The role of medical devices in airway clearance for chronic respiratory patients : steps towards implementation in primary care

The respiratory system employs multiple defense mechanisms to clear inhaled particles, with airway mucus production and clearance playing a crucial role. In chronic respiratory disorders such as Chronic Obstructive Pulmonary Disease (COPD) and cystic fibrosis (CF), mucus retention impairs airway clearance, necessitating airway clearance techniques (ACTs) to enhance sputum mobilisation. Device-assisted ACTs are widely used in clinical practice but require further investigation regarding their effect, mode of actions and implementation in primary care. This doctoral thesis explores the effectiveness of device-assisted ACTs in patients with chronic mucus retention and examines contextual factors influencing their implementation into primary care. The first part of the thesis evaluates the efficacy and mode of action of two medical devices for airway clearance. In Chapter 4, a study on CF patients demonstrated that the mobile high-frequency chest wall oscillation (mHFCWO) device (Monarch) was as effective as traditional non-mobile HFCWO devices, promoting mucus clearance, as assessed by Functional Respiratory Imaging (FRI). Chapter 5 investigated the Aerobika oscillating Positive Expiratory Pressure (oPEP) device in COPD patients, showing that twice-daily use for 15 days increased specific airway volume and improved airflow redistribution, enhancing drug deposition and lung function. The findings confirm that these device-assisted ACTs can aid airway clearance. The second part of the thesis examines factors influencing the implementation of ACTs in primary care. Chapter 6 presents a systematic review on the cost-effectiveness of respiratory physiotherapy interventions, revealing that exercise training and physical activity generally improve quality of life and economic outcomes while being cost-effective. Chapter 7 explores general practitioners' (GPs) perspectives on non-pharmacological COPD treatments, highlighting barriers such as limited awareness, organisational challenges, and scepticism regarding effectiveness. Despite clinical guidelines recommending ACTs, GPs primarily focus on pharmacotherapy, with limited engagement in interprofessional collaboration. Chapter 9 synthesises these findings, underscoring the necessity of further research on device-assisted ACTs through large-scale trials and hybrid effectiveness-implementation designs. Recommendations include enhancing referral systems, fostering interdisciplinary collaboration, integrating digital health tools, and embedding ACT-related competencies in physiotherapy and GP curricula. Addressing these challenges could facilitate the adoption of ACTs in primary care, ultimately improving outcomes for patients with chronic mucus retention.