased significantly from $23,774 to $12,028 (P<.01). In the PEP cohort (N=138), mean age was 63.7 years (SD=14); 59% were females. COPD (74%) and asthma (58%) were common comorbidities. At one-year follow-up from initiation of PEP therapy, mean all-cause and disease-specific hospitalizations trended up. Physician office visits increased by 17% (P=0.03). Use of hypertonic saline nebulization increased (P=0.01). Oral antibiotic use reduced by 11% (P=0.02) while IV antibiotic use did not change. All-cause and disease-specific bronchoscopies trended down. Disease-specific ED visits, chest X-ray, and laboratory use all trended up. Mean disease specific outpatient costs increased (P=0.04). Median disease-specific total costs increased significantly (P=0.04) CONCLUSIONS: In high risk bronchiectasis patients, HFCWO significantly improves clinical outcomes by reducing hospitalizations, antibiotics use and other health care resource utilization measures. High risk bronchiectasis patients started on PEP therapy had less favorable outcomes. CLINICAL IMPLICATIONS: In bronchiectasis patients with a high risk BACI score, HFCWO therapy should be considered for airway clearance as it has been shown to improve clinical and economic outcomes. DISCLOSURES: Advisory Board relationship with Insmed Please note: $1001 - $5000 by Ashwin Basavaraj, source=Web Response, value=Honoraria Consultant relationship with Hill-Rom Please note: $1001 - $5000 by Ashwin Basavaraj, source=Web Response, value=Consulting fee Employee relationship with Hill-Rom Company Inc. Please note: >$100000 Added 06/01/2020 by Brian Becker, source=Web Response, value=Salary Stock Ownership relationship with Hill-Rom Company Inc. Please note: $20001 - $100000 Added 06/01/2020 by Brian Becker, source=Web Response, value=Stock Ownership No relevant relationships by Mitch Dekoven, source=Web Response Employee relationship with Hillrom Please note: >$100000 Added 06/01/2020 by Angela Murray, source=Web Response, value=Salary No relevant relationships by Drishti Shah, source=Web Response Employee relationship with Hillrom Please note: >$100000 Added 06/01/2020 by Carlos Urrea, source=Web Response, value=Salary Employee relationship with Hill-Rom Inc Please note: >$100000 Added 05/31/2020 by Missy Wanjala, source=Web Response, value=Salary

SEVERE TRACHEOBRONCHOMALACIA IN AN END-STAGE RENAL DISEASE PATIENT REFERRED FOR KIDNEY TRANSPLANT EVALUATION

SESSION TITLE: Medical Student/Resident Obstructive Lung Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Tracheobronchomalacia (TBM) is characterized by loss of the integrity of the central airway wall cartilaginous structures resulting in hyper-dynamic airway collapse. In adults, TBM is either idiopathic or associated with other conditions. We present a case of severe TBM in a patient with end stage renal disease undergoing evaluation for kidney transplant. CASE PRESENTATION: A 45-year-old male with history of type one diabetes mellitus, end stage renal disease on hemodialysis and chronic obstructive pulmonary disease (COPD) diagnosed without Pulmonary function testing (PFT). He was referred for pulmonary evaluation prior to kidney transplant. He had history of recurrent pneumonia, coughing with choking sensations and high-pitched wheezing that resolved after expectoration of scant thick phlegm. He denied tobacco use, chemical exposures, or asthma. PFT revealed severe obstruction with FEV1/FVC ratio of 43.2 and FEV1 1.71 Liter. The loops showed small volumes and flattening of the expiratory loops (Figure 1). Computerized tomography (CT) scan of the chest showed crescentic deformity of the trachea and bilateral mainstem bronchi (Figure 2) consistent with TBM. He was started on airway clearance therapy with flutter valves and albuterol nebulization. Non-invasive-positive pressure ventilation (NIPPV) was denied due to unconventional indication. Shortly after outpatient evaluation, he was re-admitted for severe pneumonia requiring invasive mechanical ventilation. He failed extubation. Tracheal stent placement was unsuccessful due to intraprocedural episodes of desaturation and stent dislodgement. Percutaneous tracheostomy was performed and he was successfully weaned off mechanical ventilation. He uses cuffless tracheostomy tube and has not had pneumonia since. Unfortunately, he is not a transplant candidate due to his pulmonary disease. DISCUSSION: TBM is commonly mistaken as COPD or asthma due to the similarities in symptoms and obstructive pattern on spirometry. The gold standard for confirmation is flexible bronchoscopy and visualization of more than 50% dynamic airway collapse. 51-75% is considered mild obstruction, 76 - 90% moderate and greater than 90% is severe. Dynamic CT can be used quantify the severity of the TBM with a strong correlation. The initial treatment involves the use of bronchodilators and airway hygiene. If these fails, then NIPPV is used. The next intervention would be stenting or tracheostomy which splints the airways. Tracheobronchoplasty is a surgical option when stenting have shown significant symptoms improvement. CONCLUSIONS: This case highlights the importance of having a wide differential diagnosis when evaluating patients. A close look at the PFT flow-volume loops led us towards the diagnosis. Reference #1: Beckerman, Z. at al. Tracheobronchomalacia: Does One Size Fit All? Semin Thorac Cardiovasc Surg, 2019. 31(3): p. 486-487. Reference #2: Biswas, A., et al., Tracheobronchomalacia. Dis Mon, 2017. 63(10): p. 287-302. Reference #3: Uyar, M., et al., Tracheobronchomalacia as a Rare Cause of Chronic Dyspnea in Adults. Med Princ Pract, 2017. 26(2): p. 179-181. DISCLOSURES: No relevant relationships by RAMYA GORTHI, source=Web Response No relevant relationships by Stephanie Link, source=Web Response No relevant relationships by John Mwangi, source=Web Response

OUTCOMES WITH HIGH-FREQUENCY CHEST WALL OSCILLATION AMONG PATIENTS WITH COPD USING A LARGE CLAIMS DATABASE

SESSION TITLE: Obstructive Lung Disease Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: October 18-21, 2020 PURPOSE: High-Frequency Chest Wall Oscillation (HFCWO) is increasingly used for airway clearance therapy in patients with bronchiectasis and chronic obstructive pulmonary disease (COPD). Limited evidence currently exists on the relationship between HFCWO therapy and clinical/economic outcomes in patients with COPD who do not have bronchiectasis. Several studies have evaluated the impact of HFCWO but have yielded variable evidence. Without larger and more robust studies, there exists a clinical concern that some patients with COPD and chronic bronchitis are receiving suboptimal therapy. METHODS: A retrospective pre/post-cohort design and data from the Optum healthcare claims repository were employed. The study population included all patients having at least one medical claim with HCPCS code E0483 for the use of air-powered HFCWO devices on or between January 1, 2008 and April 30, 2018. Of these, the cohort was limited to those with >= 12 months pre- and >=12 months post-index continuous medical insurance eligibility from the first usage of HFCWO therapy; no major comorbidities indicating end of life; patients with a COPD diagnosis and no record of bronchiectasis; and patients >= age 18. Statistical comparisons were made using a paired-samples t-test of the 12-month pre and 12-month post periods, examining both respiratory-related and all-cause hospitalizations.A retrospective pre/post-cohort design and data from the Optum healthcare claims repository were employed. The study population included all patients having at least one medical claim with HCPCS code E0483 for the use of air-powered HFCWO devices on or between January 1, 2008 and April 30, 2018. Of these, the cohort was limited to those with >= 12 months pre- and >=12 months post-index continuous medical insurance eligibility from the first usage of HFCWO therapy; no major comorbidities indicating end of life; patients with a COPD diagnosis and no record of bronchiectasis; and patients >= age 18. Statistical comparisons were made using a paired-samples t-test of the 12-month pre and 12-month post periods, examining both respiratory-related and all-cause hospitalizations. RESULTS: The study population included 1172 patients with COPD-only who had initiated HFCWO therapy during the study period. Of these, 62% were female; age distribution was 4% age <40, 14% age 40-59, 61% age 60-79, 21% age 80 and over; and the mean Charlson Comorbidity Index was 2.78 + 1.9. Comparing pre and post periods, mean respiratory-related and all-cause hospitalization rates were lowered by 17.1% (0.495 vs. 0.410, p=0.025) and 13.6% (0.873 vs. 0.754, p=0.031) respectively. CONCLUSIONS: For patients with COPD in the absence of bronchiectasis, hospital utilization improved during the 12-month period following initiation of HFCWO therapy. CLINICAL IMPLICATIONS: HFCWO is associated with reduced hospitalizations in patients with COPD-only. DISCLOSURES: Employee relationship with RespirTech Please note: >$100000 Added 04/06/2020 by Gary Hansen, source=Web Response, value=Salary Scientific Medical Advisor relationship with Respirtech a Philips Company Please note: $5001 - $20000 Added 04/10/2020 by Charlene McEvoy, source=Web Response, value=Grant/Research Support Employee relationship with RespirTech, A Philips Company Please note: >$100000 Added 04/08/2020 by PRITESH PANDYA, source=Web Response, value=Salary Consultant relationship with RespirTech, A Philips Company Please note: $1001 - $5000 Added 04/08/2020 by Derek Weycker, source=Web Response, value=Grant/Research Support

Airway Clearance Techniques for Mechanically Ventilated Patients: Insights for Optimization.

Secretion management in mechanically ventilated patients is a paramount task for clinicians. A better understanding of the mechanisms of flow bias and airway dynamic compression during airway clearance therapy may enable a more effective approach for this population. Ventilator hyperinflation, expiratory rib cage compression, a PEEP-ZEEP maneuver, and mechanical insufflation-exsufflation are examples of techniques that can be optimized according to such mechanisms. In addition, novel technologies, such as electric impedance tomography, may help improve airway clearance therapy by monitoring the consequences of regional secretion displacement on lung aeration and regional lung mechanics.