Respiratory disease

causes of chronic illness, and globally is the fifth most common cause of death. In the past three decades, important advances in basic science and clinical research have greatly expanded our understanding of the pathophysiology of respiratory diseases, and the evidence base is expanding in support of both existing and new management approaches. Many factors, not least of which is increased access to medical literature via the internet, have empowered patients with advanced knowledge of their respiratory condition, and the treatment options that should potentially be available to them. Patients are no longer seen, nor are they happy to be seen, as mere recipients of care. Patients strive to work in partnership with the multidisciplinary team to avail of the best and most appropriate care for them, in the setting they need it, when they want it, and in an appropriate and timely fashion. In this issue, we have been fortunate to bring together leading respiratory physiotherapists to review how this era of evidence-based practice has been embraced by physiotherapists. These experts describe approaches to management of patients with chronic respiratory disease, based upon recognition of the need for an integrated approach, using the best of modern technology in acute and community care. Less than 100 years ago, the role of the respiratory physiotherapist was primarily focused on airway clearance; indeed until the 1970s in most countries, postural drainage (PD) and percussion was essentially the only form of airway clearance. However, as evidence for airway clearance became available, a demand for better, more reliable techniques emerged. In rapid succession, an array of techniques, technologies and devices have been developed, and these have had a huge impact on the role of the respiratory physiotherapist. In the first article of this series Pryor provides a comprehensive overview of how airway clearance has evolved, and of the developing evidence base for current approaches. She debates the limitations of Cochrane systematic reviews in providing evidence for airway clearance, and highlights why typical conclusions such as ‘there is no available evidence for airway clearance’ are misleading: evidence from clinical practice and clinical expertise clearly supports airway clearance. In this era of evidence-based medicine, we are challenged by the debate of whether to continue traditional treatments because we already know from long experience that they work, or whether we need to provide the evidence. Whether to instigate routine airway clearance in babies newly diagnosed with cystic fibrosis, or wait until they become symptomatic, causes huge disagreement amongst respiratory physiotherapists internationally. Controversial issues such as this in physiotherapy practice need to be addressed and challenged in the public forum, in order to determine better and direct the need for further research; for this special edition of the journal, Prasad and Main present a challenging pro–con debate on this topical issue. Also included within the current issue are three papers that demonstrate how new technologies and devices have had a huge and direct impact on physiotherapy practice. Nebulised drugs are very effective in respiratory diseases but are very time consuming; patients and clinicians are demanding systems that ensure best delivery with minimal inconvenience. The first of these papers by Lannefors highlights the continuing advances in technologies and techniques associated with aerosol delivery, including new devices and the formulation of new drugs that are coming onto the market. Patients with chronic respiratory disease want the opportunity to go outdoors and exercise, to be more mobile, and to travel in the same