This week’s Pulm PEEPs Pearls episode is a focused discussion between Furf and Monty about non-pharmacologic techniques for airway clearance in the non-Cystic Fibrosis bronchiectasis population. This is a focused, high-yield discussion of the key points about airway clearance, including practical tips and a discussion of the evidence.This episode was prepared in conjunction with George Doumat MD. Goerge is an internal medicine resident at UT Southwestern and joined us for a Pulm PEEPs – BMJ Thorax journal club episode. He is now acting as a Pulm PEEPs Editor for the Pulm PEEPs Pearls series.Key Learning Points1) Why airway clearance matters in non-CF bronchiectasisNon-CF bronchiectasis is defined by irreversible bronchial dilation with impaired mucociliary clearance, leading to mucus retention.Retained sputum drives the classic vicious cycle: mucus → infection → neutrophilic inflammation → airway damage → worse clearance.Airway clearance techniques (ACTs) are meant to interrupt this cycle, primarily by improving mucus mobilization and symptom control.2) What ACTs are trying to achieve clinicallyMain benefits are:More effective sputum clearanceReduced cough/dyspnea burdenImproved activity tolerance and quality of lifeEffects on spirometry are usually small.Exacerbation reduction is possible, but evidence is mixed—some longer-term data suggest benefit for specific techniques.3) The main ACT “families” and when to use themBreathing-based techniques (device-free, flexible)ACBT (Active Cycle of Breathing Technique): breath control → deep breaths with holds → huffing.Pros: portable, adaptable, good first-line option.Key requirement: teaching/coaching to get technique right.Autogenic drainage: controlled breathing at different lung volumes to move mucus from peripheral → central airways.Pros: no device, can work well once learned.Cons: more technically demanding, needs training and practice.PEP / Oscillatory PEP (stents airways + “vibrates” mucus loose)PEP: back-pressure helps prevent small airway collapse during exhalation; often paired with huff/cough.Oscillatory PEP (Flutter/Acapella/Aerobika): adds oscillation that many patients find easy and satisfying to use.Good fit for: people who benefit from airway stenting, want something portable, and prefer a device.Mechanical/manual techniques (help when patient can’t self-clear well)HFCWO (“the vest”): external chest wall oscillation; helpful for high sputum volumes, dexterity limits, or difficulty coordinating breathing maneuvers.Postural drainage/percussion/vibration: caregiver/therapist-assisted options; still useful but consider:GERD/reflux risk with certain positionsHemoptysis risk with vigorous techniques4) How to choose the “right” technique (the practical framework)There is no one-size-fits-all. Match the tool to the patient:Sputum burden (volume/viscosity)Strength, coordination, cognition, dexterityComorbidities (GERD, hemoptysis history, severe obstruction/airway collapse)Lifestyle + portability (what they’ll actually do)Cost/access and availability of respiratory therapy/physio supportA key mindset from the script: this is not a lifetime contract—reassess and adjust over time with shared decision-making.5) Evidence takeaways (what improves, what doesn’t)ACTs reliably improve sputum expectoration and often symptoms/QoL.QoL/cough scores (e.g., SGRQ, LCQ) tend to improve modestly, particularly with oscillatory PEP and some vest studies.Lung function: typically minimal change; occasional short-term FEV₁ benefit is reported in some vest trials.Exacerbations: mixed overall; the script highlights a longer-term RCT of ELTGOL showing fewer exacerbations at 12 months vs placebo exercises.Safety: generally excellent; main cautions are hemoptysis and reflux (depending on technique/positioning).6) Special population pearlsHemoptysis / fragile airways: start with gentle breathing-based ACTs (ACBT, controlled huffing); avoid overly vigorous oscillatory/manual methods if concerned.Severe obstruction or early airway collapse: PEP/oscillatory PEP can help by keeping small airways open on exhalation.Mobility/coordination barriers: consider HFCWO vest or simple oscillatory PEP devices to enable daily adherence.During exacerbations: keep it simple—1–2 reliable techniques, prioritize daily consistency, and re-check technique.7) The “real” bottom lineStart with simple, self-manageable options (often ACBT ± PEP).The “best” ACT is the one the patient will do consistently.Reassess technique and fit over time; education and demonstration are part of the therapy.References and Further Reading Lee AL et al., “Airway clearance techniques for bronchiectasis,” Cochrane Database Syst Rev. 2015; PMC7175838. PMID: 26591003.Athanazio RA et al., “Airway Clearance Techniques in Bronchiectasis,” Front Med (Lausanne). 2020; PMC7674976. PMID: 33251032.Iacono R et al., “Mucociliary clearance techniques for treating non-cystic fibrosis bronchiectasis,” Eur Rev Med Pharmacol Sci. 2015; PMID: 26078380.Polverino E et al., “European Respiratory Society statement on airway clearance techniques in bronchiectasis,” Eur Respir J. 2023; PMID: 37142337.Doumat G, Aksamit TR, Kanj AN. Bronchiectasis: A clinical review of inflammation. Respir Med. 2025 Aug;