Is there evidence for the use of Continuous Positive Airway Pressure (CPAP) in patients with bronchiectasis?

Evidence for CPAP in Bronchiectasis

CPAP is not recommended for routine use in patients with bronchiectasis as there is insufficient evidence supporting its effectiveness for this condition. 1

Current Recommendations

The evidence regarding CPAP specifically for bronchiectasis is limited. According to the British Thoracic Society guidelines, a trial of non-invasive ventilation (NIV) may be undertaken in patients with respiratory acidosis (pH<7.35) secondary to an acute exacerbation of bronchiectasis, but excessive secretions are likely to limit its effectiveness and it should not be used routinely 1.

The European Respiratory Society (ERS) guidelines for adult bronchiectasis do not recommend CPAP or NIV as routine treatments for bronchiectasis 1. Instead, they emphasize other approaches for airway clearance:

1. Airway clearance techniques taught by a trained respiratory physiotherapist
2. Pulmonary rehabilitation for patients with impaired exercise capacity
3. Mucoactive treatments for patients with difficulty expectorating sputum

Airway Clearance Approaches for Bronchiectasis

For patients with bronchiectasis, the following airway clearance approaches are recommended:

Airway Clearance Techniques

• Active cycle of breathing techniques
• Autogenic drainage
• Gravity-assisted drainage
• Positive expiratory pressure (PEP) devices
• Oscillating PEP devices
• Physical exercise

These techniques should be individualized and taught by a respiratory physiotherapist 1.

Pulmonary Rehabilitation

The ERS strongly recommends pulmonary rehabilitation for adult patients with bronchiectasis who have impaired exercise capacity, based on high-quality evidence 1.

Special Considerations

Respiratory Failure

For patients with bronchiectasis who develop respiratory failure:

• Long-term oxygen therapy should be considered for patients with respiratory failure, using the same eligibility criteria as for COPD 2
• Domiciliary non-invasive ventilation with humidification may be considered for patients with respiratory failure associated with hypercapnia 2

Excessive Secretions

A major limitation for CPAP/NIV use in bronchiectasis is the presence of excessive secretions, which can:

1. Interfere with the effectiveness of positive pressure ventilation
2. Increase the risk of complications
3. Make mask ventilation difficult to tolerate 1

Specific Clinical Scenarios

In certain clinical scenarios, CPAP might be considered:

1. Acute Hypoxemic Respiratory Failure: CPAP may improve oxygenation in patients with diffuse pneumonia who remain hypoxic despite maximum medical treatment 1

2. Hypercapnic Respiratory Failure: NIV can be used as an alternative to tracheal intubation if the patient becomes hypercapnic, but this should only be done in an ICU setting if the patient would be a candidate for intubation 1

Conclusion

While CPAP and NIV have established roles in conditions like COPD and obstructive sleep apnea, their routine use in bronchiectasis is not supported by current evidence. The management of bronchiectasis should focus on airway clearance techniques, pulmonary rehabilitation, and appropriate antibiotic therapy. If respiratory support is needed, it should be provided in appropriate settings with careful monitoring, particularly given the challenges posed by excessive secretions in this patient population.