Beyond any reasonable doubt, one of the greatest achievements of medicine in the last century has been the successful reduction of morbidity and mortality due to infectious disease. In 1938, a landmark paper in the爱丁堡医学杂志by Cookson and Mason1甚至在第四十年之前突出了支气管扩张的高致死性1,2。Thanks to improved hygiene measures and antibiotic treatment, what used to be a fatal disease has now become a chronic disease. The major, scattered lung lesions due to cystic bronchiectasis and often associated with outbreaks of infectious diseases, have given way to smaller, cylindrical bronchiectasis as a consequence of dozens of diseases being able to generate lung damage3。然而,远离灭绝的疾病,支气管扩张已经出现了力量。人类的寿命越来越多,患有更多人患有支气管扩张的慢性疾病的风险,以及广泛使用成像技术(例如胸部高分辨率计算断层扫描),增加了负担,特别是在老年人4,5。But the relevance of bronchiectasis goes beyond its mere presence, as bronchiectasis worsens the prognosis of the generating disease6and is associated with an accelerated loss of lung function7, increased mortality8和生活质量显着降低9,10。
Notwithstanding the sufferers' individual implications and new epidemiological situation, bronchiectasis still attracts little interest. In 1988, Barker and Bardana11described bronchiectasis as an “orphan disease” of the airways. However, to date, there is no or little evidence for the effectiveness of most of their treatments, including anticholinergic therapy, inhaled or oral corticosteroids, inhaled hyperosmolar agents, leukotriene receptor antagonists, short- and long-acting β2-agonists, methyl-xanthines, mucolytics, and even bronchopulmonary hygiene physical therapy12。All these treatments are actually used by extrapolation from success in other diseases with airflow obstruction. However, caution must be exercised as this is not always appropriate and might even be harmful to patients13。因此,欢迎在支气管扩张中具有适当证据水平的研究。
The increase in quantity and purulence of sputum viscosity, with retention of broncho-pulmonary secretions characteristic of bronchiectasis, leads to functional airflow obstruction, atelectasis and an increased risk of chronic colonisation of the bronchial mucosa by potentially pathogenic microorganisms, which clouds patients' prognosis14,15。虽然在非囊性纤维化支气管扩张患者中,常规胸部物理治疗程序的入学人员被认为是标准的16,17, a secular unavailability of scientific evidence of physiotherapy still occurs, and there are no studies of adequate methodology to support efficacy and effectiveness. A handful of studies, most of short-term duration and diverse methodologies, have reported improvements in airway clearance and other clinical parameters associated with physiotherapy in bronchiectasis18,19。
In the current issue of theEuropean Respiratory Journal, Murrayet al.20present a randomised controlled trial (RCT) on the effectiveness of regular chest physiotherapy on clinical, functional and microbiological outcomes, as well as quality of life. In a crossover trial design, 20 patients with clinically active bronchiectasis underwent treatment for 3 months with two daily sessions of chest physiotherapy by an oscillatory positive expiratory pressure device (the control group was not subjected to this treatment). They report improvements in the Leicester Cough Questionnaire score, a questionnaire developed and validated to determine the impact of cough severity on quality of life, and also an increase in the capacity for expectoration, exercise capacity, and an improvement in quality of life assessed by the St. George's Respiratory Questionnaire20。No significant adverse effects occurred during the trial duration, although there were no changes in lung function, microbiology or number of exacerbations. The study by Murrayet al.20has some obvious limitations, mainly related to its reduced sample size, including the statisticalversusclinical significance of some reported changes, and the lack of a placebo or sham group by study design, which the authors recognise. However, it should be considered a step forward for the following reasons: 1) it is the first study that provides valuable information with clinical trial methodology on the effectiveness of regular respiratory physiotherapy for these patients; and 2) it helps to re-open the debate about the critical need for long-term multicenter trials in bronchiectasis, with larger sample sizes and a methodology that ensures a higher level of evidence in these patients. These studies should serve not only to answer the seminal question of whether regular chest physiotherapy is effective or not, but to address other key questions that remain unsolved yet, such as: What is the most effective technique?, How many times a day and for how long should chest physiotherapy programs be used for?, What is the effectiveness of chest physiotherapy treatments combined with antibiotics, bronchodilators and/or muscle training?, What is the effectiveness of physiotherapy long-term and what are the related effects on lung function decline or exacerbations?, Are there subpopulations of patients with bronchiectasis who might benefit the most from treatment?, and Is treatment cost-effective?, among other issues. While waiting for these studies, we will continue living in the realm of expert opinion. M.C. Sosman, a reputed radiologist from Boston (MA, USA) lectured to his students that “… we see only what we look for, and we recognize only what we know”21。也许,必要的第一步应该是临床医生怀疑支气管扩张的诊断,一种越来越重要的疾病,并考虑到患有阻塞性气道的患者,并不总是不仅慢性阻塞性肺病或哮喘都应该归咎于支气管损伤。在Barker和Bardana的最先进的研究后二十年11, bronchiectasis remains an “orphan disease” of the airways.
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