Self-management for non-cystic fibrosis bronchiectasis

Background

Bronchiectasis is a respiratory condition that may occur in both children and adults and is being diagnosed with increasing frequency. It is a long-term condition, where people have recurrent chest infections and symptoms that include cough, mucus production and recurrent flare-ups (exacerbations) that reduce their quality of life. The main aims of management are to reduce the risk of flare-ups using various treatments including antibiotics, inhalers and physiotherapy exercises. It is important for people/carers to stick to their treatments and self-management strategies can help people to do this by teaching them about their condition, available treatments, exercise and what to do if their condition changes. The objective of the review is to assess the effectiveness and value for money of self-management interventions for adults and children with non-cystic fibrosis bronchiectasis.

Review question

We assessed the benefits and possible harms of self-management strategies, including patient education, airway clearance techniques, education aimed at increasing adherence to medication, exercise (including pulmonary rehabilitation), and action plans for children and adults with bronchiectasis.

Study characteristics

We conducted a search on 13 December 2017 and found just two UK studies that included 84 participants, comparing a self-management approach with normal care for adults with bronchiectasis. One study looked at the impact of an expert patient self-management programme and the other, involving just a small number of participants with bronchiectasis, looked at self-management in combination with exercises to improve lung function. Neither study included children.

Main results

Health-related quality of life did not improve in either study. Although there were more deaths in the group receiving self-management in one study, the numbers were very small and we do not know whether the difference is meaningful. The number of admissions to hospital, and lung function showed no benefit from self-management. In one of the studies, people receiving self-management felt more empowered to manage their condition. There was no information on the impact of self-management on symptoms of bronchiectasis, adverse events or potential cost savings arising from more effective self-management. There are no studies looking at self-management in children.

Overall there is not enough information to assess whether strategies to support self-management may help people with bronchiectasis and further studies are needed. Future studies will need to look at how often flare ups occur, how often antibiotics are prescribed, and how long for, whether people have a better quality of life, and the impact of self-management on costs of care. It is also important to look at self-management for bronchiectasis in children.

Quality of the results

This review is based on only two small trials and the quality of the studies is very poor. With only two studies looking at very specific approaches to self-management we cannot say with any degree of certainty whether self-management strategies work for people with bronchiectasis, but until further evidence is available we advocate adherence to current international guidelines that recommend self-management for people with bronchiectasis.

Authors' conclusions: 

There is insufficient evidence to determine whether self-management interventions benefit people with bronchiectasis. In the absence of high-quality evidence it is advisable that practitioners adhere to current international guidelines that advocate self-management for people with bronchiectasis.

Future studies should aim to clearly define and justify the specific nature of self-management, measure clinically important outcomes and include children as well as adults.

Read the full abstract...
Background: 

Bronchiectasis is a long term respiratory condition with an increasing rate of diagnosis. It is associated with persistent symptoms, repeated infective exacerbations, and reduced quality of life, imposing a burden on individuals and healthcare systems. The main aims of therapeutic management are to reduce exacerbations and improve quality of life. Self-management interventions are potentially important for empowering people with bronchiectasis to manage their condition more effectively and to seek care in a timely manner. Self-management interventions are beneficial in the management of other airways diseases such as asthma and COPD (chronic obstructive pulmonary disease) and have been identified as a research priority for bronchiectasis.

Objectives: 

To assess the efficacy, cost-effectiveness and adverse effects of self-management interventions for adults and children with non-cystic fibrosis bronchiectasis.

Search strategy: 

We searched the Cochrane Airways Specialised Register of trials, clinical trials registers, reference lists of included studies and review articles, and relevant manufacturers’ websites up to 13 December 2017.

Selection criteria: 

We included all randomised controlled trials of any duration that included adults or children with a diagnosis of non-cystic fibrosis bronchiectasis assessing self-management interventions delivered in any form. Self-management interventions included at least two of the following elements: patient education, airway clearance techniques, adherence to medication, exercise (including pulmonary rehabilitation) and action plans.

Data collection and analysis: 

Two review authors independently screened searches, extracted study characteristics and outcome data and assessed risk of bias for each included study. Primary outcomes were, health-related quality of life, exacerbation frequency and serious adverse events. Secondary outcomes were the number of participants admitted to hospital on at least one occasion, lung function, symptoms, self-efficacy and economic costs. We used a random effects model for analyses and standard Cochrane methods throughout.

Main results: 

Two studies with a total of 84 participants were included: a 12-month RCT of early rehabilitation in adults of mean age 72 years conducted in two centres in England (UK) and a six-month proof-of-concept RCT of an expert patient programme (EPP) in adults of mean age 60 years in a single regional respiratory centre in Northern Ireland (UK). The EPP was delivered in group format once a week for eight weeks using standardised EPP materials plus disease-specific education including airway clearance techniques, dealing with symptoms, exacerbations, health promotion and available support. We did not find any studies that included children. Data aggregation was not possible and findings are reported narratively in the review.

For the primary outcomes, both studies reported health-related quality of life, as measured by the St George's Respiratory Questionnaire (SGRQ), but there was no clear evidence of benefit. In one study, the mean SGRQ total scores were not significantly different at 6 weeks', 3 months' and 12 months' follow-up (12 months mean difference (MD) -10.27, 95% confidence interval (CI) -45.15 to 24.61). In the second study there were no significant differences in SGRQ. Total scores were not significantly different between groups (six months, MD 3.20, 95% CI -6.64 to 13.04). We judged the evidence for this outcome as low or very low. Neither of the included studies reported data on exacerbations requiring antibiotics. For serious adverse events, one study reported more deaths in the intervention group compared to the control group, (intervention: 4 of 8, control: 2 of 12), though interpretation is limited by the low event rate and the small number of participants in each group.

For our secondary outcomes, there was no evidence of benefit in terms of frequency of hospital admissions or FEV1 L, based on very low-quality evidence. One study reported self-efficacy using the Chronic Disease Self-Efficacy scale, which comprises 10 components. All scales showed significant benefit from the intervention but effects were only sustained to study endpoint on the Managing Depression scale. Further details are reported in the main review. Based on overall study quality, we judged this evidence as low quality. Neither study reported data on respiratory symptoms, economic costs or adverse events.

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