Hose It Down, Then Sweep: A Way to Think About Airway Clearance and Bronchiectasis
Clients sometimes ask me, “Can I skip nebulizing and just use my Aerobika?”
Others ask the opposite: “Can I just nebulize?”
As with so many things in bronchiectasis, there isn’t one answer for everyone. Airway clearance should be personalized to the individual.
I have an analogy that may help explain why nebulizing and moving mucus out of the lungs can be two different parts of airway clearance.
What Do the Guidelines Say?
The 2025 European Respiratory Society (ERS) guideline made airway clearance a major priority. It strongly recommends that people with bronchiectasis be taught airway-clearance techniques. The guideline emphasizes that these techniques should be personalized, that no single technique has been shown to be best for everyone, and that they are best taught by a respiratory physiotherapist with appropriate experience.
The new U.S. guideline from CHEST, Management of Adult Bronchiectasis, includes these recommendations:
“For patients with bronchiectasis, we suggest the use of nebulized hypertonic saline for airway clearance.”
And:
“For people with bronchiectasis, we suggest the use of oscillatory positive expiratory pressure (PEP) for airway clearance.”
The guideline also includes breathing techniques and high-frequency chest wall oscillation among the airway-clearance options.
These are conditional recommendations based on the available evidence. They do not mean that every person needs every technique or device. Work with a respiratory professional to determine what may be appropriate for you.
Imagine a Dirty Walkway
Imagine a walkway covered with dirt and debris.
You take out the hose and give it a good soaking. The water loosens everything up. But if you stop there, what might you have?
A muddy walkway.
You still need to sweep.
Our lungs obviously aren’t sidewalks, but I think this is a useful way to picture what we’re trying to accomplish during airway clearance.
For me, nebulized hypertonic saline is the hose. It helps hydrate and loosen my mucus.
My Aerobika is part of the sweep. As an oscillating positive expiratory pressure (OPEP) device, it helps mobilize those loosened secretions so I can move them up and out, sometimes with the additional help of gentle huff coughing, postural drainage, and exercise.
Hose. Then sweep.
That simple image helps explain why, for some of us, airway clearance involves more than one step.
What Does National Jewish Health Recommend?
I was particularly interested to hear Cheryl Torres, RRT, lead respiratory therapist at National Jewish Health, discuss the equipment they use and the option of combining nebulization with OPEP during a recent patient conference.
In Ms. Torres’ words:
“The Ombra compressor is the one that we generally use if you want a higher PSI (pressure per square inch-my note) or a stronger delivery. The AeroEclipse is the nebulizer cup that we do use here. There are other ones out there. Some patients like using the Pari’s, but the Pari nebulizer is one out there that we used to use in the past, but then we switched over to the AeroEclipse because in studies it shows that the particle size is a lot smaller.”
She also described how people may use the nebulizer and Aerobika together or separately:
“And you can use it with or without. It doesn’t matter. Some patients have a preference. Maybe they want to do their nebulizer first and then follow it up with their Aerobika. You can do it definitely that way. Some patients like to save time and get a little bit better therapy as far as creating that back pressure to open up those airways and just really getting that aerosol down.”
She added:
“This is going to be the nebulizer cup that we use here at National Jewish.”
That last part caught my attention because it gets to something I care a lot about: making airway clearance both effective and manageable.
My Airway-Clearance “Dynamic Duo”
Years ago, I switched to an Ombra compressor and AeroEclipse nebulizing cup, and it made a noticeable difference in my airway-clearance routine.
One of my favorite features is that the AeroEclipse can be connected directly to the Aerobika.
Instead of necessarily nebulizing first and then using my Aerobika, I can use them together. As Cheryl explained, some people prefer doing the two separately, while others combine them to save time and create back pressure while getting the aerosol down into the lungs.
I think of it as hosing and sweeping at the same time.
For someone who performs airway clearance every day, sometimes more than once a day, finding ways to streamline the process can make a big difference. Even the best routine won’t help much if it is so cumbersome that we don’t stick with it.
Could This Have Helped Me Clear MAC?
I can’t say that one device, one technique, or one change cleared my MAC infection. That would be an enormous claim, and bronchiectasis and NTM simply aren’t that straightforward.
But I do believe improving my airway clearance was one of several factors that contributed to my being able to clear my second MAC infection without antibiotics.
I was consistent. I nebulized. I used OPEP. I exercised. I worked on my nutrition and weight. I addressed reflux. And I kept looking for ways to make my airway clearance more effective and manageable.
For me, it was a team effort.
Hose It Down. Then Sweep.
If there is one image I want you to remember, it’s that dirty walkway.
The hose helps loosen the dirt. The broom helps move it away.
Nebulized saline can help hydrate and loosen mucus. Airway-clearance techniques, including OPEP, can help mobilize secretions so they can be moved up and out.
Your “hose” and your “sweep” may look different from mine. That’s exactly why airway clearance should be individualized.
Ask a respiratory professional to help you determine which techniques, devices, and combination make the most sense for your lungs.
Because when it comes to airway clearance, the goal isn’t simply to loosen mucus. We want to move it up and out.
Frequently Asked Questions
Q: Can I just nebulize and skip an airway clearance device?
A: Not necessarily. Nebulized saline can help hydrate and loosen mucus, but loosening mucus and moving it out of the lungs are different jobs. Depending on your individual needs, an airway clearance technique, such as an OPEP device, huff coughing, active cycle of breathing, or postural drainage, may help mobilize that mucus so it can be cleared.
Q: Can I use an Aerobika or Acapella without nebulizing first?
A: Some people can. Airway clearance should be individualized. However, if your mucus is thick or difficult to move, nebulized saline may help hydrate and loosen it before or during airway clearance.
Q: What do the CHEST guidelines say about hypertonic saline?
A: The 2026 CHEST guideline suggests the use of nebulized hypertonic saline for airway clearance in people with bronchiectasis. This is a conditional recommendation based on very low-certainty evidence.
Q: What do the CHEST guidelines say about OPEP devices?
A: CHEST also suggests oscillatory positive expiratory pressure, or OPEP, for airway clearance. Devices such as the Aerobika and Acapella provide resistance and oscillations during exhalation that can help mobilize mucus.
Q: So is nebulizing the “hose” and OPEP the “sweep”?
A: That’s my analogy. Think of nebulized saline as hosing down a dirty walkway to loosen what is stuck. Then you still need a way to move the debris. For some people with bronchiectasis, OPEP, huff coughing, postural drainage, or another airway clearance technique provides that “sweep.”
Q: Does everyone with bronchiectasis need the same airway clearance routine?
A: No. There is no one-size-fits-all routine. Your airway clearance plan should take into account your symptoms, mucus production, lung function, infections, CT findings, ability to tolerate different techniques, and other health conditions. Ideally, your technique should be assessed and personalized with a respiratory professional experienced in bronchiectasis.
Q: What is the most important takeaway?
A: Loosening mucus and clearing mucus are not necessarily the same thing. The goal is to find the safest, most effective and easiest combination for your lungs and review it with your healthcare team.
Want to Learn More about Bronchiectasis?
The BE CLEAR® Guide to Bronchiectasis is designed to help you understand and manage your chronic lung condition at your own pace. Whether you’re newly diagnosed or looking to strengthen your daily routine, the guide offers expert-informed content, practical suggestions, and compassionate support every step of the way.
