Abstract
Introduction
Despite being a proposed treatment, there is no agreement on airway clearance management for patients hospitalised with an acute exacerbation of chronic obstructive pulmonary disease (AECOPD). The aim of this work was to establish international consensus on the selection of airway clearance techniques (ACTs) for these patients and identify which ACTs are commonly used.
Methods
A modified Delphi study was employed. A panel of experienced physiotherapists working in Europe (n=162, 12 countries) was invited to respond to two online Delphi survey rounds. A 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree) was used; consensus was defined as a median score of ≤2 or ≥4 and 75% agreement.
Results
Consensus was reached for the use of seven ACTs, including forced expiratory techniques (FETs), positive expiratory pressure (PEP) and oscillatory positive expiratory pressure (OPEP), in cases of limited treatment time, obesity, low patient motivation or for localised secretions. Consensus was reached against the use of five ACTs, including manual percussion, vibrations and shaking, in patients with resting breathlessness, frailty, obesity or high resting lung volumes. The most used ACTs among participants were PEP, FETs and active cycle of breathing techniques. Participants from nine countries identified ACTs that are commonly used by all of the country's participants.
Conclusions
European-based physiotherapists report using a variety of ACTs, with some regional preferences noted in certain countries. Consensus was able to be reached regarding which ACTs should be used or avoided for patients hospitalised with AECOPD under a range of clinical circumstances.
Shareable abstract
European-based physiotherapists report using a variety of airway clearance techniques, with some regional preferences. Consensus was reached for patients hospitalised with AECOPD under a range of clinical circumstances. https://bit.ly/3XlqEGQ
Introduction
Chronic obstructive pulmonary disease (COPD) is a common respiratory disease that affects over 300 million people worldwide [1, 2]. An acute exacerbation of COPD (AECOPD) is a sudden worsening in respiratory symptoms that may be caused by infections or environmental stress, or triggered or worsened by comorbidities such as heart disease [3, 4]. Exacerbations are associated with decreased quality of life, increased rates of hospitalisation and mortality, and a higher risk of future exacerbations [5–8].
Patients with AECOPD commonly present with increased sputum production and retention [9, 10], thereby indicating prescription of airway clearance techniques (ACTs). Mucus plugging of medium- to large-sized airways in patients with COPD has been identified as an independent predictor of all-cause mortality, irrespective of lung function and other confounding variables [11]. ACTs encompass various strategies designed to remove excess secretions from the airways [12]. These techniques can be performed independently, with assistance and/or with the use of devices [13–15]. A wide range of ACTs are available and can be used by physiotherapists to treat patients with AECOPD [16]. However, current literature does not support any single ACT as superior over another and airway clearance recommendations in major international COPD guidelines lack clarity to effectively inform evidence-based decision-making for patients hospitalised due to AECOPD [8, 10, 17–20]. Consequently, technique choice can vary widely depending on the setting and availability, the preferences of healthcare professionals and patients, or even the country of care.
The lack of evidence-based recommendations encourages seeking clinical guidance through expert-informed Delphi methods to aid decision-making and optimise ACT selection, especially for treating hospitalised patients with AECOPD. In the absence of robust research evidence, the Delphi method provides a recognised approach to formulating clinical agreement based on the opinion of a purpose-built panel and through a structured consensus-building process [21, 22]. The main objective of this study was to establish an international consensus on the selection and use of ACTs for hospitalised patients with AECOPD, using Delphi methodology. The secondary objective was to identify which ACTs are clinically used for patients hospitalised with AECOPD across Europe.
Methods
Study design and Delphi process
This modified Delphi consensus study comprised two rounds of structured, online surveys (figure 1). Invitations to the Delphi rounds were sent by email from September 2023 to January 2024. The identified eligible participants received an email invitation, including a letter explaining the purpose of the study, the study plan, definitions of ACTs and AECOPD, and the Delphi survey link. Each Delphi survey round lasted approximately 3 weeks, with email reminders. Participants had a minimum of 2 weeks to complete the survey. When applicable, the invitations and/or reminders were sent from those in the research group with the closest links to the nationality of the invited participant, in order to increase engagement and response rates. Participation in the study merited membership of the Current use of Airway Clearance Techniques in hOspitalS (CACTOS) Delphi Panel and authorship of the scientific publication of the final document. The surveys were in English and responses were collected and stored in REDCap via Aarhus University, Denmark (https://redcap.au.dk/).
FIGURE 1.
Flowchart of the Delphi process.
Delphi panel participants
Purposeful sampling through nominal and snowball techniques were used to ensure representation from different European countries in the Delphi panel. Physiotherapists were eligible to participate if they declared that they either 1) treated patients with AECOPD in a hospital using ACTs within the last 3 years and/or 2) had worked on or supervised a research project for patients with AECOPD in a hospital using ACTs within the last 3 years. Participants who did not confirm their eligibility in Delphi survey round 1 were excluded.
During an international workshop related to the study in Aarhus, Denmark (June 2023), a group of 12 potential Danish participants was identified. To ensure a balanced representation, we aimed to include approximately 12 participants from each of the countries involved.
This was a low-risk survey-based study that did not include sensitive information or potentially sensitive topics; therefore, ethics approval was not required. The study adhered to the Declaration of Helsinki and has been reported to the Danish Data Protection Agency through registration at Aarhus University Hospital (record number: 1-16-02-266-23). Anonymity of responses was assured; all participants were assigned a unique identification number.
Delphi survey development
Delphi survey round 1 was developed through a scoping review [23], a team of experts comprising international physiotherapists, medical researchers and clinicians, and input from the participants of three international workshops held in Aarhus (Denmark), London (UK), and Brussels (Belgium) that involved research physiotherapists, clinicians and a methodologist. The surveys consisted of a descriptive and a consensus part. The descriptive part included questions about eligibility to participate and the demographics of the participants (age, gender, country, etc.). Participants were also asked to indicate whether they used specific ACTs and had access to specific ACT equipment.
In the consensus part, participants were asked to rate their agreement with the use of a list of individual ACTs, based on specific clinical statements that reflected common patient physiology and symptoms (hypoxia, cardiac stability, etc.), as well as potential barriers and enablers of ACTs (limited treatment time, etc.). This part was presented as clinical statements accompanied by relevant ACTs and associated equipment items. The included statements and items were discussed among the researchers between the Delphi survey rounds, which resulted in the addition of new items to the ACTs or merging similar items. Moreover, during round 1, participants could suggest ACTs that were not included in the survey or modifications to the clinical statements and ACT items [24].
All items that did not reach consensus in round 1 were carried forward to round 2. Eligibility items, demographic items, items that reached consensus in round 1 and items with more than 30% of “unable to score” or missing responses in round 1 were removed. Additionally, new items proposed by the participants and agreed by the research team through discussion and voting were added in round 2. For each round, the final version of the survey was pilot-tested by the researchers, to ensure clarity of the items and to identify any technical issues.
Rating and consensus
Participants were asked to rate each ACT item on a 5-point Likert scale from 1 (strongly disagree) to 5 (strongly agree) [25]. An “unable to score” option was added to each item, to avoid forced decisions [26]. Consensus was defined as items with a median score of either ≤2 or ≥4 on the Likert scale and ≥75% agreement in a combined score of 1 (ACTs not to use) and 2 or a combined score of 4 and 5 (ACTs to use) [27]. Statements with a level of agreement between 70–75% were considered “near consensus”, as a 70% cutoff for consensus is often used in other studies [28–30]. The remaining items were considered “no consensus” items.
The rating was based on the participant's own experience and opinion. Each participant of round 2 received individual and group average ratings from round 1, including the number of participants, demographics and the distribution of responses to each statement and ACT item. Participants were asked to consider the group's average ratings of those items that did not reach consensus, along with their individual responses, and to rate each of the new items and those that did not reach consensus previously.
Analysis
Descriptive statistics, such as distribution (frequency and percentages of agreement or disagreement), central tendencies (median and mode) and dispersion (interquartile range), were used. Strength of agreement or disagreement was assessed using the median score and its qualitative descriptor and was reported for all items as per Audag et al. [31]. Response rates were reported, as well as rates of missing data and the “unable to score” option. All available responses were included in the analysis, i.e. including responses from participants who only completed the round 1 and surveys with missing items. Demographic data for round 2 were reported and extracted from participation in round 1. Analyses were performed with Stata 17.0 (StataCorp, College Station, TX, USA).
Results
Delphi panel participant recruitment and demographics
12 European countries were represented in both Delphi survey rounds (table 1). 162 physiotherapists were invited to participate in the study and 104 participants completed round 1 (64.2% response rate). Six participants were excluded due to eligibility and duplicates. 98 physiotherapists were invited to participate in round 2 and 65 of them completed this round (66.3% response rate). Participant demographics were similar in both rounds (table 2). Most of the participants were women, worked in public hospitals and had a master's degree. The participants reported using ACTs in approximately 10 hospitalised patients with AECOPDs per month (table 2).
TABLE 1.
Invited experts and included participants in Delphi survey rounds 1 and 2, per country
| Country | Experts invited | Expert participants in Delphi round 1 | Expert participants in Delphi round 2 |
|---|---|---|---|
| Denmark | 12 | 10 | 7 |
| Norway | 11 | 11 | 10 |
| Sweden | 9 | 5 | 4 |
| United Kingdom | 13 | 6 | 4 |
| Portugal | 12 | 6 | 3 |
| Spain | 10 | 4 | 3 |
| Italy | 17 | 14 | 12 |
| Greece | 16 | 9 | 4 |
| Switzerland | 18 | 7 | 2 |
| Belgium | 15 | 10 | 6 |
| France | 18 | 11 | 7 |
| Turkey | 11 | 5 | 3 |
| Total | 162 | 98 | 65 |
Data presented as numbers (n). Participants were included only if they submitted complete and valid responses. All invited experts were asked to complete Delphi survey round 1. All participants of Delphi survey round 1 were invited to complete round 2.
TABLE 2.
Delphi panel participant demographic characteristics in Delphi survey round 1 (n=98) and 2 (n=65)
| Characteristic | Delphi round 1 | Delphi round 2 |
|---|---|---|
| Age# | 42.4±10.2 | 43.1±10.5 |
| Gender | ||
| Female | 59 (60.2) | 46 (70.7) |
| Male | 39 (39.8) | 19 (29.2) |
| Type of hospital currently working in | ||
| Public | 78 (79.6) | 47 (72.3) |
| Private | 9 (9.2) | 7 (10.8) |
| Other or more than one type of hospital | 11 (11.2) | 11 (16.9) |
| Highest completed education | ||
| Bachelor's degree | 15 (15.3) | 7 (10.7) |
| Master's degree | 45 (45.9) | 32 (49.2) |
| PhD | 33 (33.7) | 23 (35.4) |
| Other | 5 (5.1) | 3 (4.6) |
| Average number of patients with an AECOPD treated per month ¶ | 10 (5–15) | 10 (5–12.5) |
All characteristics are presented as number (%) except for columns marked with #, which are presented as mean±sd, and ¶, which are presented as median (interquartile range). AECOPD: acute exacerbation of COPD; PhD: doctor of philosophy.
Delphi surveys
Delphi survey round 1 had nine statements with 96 ACT items: eight statements with 11 ACT items and one statement with eight ACT items (table 3 and the online supplement). This part also included two open-ended questions inviting participant suggestions on statements and ACT items. In addition, round 1 included information about the participants, including confirmation of fulfilling the eligibility criteria and demographic data such as age, gender, country of graduation as a physiotherapist, current country of employment, type of hospital of current employment, level of education and clinical cases encountered in current practice.
TABLE 3.
Delphi survey statements and the number of their related airway clearance techniques (ACTs) that could reach consensus in Delphi survey round 1 (total items, n= 96) and 2 (total items, n=170)
| Statement | ACTs in Delphi round 1 | ACTs in Delphi round 2 |
|---|---|---|
| 1) If I have limited time, I would use the following ACT | 11 | 12 |
| 2) If I treat a patient with breathlessness at rest, I would use the following ACT | 11 | 15 |
| 3) If I treat a patient who is physically very tired, I would use the following ACT | 11 | 15 |
| 4) If I treat a patient who is frail, I would use the following ACT | 11 | 12 |
| 5) If I treat a patient who is very obese (BMI >40 kg·m−2), I would use the following ACT | 11# | 10# |
| 6) If I treat a patient with low motivation for airway clearance, I would use the following ACT | 11 | 15 |
| 7) If my patient is not able to perform ACT independently, I would use the following ACT | 11 | 16 |
| 8) If my patient cannot easily follow instructions, I would use the following ACT | 11 | 16 |
| 9) If my patient is currently on NIV, I would use the following ACT | 8 | 12 |
| 10) If I treat a patient showing evidence of localised secretions (X-ray, computed tomography scan, auscultation) during AECOPD, I would use the following ACT | NA | 16 |
| 11) If I treat a patient with having highly viscous or viscoelastic secretion during AECOPD, I would use the following ACT | NA | 16 |
| 12) If I treat a patient with high resting lung volume (i.e. hyperinflation, evidenced either via lung function test or clinically) during AECOPD, I would use the following ACT | NA | 15 |
The table presents the number of possible ACTs to choose from in each round. In Delphi round 1, it is all ACTs that were included in the survey. In Delphi round 2, it is the ACTs that were included in the survey, incorporating the newly selected ones, but excluding the ACTs that already reached consensus in round 1 and those with >30% missing values. AECOPD: acute exacerbation of COPD; BMI: body mass index; NA: not available (these statements were included only in the Delphi round 2); NIV: noninvasive ventilation. #: As presented in table 5, in Delphi round 1, six items reached consensus for this statement. In Delphi round 2, five new items were added; therefore, the total number of items in this round is one fewer, i.e. number of items in Delphi round 1>number of items in Delphi round 2.
Round 2 had 12 statements with 170 ACTs items, including four statements with 16 ACT items, four statements with 15 ACT items, three statements with 12 ACT items and one statement with 10 ACT items (table 1 and the online supplement). This round included three new statements with five new ACT items for each of them, based on the open-ended questions in round 1. Participant suggestions that did not move forward to round 2 were excluded due to the pre-specified definitions used in this study, with the voting results and reasons for exclusion being recorded and made available.
Airway clearance consensus items
Consensus was achieved for 14 of the 96 ACT items in round 1 (15%) and for 12 additional ACT items out of the 170 items in round 2 (7%). Moreover, 13 items approached consensus in round 2 (8%). The three statements regarding patients who were unable to perform ACTs independently, could not follow instructions or were using noninvasive ventilation (NIV) were the only ones that did not include any consensus ACT items. The ACT items that most often reached consensus for use in patients with AECOPD included positive expiratory pressure (PEP) and oscillatory positive expiratory pressure (O-PEP), whereas those that most often reached consensus for nonuse included manual percussion, vibrations and shaking (table 4).
TABLE 4.
Consensus on airway clearance techniques (ACTs) for Delphi rounds 1 and 2
| Statement | Agreement (%) | Missing or “I do not know” (%) | Likert response (median, IQR) | Consensus decision | Delphi round when/if consensus was achieved |
|---|---|---|---|---|---|
| 1) If I have limited time, I would use the following ACT: | |||||
| FET | 75.8 | 3.1 | 4 (4–5) | Agree | Round 1 |
| ACBT | 61.9 | 3.1 | 4 (3–5) | Agree | No consensus |
| Manual percussions | 77.8 | 8.2 | 1.5 (1–2) | Strongly disagree | Round 1 |
| Manual vibrations or shaking | 69.4 | 4.6 | 1 (1–2) | Strongly disagree | No consensus |
| GAD | 73.8 | 6.2 | 1 (1–3) | Strongly disagree | No consensus |
| HFCWO | 56.7 | 31.6 | 2 (1–3) | Disagree | No consensus |
| IPV | 36.7 | 24.6 | 3 (2–4) | Neutral | No consensus |
| AD | 42.6 | 6.2 | 3 (2–4) | Neutral | No consensus |
| ELTGOL | 58.3 | 7.7 | 4 (3–4.5) | Agree | No consensus |
| PEP | 86.3 | 3.1 | 5 (4–5) | Strongly agree | Round 1 |
| O-PEP | 78.3 | 7.7 | 4 (4–5) | Agree | Round 2 |
| Simeox | 40.5 | 43.1 | 3 (2–4) | Neutral | No consensus |
| SCT | 60.4 | 10.8 | 4 (3–5) | Agree | No consensus |
| MI/E | 40.3 | 15.4 | 3 (2–4) | Neutral | No consensus |
| MetaNeb | 54.3 | 46.2 | 3 (2–3) | Neutral | No consensus |
| IPPB | 33.3 | 35.4 | 3 (2–4) | Neutral | No consensus |
| 2) If I treat a patient with breathlessness at rest, I would use the following ACT: | |||||
| FET | 54,0 | 3.1 | 2 (1–4) | Disagree | No consensus |
| ACBT | 62.9 | 4.6 | 4 (3–4) | Agree | No consensus |
| Manual percussions | 78.7 | 6.2 | 2 (1–2) | Strongly disagree | Round 2 |
| Manual vibrations or shaking | 77.1 | 6.2 | 2 (1–2) | Strongly disagree | Round 2 |
| GAD | 72.1 | 12.2 | 1 (1–2) | Strongly disagree | No consensus |
| HFCWO | 68.8 | 34.7 | 2 (1–3) | Strongly disagree | No consensus |
| IPV | 42.9 | 24.6 | 3 (2–4) | Neutral | No consensus |
| AD | 43.3 | 4.6 | 3 (2–4) | Neutral | No consensus |
| ELTGOL | 40.7 | 9.2 | 3 (2–4) | Neutral | No consensus |
| PEP | 67.7 | 4.6 | 4 (3–4) | Agree | No consensus |
| O-PEP | 53.5 | 10.8 | 4 (3–4) | Agree | No consensus |
| Simeox | 36.11 | 44.6 | 3 (2–4) | Neutral | No consensus |
| SCT | 49.12 | 12.3 | 3 (3–4) | Neutral | No consensus |
| MI/E | 58.2 | 15.4 | 2 (1–3) | Disagree | No consensus |
| MetaNeb | 44.12 | 47.7 | 3 (2–3) | Neutral | No consensus |
| IPPB | 40.91 | 32.3 | 3 (2–3) | Neutral | No consensus |
| 3) If I treat a patient who is physically very tired, I would use the following ACT: | |||||
| FET | 58.1 | 4.6 | 4 (3–4) | Agree | No consensus |
| ACBT | 57.4 | 6.2 | 4 (3–4) | Agree | No consensus |
| Manual percussions | 72.6 | 4.6 | 2 (1–3) | Strongly disagree | No consensus |
| Manual vibrations or shaking | 66.1 | 4.6 | 2 (1–2) | Disagree | No consensus |
| GAD | 57.4 | 6.2 | 2 (1–4) | Disagree | No consensus |
| HFCWO | 52.2 | 30.0 | 2 (1–4) | Strongly disagree | No consensus |
| IPV | 49.0 | 21.5 | 3 (2–4) | Neutral | No consensus |
| AD | 32.8 | 6.2 | 3 (2–4) | Neutral | No consensus |
| ELTGOL | 50.0 | 10.8 | 3.5 (3–4) | Agree | No consensus |
| PEP | 66.1 | 4.6 | 4 (3–4) | Agree | No consensus |
| O-PEP | 55.2 | 10.8 | 4 (3–4) | Agree | No consensus |
| Simeox | 40.5 | 43.1 | 3 (2–4) | Neutral | No consensus |
| SCT | 45.5 | 15.4 | 3 (2–4) | Neutral | No consensus |
| MI/E | 37.5 | 13.8 | 3 (2–4) | Neutral | No consensus |
| MetaNeb | 40.0 | 46.2 | 3 (2–4) | Neutral | No consensus |
| IPPB | 35.0 | 38.5 | 3 (2.5–4) | Neutral | No consensus |
| 4) If I treat a patient who is frail, I would use the following ACT: | |||||
| FET | 69.8 | 3.1 | 4 (3–4) | Agree | No consensus |
| ACBT | 71.0 | 4.6 | 4 (3–4) | Agree | No consensus |
| Manual percussions | 83.9 | 11.2 | 1 (1–2) | Strongly disagree | Round 1 |
| Manual vibrations or shaking | 80.2 | 12.2 | 1 (1–2) | Strongly disagree | Round 1 |
| GAD | 58.1 | 4.6 | 2 (1–4) | Disagree | No consensus |
| HFCWO | 64.1 | 34.7 | 2 (1–3) | Strongly disagree | No consensus |
| IPV | 47.1 | 21.5 | 3 (2–4) | Neutral | No consensus |
| AD | 42.6 | 6.2 | 3 (2–4) | Neutral | No consensus |
| ELTGOL | 56.9 | 10.8 | 4 (3–4) | Agree | No consensus |
| PEP | 79.8 | 4.1 | 4 (4–5) | Agree | Round 1 |
| O-PEP | 62.7 | 9.2 | 4 (3–4) | Agree | No consensus |
| Simeox | 41.7 | 44.6 | 3 (2–4) | Neutral | No consensus |
| SCT | 50.0 | 16.9 | 3.5 (3–4) | Agree | No consensus |
| MI/E | 29.6 | 16.9 | 3 (2–4) | Neutral | No consensus |
| MetaNeb | 50.0 | 50.8 | 3 (2–3) | Neutral | No consensus |
| IPPB | 41.0 | 40.0 | 3 (2–4) | Agree | No consensus |
| 5) If I treat a patient who is very obese (BMI >40 kg·m−2), I would use the following ACT: | |||||
| FET | 82.1 | 3.1 | 4 (4–5) | Agree | Round 1 |
| ACBT | 78.9 | 8.2 | 4 (4–5) | Agree | Round 1 |
| Manual percussions | 80.2 | 12.2 | 1 (1–2) | Strongly disagree | Round 1 |
| Manual vibrations or shaking | 77.9 | 12.2 | 1 (1–2) | Strongly disagree | Round 1 |
| GAD | 67.2 | 6.2 | 2 (1–3) | Disagree | No consensus |
| HFCWO | 64.2 | 18.5 | 2 (2–3) | Disagree | No consensus |
| IPV | 59.6 | 20.0 | 2 (1–4) | Disagree | No consensus |
| AD | 50.8 | 9.2 | 4 (3–4) | Agree | No consensus |
| ELTGOL | 49.2 | 9.2 | 3 (2–4) | Neutral | No consensus |
| PEP | 93.6 | 4.1 | 5 (5–5) | Strongly agree | Round 1 |
| O-PEP | 82.2 | 14.3 | 4 (4–5) | Agree | Round 1 |
| Simeox | 43.2 | 43.1 | 3 (3–4) | Neutral | No consensus |
| SCT | 69.8 | 18.5 | 4 (3–4) | Aree | No consensus |
| MI/E | 45.5 | 15.4 | 3 (2–4) | Neutral | No consensus |
| MetaNeb | 38.2 | 47.7 | 3 (3–4) | Neutral | No consensus |
| IPPB | 47.5 | 38.5 | 3 (3–4) | Agree | No consensus |
| 6) If I treat a patient with low motivation for airway clearance, I would use the following ACT: | |||||
| FET | 79.0 | 4.6 | 4 (4–4) | Agree | Round 2 |
| ACBT | 40.3 | 4.6 | 3 (2–4) | Neutral | No consensus |
| Manual percussions | 72.1 | 6.2 | 2 (1–3) | Disagree | No consensus |
| Manual vibrations or shaking | 69.4 | 4.6 | 2 (1–3) | Disagree | No consensus |
| GAD | 70.0 | 9.2 | 2 (1–3) | Disagree | No consensus |
| HFCWO | 42.3 | 21.5 | 3 (2–4) | Neutral | No consensus |
| IPV | 40.0 | 23.1 | 3 (2–4) | Neutral | No consensus |
| AD | 56.7 | 7.7 | 2 (2–3) | Disagree | No consensus |
| ELTGOL | 40.4 | 12.3 | 3 (2–4) | Neutral | No consensus |
| PEP | 80.6 | 5.1 | 4 (4–5) | Agree | Round 1 |
| O-PEP | 81.0 | 10.8 | 4 (4–4) | Agree | Round 1 |
| Simeox | 44.7 | 41.5 | 3 (2–4) | Neutral | No consensus |
| SCT | 58.2 | 15.4 | 4 (3–4) | Agree | No consensus |
| MI/E | 42.6 | 16.9 | 3 (2–4) | Neutral | No consensus |
| MetaNeb | 38.2 | 47.7 | 3 (2–4) | Neutral | No consensus |
| IPPB | 43.9 | 36.9 | 3 (2–4) | Agree | No consensus |
| 7) If my patient is not able to perform ACT independently, I would use the following ACT: | |||||
| FET | 45.9 | 6.2 | 3 (2–4) | Neutral | No consensus |
| ACBT | 63.4 | 6.2 | 2 (2–3) | Disagree | No consensus |
| Manual percussions | 65.0 | 7.7 | 2 (1–3.5) | Disagree | No consensus |
| Manual vibrations or shaking | 59.7 | 4.6 | 2 (1–4) | Disagree | No consensus |
| GAD | 54.1 | 6.2 | 2 (1–4) | Disagree | No consensus |
| HFCWO | 43.1 | 6.2 | 3 (2–4) | Neutral | No consensus |
| IPV | 53.1 | 9.2 | 4 (2–4) | Agree | No consensus |
| AD | 67.8 | 9.2 | 2 (2–3) | Disagree | No consensus |
| ELTGOL | 51.7 | 10.8 | 2 (2–3) | Disagree | No consensus |
| PEP | 59.0 | 6.2 | 4 (3–4) | Agree | No consensus |
| O-PEP | 48.2 | 13.8 | 3 (3–4) | Neutral | No consensus |
| Simeox | 36.1 | 44.6 | 3 (2–4) | Neutral | No consensus |
| SCT | 48.1 | 4.6 | 3 (2–3) | Neutral | No consensus |
| MI/E | 52.7 | 15.4 | 4 (2–4) | Agree | No consensus |
| MetaNeb | 42.4 | 49.2 | 3 (2–4) | Neutral | No consensus |
| IPPB | 34.1 | 36.9 | 3 (3–4) | Neutral | No consensus |
| 8) If my patient cannot easily follow instructions, I would use the following ACT: | |||||
| FET | 40.9 | 4.6 | 3 (2–4) | Neutral | No consensus |
| ACBT | 62.3 | 6.2 | 2 (2–3) | Disagree | No consensus |
| Manual percussions | 66.7 | 7.7 | 2 (1–3.5) | Disagree | No consensus |
| Manual vibrations or shaking | 60.7 | 6.1 | 2 (1–4) | Disagree | No consensus |
| GAD | 52.5 | 6.2 | 2 (1–4) | Disagree | No consensus |
| HFCWO | 40.0 | 23.1 | 3 (2–4) | Neutral | No consensus |
| IPV | 47.1 | 21.5 | 3 (2–4) | Neutral | No consensus |
| AD | 60.0 | 7.7 | 2 (1–3) | Disagree | No consensus |
| ELTGOL | 63.8 | 10.8 | 2 (2–3) | Disagree | No consensus |
| PEP | 59.7 | 4.6 | 4 (3–4) | Agree | No consensus |
| O-PEP | 48.3 | 10.8 | 3 (3–4) | Neutral | No consensus |
| Simeox | 34.2 | 41.5 | 3 (2–4) | Neutral | No consensus |
| SCT | 55.8 | 20.0 | 2 (2–3) | Disagree | No consensus |
| MI/E | 41.5 | 18.5 | 3 (2–4) | Disagree | No consensus |
| MetaNeb | 36.4 | 49.2 | 3 (2–4) | Neutral | No consensus |
| IPPB | 33.3 | 40.0 | 3 (2–4) | Neutral | No consensus |
| 9) If my patient is currently on NIV, I would use the following ACT: | |||||
| FET | 60.0 | 7.7 | 4 (2–4) | Agree | No consensus |
| ACBT | 55.0 | 7.7 | 4 (2–4) | Agree | No consensus |
| Manual percussions | 70.0 | 7.7 | 2 (1–3) | Disagree | No consensus |
| Manual vibrations or shaking | 65.0 | 7.7 | 2 (1–4) | Disagree | No consensus |
| GAD | 56.7 | 7.7 | 2 (1–4) | Disagree | No consensus |
| HFCWO | 59.7 | 31.6 | 2 (1–3) | Strongly disagree | No consensus |
| AD | 47.5 | 9.2 | 3 (2–4) | Neutral | No consensus |
| ELTGOL | 43.1 | 10.8 | 3 (2–4) | Neutral | No consensus |
| Simeox | 47.2 | 44.6 | 3 (1–3) | Neutral | No consensus |
| SCT | 45.3 | 18.5 | 3 (2–4) | Neutral | No consensus |
| MI/E | 47.2 | 18.5 | 3 (2–4) | Neutral | No consensus |
| MetaNeb | 31.3 | 50.8 | 3 (2–4) | Neutral | No consensus |
| IPPB | 32.5 | 38.5 | 3 (1.5–4) | Agree | No consensus |
| 10) If I treat a patient showing evidence of localised secretions (X-ray, computed tomography scan, auscultation) during AECOPD, I would use the following ACT: | |||||
| FET | 71.4 | 3.1 | 4 (3–5) | Agree | No consensus |
| ACBT | 71.7 | 7.7 | 4 (3–5) | Agree | No consensus |
| Manual percussions | 70.5 | 6.2 | 2 (1–3) | Disagree | No consensus |
| Manual vibrations or shaking | 66.1 | 4.6 | 2 (1–3) | Disagree | No consensus |
| GAD | 53.2 | 4.6 | 2 (1–4) | Disagree | No consensus |
| HFCWO | 48.0 | 23.1 | 3 (2–4) | Neutral | No consensus |
| IPV | 47.1 | 21.5 | 3 (2–5) | Neutral | No consensus |
| AD | 50.0 | 7.7 | 3.5 (3–4) | Agree | No consensus |
| ELTGOL | 79.31 | 10.8 | 4 (4–5) | Agree | Round 2 |
| PEP | 90.3 | 4.6 | 4 (3–4) | Strongly agree | Round 2 |
| O-PEP | 84.5 | 10.8 | 4 (4–5) | Agree | Round 2 |
| Simeox | 44.4 | 44.6 | 3 (2.5–4) | Neutral | No consensus |
| SCT | 51.9 | 16.9 | 4 (3–4) | Agree | No consensus |
| MI/E | 39.6 | 18.5 | 3 (2–4) | Neutral | No consensus |
| MetaNeb | 38.2 | 47.7 | 3 (2–4) | Neutral | No consensus |
| IPPB | 45.5 | 38.5 | 3 (3–4) | Agree | No consensus |
| 11) If I treat a patient with having highly viscous or viscoelastic secretion during AECOPD, I would use the following ACT: | |||||
| FET | 69.9 | 3.1 | 4 (3–5) | Agree | No consensus |
| ACBT | 63.3 | 7.7 | 4 (3–4) | Agree | No consensus |
| Manual percussions | 71.7 | 7.7 | 2 (1–3) | Disagree | No consensus |
| Manual vibrations or shaking | 65.6 | 6.2 | 2 (1–3) | Disagree | No consensus |
| GAD | 59.0 | 6.2 | 2 (1–3) | Disagree | No consensus |
| HFCWO | 43.1 | 21.5 | 3 (2–4) | Neutral | No consensus |
| IPV | 58.8 | 21.5 | 4 (3–4) | Agree | No consensus |
| AD | 44.1 | 9.2 | 3 (3–4) | Neutral | No consensus |
| ELTGOL | 54.2 | 10.8 | 4 (3–4) | Agree | No consensus |
| PEP | 80.6 | 4.6 | 4 (4–4) | Agree | Round 2 |
| O-PEP | 87.9 | 10.7 | 4 (4–5) | Strongly agree | Round 2 |
| Simeox | 51.4 | 43.1 | 4 (3–4) | Agree | No consensus |
| SCT | 52.8 | 18.5 | 4 (3–4) | Agree | No consensus |
| MI/E | 40.7 | 16.9 | 3 (2–4) | Neutral | No consensus |
| MetaNeb | 34.3 | 46.2 | 3 (3–4) | Neutral | No consensus |
| IPPB | 48.7 | 40.0 | 3 (3–4) | Agree | No consensus |
| 12) If I treat a patient with high resting lung volume (i.e. hyperinflation, evidenced either via lung function test or clinically) during AECOPD, I would use the following ACT: | |||||
| FET | 59.0 | 6.2 | 4 (3–4) | Agree | No consensus |
| ACBT | 51.7 | 7.7 | 4 (2–4) | Agree | No consensus |
| Manual percussions | 82.0 | 6.2 | 2 (1–2) | Strongly disagree | Round 2 |
| Manual vibrations or shaking | 78.3 | 9.2 | 2 (1–2) | Strongly disagree | Round 2 |
| GAD | 70.0 | 7.7 | 2 (1–3) | Disagree | No consensus |
| HFCWO | 55.8 | 20.0 | 2 (2–3) | Disagree | No consensus |
| IPV | 39.2 | 21.5 | 3 (2–4) | Neutral | No consensus |
| AD | 39.0 | 9.2 | 3 (2–4) | Neutral | No consensus |
| ELTGOL | 58.6 | 10.8 | 4 (3–4) | Agree | No consensus |
| PEP | 79.4 | 3.1 | 4 (4–5) | Agree | Round 2 |
| O-PEP | 73.7 | 12.3 | 4 (3–5) | Agree | No consensus |
| Simeox | 41.7 | 44.6 | 3 (2.5–4) | Neutral | No consensus |
| SCT | 41.5 | 18.5 | 3 (3–4) | Neutral | No consensus |
| MI/E | 63.5 | 20.0 | 2 (1–3) | Disagree | No consensus |
| MetaNeb | 45.5 | 49.2 | 3 (2–3) | Neutral | No consensus |
The total number of responses was 98 for statements that achieved consensus or were removed in round 1. The total number of responses was 65 for the remaining statements. When consensus (75% agreement) was achieved, the columns are bolded. Items approaching consensus (between 70 and 75% agreement) are italicised. The scores on the Likert scale ranges from 1 to 5. The corresponding qualitative descriptor to each median score is given in the column “strength of consensus”. The percentage of agreement is calculated from the number of patients who answered on the Likert scale. Q1 is the 25th percentile, Q3 is the 75th percentile. ACBT: active cycle of breathing techniques; AD: autogenic drainage; AECOPD: acute exacerbation of COPD; BMI: body mass index; ELTGOL: slow expiration with glottis opened in lateral posture; FET: forced expiratory technique; GAD: gravity-assisted drainage; HFCWO: high-frequency chest wall oscillation; IPPB: intermittent positive pressure breathing; IPV: intrapulmonary percussive ventilation; IQR: interquartile range; MI/E: mechanical insufflation–exsufflation; NIV: noninvasive ventilation; O-PEP: oscillating positive expiratory pressure; PEP: positive expiratory pressure; SCT: specific cough technique.
TABLE 5.
Use of airway clearance techniques (ACTs) per country
| Round 1 (n=98) | Round 2 (n=65) | |||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Country | FET | ABCT | Manual percussions | Manual vibrations or shaking | GAD | HFCWO | IPV | Autogenic drainage | ELTGOL | PEP | O-PEP | Simeox | SCT | MI/E | MetaNeb | IPPB |
| Denmark n=10 | 10 (100) | 4 (40) | 1 (10) | 1 (10) | 4 (40) | 0 (0) | 0 (0) | 2 (20) | 5 (50) | 10 (100) | 2 (20) | 0 (0) | 4 (57) | 1 (14) | 0 (0) | 1 (14) |
| Norway n=11 | 10 (91) | 11 (100) | 0 (0) | 0 (0) | 1 (9) | 0 (0) | 0 (0) | 2 (18) | 4 (36) | 11 (100) | 6 (50) | 0 (0) | 9 (90) | 0 (0) | 0 (0) | 0 (0) |
| Sweden n=5 | 4 (80) | 2 (40) | 0 (0) | 0 (0) | 2 (40) | 0 (0) | 0 (0) | 0 (0) | 1 (20) | 5 (100) | 1 (20) | 0 (0) | 3 (75) | 0 (0) | 2 (50) | 0 (0) |
| UK n=6 | 6 (100) | 6 (100) | 3 (50) | 3 (50) | 1 (17) | 0 (0) | 0 (0) | 3 (50) | 0 (0) | 3 (50) | 4 (67) | 0 (0) | 3 (75) | 3 (75) | 0 (0) | 4 (100) |
| Spain n=4 | 2 (50) | 0 (0) | 0 (0) | 0 (0) | 0 (0) | 0 (0) | 1 (25) | 2 (50) | 3 (75) | 2 (50) | 4 (100) | 0 (0) | 2 (67) | 1 (33) | 0 (0) | 0 (0) |
| Portugal n=6 | 6 (100) | 5 (83) | 0 (0) | 0 (0) | 0 (0) | 1 (17) | 1 (17) | 2 (33) | 4 (67) | 3 (50) | 5 (83) | 0 (0) | 1 (33) | 3 (100) | 0 (0) | 1 (33) |
| Italy n=14 | 12 (86) | 9 (64) | 0 (0) | 0 (0) | 1 (7) | 2 (17) | 6 (43) | 7 (50) | 13 (93) | 14 (100) | 6 (43) | 6 (50) | 8 (67) | 1 (8) | 4 (33) | 4 (33) |
| Greece n=9 | 7 (78) | 8 (89) | 6 (67) | 7 (78) | 6 (67) | 0 (0) | 0 (0) | 5 (56) | 2 (22) | 3 (33) | 0 (0) | 0 (0) | 3 (75) | 1 (25) | 0 (0) | 0 (0) |
| Switzerland n=7 | 5 (71) | 3 (43) | 1 (14) | 0 (0) | 1 (14) | 0 (0) | 5 (71) | 7 (100) | 6 (86) | 4 (57) | 4 (57) | 1 (50) | 1 (50) | 1 (50) | 0 (0) | 0 (0) |
| Belgium n=10 | 6 (60) | 3 (30) | 0 (0) | 0 (0) | 0 (0) | 0 (0) | 4 (40) | 6 (60) | 7 (70) | 9 (90) | 8 (80) | 0 (0) | 4 (67) | 1 (17) | 0 (0) | 2 (20) |
| France n=11 | 6 (55) | 6 (55) | 0 (0) | 0 (0) | 0 (0) | 0 (0) | 0 (0) | 4 (36) | 7 (64) | 7 (64) | 5 (45) | 1 (14) | 1 (14) | 2 (29) | 0 (0) | 2 (29) |
| Turkey n=5 | 4 (80) | 5 (100) | 4 (80) | 3 (60) | 1 (20) | 3 (60) | 0 (0) | 2 (40) | 2 (40) | 4 (80) | 2 (40) | 0 (0) | 2 (67) | 1 (33) | 0 (0) | 0 (0) |
| Total n=98 | 78 (80) | 62 (63) | 15 (15) | 14 (14) | 17 (17) | 6 (6) | 17 (17) | 42 (43) | 54 (55) | 75 (77) | 47 (48) | 8 (12) | 41 (63) | 15 (23) | 6 (9) | 14 (22) |
Data presented as frequency (percentage) of participants from number of total participants from each country. Note: “Country” refers to the location where each Delphi participant is currently employed. ACBT: active cycle of breathing technique; ELTGOL: slow expiration with glottis opened in lateral posture; FET: forced expiratory technique; GAD: gravity-assisted drainage; HFCWO: high-frequency chest wall oscillation; IPPB: intermittent positive pressure breathing; IPV: intrapulmonary percussive ventilation; MI/E: mechanical insufflation–exsufflation; O-PEP: oscillating positive expiratory pressure; PEP: positive expiratory pressure; SCT: specific cough technique.
Participants reached consensus on which ACTs to use for six out of the 12 statements and on which ACTs not to use for seven out of the 12 statements. For ACTs to use, PEP reached consensus on six statements, O-PEP on four statements and FET on three statements. These treatments were selected in cases of limited treatment time, in very obese patients or in patients with low motivation for airway clearance. Additionally, PEP and O-PEP were selected for patients with evidence of localised secretions, and PEP for patients with frailty and high resting lung volume. The use of slow expiration with glottis opened in lateral posture (ELTGOL) reached consensus for three statements and active cycle of breathing techniques (ACBTs) for one statement, recommended in patients with evidence of localised, viscous or viscoelastic secretions. No consensus was reached on the use of ACTs in patients with breathlessness at rest, those very physically tired, those unable to perform ACTs independently, patients who cannot easily follow instructions and those on NIV (table 4). On ACTs not to use, manual percussion reached consensus on six statements and vibrations and shaking on five statements. These items reached consensus for patients with resting breathlessness, frailty, obesity and high resting volume. Consensus was also reached not to use manual percussion in cases of limited treatment time (table 4).
Airway clearance management across Europe
The most used ACTs for hospitalised patients with AECOPD were PEP, FETs and ACBTs. All participants from Denmark, Norway, Sweden and Italy reported using PEP. All participants from Denmark, UK and Portugal reported using FETs, and all participants from Norway, UK and Turkey reported using ACBTs. Some ACTs were reported as being used unanimously in certain countries, namely O-PEP in Spain, autogenic drainage in Switzerland and mechanical insufflation–exsufflation in Portugal. Greece, Belgium and France were the only countries whose participants did not have an ACT that was unanimously reported as commonly used by all the respondents of the country (100%). The most used ACTs were, ACBT in Greece (89%), PEP in Belgium (90%) and PEP and ELTGOL in France (64% for both).
In round 1, 78 out of 98 participants (80%) reported using exercise as an ACT. In addition, 83 participants (86%) considered physical activity and/or exercise as an ACT. Of these, 72 participants (87%) used physical activity and/or exercise in combination with other ACTs and only 34 participants (41%) used it as a standalone ACT. Access to ACT equipment is presented in table S1.
Discussion
This study was the first to investigate international consensus on ACTs for hospitalised patients with AECOPD. It also identified which ACTs are used across Europe. Following the invitation of 162 physiotherapists from 12 European countries to establish a Delphi panel and conduct two Delphi survey rounds, participants reached consensus on 26 items relating to the selection of specific ACTs. This consensus of ACTs to use or not to use is intended to support clinical decision-making and prioritisation of future research studies.
It is possible that some of these findings reflect recommendations of the clinical guidelines on airway clearance during clinically stable COPD or less severe exacerbations [17–20]. Specifically, guidelines often report the use of PEP, O-PEP and FETs, which may explain why these ACTs were more often favoured over others by our participants. In addition, these ACTs are accessible, easy to use and include devices of a relatively low cost, if applicable [12]. Consequently, our results might indicate that these ACTs can be preferable or more widely practiced compared to other ACTs because they do not require special training or expensive equipment. Access to equipment and associated costs might have influenced our findings. Use of individual ACTs in specific countries was identified and can be partially related to availability, access and training. Similarly, the use of ELTGOL could be attributed to the influence of studies on COPD that have explored the mechanisms of action of this technique [32, 33]. Still, it is unknown whether physiology, characteristics and practical aspects of ACTs during clinically stable stages of the disease remain equally important and relevant during severe acute exacerbations that require hospitalisation.
Furthermore, ACTs that were considered “traditional” and have a more passive component, such as manual percussions, vibrations and shaking, were often included in the consensus for ACTs not to use. These ACTs might have been perceived as less favourable by the Delphi panel as they can be time consuming or physically demanding for frail patients or those with fatigue, which were clinical statements included in the surveys. These techniques have also shown lower patient preference, as they usually require assistance. The variation observed when patients are unable to perform ACTs independently likely reflects the necessity of applying clinical judgment and adapting approaches on a case-by-case basis.
Physical activity and exercise were included in our survey as ACT options due to the ongoing debate regarding their effectiveness in airway clearance management and because some geographical areas, such as Australia, utilise exercise as the most commonly used ACT for managing COPD [8]. Herrero-Cortina et al. [34] concluded that there is insufficient evidence to recommend the use of exercise as an exclusive ACT in bronchiectasis. Current studies are investigating this research question in different patient populations, such as people with cystic fibrosis, where it is considered highly relevant and a high research priority [35].
Investigations into chronic respiratory conditions and their management during severe acute exacerbations are very limited. Recent large studies have reported the international use of ACTs in other respiratory conditions during clinically stable stages [36]. Data from the European Multicentre Bronchiectasis Audit and Research Collaboration, including 16 723 people with bronchiectasis from 28 countries, reported similar results to ours, demonstrating variability in the use of individual ACTs across Europe and identifying frequently used ACTs, such as the ACBT [36]. These international audit data indicated that ACTs were used mainly in patients with higher disease severity. Similarly, national surveys on bronchiectasis that investigated ACTs during clinically stable stages also indicated that ACTs are used reactively rather than proactively [37]. Furthermore, bronchiectasis guidelines recommend that a change in ACT may be necessary during an acute exacerbation due to changes in symptoms and sputum characteristics [38]. This is also likely to apply to individuals living with COPD, so results from individuals in a stable clinical state may not be applicable during an AECOPD. Thus, it is paramount to further assess airway clearance management during AECOPD, including its effectiveness and role in milder disease severities.
In support of this, the items that did not reach consensus highlight the considerable variability in clinical opinion and practice. Unsurprisingly, the statements that did not reach consensus for ACTs in AECOPD are in areas where the evidence base is limited, suggesting important uncertainties. This variability may contribute to differences in patient care and highlights the need for high-quality studies to clarify the efficacy and effectiveness of patient selection and support for more standardised and optimal practice.
Regarding the Delphi process, we planned two survey rounds a priori to mitigate respondent fatigue bias, as the surveys were lengthy and included repetitive answer options [39]. While the number of rounds in Delphi surveys typically ranges from two to four, there is limited evidence on the optimal number of rounds [40]. Furthermore, the threshold for consensus was defined as 75% a priori, although we also reported on “nearly consensus” items (70%). There is no agreement on the most appropriate threshold for a Delphi study, but our selection was based on a previous systematic review in Delphi studies, which identified consensus thresholds between 50% and 97%, with a median threshold of 75% [27].
The modified Delphi process followed a standardised methodology and was led by a multinational research team and the active participation of many clinicians and researchers, through a series of international workshops. The selection of relevant ACTs was additionally informed by a scoping review that used systematic methodology [41]. Still, it should be noted that our study is not without limitations. We aimed to establish international consensus but only participants from 12 European countries were included. Moreover, the number of participants from each country of employment was not equal, ranging from three to 14 per country, and in some instances, the sample size was small due to low response rates. Consequently, a few countries may have been under-represented. Low response rate is a common issue in surveys and we tried to address this through the engagement techniques reported in the methods section. As most participants reported an ORCID ID, the sample may have been weighted towards academic physiotherapists, which represents a potential limitation that could have influenced the perspectives captured in this study. Additionally, this was a study investigating expert consensus, so the views of patients and families were not considered. Finally, our strict consensus threshold could have precluded some additional agreement; therefore, a lower threshold has also been reported.
Conclusion and implications
This study identified some European consensus on the selection of ACTs for patients hospitalised with AECOPD and provided the first overview on the use of ACTs across Europe in this population. PEP and O-PEP were the most likely to reach a consensus on the ACT to use, while manual percussion, vibrations and shaking were the most likely to reach a consensus on the ACT not to use. It is important to highlight that this consensus represents the collective opinions of experienced physiotherapists and that future clinical studies are required to validate and expand on our results. Importantly, further investigations of countries outside Europe and further work on the use of individual ACTs for patients with AECOPD are required. Future research should also consider evaluating pragmatic and combined approaches to ACTs in AECOPD.
Footnotes
Provenance: Submitted article, peer reviewed.
Current Use of Airway Clearance Techniques in Hospitals (CACTOS) Delphi Panel: France: Valentin Rémi (Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique; AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Département R3S (Respiration, Réanimation, Réadaptation respiratoire, Sommeil), Paris, France); Mathieu Delorme (Centre de Recherche Cardio-Thoracique de Bordeaux, INSERM U1045, CRCTB; Plateforme Technologique d'Innovation Biomédicale (PTIB), Hôpital Xavier Arnozan, Pessac, France); Nicolas Lebrun (Service de Pneumologie, Allergologie et Oncologie Thoracique, Centre Hospitalier Universitaire d'Orléans, Orléans La Source, France); Beaumont Marc (CH des Pays de Morlaix, Pulmonary Rehabilitation Unit, Inserm, Univ Brest, UMR 1304, GETBO, France); Julien Lambert (Service de Pneumologie, Allergologie et Oncologie Thoracique, Centre Hospitalier Universitaire d'Orléans, Orléans La Source, France); Thibault Herlem (Hôpital Saint Philibert, Service MPRF (Médecine Physique et Réadaptation Fonctionnelle), Lomme, France); Yann Combret (Physiotherapy Department, Le Havre Hospital, Le Havre, France); Margaux Machefert (Paris-Saclay University, France); Clément Medrinal (ICU Department Le Havre Hospital, Montivilliers, France); Guillaume Prieur (Pulmonology Department, Groupe Hospitalier du Havre, Montivilliers, France); Hélène Laurent (Service Soins Oncologiques de Support, Centre de Lutte Contre le Cancer Centre Jean Perrin, Clermont-Ferrand, France); Lacombe Matthieu (AFM-Téléthon, Département des Actions Médicales; Département des Actions Médicales, Évry-Courcouronnes, France). Belgium: Christophe Thibon (Institut de Recherche Expérimentale et Clinique (IREC), Pôle de Pneumologie, ORL and Dermatologie, Université Catholique de Louvain, Brussels, Belgium); Inés Martín Corrons (Service de Pneumologie, Cliniques Universitaires Saint-Luc, Woluwe Saint-Lambert, Belgium); Thibault Coppens (Kinthico, Rosières, Belgium); Bruno Zwaenepoel (Universiteit Gent, Department of Rehabilitation Sciences, Campus UZ Gent, Ghent, Belgium); Daniel Langer (Department of Rehabilitation Sciences, KU Leuven, Leuven, Belgium); Olivier Van Hove (Department of Pneumology, Erasme Hospital (HUB), Brussels, Belgium). Switzerland: Cedric Dumans (Service de Médecine Interne/Pneumologie, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland); Lucas Fasquel (Service de physiothérapie, Réseau Hospitalier Neuchâtelois – Site Pourtalès, Neuchâtel, Switzerland); Grégory Deletre (CHVR (Centre Hospitalier du Valais Romand), MTT (Médico-Thérapeutique), Physiothérapie, Sion, Switzerland); Marius Hennemann (Physiothérapie Départements Chirurgie, Cœur-Vaisseaux et Centres Interdisciplinaires, CHUV, Lausanne, Switzerland); Joachim M. Schmidt Leuenberger (Department of Physiotherapy, Inselspital, Bern University Hospital, Bern, Switzerland); Jonathan Dugernier (Haute École Arc Santé, HES-SO, University of Applied Sciences and Arts of Western Switzerland, Neuchâtel, Switzerland); Samuel Müller (Réseau Hospitalier Neuchâtelois, Neuchâtel, Switzerland). Denmark: Mariana Bichuette Cartuliares (Department of Emergency Medicine, University Hospital of Southern Denmark, Aabenraa, Denmark); Barbara C. Brocki (Department of Physiotherapy and Occupational Therapy, Aalborg University Hospital, Aalborg, Denmark); Jane Gamborg Jensen (Department of Physiotherapy and Occupational Therapy, Aalborg University Hospital, Aalborg, Denmark); Elisabeth Bomholt Østergaard (VIA University College, Research Center for Rehabilitation, Research Programme for Mind and Body in Mental Health, Aarhus, Denmark); Linette Marie Kofod (PMR-C, Department of Physio- and Occupational Therapy, Copenhagen University Hospital, Hvidovre, Hvidovre, Denmark); Hanne Rohde (Herlev og Gentofte Hospital, Afdelingen for Fysioterapi og Ergoterapi 3, Hellerup, Denmark); Anders Staun Kristensen (Department of Physiotherapy and Occupational Therapy, Aalborg University Hospital, Aalborg, Denmark); Janne Hastrup Jensen (Aarhus University Hospital, Aarhus, Denmark). Norway: Bente Frisk (Department of Health and Functioning, Western Norway University of Applied Sciences, Bergen, Norway); Anne Kristine Brekka (Thoracic Department, Haukeland University Hospital, Helse-Bergen HF, Bergen, Norway); Tonje Klaette (Section for Physiotherapy, Department of Clinical Services, Division of Medicine, Oslo University Hospital, Oslo, Norway); Mona Lund Veie (Department of Physiotherapy and Occupational Therapy, Levanger Hospital, North-Trondelag Health Trust, Norway); Marthe Vinterhus Høiberg (Department of Physiotherapy, Sørlandet Hospital Arendal, Norway); Elin Johnsen (Helse Førde, Førde, Norway); Ulla Pedersen (Department of Cardiac and Pulmonary Rehabilitation, Lovisenberg Rehabilitation, Cathinka Guldberg's Hospital, Norway); Silje Ask Solbakken (Department of Cardiac and Pulmonary Rehabilitation, Lovisenberg Rehabilitation, Cathinka Guldberg's Hospital, Jessheim, Norway); Anita Grongstad (Department of Cardiac and Pulmonary Rehabilitation, Lovisenberg Rehabilitation, Cathinka Guldberg's Hospital, Jessheim, Norway); Åse Iren Steine (Department of Physiotherapy, Haukeland University Hospital, Bergen, Norway); Katrine Mikkelson (Department of Physiotherapy, Haukeland University Hospital, Bergen, Norway). Sweden: Jenny Höglund (Faculty of Medicine and Health, Örebro University, Örebro, Sweden); Ulrika Thunstrom (Danderyd University Hospital, Department of Orthopaedics, Division of Physiotherapy, Stockholm, Sweden); Karin Wadell (Community Medicine and Rehabilitation, Umeå University, Umeå, Sweden); Pernilla Sönnerfors (Medical Unit Occupational therapy and Physiotherapy, Women's Health and Allied Health Professionals Theme, Karolinska University Hospital, Stockholm, Sweden); Elisabeth Westerdahl (University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Örebro, Sweden). Greece: Vaia Sapouna (Clinical Exercise Physiology and Rehabilitation Research Laboratory, Physiotherapy Department, School of Health Sciences, University of Thessaly, 3rd Old National Road Lamia-Athens, Lamia, Greece); Maria Isakoglou (Clinical Exercise Physiology and Rehabilitation Research Laboratory, Physiotherapy Department, School of Health Sciences, University of Thessaly, 3rd Old National Road Lamia-Athens, Lamia, Greece); Dimitra Karadimou (University Hospital of Alexandroupolis, Dragana Alexadroupoli, Greece); Eleni A. Kortianou (Clinical Exercise Physiology and Rehabilitation Research Laboratory, Physiotherapy Department, School of Health Sciences, University of Thessaly, Greece.); Vangelis Bekas (Sotiria Hospital, Athens, Greece); Alexis Kokolios (Sotiria Hospital, Athens, Greece); Lina Bebeletsi (University Hospital of Alexandroupolis, Dragana Alexadroupoli, Greece); Athena Anastasaki (Chania Hospital, Greece); Maria Isakoglou (Clinical Exercise Physiology and Rehabilitation Research Laboratory, Physiotherapy Department, School of Health Sciences, University of Thessaly, 3rd Old National Road Lamia-Athens, Lamia, Greece). UK: Kira Helen Neal (Mid and South Essex NHS Foundation Trust, UK); Angeliki Perdikari (NHS Greater Glasgow and Clyde, UK); Lizzie Grillo (Guys and St Thomas’ NHS Foundation Trust, Royal Brompton Hospital, UK); Paul McCallion (Newcastle University, UK); Charles C. Reilly (Department of Physiotherapy King's College Hospital NHS Foundation Trust, UK); Rachael Colclough (Queen Elizabeth Hospital Birmingham, UK). Italy: Hilari Zatti (Department of Neuroscience, Section of Rehabilitation, Hospital-University of Padova, Italy); Martina Santambrogio (University of Milan, Department of Pathophysiology and Transplantation, Milan, Italy); Raffaella Bellini (Azienda Ospedaliera Universitaria di Verona, Italy); Salvatore Sciurello (University of Milan, Italy); Andrea Lanza (Interdepartmental Respiratory Physiotherapists Team, Niguarda Hospital, Milan, Italy); Salvatore Musella (Department of Respiratory Pathophysiology and Rehabilitation, Monaldi Hospital, Naples, Italy); Angela Bellofiore (Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Healthcare Professions Department, Milan, Italy); Francesco D'Abrosca (Associazione Italiana dell'Insufficienza Respiratoria (ARIR), ASST GOM Niguarda, Milan, Italy); Mariangela Retucci (Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Italy); Elena Compalati (Fisioterapista Cardio-Respiratoria e di Area Critica, Collaboratrice in Ricerca, Pneumologia Riabilitativa, IRCCS Santa Maria Nascente, Fondazione Don Gnocchi, Milan, Italy); Veronica Polelli (IRCCS Humanitas Research Hospital, Physiotherapy Unit, Rozzano, Milan, Italy); Marta Lazzeri (ARIR, ASST GOM Niguarda, Milan, Italy); Carla Simonelli (ICS Maugeri SpA Benefit, Italy); Veronica Rossi (Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico); Salvatore Caiffa (IRCCS Policlinico San Martino Hospital, Largo Rosanna Benzi, Genoa, Italy). Spain: Victoria Alcaraz Serrano (School of Health Sciences, Ramon Llull University, Spain); Lourdes Manglano (Hospital Universitario del Henares, Spain); Gerard Muñoz Castro (Girona Biomedical Research Institute, Department of Pneumology, Dr Josep Trueta University Hospital, Department of Physical Therapy, EUSES and ENTI, University of Girona and University of Barcelona, Girona, Spain); Antonio Tomás Ríos Cortés (Hospital General Universitario Santa Lucía, Cartagena, Spain). Portugal: Ana Filipa Machado (Comprehensive Health Research Center (CHRC), NOVA Medical School, NOVA University of Lisbon, Portugal); Vitor Hugo Azevedo (Alcoitão School of Health Sciences, Department of Physiotherapy, Portugal); Alda Sofia Pires de Dias Marques (Lab3R, School of Health Sciences (ESSUA) and Institute of Biomedicine (iBiMED), University of Aveiro, Aveiro, Portugal); Alexandre Silva (Unidade Local de Saúde Entre Douro e Vouga, Portugal); Filipa Carvalho Kendall (Unidade Local de Saúde São João, EPE, Alameda Prof. Hernâni Monteiro, Porto, Portugal); Miguel Gonçalves (University of Porto e Centro Hospitalar Universitario De Sao Joao, Porto, Portugal). Turkey: Zeynep Aribaş (Trakya University, Edirne, Turkey); Deniz Inal-Ince (Hacettepe University, Faculty of Physical Therapy and Rehabilitation, Ankara, Turkey); Melda Saglam (Hacettepe University, Faculty of Physiotherapy and Rehabilitation, Department of Cardiorespiratory Physiotherapy and Rehabilitation, Ankara, Turkey); Esra Pehlivan (University of Health Sciences, Faculty of Hamidiye Health Sciences, Department of Physiotherapy and Rehabilitation, İstanbul, Turkey); Aslihan Cakmak-Onal (Hacettepe University, Faculty of Physical Therapy and Rehabilitation, Ankara, Turkey); Gamze Koyuturk (Istanbul Topkapi University, Istabul, Turkey).
Ethics statement: This anonymous survey did not require ethics but received data protection institutional approval.
Conflict of interest: C. Schrøder, W. Poncin, G. Reychler, N. Audag, L. Gely, O. Contal, K. Ides, E. Grigoriou and I. Mechlenburg declare no conflicts of interest. A. Oliveira serves on the editorial board of ERJ Open Research but was not involved in the review or decision process for this manuscript. P. Cnockaert is a Research Fellow (ASP-REN mandate) of the FRS-FNRS (Fonds de la Recherche Scientifique, Belgium), which is unrelated to this work. M.D.L. O'Connell reports grants from the National Institute for Health Research and the Stroke Association, UK, unrelated to this work. C. Osadnik reports funding from the Medical Research Futures Fund, Australian Government, unrelated to this work. B. Herrero-Cortina reports receiving honoraria for lectures on airway clearance management from the Spanish Society of Pulmonology and Thoracic Surgery (SEPAR). A. Spinou reports a grant from Asthma & Lung UK, unrelated to this work and is the European Respiratory Society Chair for the Task Force on airway clearance techniques for adults with bronchiectasis.
Support statement: This study was funded by the Circle U Seed (funding number 2023-07). The funder had no role in the study design, data collection, analysis, interpretation of data, writing of the manuscript, or the decision to submit the article for publication. Funding information for this article has been deposited with the Open Funder Registry.
Contributor Information
on behalf of the Current Use of Airway Clearance Techniques in Hospitals (CACTOS) Delphi Panel:
Valentin Rémi, Mathieu Delorme, Nicolas Lebrun, Beaumont Marc, Julien Lambert, Thibault Herlem, Yann Combret, Margaux Machefert, Clément Medrinal, Guillaume Prieur, Hélène Laurent, Lacombe Matthieu, Christophe Thibon, Inés Martín Corrons, Thibault Coppens, Bruno Zwaenepoel, Daniel Langer, Olivier Van Hove, Cedric Dumans, Lucas Fasquel, Grégory Deletre, Marius Hennemann, Joachim M. Schmidt Leuenberger, Jonathan Dugernier, Samuel Müller, Mariana Bichuette Cartuliares, Barbara C. Brocki, Jane Gamborg Jensen, Elisabeth Bomholt Østergaard, Linette Marie Kofod, Hanne Rohde, Anders Staun Kristensen, Janne Hastrup Jensen, Bente Frisk, Anne Kristine Brekka, Tonje Klaette, Mona Lund Veie, Marthe Vinterhus Høiberg, Elin Johnsen, Ulla Pedersen, Silje Ask Solbakken, Anita Grongstad, Åse Iren Steine, Katrine Mikkelson, Jenny Höglund, Ulrika Thunstrom, Karin Wadell, Pernilla Sönnerfors, Elisabeth Westerdahl, Vaia Sapouna, Maria Isakoglou, Dimitra Karadimou, Eleni A. Kortianou, Vangelis Bekas, Alexis Kokolios, Lina Bebeletsi, Athena Anastasaki, Maria Isakoglou, Kira Helen Neal, Angeliki Perdikari, Lizzie Grillo, Paul McCallion, Charles C. Reilly, Rachael Colclough, Hilari Zatti, Martina Santambrogio, Raffaella Bellini, Salvatore Sciurello, Andrea Lanza, Salvatore Musella, Angela Bellofiore, Francesco D'Abrosca, Mariangela Retucci, Elena Compalati, Veronica Polelli, Marta Lazzeri, Carla Simonelli, Veronica Rossi, Salvatore Caiffa, Victoria Alcaraz Serrano, Lourdes Manglano, Gerard Muñoz Castro, Antonio Tomás Ríos Cortés, Ana Filipa Machado, Vitor Hugo Azevedo, Alda Sofia Pires de Dias Marques, Alexandre Silva, Filipa Carvalho Kendall, Miguel Gonçalves, Zeynep Aribaş, Deniz Inal-Ince, Melda Saglam, Esra Pehlivan, Aslihan Cakmak-Onal, and Gamze Koyuturk
Supplementary material
Please note: supplementary material is not edited by the Editorial Office, and is uploaded as it has been supplied by the author.
Table S1
01331-2025.SUPPLEMENT
Delphi survey round 1
01331-2025.SUPPLEMENT3
Delphi survey round 2
01331-2025.SUPPLEMENT2
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Please note: supplementary material is not edited by the Editorial Office, and is uploaded as it has been supplied by the author.
Table S1
01331-2025.SUPPLEMENT
Delphi survey round 1
01331-2025.SUPPLEMENT3
Delphi survey round 2
01331-2025.SUPPLEMENT2