Airway clearance techniques (ACTs) are part of the main management strategy for patients with bronchiectasis. Despite being a priority for patients, accessibility, implementation and reporting of ACTs are variable in clinical settings and research studies. This European Respiratory Society statement summarises current knowledge about ACTs in adults with bronchiectasis and makes recommendations to improve the future evidence base. A task force of 14 experts and two patient representatives (10 countries) determined the scope of this statement through consensus and defined six questions. The questions were answered based on systematic searches of the literature. The statement provides a comprehensive review of the physiological rationale for ACTs in adults with bronchiectasis, and the mechanisms of action along with the advantages and disadvantages of each ACT. Evidence on ACTs in clinical practice indicates that the most frequently used techniques are active cycle of breathing techniques, positive expiratory pressure devices and gravity-assisted drainage, although there is limited evidence on the type of ACTs used in specific countries. A review of 30 randomised trials for the effectiveness of ACTs shows that these interventions increase sputum clearance during or after treatment, reduce the impact of cough and the risk of exacerbations, and improve health-related quality of life. Furthermore, strategies for reducing the risk of bias in future studies are proposed. Finally, an exploration of patients’ perceptions, barriers and enablers related to this treatment is also included to facilitate implementation and adherence to ACTs.

People with respiratory disease have increased risk of developing frailty, which is associated with worse health outcomes. There is growing evidence of the role of rehabilitation in managing frailty in people with respiratory disease. However, several challenges remain regarding optimal methods of identifying frailty and delivering rehabilitation for this population. The aims of this American Thoracic Society workshop were to outline key definitions and concepts around rehabilitation for people with respiratory disease and frailty, synthesize available evidence, and explore how programs may be adapted to align to the needs and experiences of this population. Across two half-day virtual workshops, 20 professionals from diverse disciplines, professions, and countries discussed key developments and identified opportunities for future research, with additional input via online correspondence. Participants highlighted a “frailty rehabilitation paradox” whereby pulmonary rehabilitation can effectively reduce frailty, but programs are challenging for some individuals with frailty to complete. Frailty should not limit access to rehabilitation; instead, the identification of frailty should prompt comprehensive assessment and tailored support, including onward referral for additional specialist input. Exercise prescriptions that explicitly consider symptom burden and comorbidities, integration of additional geriatric or palliative care expertise, and/or preemptive planning for disruptions to participation may support engagement and outcomes. To identify and measure frailty in people with respiratory disease, tools should be selected on the basis of sensitivity, specificity, responsiveness, and feasibility for their intended purpose. Research is required to expand understanding beyond the physical dimensions of frailty and to explore the merits and limitations of telerehabilitation or home-based pulmonary rehabilitation for people with chronic respiratory disease and frailty.

Objective: To determine the effectiveness of exercise rehabilitation in people with multimorbidity. Exercise capacity was the primary outcome. Secondary outcomes were: health-related quality of life, activities of daily living, cardiometabolic outcomes, mental health outcomes, symptom scores, resource utilization, health behaviours, economic outcomes, and adverse events.Data sources: A search was conducted in MEDLINE, CINHAL, EMBASE, and Cochrane Central Register of Controlled Trials databases. Study selection and extraction: Randomized and non-randomized controlled trials and cohort studies of exercise rehabilitation vs any comparison in people with multimorbidity.Data synthesis: Forty-four reports (38 studies) were included. Rehabilitation ranged from 8 weeks to 4 years, with 1–7 sessions of rehabilitation weekly. Exercise included aerobic and resistance, limb training, aquatic exercises and tai chi. Compared with usual care, exercise rehabilitation improved 6-min walk distance (weighted mean difference (WMD) 64 m, 95% CI 45–82) and peak oxygen consumption (WMD 2.74 mL/kg/min, 95% CI –3.32 to 8.79). Effects on cardiometabolic outcomes and health-related quality of life also favoured rehabilitation; however; few data were available for other secondary outcomes.Conclusion: In people with multimorbidity, exercise rehabilitation improved exercise capacity, health-related quality of life, and cardiometabolic outcomes. LAY ABSTRACTChronic disease is a common health problem worldwide. It is increasingly common for people to have more than 1 chronic disease, which is called multimorbidity, and the interaction of their multiple health problems may worsen their health outcomes. Exercise rehabilitation is an effective and established treatment to improve health for people with different chronic diseases, such as heart and lung disease; however, the benefit of structured rehabilitation in people with multimorbidity has not been systematically reviewed. A literature search was performed to investigate the clinical outcomes following exercise rehabilitation in people with multimorbidity. Compared with usual medical care, the results showed that exercise rehabilitation improved exercise capacity, measured by walking distance in a formal test, health-related quality of life and the body’s ability to use oxygen, in people with multimorbidity. There were few data regarding the benefit of rehabilitation on other outcomes, and more well-designed robust trials are needed.

People with bronchiectasis experience chronic productive cough and acute exacerbations, which are linked to poorer quality of life and a higher rate of disease progression. The clinical guidelines for bronchiectasis management recommend physiotherapy [1, 2]. These guidelines advise the prescription of airway clearance techniques (ACTs) to improve sputum clearance and reduce symptoms [1, 2]. Mucoactive agents may be cautiously considered when required [1, 2]. Individuals with reduced exercise tolerance are recommended to engage in pulmonary rehabilitation or undertake exercise or physical activity [1, 2]. Surveys of physiotherapy management for people with bronchiectasis have described commonly applied ACTs [3, 4] but have not alluded to technique combinations, a strategy considered a key approach towards personalising therapy [3–5]. Other audits have highlighted that ACTs were applied in only 49% and 52% of people with bronchiectasis in Europe and Australia respectively, reflecting a potential underuse of this therapeutic approach [6, 7]. Low referral rates to pulmonary rehabilitation have been noted [3, 7], and the prescription of exercise and physical activity beyond pulmonary rehabilitation is unknown [3].