When you have Alpha-1 lung disease, mucus can build up in your lungs. If you can’t clear the mucus by coughing, it can make you sick and cause damage. Luckily, there are several techniques that can help. Read on to learn more about airway clearance.

What Is Airway Clearance?

Breathing comes naturally to everyone, but for some it does not come easily. Some Alphas are unable to keep their airways clear and their lungs healthy. This may happen because the normal pulmonary defense system is impaired by lung disease.

Respiratory health depends, in part, on consistent clearance of airway secretions by mucociliary clearance (MCC) and by an effective cough. Some individuals with Alpha-1 COPD, however, are prone to recurrent episodes of respiratory inflammation, infection, and eventually, irreversible lung damage. Mounting evidence demonstrates a strong association between mucus secretion retention and illness, exacerbation, hospitalization, sharply declining FEV1, and death. For those individuals who have problems with excess secretions, improvement of MCC is a vital treatment goal that can be accomplished with an individualized bronchial treatment plan that includes effective airway clearance therapy.

This section will cover a brief overview of normal airway clearance and several types of secretion clearance techniques you can use when excess mucus is a problem. Despite the observation that retained secretions can be the starting place for serious respiratory illness, there is little evidence to support one secretion clearance technique over another for Alphas. However, lack of evidence does not mean lack of benefit.

Choosing an Airway Clearance Method

If you feel that excess respiratory secretions may be a problem for you, you should seek an evaluation of this problem from your healthcare provider. He or she can assess your respiratory function and recommend an airway clearance method that is appropriate for you. Therapeutic results depend upon using a method adapted to the individual and family circumstances. The airway clearance method chosen should help you achieve optimal health and quality of life goals. Making the appropriate choice requires accurate information. Useful decision-making criteria include:

  • Medical contraindications
  • Ease of teaching/learning
  • Effectiveness of the technique
  • Ease of complying with the technique
  • Fatigue or work required (for the Alpha and caregiver)
  • Need for equipment/skilled caregiver
  • Alpha’s ability to tolerate technique
  • Alpha’s age, motivation, ability, concentration level, and caregiver situation
  • Cost

Normal Airway Clearance

Normal airway clearance is accomplished by the following methods:

  • Mucociliary clearance (MCC): The entire respiratory system is lined with cells that secrete mucus. Airway mucus is a complex substance that forms a protective barrier lining in the respiratory tract. Bacteria and other airborne particles become trapped in this sticky mucus and are then swept upwards and outwards by tiny hair-like structures called cilia. The interaction between normal mucus, cilia, and associated structures make up the MCC.
  • Cough: An effective cough is capable of removing a substantial amount of mucus. Effective cough relies on three phases. The first phase, an inspiratory “gasp,” facilitates an increase in lung volume. During the second phase, sudden closure of the glottis (vocal cords), coupled with expiratory muscle activity, helps to build pressure in the lungs. Relaxation of the glottis precedes the third, expulsive, phase of coughing. Airflow velocities, especially in the central airways, become high (up to three-fourths the speed of sound), and mucus is expelled toward the mouth to be either spit-out or swallowed. A healthy MCC system moves respiratory secretions to central airways where final clearance is accomplished by a combination of coughing and swallowing.

In healthy individuals, rates of mucus secretion and clearance are balanced. The consistency of mucus also is in balance. The mucus is thick enough to trap bacteria and other inhaled particles, but thin enough to be moved easily by cilia. When airways are kept free of harmful bacteria, other particles, and excess mucus, airways remain open and permit normal exchange of vital oxygen and carbon dioxide.

Impaired Airway Clearance

When mucus secretion and mucus clearance are not in balance, excessive airway mucus can cause serious problems. This condition is called impaired airway clearance. Impaired secretion clearance can occur as a result of any event or dysfunction that disrupts normal airway clearance mechanisms.

When this occurs, excess and often sticky mucus may accumulate in the airways, making breathing more difficult. More energy and effort are required to take in vital oxygen, and to exhale carbon dioxide. Some Alphas may find themselves caught up in the vicious cycle of recurrent, ever-worsening episodes of inflammation, pulmonary infection, and increased production of excess mucus. This can lead to airway obstruction, lung damage, and respiratory failure.

To break this vicious cycle, airway clearance therapy can be essential. People at risk for impaired clearance may have one or more of the following problems:

1. Ineffective ciliary clearance: Normal cilia beat in a coordinated fashion to mobilize mucus and clear particulate matter from the airways. Damaged or poorly functioning cilia perform this function inadequately or not at all. Ciliary impairment is associated with conditions including:

  • Smoking or exposure to secondhand smoke.
  • Following lung transplantation

2. Excessive or abnormal mucus production: Certain disorders and/or treatments can cause excess mucus production and, in some cases, mucus that is abnormally thick and sticky. Large quantities of mucus with altered physical properties may overwhelm the mucociliary apparatus, inhibiting normal airway clearance. Abnormal amounts of mucus with altered physical properties are present in:

  • Bronchiectasis
  • Asthma
  • COPD (emphysema, chronic bronchitis)
  • Mechanical ventilation

3. Ineffective cough: Cough function may be weak or ineffective in Alpha-1 COPD due to the following:

  • Weakness of the diaphragm and accessory muscles of inspiration diminish the ability to inhale and exhale
  • Poor coordination of the swallowing muscles impairs closure of the glottis and the ability to build up the pressure needed to produce an effective cough
  • Poor coordination of the expiratory muscles compromises expulsive force and inhibits the separation of mucus from the bronchial wall

4. Cough function is frequently impaired in:

  • Alphas who depend on mechanical ventilation
  • Alphas who have received a lung transplant

5. Dysphagia/aspiration/gastroesophageal reflux:

  • Dysphagia, or difficulty in swallowing, is a consequence of anatomical abnormalities or weakness of the muscles associated with swallowing.
  • Aspiration involves the inhalation of secretions, vomit, or foreign material into the lungs. Because saliva and gastric contents contain bacteria, aspiration introduces microorganisms into airways.
  • Gastroesophageal reflux occurs when a defective lower esophageal sphincter allows stomach contents to surge backwards into the throat.

6. Obstructive lung disease: Obstructive lung disease includes conditions where airway size is decreased as a result of structural changes, bronchospasm, and/or excess mucus, which limits the ability to exhale. Obstructive lung diseases include:

  • COPD: emphysema, and chronic bronchitis
  • Bronchiectasis
  • Asthma

What is Airway Clearance Therapy (ACT) and Why is it Important?

Airway clearance techniques are indicated for specific problems that have known clearance abnormalities. Since not all Alphas have problems with excess secretions, it has been suggested that such techniques may be required only for individuals with a daily sputum production of greater than 30 mL. For example, this can occur in people who have bronchiectasis or acute bronchitis. For these people, good respiratory health is impossible without efficient clearance of airway secretions. Improvement of MCC is a vital treatment goal for individuals who experience episodes of respiratory inflammation, infection, and eventually, irreversible lung damage. The improvement of MCC can be accomplished with an individualized bronchial hygiene treatment plan that includes effective airway clearance therapy.

It is important to work with your healthcare provider to develop the airway clearance therapy plan that is best for you.

A detailed description of each of these therapeutic methods is presented at the end of this section. Some of these can techniques can be carried out on your own, once you have been properly instructed. Others require the assistance of a caregiver or therapist. A summary of the airway clearance therapies to consider includes:

1. Forced expiratory technique (FET): Sometimes called huff coughing, this technique consists of one or two huffs from mid-to-low lung volumes with the glottis open, followed by relaxed diaphragmatic breathing.

2. Chest physiotherapy (CPT): CPT is an airway clearance technique based on the theory that percussion of various areas of the chest and back transmit shock waves through the chest wall, loosening secretions in the airways. If the individual is strategically positioned, the loosened secretions will then drain into the upper airways, where they can be cleared using coughing and huffing techniques.

3. Autogenic drainage: This is a three-level breathing sequence beginning at low lung volumes, followed by breathing at mid-lung volumes, followed by deep breathing and huff coughing.

4. Positive expiratory pressure (PEP): With this technique, the Alpha-1 COPD individual exhales against a pressure of 10-20 cm H2O.

5. Vibratory PEP: This technique uses a device that produces PEP with oscillations in the airway during the expiratory phase of breathing.

6. Intrapulmonary percussive ventilation (IVP): This technique uses a pneumatic, oscillating pressure device that generates oscillations in the range of 100-300/min at pressures at 5-35 cm H2O.

7. High-frequency chest wall oscillation (HFCWO): This technique uses an inflatable vest that attaches by hoses to an air pulse generator, producing pressure to about 50 cm H2O at frequencies of 5-25 Hz.