Ancillary treatment of patients with lung disease due to non-tuberculous mycobacteria: a narrative review

Abstract

Background and objective: Non-tuberculous mycobacterial lung disease (NTM-LD) manifests with bronchiectasis, inflammatory bronchiolitis, nodules, and/or cavitation. Bronchiectasis is characterized by permanently dilated airways wherein mucus accumulates, creating a vicious cycle of chronic injurious inflammation and recurrent infections. While antibiotics are an important part of the treatment of NTM-LD, airway clearance techniques to mitigate this pathogenic mechanism of bronchiectasis as well as other ancillary measures are also important components of NTM-LD treatment. The objective of this contemporaneous Narrative Review is to emphasize the importance of such ancillary measures.

Methods: We searched PubMed for the key words of "airway clearance", "pulmonary rehabilitation", "nutrition", "swallowing dysfunction", "gastroesophageal reflux", "vestibular dysfunction", or "cochlear dysfunction" with that of "non-tuberculous mycobacterial lung disease", "bronchiectasis", or "respiratory disease". The bibliographies of identified articles were further searched for relevant articles not previously identified. Each relevant article was reviewed by one or more of the authors and a narrative review was composed.

Key content and findings: Herein, we discuss five ancillary treatment measures that are pertinent to patients with bronchiectasis and NTM-LD: (I) airway clearance; (II) physical and pulmonary rehabilitation; (III) nutrition; (IV) diagnosis and mitigation of swallowing dysfunction and of gastroesophageal reflux disease (GERD); and (V) minimization of vestibular and cochlear dysfunction associated with some anti-NTM drugs.

Conclusions: While antibiotics is often the central focus of treatment of NTM-LD, given its propensity for recurrent and recalcitrant infection, other ancillary measures to break the vicious cycle of injurious inflammation and infection should also be emphasized to optimize treatment success.

Keywords: Airway clearance; aspiration; bronchiectasis; gastroesophageal reflux; nutrition; vestibular dysfunction.

Figure 1

Vicious cycle of bronchiectasis. Independent of the underlying risk factor for bronchiectasis, once it is established, bronchiectasis tends to beget more bronchiectasis. The excessive mucus and ciliary dysfunction in the bronchiectatic airway predispose to recurrent infections, which exacerbates airway inflammation, resulting in more mucus accumulation, ciliary dysfunction, and progression of bronchiectasis. In addition to treatment of infections, airway clearance measures can help mitigate these pathogenic mechanisms that drive bronchiectasis.

Figure 2

Basic breathing and cough techniques to help expectorate sputum. (A) Pursed-lip breathing: following inhalation, bring the lips loosely together and exhaled through the mouth against resistance. (B) Huff cough: with mouth open, inhale either a normal or deep breath, hold for 2–3 seconds, and then exhale using your abdomen, making a “HAA” sound, as in fogging a mirror. (C) ACBT is comprised of cycles of shallow and deep breathing, followed by huff and strong, active coughs. There are three steps to ACBT. Step 1: take 8 to 10 slow, shallow, relaxed breaths (also known as Breathing Control) in through the nose and out through pursed lips. Step 2: take 3 to 5 slow deep breaths, expanding the lung bases. If coughing is triggered by deep breathing, return to Step 1. Repeat Steps 1 and 2 until there is a sensation of secretions in the chest or throat, then proceed to the next step. Step 3: perform 2 to 3 huff coughs followed by strong, active coughs to expectorate the sputum. ACBT, Active Cycle of Breathing Technique.

Figure 3

Positive expiratory pressure mucus clearing devices and their use. (A) PEP devices may be used with a mask or mouthpiece. (B) Algorithm of PEP use. PEP, positive expiratory pressure.

Figure 4

Various OPEP devices. (A) Acapella^® OPEP devices. Acapella^® blue is for individuals who are only able to maintain expiratory flows of <15 liters/minute for 3 seconds and thus for patients with suboptimal inspiratory capacity such as children; and Acapella^® green is for those who are able to maintain expiratory flows of >15 liters/minute for 3 seconds (most adults); Acapella Choice^® can be used by all patients. (B) Aerobika^® OPEP device with a manometer; a manometer guide correlating exhalation pressure with resistance indicator and number of beats per second (Hz) achievable; and the device attached to a nebulizer. OPEP, oscillatory positive expiratory pressure.

Figure 5

The HFCWO devices. Several different manufactured HFCWO devices are shown. Basic instructions for set up and use are usually provided by the manufacturer technician, the use time and frequency by the pulmonologist, and incorporation of breathing techniques and/or OPEP devices with the HFCWO equipment by the physical therapists who specialize in secretion clearance techniques. See relevant text on additional discussions on its use. HFCWO, high frequency chest wall oscillation; OPEP, oscillatory positive expiratory pressure.

Figure 6

Manual techniques. (A) Cupped hand used for “clapping” chest physiotherapy to help disrupt airway mucus. This “cupping-and-clapping” technique can be performed with one or both hands and is applied relatively rapidly to the chest wall in a patient who is supine, prone, sitting up, or in another position. (B) Position of the hand used for the shaking technique (the larger movements depicted by the longer double-arrow) or (C) the vibrating technique (the smaller movements depicted by the shorter double-arrow) typically performed on and parallel to the chest wall. The orientation of the hand depicted is for shaking or vibrating the chest wall in a patient who is sitting upright.

Figure 7

Postural drainage positions. The different positions used are aimed to target drainage from specific lung lobes and segments. (A) Upper lobes, apical segments: patient sits and leans back 30 degrees. Cupping and clapping over area between the clavicle and top of scapula on both sides. (B) Upper lobes, posterior segments: patient leans forward 30 degrees. Cupping and clapping over upper back on both sides. (C) Upper lobes, anterior segments: patient lies supine with knees bent. Cupping and clapping between clavicles and nipples on both sides. (D) Right middle lobe: patient lies in Trendelenburg position and rotate to left 1/4 turn with knees flexed. In males, cupping and clapping over right nipple area. In women, raise right arm over the head and perform cupping and clapping at mid-axillary line. (E) Lingula: patient lies in Trendelenburg position and rotate to right 1/4 turn with knees flexed. In males, cupping and clapping over left nipple area. In women, raise left arm over the head and perform cupping and clapping at mid-axillary line. (F) Lower lobes, anterior basal segments: patient lies in Trendelenburg position on contralateral side with pillow under knees. Cupping and clapping over lower ribs at mid-axillary line. (G) Lower lobes, lateral basal segments: patient lies in Trendelenburg prone position and rotate 1/4 turn upward ipsilaterally with legs between pillow and upper legs flexed. Cupping and clapping over upper part of lower ribs. (H) Lower lobes, posterior basal segments: patient lies in Trendelenburg prone position with pillows under hips. Cupping and clapping over lower ribs just lateral to the spine. (I) Lower lobes, superior segments: patient lies prone with two pillows under hips. Cupping and clapping over the middle of the back at the scapula tips next to the spine.

Figure 8

Exercises for promoting gaze stability. Adaption: (A) to test the vestibular-ocular reflex, have a target directly in front of the subject at eye level; the target may be as simple as an “X” written on a sheet of paper taped to a wall. (B) Sit or stand at one arm length from the target. Move the head quickly from side-to-side as if shaking the head for “no” while maintaining direct eye contact with the target. Repeat while shaking the head up and down. Substitution: To perform this exercise, place two targets (“X” and “Y”) at eye level approximately 10 inches apart (close enough so when the subject is looking at one target, the second one is in the peripheral vision). (C) Look at one target with the head facing in the same direction as the target. (D) Then move only the eyes to the second target. (E) Then move the head to face the second target. Be sure to keep the target in focus when moving the head and be as accurate as possible. Gradually increase the speed of the head turn and length of time while keeping the target in focus. Imaginary: (F) sit or stand facing the target one arm length away and focus on the target. (G) Close both eyes. (H) Turn head to the side while keeping closed eyes focused to the direction of the target. (I) Then open eyes and ask if the eyes are still fixated on the target. Repeat in opposite direction. Gradually increase the speed of the head turn. Exercise can also be performed with up and down head movements.