ORIGINAL ARTICLES

RESPIRATORY INSUFFICIENCY☆

Active cycle breathing technique (ACBT), which includes cycle of breathing control, thoracic expansion exercises and forced expiratory technique (FET), appears to have beneficial effects in patients with a variety of respiratory diseases. This systematic review provides an update on the new related studies, expanding the evidence base through the last 12 years and specifically evaluating the effectiveness of ACBT on pulmonary function-related outcome variables in patients with chronic respiratory diseases.

MEDLINE/Pubmed, PEDro, and Cochrane Library for Randomized Controlled Trials were searched between September 2008 and December 2021, in continuance of a previous systematic review, to identify randomized clinical trials and/or crossover studies comparing ACBT to other respiratory treatment techniques in patients with chronic obstructive pulmonary diseases, cystic fibrosis, or bronchiectasis.

Eleven studies were included and the quality of most of them was moderate to good. The outcomes most frequently assessed were forced expiratory volume in 1 s (FEV₁), sputum wet weight, forced vital capacity (FVC), and peak expiratory flow rate. Secondary outcomes were quality of life and dyspnea. Various comparators were identified and most of them assessed the ACBT as an effective method in comparison with other respiratory treatment modalities. Most studies revealed that ACBT/FET had at least an equally beneficial short-term effect on sputum wet weight, FEV₁ and FVC compared to other treatment methods.

The results of this updating review reinforced the data of a previous systematic review regarding the beneficial impact of ACBT for the short-term improvement in respiratory tract secretions clearance and pulmonary function. ACBT is effective in increasing the expectorated sputum volume, in reducing viscoelasticity of the secretion and in relieving symptoms such as dyspnea.

La enfermedad pulmonar obstructiva crónica (EPOC) se relaciona con el tabaquismo como principal agente etiológico, si bien existen otros factores de riesgo que pueden interactuar influyendo en el desarrollo de la enfermedad. La definición de EPOC se asienta en tres puntos: la presencia de síntomas respiratorios persistentes, la exposición a agentes etiológicos y un cociente espirométrico obstructivo no reversible. La espirometría forzada con prueba broncodilatadora es la prueba de elección para confirmar el diagnóstico de EPOC, no obstante, se están intentando desarrollar métodos alternativos para el cribado de la enfermedad, dado el importante infradiagnóstico actual de esta patología.

Con el fin de avanzar en una medicina más personalizada, en el paciente se han adoptado herramientas de clasificación como son los fenotipos clínicos y los rasgos tratables, permitiendo adecuar los tratamientos en función de las características de los pacientes. El tratamiento no farmacológico, como la deshabituación tabáquica, la vacunación, el ejercicio físico… es fundamental en el manejo de la enfermedad, así como el tratamiento farmacológico basado en los fenotipos clínicos. Los eosinófilos se han convertido en un marcador clave a la hora de instaurar el tratamiento con glucocorticoides inhalados.

En el seguimiento de la enfermedad, es de especial relevancia evaluar el grado de control de esta, siendo un elemento fundamental para establecer un adecuado control la ausencia de agudizaciones. Estas conllevan importantes implicaciones en la mortalidad, morbilidad y calidad de vida de los pacientes, siendo necesarios más estudios para definir mejor los fenotipos de las agudizaciones y sus biomarcadores.

Chronic Obstructive Pulmonary Disease (COPD) is related to smoking as the main etiological agent although there are other risk factors that can interact influencing the development of the disease. The definition of COPD is based on three points: the presence of persistent respiratory symptoms, exposure to risk agents, and a non-reversible obstructive spirometric ratio. Forced spirometry with a bronchodilator test is necessary to confirm the diagnosis of COPD, however, attempts are being made to develop alternative methods for screening given the current significant underdiagnosis of this pathology.

In order to advance in a more personalized medicine for the patient, classification tools have been adopted such as clinical phenotypes and treatable traits, allowing treatments to be adapted according to the characteristics of the patients. Non-pharmacological treatment (smoking cessation, vaccination, physical exercise...) are essential for the management of the disease, as well as pharmacological treatment based on clinical phenotypes. Eosinophils have become a key marker when establishing treatment with inhaled glucocorticoids.

In the follow-up of the disease, it is very relevant to evaluate the degree of control being a fundamental element the absence of exacerbations given their implications in mortality, morbidity and quality of life of patients. More studies are needed to better define the phenotypes of exacerbations and their biomarkers.

Chronic obstructive pulmonary disease (COPD) is a lung disease, that is frequently associated with extra pulmonary manifestations such as skeletal muscle wasting and cachexia. This complex syndrome has raised the question as to whether COPD is the pulmonary manifestation of a systemic disease. In addition, patients with COPD often develop other co-morbidities, such as ischemic heart disease, heart failure, osteoporosis, anemia, lung cancer, and depression. These diseases potentiate the morbidity of COPD, increasing health care utilization and mortality in these patients. The high prevalence of these co-morbidities in patients with COPD compared with those without it, suggest a common pathophysiological origin. Whatever the mechanisms, novel approaches aimed at integrating the multiple morbidities seen in patients with COPD and other chronic diseases, provide new avenues of research and allow us to develop more comprehensive, precise and effective therapeutic approaches.

Le concept de médecine personnalisée est un concept récent, mais les notions sous-jacentes ne sont pas nouvelles : savoir adapter la prise en charge aux caractéristiques des patients est l’un des éléments qui font de la médecine un art. Les avancées de la science permettent maintenant d’affiner considérablement les applications de ce concept dans de nombreux domaines médicaux, dont la BPCO : les travaux de recherche ont permis d’identifier des phénotypes, des endotypes, des « caractéristiques traitables ». La personnalisation porte sur toutes les composantes de la prise en charge. Par exemple, la décision de pratiquer une spirométrie de repérage repose non seulement sur les facteurs de risque (âge, tabac, autres expositions), mais aussi sur l’existence de symptômes. La recherche des diverses comorbidités fréquemment associées à la BPCO est basée sur les facteurs de risque et leurs combinaisons, variables d’un individu à l’autre. La réhabilitation et ses composantes sont par essence individualisées en profondeur, ce qui représente une condition majeure de leur succès. Enfin et peut-être surtout, la personnalisation de la prise en charge médicamenteuse, jusqu’ici assez pauvre en biomarqueurs d’intérêt (prédictifs de réponse), pourrait bénéficier de l’apport du taux d’éosinophiles circulants. Reste à savoir de quelle manière. Il faut espérer que d’autres biomarqueurs viendront enrichir la panoplie !

The concept of personalised medicine is recent but the underlying notions are not new: knowing how to adapt care to patients’ characteristics is one of the components of the “art of medicine”. The advances of science allow to refine considerably the applications of the concept in many fields of medicine including COPD: research has identified phenotypes, endotypes and treatable traits. Personalisation can be applied to all components of care. For instance, the decision to perform screening spirometry relies not only on risk factors (age, smoking, other exposures) but also on symptoms. Assessment of comorbidities often associated with COPD is based on risk factors and their combinations, variable between individuals. Rehabilitation and its components are in essence highly individualised, which a major condition for their success. Last but not least, personalisation of pharmacological therapy, which has long been rather poor, could not benefit from biomarkers of interest (predictive of response), such as blood eosinophil count. Practical strategies using these still need to be established, and new biomarkers may usefully enrich the collection!