To date there have been limited published studies of antibiotic usage to control airway inflammation in PCD. With PCD being relatively new to the research arena there are unfortunately very limited data collection and or research into specific PCD treatment and management. Much of what doctors do today to treat their PCD patients is borrowed from Cystic Fibrosis (CF) research and established CF treatments and guidelines. This is in part because CF is basically mucoclearance issues just as PCD is. However though the disease path in CF seems similar to PCD, both diseases are due to different physiological reasons which are independent of each other.

Another treatment method often see in CF that is currently under use in PCD care is the usage of low dose antibiotics, sometimes referred to as prophylactic antibiotics, which are aimed to target airway inflammation. Airway inflammation is a key factor in disease progression in Cystic Fibrosis patients, more so than chest infections. The theory behind low dose antibiotics for inflammation is to control inflammation and or erase inflammation which should slow down disease progression. These low dose antibiotics called “macrolides” are often given three times a week; usually on Monday, Wednesday, and Friday schedule. Macrolides are a broad spectrum antibiotic class which includes Clarithromycin (Biaxin), Azithromycin (Zithromax), Erythromycin, Spriamcin, and Telithromycin. Macrolide antibiotics are often prescribed to treat everyday infections, but have lately come to be known for their anti inflammatory properties. Those anti inflammatory properties have made them an excellent choice for use in controlling airway inflammation and thereby reducing or slowing disease progression in CF. Whether this translates over to disease progression in PCD remains to be seen. However, when put in practice by physicians for their PCD patients the antidotal evidence suggests that reducing inflammation in PCD seems to slow the disease progression in PCD.

One common misconception in using low dose prophylactic macrolides is that the patient should not get/ acquire respiratory infections because the patient is on prophylactic antibiotics. It’s important to note that low dose prophylactic antibiotics do not provide therapeutic treatment of any systematic infections in the body. This is because the dosage of the macrolides is not high enough to actively fight an infection in the body. The main purpose of the use of longterm macrolides is to target inflammation, not to target and prevent any other infections.

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 Probiotics are basically microorganisms that live in your gut, the female vagina, and even on your skin. Probiotics also refers to the same microorganisms found in certain food and dietary supplements. An imbalance in probiotics for any reason can lead to gastrointestinal issues, yeast infections on the skin and personal areas where the skin is extra moist and in the female vagina. In order to prevent the imbalance of probiotics it is recommended that people supplement them into their diet by either live cultures, found in certain foods, or by daily supplemental pills. Probiotics are said to be safe from age one years old and older for both male and females. Caution should be used if a person suffers from certain medical conditions or if a person is taking certain medications. Although probiotics are said to be safe while on antibiotics; it important to note that using live culture probiotics with certain antibiotics can have serious, even fatal consequences. It is always important if you use medication to consult BOTH your doctor and your pharmacist about any and all over the counter medications, supplements, and live culture foods take you are taking or eating. It is equally important to discuss with your pharmacist and your doctor about the total quantity of probiotics that you are supplementing with. Not only does having too little probiotics in your system cause issues, but having too much probiotics in your system can be equally harmful to your kidneys, your liver, and your pancreas.

Antibiotics can not distinguish good bacteria from the bad bacteria, so antibiotics target all bacteria. Your doctor may prescribe probiotics alongside antibiotics to help replace probiotics in your system that are killed off by the antibiotics. It is important to take your probiotics and antibiotics at least two hours apart to get the full benefit of probiotic supplementation. As your body digests the antibiotic(s) your gut becomes unfriendly to bacteria including your probiotics already in your system. Taking your probiotic supplement two hours after your antibiotic(s) helps to replenish the probiotics in your system to replace the ones that were targeted by the antibiotic(s). This consumption process is extremely important if you are using live culture probiotics/ foods as your probiotics supplement.

So just what are live culture foods? Live culture foods are foods which contain active microorganisms. Although these foods contain probiotics they are not necessarily packed with probiotics, as many believe. Another myth that we need to dispense with is that all fermented foods contain live active probiotics. They really do not. The only fermented foods that contain live culture probiotics are yogurt, natto, Kifer, kombucho, sauerkraut, kimchi, tempeh, pickles, and lassi. The fermentation process of these foods allow probiotics like Lactobacilli and Bifidobacteria to flourish in these foods. It is important to note here that eating fermented foods while on certain antibiotics and if you have certain medical conditions can have serious even deadly consequences; due to the tyramine and histamine levels found in these foods. Kifer even has a specific antibiotic warning on their products pertaining to the use of the antibiotic Linezolid with their products. 

***This topic is not meant to be an all encompassing article on probiotics, nor does it replace or is it intended to replace medical advice from your licensed medical professional. If you have specific questions regarding yourself or a family member, please seek the advice of a licensed medical professional.***

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Atelectasis is a complete or partial collapse of the lung, a lung lobe, or partial lung lobe (segment). In atelectasis the lung or lung segment does not inflate and the air sacs or alveoli are no longer filled with air. This section of the lungs can not take part in gas exchange any longer. If the atelectasis comes on gradually and is relatively a small collapse, then the other areas of the lungs can take up slack for the collapsed area and adequately supply the body with the required gas exchange needed. Rapid onset of atelectasis, especially if the area of collapse is big, can lead to shortness of breath, rapid heart rate, coughing, and cyanosis. There usually isn’t pain associated with atelectasis unless the area of atelectasis is big; or the pain is associated with the cause of the atelectasis like pneumonia, injury, or even the obstruction causing the atelectasis itself. Children with atelectasis may appear agitated, anxious, or even scared. Complications of atelectasis can include low blood oxygen, pneumonia, and respiratory failure. The symptoms of atelectasis may reflect the underlying condition that initially caused the atelectasis. Underlying medical conditions that are often associated with atelectasis are conditions that cause respiratory weakness, primary ciliary dyskinesia, cystic fibrosis, lung tumor, lung cancer, conditions that cause fluid build up in the lungs, lung scar tissue, airway blockage, chest injuries, and atelectasis can even be a complication after a surgical procedure.

Atelectasis has many causes and typically occurs when the lungs can not expand and fill with air. Atelectasis is very common after surgery where the patient is given medication to sleep and stifle their cough responses. Limiting a patient’s ability to cough allows mucus to fill and sit in the airways which can lead to mucus plugging and or pneumonia. Those areas of infection and or mucus plugging can become obstructions which trigger an episode of atelectasis. Airway blockages are another cause of atelectasis. Blockages can be caused any number of things like a mucus plug, foreign objects (popcorn), cancer, poorly place ventilator tubing, and many other things. Once the airway has been blocked off, and the air in the air sacs have already been exchanged into the body new air cant get past the blockage, so the air sacs deflate. Factors that increase a patient’s risks of atelectasis is age, having a condition that interferes with spontaneous coughing, confinement to bed, having a condition that impairs swallowing function, lung diseases (like cystic fibrosis, primary ciliary dyskinesia, bronchiectasis, COPD, and asthma), premature birth, recent abdominal or chest surgery, recent general anesthesia, having a condition that causes weak respiratory muscles (like muscular dystrophy, SMA, spinal cord injury, or so on), and having any condition that can cause shallow breathing (like medication side effects or mechanical limitations like shallow breathing due to a rib fracture.

The main goals of treatment in atelectasis are to treat the cause of the condition and to reinflate the lung. Treatments will vary based on the underlying condition that caused the atelectasis in the first place. Airway obstructions can be cleared with a surgical procedure known as a bronchoscopy, usually reserved for foreign objects, or mucus plugging that does not clear up with manual chest percussion and autogenic drainage. For the most part atelectasis is usually treated with deep breathing exercises, coughing, autogenic drainage techniques, chest percussion, and breathing medications. If the atelectasis is caused by chest pressure, the doctors will remove the cause of the pressure; usually a tumor or fluid build up in the chest cavity. In cases where those things are not enough surgery (bronchoscopy) or medical devices such as PEEP (positive end-expiratory pressure) or a CPAP (continuous positive airway pressure) may be prescribed. 

Atelectasis appears to be a common condition associated with PCD (primary ciliary dyskinesia). This is surmised due to the ineffective mucus clearance that affects PCD patients. Mucus in PCD that can not be cleared becomes thick and oftentimes leads to plugging. The ineffective mucus clearance in PCD can also lead to pneumonia and other types of respiratory infections that can lead to obstructions in the lungs and trigger an episode of atelectasis. Atelectasis can be periodic and last for a short or a long amount of time; including several years. In PCD areas of the lungs most effected by atelectasis are the right middle lobe, left lingula, and both the right and lower lobes. However; lobar or segmental atelectasis with associated bronchiectasis in the middle lobes is more common in childhood PCD.

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Pulmonary rehabilitation is often prescribed for pulmonary patients who have chronic lung disease and continue to decline or have complications despite being prescribed the standard medical treatment for their particular lung disease. In pulmonary rehab the patient’s care plan is based on the individual patient’s needs. Topics covered in a pulmonary rehabilitation program can include nutrition, mucus clearance techniques, oxygen, energy conservation, exercise, community resources, disease knowledge, evaluation of patient equipment needs, and many others.

To better enable the respiratory therapist develop a care plan tailored to the specific patient’s needs, at the start of the program the patient will be evaluated using the six minute walk test. This test is designed to see how well and how far the patient can walk for, for a full six minutes. Before the patient starts the test, they will sit for approximately five minutes of rest, their blood pressure is taken just prior to the start of the test; and they are hooked up to a pulse oximeter, which will be used to monitor their heart rate and oxygen saturation. During the walk test the patient will walk at a pace they feel comfortable at, while their heart rate and oxygen saturation’s are being monitored throughout the entire six minutes. They are encouraged to keep moving as much as they can as fast as they are able. The patient is instructed that they may stop and lean and rest for a few seconds if they feel the need to, but otherwise try to keep moving. At the end of six minutes the patient’s blood pressure is taken again and their heart rate and oxygen saturation is closely monitored until they return to a normal range. The patient’s blood pressure, heart rate, and oxygen saturation is again taken five minutes after the time noted for the end of the patient’s walk test (basically to see how the patient has recovered five minutes after finishing the walk test. The results of the walk test are then used to tailor a pulmonary rehabilitation exercise program that will meet the needs of thar particular patient.

The next rehabilitation session after the evaluation session the patient will receive their personally tailored exercise plan and schedule of exercise sessions that they will complete during pulmonary rehabilitation; exercise sessions are done with the care and guidance of a respiratory therapist and a physical therapist during each exercise session. Exercise sessions for pulmonary rehabilitation are typically done two days a week for approximately nineteen sessions. During the exercise portion of their rehabilitation program the patient’s vitals will be monitored and evaluated to tweak their exercise program on a daily basis. Their oxygen support needs will be continually monitored and evaluated during aerobic exercise and weight training. Respiratory patients typical will have trouble with their oxygen saturation dropping during aerobic exercising either on the treadmill, the stationary bike, or the elliptical machine. Most patients with obstructive lung disease/ disorders like PCD will have the most trouble with the treadmill; where the patient has to carry and move their entire body. Exercises where obstructive lung disease/ disorder patients can sit down, like the stationary bike and weight training, are typically where these patients tire out less than those with restrictive lung disease/ disorders. Restrictive lung disease/ disorder patients tend to do better on the treadmill and worse on exercises while seated. During the exercise sessions patients will also be coached to use proper breathing and energy conservation techniques while exercising; like pursed lip breathing and diaphragmatic breathing.

The second part of a patient’s weekly pulmonary rehabilitation program is educational classes, which are typically held one to two days a week. Educational classes can be done in one on one sessions with the educational instructor or the classes can be held in a group setting with an educational instructor. The patient can also request one on one training only, or certain classes as one on one. Typically mucus clearance technique classes for those with PCD, in this writer’s opinion should always be done one on one. In PCD where germs, bacteria, and debris that are breathed into the patient’s lungs can stay in a PCDers system for up to seven times longer than they do in a non PCD patient’s system; a group setting where other respiratory patients are practicing mucus clearance techniques in close proximity of one another in an enclosed classroom is not the ideal setting in infection control for the PCD patient. Also remember the golden rule in infection control and cross contamination protocols, CF and PCD patients should not be in the same sessions; even in pulmonary rehabilitation, and this applies to exercise sessions as well as educational sessions. 

In the educational classes, besides mucus clearance techniques we discussed above, patients will learn how to properly breathe to help get the most out of their lungs during a wide variety of activities; including activities of daily living, like dressing, showering, climbing the stairs in their home, brushing their hair, and so on. Patients will also learn how to conserve energy during house keeping duties, shopping, driving, and so forth. The patients will be made aware of community resources available to respiratory patients in their area to help respiratory patients continue to remain active in their community, to help the patients get to where they need to go, and allow the patients to remain independent at home; like grocery shopping delivery services, transportation opportunities to help these patients get around and even to their doctor appointments. Patients will be given the tools to help them better advocate for themselves to their healthcare providers and community outreach programs that are available in their community for respiratory patients. During pulmonary rehabilitation, educational classes on emotions and relaxation are very important as emotions and relaxation can play an important role during a breathing crisis. Most pulmonary rehabilitation programs give the patient the opportunity to pick and choose which educational classes are important to that particular patient, and if that patient wants to skip any classes that aren’t important to that patient; it is perfectly acceptable for the patient to miss those classes. In this writers opinion; if it’s the patient’s first or second time through a pulmonary rehabilitation program, the patient should attend all sessions. The same is true if it has been years since the patient has been through a pulmonary rehabilitation program, because technology and research in the pulmonary field is always changing and advancing.

Educational classes that should be done on a one on one basis for each patient are as follows; equipment evaluation, medications, disease knowledge, nutrition, and supplemental oxygen needs. The patient’s medications and proper delivery of said medication should be evaluated. Instructions on how to get the most out of your inhaled medications should be given through coaching and demonstration. Medication taken through nebulizers is often thought to be the easiest and most effective medication delivery method for respiratory patients; mainly because the patient doesn’t have to think or use a specific breathing technique to ensure most of the medication actually gets into the lungs versus the digestive system. However nebulizers are time consuming and less transportable than inhalers. Inhalers are as effective as nebulizers, if, if the patient uses them properly. Inhalers used without proper techniques and spacers are less effective if the bulk of the medication ends up in the patient’s digestive system instead of their respiratory system. Patients should be given instructions on how to use spacers with inhalers to enable the medication to be properly inhaled into the lungs. The patient’s current respiratory equipment should be evaluated and upgraded as needed; including nebulizers, airway clearance devices, and supplemental oxygen equipment. This is also a great time to see if the patient could benefit from newer technologies available in current respiratory equipment that the patient may or may not already have. These one on one sessions with the respiratory therapist should include direct educational knowledge of the exact patient’s respiratory disease/ disorder. The respiratory therapist should be able to answer the patient’s specific questions about their disease/ disorder and address the patient’s individual concerns about their disease/ disorder. If the patient is deemed during their pulmonary rehabilitation program to need supplemental oxygen during activity, sleeping, and or during everyday activity; then extensive training and educational instruction should take place in both the exercise sessions and educational sessions, whether or not these sessions are done in a group setting or in a one on one session.

Nutritional education for respiratory patients is an important part of maintaining respiratory health, whether the educational session are private or done in a group is up to the patient and their therapists (respiratory and physical). Good nutrition is essential in any respiratory disease/ disorder. eating too much in a single setting can lead to the patient experiencing shortness of breath due to the addional abdominal weight of the food. Whereas eating too little can lead to losing muscles that helps the patient breath more easily. Protein is an important dietary nutrient that helps repair tissue, build muscle, an helps the body fight infections. Respiratory patients need a minimum of nine ounces of protein a day. Healthy sources of fats are a concentrated form of energy that is virtual to respiratory patients; if the patient needs more calories, this is where they should get those calories from, healthy fats. Patients should avoid unhealthy fats, that promote heart disease, when trying to increase their caloric intake. Carbohydrates are another topic to cover, as carbohydrates are hard on the respiratory system. During the metabolism or processing of carbohydrates in the body, carbohydrates are broken down into CO2 (carbon dioxide) and H2O (water). The water is then processed out of the body through the kidneys. The carbon dioxide has to process out of the body through the lungs. Eating too much carbohydrates puts an extra load on the lungs in the form of exchanging carbon dioxide with oxygen; this can tire out an already tired respiratory patient. Complex carbohydrates are better for respiratory patients, because they stay around in the body longer and take longer to breakdown into carbon dioxide and water. Simple carbohydrates breakdown more quickly than complex carbohydrates after eating and result in higher carbon dioxide production; which increases a respiratory patient’s shortness of breath and tires the patient out more quickly. Nutrition plays a huge role in maintaining respiratory health, symptoms, and exacerbations; today’s topic barely covers these ways, but we will be revisiting nutrition in future topics where we will separate the myths from the facts in respiratory health.

Pulmonary rehabilitation is a great resource and program for all respiratory patients. No matter how many times a patient attends a program there is always something to learn. However a word of caution, from this writer’s perspective; if the pulmonary patient is a retuning rehab client and the program in question says that the patient is an old pro that the rehab program doesn’t think that they can teach the patient anything new, find a new program... These pulmonary rehabilitation programs can and are often used to tweak and remind patients about things and techniques that they may have become lackadaisical with, that the patient might not have ever been taught, and to help the patient have a better overall quality of life. Pulmonary rehabilitation programs can be attend many times throughout the patient’s life span, usually at the discretion of their pulmonary physician or even their insurance carrier. Insurance companies will usually recommend pulmonary rehabilitation after the respiratory patient has gone though repeated exacerbations, just as a check up to see if there is something that can help the patient stay their healthiest. However, Medicare coverage has certain lifetime caps on pulmonary rehabilitation program visits, once a patient is covered by Medicare; currently the cap is set at 19 days/ sessions per a patients lifetime.

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