Managing an exacerbation through physiotherapy

An exacerbation is a flare up of your lung condition, where your condition can worsen and is usually caused by a chest infection. During an exacerbation it is likely that your chest symptoms may feel worse. Common symptoms include a change in the colour, thickness and quantity of your sputum, as well as coughing more, feeling breathless and struggling to get up and move around. The degree of symptoms varies with each individual.

When you have an exacerbation, the amount of sputum you produce may increase, it may also change colour and become thicker making it more difficult to clear. When you are taking medication for an infection it is essential for you to keep your chest as clear as possible to give the treatments the best chance of working. This is because if sputum is trapped in your airways, it can cause inflammation and provide an ideal environment for bacteria (germs) to thrive. The clearer your chest is, the more likely it is for treatments to work.

Airway clearance techniques can help loosen sputum from the lungs so it can be cleared from the airways and improve lung function and breathing.

There are various airway clearance techniques patients can use, but these will be tailored for each individual to ensure the technique is suited to their needs. Some techniques include breathing exercises alone and others use a device alongside the breathing exercise. You will be taught the technique that is best suited to your needs by a specialist physiotherapist.

If you have already been taught an airway clearance technique and regime before this exacerbation, these techniques may need to be adapted whilst you are currently unwell to ensure they are as effective as possible in clearing your chest.

It is essential that you contact your physiotherapist if you are struggling to clear your chest or are unable to perform the airway clearance techniques. Please see the ‘Contact us’ section below to contact the physiotherapy team.

It is essential you keep hydrated and drink plenty of fluids during an exacerbation. Being dehydrated can affect your sputum and cause it to become thicker and stickier. Your airways can also become dry, making it harder for sputum to clear, causing an irritable cough in some people. If you are unable to clear your sputum effectively this can lead to your antibiotic therapy not working, as well as possibly worsening your cough, and/or worsening your shortness of breath.

Drinking plenty of fluids, including water and decaffeinated drinks is important and you should aim to drink 1.5-2 litres of water a day. You may be prescribed saline or salty saline (MucoClear, Nebusal) to take in a nebuliser (a device that allows you to breathe in medication through a mask or mouthpiece).  This can be helpful if your sputum is very thick and sticky. This should be done before you do your airway clearance techniques. Please talk to your physiotherapist about this.  

Patients who use inhalers and nebulisers need to know what order to take their inhalers and nebulisers in line with their physiotherapy airway clearance techniques. As a general rule of thumb, you should take your inhaler and/or nebulisers (medicines that open your airways) first (such as a salbutamol inhaler (commonly known as Ventolin) and/or ipratropium bromide (commonly known as Atrovent). You should then take your saline (Mucoclear) or salty saline (Nebusal) medications before completing your airway clearance, and as prescribed by your physiotherapist. Following this, you can take your preventer and steroid inhalers and/or nebulised antibiotic (such as Fostair, Trimbow, and/or Colomycin).

• Loosen: Keeping hydrated is essential and has a direct impact on your secretions, so it is essential to drink plenty of fluids. If your secretions are very thick or sticky, then you may be advised to take a nebuliser with saline (MucoClear) or salty saline (Nebusal) to help loosen these secretions. Please ask your physiotherapist for advice if you are unsure.
• Inhalers: Some patients may be on medications to open up their airways e.g. a blue inhaler (Ventolin). It may be important to use this before your airway clearance (with advice from your medical team and physiotherapist).
• Frequency: Increase the frequency of your airway clearance regime e.g. once a day to twice a day.
• Time: Increase the length of your airway clearance e.g. from 10 minutes to 20 minutes until your cough is clear or you require a rest.

When you are unwell, it is important to rest and allow yourself time to recover. Having enough energy is important to enable you to clear your chest. However, some daily activity is helpful and will aid your recovery. Physically moving around helps with airway clearance as the air will move in and out your chest more quickly which can help to break up and clear the sputum.

Activity can also help with mood and mental health. After a few days of your medications, if you start to feel better, it is good to start doing some physical activity. This could include gentle low impact exercise like walking, yoga, stretching etc. If you are normally very physically active, you may feel you can manage more than this.

Whatever exercise/activity you choose to do, start at a lower level than what you are used to, building up slowly over time. Your exercise/activity should be comfortable, and easy to recover from. You should stop if you experience chest pain, feeling faint or unexpected breathlessness. You should always seek advice if unsure.

Please see the ‘Contact us’ section below to contact the physiotherapy team.

If you feel unwell or don’t feel like you are getting better, contact the relevant clinical team on the numbers below as soon as possible. In an emergency call 999 for an ambulance or go to your nearest emergency department (A&E).

If you feel like you are struggling to clear your chest then it is important to discuss this with the physiotherapy team. You will hopefully have been assessed on day one of your antibiotic courses and may have also received some follow up. However, if you feel like your chest is not clearing or physiotherapy is difficult due to breathlessness, wheezing, chest pain or thick secretions then please seek advice from the team, as per the ‘contact us’ section.

Some patients may not require a follow up and going back to your usual airway clearance and exercise is advised. Sometimes it will be necessary to have a follow up after a few months to see how things are progressing. This is especially important if you notice your infection frequency has increased or if your airway clearance is difficult to remember or complete. Physiotherapists can help to ensure you have the best tool kit to look after your condition long term. You may benefit from pulmonary rehabilitation following an exacerbation to improve your fitness.