What is the diagnosis and treatment for Bronchiectasis?

From the Guidelines

Bronchiectasis management should focus on preventing exacerbations, clearing mucus, and treating infections, with daily airway clearance techniques and antibiotics prescribed based on sputum cultures, typically for 14 days, as the cornerstone of treatment. The goal of management is to break the vicious cycle of chronic bacterial infection, inflammation, impaired mucociliary clearance, and structural lung disease 1.

Key Management Strategies

• Daily airway clearance techniques, including chest physiotherapy, postural drainage, and devices like flutter valves or positive expiratory pressure devices, should be performed for 20-30 minutes, 1-2 times daily 1.
• For acute exacerbations, antibiotics should be prescribed based on sputum cultures, typically for 14 days, with common choices including amoxicillin-clavulanate, azithromycin, or ciprofloxacin 1.
• For patients with frequent exacerbations (≥3 per year), macrolide maintenance therapy may be considered, such as azithromycin 250-500 mg three times weekly 1.
• Inhaled bronchodilators like albuterol can help with associated airflow obstruction, and mucolytics such as hypertonic saline or inhaled N-acetylcysteine may improve mucus clearance 1.
• Adequate hydration is crucial to maintain thin secretions, and patients should be encouraged to drink plenty of fluids 1.

Long-Term Management

• Long-term antibiotic treatment should be considered for adults with bronchiectasis who have three or more exacerbations per year, with the choice of antibiotic based on antibiotic susceptibility and patient tolerance 1.
• Long-term treatment with an inhaled antibiotic may be beneficial for adults with bronchiectasis and chronic P. aeruginosa infection, and macrolides may be considered for adults with bronchiectasis not infected with P. aeruginosa 1.
• Pulmonary rehabilitation programs can improve exercise tolerance and quality of life, and should be considered for adult patients with bronchiectasis and impaired exercise capacity 1.

Monitoring and Follow-Up

• Regular monitoring of lung function, symptoms, and quality of life is essential to adjust treatment and prevent disease progression 1.
• Sputum cultures should be performed regularly to guide antibiotic therapy and detect potential resistance 1.
• Patients should be educated on the importance of adherence to treatment, and encouraged to attend follow-up appointments to monitor disease progression and adjust treatment as needed 1.

From the Research

Definition and Characteristics of Bronchiectasis

• Bronchiectasis is a chronic lung condition characterized by recurrent chest infections, chronic sputum production and cough, and limited exercise tolerance 2.
• The condition may be caused by various aetiologies, but these features are shared by most patients with bronchiectasis regardless of the cause 2.

Management of Bronchiectasis

• Airway clearance techniques and hyperosmolar agents are key components of bronchiectasis management and are consistently recommended for clinical implementation 2, 3.
• Pulmonary rehabilitation and exercise are also recommended for patients with bronchiectasis, with relatively strong evidence supporting their use during a clinically stable stage of the disease 2, 3.
• Self-management programmes are an important part of bronchiectasis treatment, but there is a lack of consensus regarding their definition and outcomes, which presents hurdles to establishing a cohesive evidence base 2.

Airway Clearance Techniques

• No single airway clearance technique has shown superior effect over another, and consideration of the physiological effects underpinning a technique is essential to effectively personalize airway clearance 3.
• The active cycle of breathing technique may be more effective at improving gas exchange, sputum volume, and health-related quality of life compared to postural drainage and percussion 4.
• Oscillating positive expiratory pressure devices may be preferred by patients over other airway clearance techniques 4.

Mucoactive Therapies

• Mucoactive therapies, such as inhaled antibiotics and long-term macrolide therapy, have been shown to be beneficial in bronchiectasis patients 5.
• The prescription of mucoactive therapies should be done in conjunction with airway clearance techniques, and the mechanism of action of mucoactive drugs and their timing with airway clearance techniques should be taken into consideration 3.

Future Directions

• There is a growing recognition of the importance of patient-managed interventions in bronchiectasis management, and efforts to improve research methodologies and increase research funding are needed to further advance our understanding of these interventions 2.
• Promising treatments in development for the management of bronchiectasis include novel anti-inflammatory therapies 5.