What does it mean to offer the Active Cycle of Breathing Techniques (ACT) or oscillating positive expiratory pressure (OPEP) to patients with bronchiectasis?

What Does This Recommendation Mean?

The British Thoracic Society guideline recommends that all patients with bronchiectasis should be offered either the Active Cycle of Breathing Techniques (ACBT) or oscillating positive expiratory pressure (OPEP) devices as first-line airway clearance therapy to help clear mucus from their lungs and reduce exacerbations. 1

Understanding the Recommendation

This is a Grade D recommendation from the 2019 BTS guideline, meaning it's based on expert consensus and lower-quality evidence, but represents standard care for bronchiectasis management 1. The guideline specifically states these two techniques should be "offered" to individuals with bronchiectasis as the primary airway clearance options.

What This Means in Practice:

For ACBT (Active Cycle of Breathing Techniques):

• This is the most commonly taught technique in the UK, used by 91% of respiratory physiotherapists 1
• It's a self-directed breathing exercise combining relaxed breathing, deep breathing exercises, and forced expiration (huffing)
• Can be performed independently without equipment
• Often combined with gravity-assisted positioning for enhanced effectiveness
• Studies show it improves cough-related quality of life during exacerbations 1

For OPEP (Oscillating Positive Expiratory Pressure):

• Uses handheld devices (like Acapella or Flutter) that create vibrations and positive pressure during exhalation
• Helps mobilize secretions through oscillatory effects
• May improve adherence compared to ACBT alone - one study showed 85% adherence with OPEP versus 74% with standard techniques 2
• Patients often prefer these devices (44% preference in one study) 1
• Recent evidence suggests OPEP reduces exacerbations when used twice daily 3

Clinical Implementation Algorithm:

Step 1: Initial Assessment

• All patients with bronchiectasis producing sputum should be referred to a respiratory physiotherapist 1
• Review CT imaging to identify affected lung segments for targeted positioning 1

Step 2: Choose Initial Technique

• Offer ACBT first if: Patient prefers no equipment, has good understanding and motivation, or cost is a barrier
• Offer OPEP first if: Patient prefers device-based therapy, has adherence concerns, or finds ACBT too complex 1
• The 2025 ERS guideline supports starting with independent techniques (like ACBT) before adding devices 4

Step 3: Training Requirements

• Minimum 10 minutes, maximum 30 minutes per session 1
• Continue until two clear huffs/coughs are completed or fatigue develops 1
• Perform twice daily as standard 1
• Include forced expiration technique (huffing) with all methods 1

Step 4: Enhance Effectiveness

• Add gravity-assisted positioning (modified postural drainage without head-down tilt) unless contraindicated 1
• If gastroesophageal reflux worsens with positioning, teach techniques in sitting position 1
• Consider pre-treatment with bronchodilators if patient has airway hyperreactivity 1

Step 5: Monitoring

• Review within 3 months of initial assessment 1
• Annual review for all patients in secondary care 1
• Immediate review if deterioration occurs (increased exacerbations or worsening symptoms) 1

Important Caveats:

No technique is definitively superior - studies show ACBT and OPEP have similar effectiveness for sputum clearance 1. A 2026 RCT found ACBT and walking with huffing produced similar sputum weights and quality of life improvements, though ACBT showed longer time to next exacerbation (158 vs 89 days for OPEP) 5.

Patient preference is critical - adherence is only 41% overall, worse in younger patients and those who don't understand the necessity 1. The guideline explicitly states to consider patient preference when recommending techniques 1.

Alternative options exist if ACBT or OPEP fail or are unacceptable: autogenic drainage, high-frequency chest wall oscillation, or intrapulmonary percussive ventilation 1.

During exacerbations, patients should be seen daily by a physiotherapist until airway clearance is optimized 1. Manual techniques may be added when patients are fatigued 1.

The evidence base is limited - most studies are small, underpowered, and at high risk of bias 6. The guideline acknowledges this and calls for larger RCTs with clinically important outcomes 1.

The bottom line: This recommendation establishes ACBT and OPEP as standard first-line airway clearance options that should be routinely offered, taught by trained physiotherapists, and individualized based on patient factors and preferences to maximize long-term adherence and clinical benefit.