Airways clearance techniques for people with chronic obstructive pulmonary disease: A scoping review protocol
Creators: name: Oliveira, Ana
name: Schrøder, Christine Krogsgaard
name: Arietta Spinou
name: Mechlenburg, Inger
Publisher: name: Open Science Framework
Year: 2023
Subjects: subject: Analytical, Diagnostic and Therapeutic Techniques and Equipment
subject: Rehabilitation and Therapy
subject: Medicine and Health Sciences

description: Abstract Objective: To identify and map the airway clearance techniques (ACTs) used for people with chronic obstructive pulmonary disease (COPD) and the factors that affect clinical decision making worldwide. Introduction: People with COPD commonly experience mucus hypersecretion and sputum retention, which contributes to an increase in their respiratory symptoms and the risk of exacerbations. Managing sputum is thus a main concern in this population. However, the use of ACTs in people with COPD in different healthcare settings and stages of the disease is still uncertain. The factors that influence clinical choices on selecting specific ACTs are also unclear. Inclusion criteria: This scoping review will include original research and grey literature that explore the use of ACTs for people with chronic respiratory diseases, in any healthcare context. Methods: The review will be conducted following the Joanna Briggs Institute (JBI) methodology for scoping reviews. Searches will be conducted in databases of peer-reviewed publications and grey literature. Search results will be exported to Covidence for title, abstract, and full-text screening. Studies published in English, Portuguese, Danish, Norwegian, Swedish, Spanish, French, or Greek will be considered. Data will be extracted using a pilot-tested template, and findings will be presented using a narrative summary and supplemented by figures or tables. Keywords: sputum, chronic obstructive pulmonary disease, hypersecretion, airway clearance, chest physiotherapy Introduction Chronic obstructive pulmonary disease (COPD) is a common respiratory disease characterized by restriction of airflow and breathing problems (1). The estimated global prevalence of COPD is greater than 10%, affecting more than 384 million people worldwide (2). COPD is associated with high morbidity, mortality, and healthcare costs, which will only increase as the world population grows older (1). COPD is considered the third leading cause of death worldwide, causing 3.23 million deaths in 20193. The management of bronchial secretion is one of the main problems encountered in COPD (4,5). People with COPD commonly experience mucus hypersecretion and sputum retention, which contributes to an increase in breathing problems and a higher risk of exacerbations6. The term airway clearance technique (ACT) refers to various strategies used to eliminate excess secretion from the airways. A wide range of techniques has been developed and are used for airway clearance in people with COPD, such as techniques that patients can practice independently or with assistance or by using devices (7-9). However, there is uncertainty about the effectiveness of these techniques, and which technique is used may differ according to the healthcare professional and patient preferences, country of use, and healthcare setting (10). In preparation for this scoping review protocol, an initial search of the literature was conducted in Prospero, Embase, Medline, Cochrane Database of Systematic Reviews, and Joanna Briggs Institute (JBI) Evidence Synthesis. No previous or ongoing scoping review on ACTs for people with COPD was identified, though we did identify a few systematic reviews (11-16). However, these reviews were published between 2000-2013 and therefore did not include recent evidence. Only two newer systematic reviews were identified (17,18). The main objective of these systematic reviews was to evaluate the effect of ACTs for people with COPD and therefore only included randomized controlled trials, which limits the identification of different techniques and mapping of the ACTs used in real-life settings. In order to support healthcare professionals in choosing optimal techniques for airway clearance and lay a foundation for the development of future clinical recommendations, we need a full understanding of all available ACTs for people with COPD. The main objective of this scoping review is to identify and map ACTs used for people with COPD within any healthcare or research context. The secondary objectives are to 1) systematically map the local recommendations and current guidelines for the use of ACTs for people with COPD; 2) map ACTs used for people with COPD per country, stage of the COPD (i.e., stable vs. acute), and healthcare context (i.e., hospital, home or community); and 3) explore the factors that are included in the choice of the appropriate ACT in clinical practice and research. Review Questions What ACTs are used for people with COPD? How do we decide which ACT to use? Secondary research questions: 1) What are the recommendations of current guidelines and local guidance, for the use of ACTs in people with COPD? 2) What is the distribution of ACTs used per country, COPD stage (i.e., stable vs. acute), and healthcare setting (i.e., inpatient vs. outpatient at home vs. outpatient in the community)? 3) What do clinicians or researchers take into account when they decide which ACT to use? Inclusion criteria Participants This review will consider studies describing the use of ACTs with the goal of improving the airway clearance of adults (≥18 years old) with a diagnosis of COPD, including those with stable COPD or exacerbations of COPD. People admitted to an intensive care unit due to severe acute exacerbation of COPD will be excluded. Studies including participants with additional respiratory diagnoses will not be excluded unless COPD is not the main condition. It will also consider audits and surveys that investigate the use of ACTs in these patients and the factors that influence clinical decision making for their selection. Concept This review will examine studies that investigate the concept of ACTs, which refer to a variety of strategies aimed at promoting the mobilization and removal of secretions from the airways. Specifically, this scoping review will focus on techniques developed to enhance airway clearance and alleviate symptoms associated with sputum. Techniques with different primary objectives, including exercise, respiratory muscle training, breathing pattern retraining techniques, and non-invasive ventilation (NIV), will be excluded from this review. Cough maneuvers, which are a physiological mechanism for expectorating sputum, will not be considered as an individual ACT, as they are frequently used as a control treatment arm in trials. Additionally, humidification and pharmacological approaches, such as mucoactive agents, will be excluded. Context This review will encompass studies that examine the delivery of ACTs in both institutional and non-institutional settings, i.e., homes and communities, to ensure a comprehensive scope. Examples of relevant contexts may include hospital inpatient services, outpatient clinics, community services, or home-care settings. The studies included in this review will not be restricted based on the location of the sample, cultural background, race, or date of publication. Types of sources This scoping review will consider quantitative, qualitative, and mixed-methods study designs, as well as clinical practice guidelines, systematic reviews, audits, and surveys on the use of ACTs for inclusion. If systematic reviews meet the inclusion criteria during the title and abstract screening, the individual studies included in the review will be screened for eligibility. Only systematic reviews that report findings for the role of ACTs in people with COPD will be included in data extraction. Conference abstracts will not be included. In addition, grey literature will be searched at Global Initiative for Chronic Obstructive Lung Disease (GOLD) and physiotherapy association websites of the United Kingdom, Portugal, Denmark, Norway, Sweden, Greece, Spain, Belgium, France, Australia, Canada, and the United States, position statements and other practice guidance related to ACTs. Methods The scoping review will be conducted in accordance with the JBI methodology for scoping reviews and reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA-ScR) extension for scoping reviews (19,20). The protocol will be registered with the Open Science Framework (OSF) from the Center for Open Science prior to title and abstract screening, to improve research transparency and reduce the risk of bias. Search strategy The research team collaboratively developed the search strategy for this scoping review and worked with a university librarian to locate both published and unpublished primary studies, reviews, clinical practice guidelines, audits, and surveys related to the use of ACTs and their decision-making. An initial limited search of the JBI Evidence-Based Practice Database and Pubmed was conducted to identify relevant articles, using free text words, keywords, and Medical Subject Heading (MeSH) terms found in article titles and abstracts. The search strategy will be validated with 4 articles that would fit the review eligibility criteria and that were identified a priori by the research team. Then, the full search strategy will be adapted for each included information source, and four databases will be searched: Medline via Pubmed (1946 to 2023), Embase via Elsevier (1974 to 2023), Cinahl via EBSCOHost (1937-2023), and Scopus via Elsevier. The Cochrane database (1995-2021) will also be searched for healthcare interventions and practice guidelines (see Appendix I for a complete description of the Medline database search strategy). Ongoing studies will be identified by searches in the Clinical Trials gov and the International Clinical Trials Registry Platform (ICTRP). A combination of subject headings and keywords will be used to search titles and abstracts in the selected databases. In addition, references of relevant articles will be hand-searched to expand the search. Grey literature will also be searched from the most recent report from the Global Initiative for Chronic Obstructive Lung Disease and national and international physiotherapy association websites of the United Kingdom, Portugal, Denmark, Norway, Sweden, Greece, Spain, Belgium, France, Australia, Canada, and the United States, as well as for position statements and other practice guidance related to ACTs. Literature included in the review may be published in English, Portuguese, Danish, Norwegian, Swedish, Spanish, French, or Greek but must have an English abstract for screening purposes. Study/Source of evidence selection Following the search, all identified records will be collated and imported into Covidence (Veritas Health Innovation, Melbourne, Australia) where duplicates will be removed. The remaining studies will remain in Covidence for abstract and full-text screening. To ensure understanding of eligibility criteria and resolve any disagreements, a pilot test with 25 articles will be conducted by the research team. A 75% or more agreement will be sought before proceeding with screening (21). Then, two independent reviewers will assess the titles and abstracts against the inclusion criteria and the citations that meet the criteria will undergo full-text analysis. In each screening phase, citations achieving agreement for inclusion by the independent reviewers will be included. Disagreements between reviewers will be resolved through discussion or with another reviewer. The exclusion of papers that do not meet the inclusion criteria will be recorded and reported. The results of the search will be reported in a PRISMA-ScR flow diagram in the final scoping review (22). Data extraction At least two independent reviewers will extract data from the papers included in the scoping review using a data extraction tool adapted from Peters et al (21). The tool will address the review objectives and study design type. The extracted data will include specific details describing the population, concept, context, methods, and key findings relevant to the scoping review questions. The draft data extraction tool provided in Appendix II will be modified and revised as necessary during the process of extracting data from each included paper. Modifications will be detailed in the full scoping review. To ensure consistency of extraction and to identify any need to refine the data extraction tool, both reviewers will extract data from the first three references. Any disagreements between the reviewers will be resolved through discussion or with another reviewer. Data analysis and presentation The extracted data will be reported in a narrative summary providing the answer to our research questions, and key findings will be presented in a table within the manuscript. We will also illustrate themes and their relationships in an infographic or schematic. Discussion This is the first scoping review that will identify and map ACTs used for people with COPD worldwide and the relevant decision-making factors. By exploring a broad range of literature with the inclusion of original studies, audits and surveys on techniques, and recommendations from international societies, this scoping review will provide a comprehensive overview of all available ACTs in this population. In addition, this scoping review will map the factors influencing the decision-making process within any healthcare or research context. Since airway clearance is one of the main problems encountered in COPD, the results of this scoping review will be of interest to all healthcare professionals and policymakers involved in the management of COPD. The findings of this scoping review will allow these stakeholders to get a better understanding of the scope of ACTs for people with COPD within different population- and healthcare settings. In doing so, this scoping review will provide a foundation for the development of future international clinical guidelines, support healthcare professionals in choosing optimal ACTs and ensure that people with COPD receive the most appropriate care. References 1. Agustí A, Vogelmeier C, Faner R. COPD 2020: changes and challenges. American Journal of Physiology-Lung Cellular and Molecular Physiology. 2020; 319(5):L879-L83. 2. Adeloye D, Chua S, Lee C, Basquill C, Papana A, Theodoratou E, et al. Global and regional estimates of COPD prevalence: Systematic review and meta-analysis. J Glob Health. 2015; 5(2):020415. 3. Chronic obstructive pulmonary disease (COPD). World Health Organization (WHO). URL https://www.who.int/news-room/fact-sheets/detail/chronic-obstructive-pulmonary-disease-(copd). Accessed 07.04.2023. 4. Tian PW, Wen FQ. Clinical significance of airway mucus hypersecretion in chronic obstructive pulmonary disease. J Transl Int Med. 2015; 3(3):89-92. 5. Rogers DF. The Role of Airway Secretions in COPD: Pathophysiology, Epidemiology and Pharmacotherapeutic Options. COPD: Journal of Chronic Obstructive Pulmonary Disease. 2005; 2(3):341-53. 6. Belli S, Prince I, Savio G, Paracchini E, Cattaneo D, Bianchi M, et al. Airway Clearance Techniques: The Right Choice for the Right Patient. Front Med (Lausanne). 2021; 8:544826. 7. Pakpahan R, Tarigan AP. The Effect of the Combination of Chest Physiotherapy and Active Cycle Breathing Technique on Respiratory Rate and Ability to Expend Sputum in Chronic Exacerbation Obstructive Lung Disease Patients at Haji Adam Malik Hospital Medan. European Journal of Molecular &amp; Clinical Medicine. 2021; 8(3):616-23. 8. Shen M, Li Y, Ding X, Xu L, Li F, Lin H. Effect of active cycle of breathing techniques in patients with chronic obstructive pulmonary disease: a systematic review of intervention. Eur J Phys Rehabil Med. 2020; 56(5):625-32. 9. Saeed MA, Ruth Emily B, Abdullah SSA, Ali MA, Winston ASB, Michael IP, et al. Use of oscillatory positive expiratory pressure (OPEP) devices to augment sputum clearance in COPD: a systematic review and meta-analysis. Thorax. 2020; 75(10):855. 10. Bhowmik A, Chahal K, Austin G, Chakravorty I. Improving mucociliary clearance in chronic obstructive pulmonary disease. Respiratory Medicine. 2009; 103(4):496-502. 11. Ides K, Vissers D, De Backer L, Leemans G, De Backer W. Airway Clearance in COPD: Need for a Breath of Fresh Air? A Systematic Review. COPD: Journal of Chronic Obstructive Pulmonary Disease. 2011; 8(3):196-205. 12. Osadnik CR, McDonald CF, Jones AP, Holland AE. Airway clearance techniques for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2012; (3):Cd008328. 13. Hill K, Patman S, Brooks D. Effect of airway clearance techniques in patients experiencing an acute exacerbation of chronic obstructive pulmonary disease: a systematic review. Chron Respir Dis. 2010; 7(1):9-17. 14. Jones AP, Rowe BH. Bronchopulmonary hygiene physical therapy for chronic obstructive pulmonary disease and bronchiectasis. Cochrane Database Syst Rev. 2000; (2):Cd000045. 15. Tang CY, Taylor NF, Blackstock FC. Chest physiotherapy for patients admitted to hospital with an acute exacerbation of chronic obstructive pulmonary disease (COPD): a systematic review. Physiotherapy. 2010; 96(1):1-13. 16. Andrews J, Sathe NA, Krishnaswami S, McPheeters ML. Nonpharmacologic airway clearance techniques in hospitalized patients: a systematic review. Respir Care. 2013; 58(12):2160-86. 17. Dobler CC, Morrow AS, Farah MH, Beuschel B, Majzoub AM, Wilson ME, et al. Nonpharmacologic Therapies in Patients With Exacerbation of Chronic Obstructive Pulmonary Disease: A Systematic Review With Meta-Analysis. Mayo Clinic proceedings. 2020; 95(6):1169-83. 18. Daynes E, Jones AW, Greening NJ, Singh SJ. The Use of Airway Clearance Devices in the Management of Chronic Obstructive Pulmonary Disease. A Systematic Review and Meta-analysis of Randomized Controlled Trials. Ann Am Thorac Soc. 2021; 18(2):308-20. 19. Aromataris E, Munn Z (Editors). JBI Manual for Evidence Synthesis. JBI, 2020. Available from https://synthesismanual.jbi.global. 20. Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. 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Appendix I: Search strategy Medline via PubMed: Searched April 26th, 2023 #1 Pulmonary Disease, Chronic Obstructive[Mesh] OR “Chronic Obstructive Lung Disease*” OR “Chronic Obstructive Pulmonary Disease*” OR “Chronic Obstructive Airway Disease*” OR “COPD” OR “COAD” OR “Chronic Airflow Obstruction*” OR “emphysema” or “bronchitis” 150,630 records retrieved #“physiotherap*” OR “physical therap*” OR “airway* clearance” OR “sputum clearance” OR “mucus clearance” OR “lung clearance” OR “tracheobronchial clearance” OR “mucociliary clearance” OR “sputum clearence” OR “bronchopulmonary hygiene” OR “pulmonary hygiene” OR “lung hygiene” OR “oscilat*” OR “PEP” OR “positive expiratory pressure” OR “Flutter” OR “Acapella” OR “Cornet” OR “Quake” OR “Aerobika” OR “Threshold” OR “TheraPEP” OR “intermittent positive pressure breathing” OR “IPPB” OR “IPV” OR “intrapulmonay percussive ventilation” OR “HFCWO” OR “High Frequency Chest Wall Oscillation” OR “autogenic drainage” OR “ELTGOL” OR “slow expiration with glottis opened in lateral posture” OR “Expiration Lente Totale Glotte Ouverte” OR “ACBT” OR “active cycle*” OR “postural drainage” OR “gravity-assisted drainage” OR “percussion” OR “clapping” OR “vibration” OR “shaker” OR “shaking” OR “Physical Therapy Modalities” OR “AFE” OR “simeox” 555,225 records retrieved #3 #1 AND #2 5,474 records retrived