What is the treatment for bronchiectasis?

From the Guidelines

The treatment for bronchiectasis focuses on managing symptoms, preventing exacerbations, and slowing disease progression, with airway clearance techniques and medications such as bronchodilators, inhaled corticosteroids, and long-term antibiotics being essential components of therapy. The goal of treatment is to improve quality of life, reduce morbidity, and prevent mortality. According to the European Respiratory Society guidelines for the management of adult bronchiectasis 1, airway clearance techniques, including postural drainage, chest physiotherapy, and devices like flutter valves or positive expiratory pressure masks, are crucial in helping to clear mucus.

Medications used in the treatment of bronchiectasis include:

• Bronchodilators, such as albuterol or ipratropium, to improve airflow
• Inhaled corticosteroids, like fluticasine or budesonide, to reduce inflammation in some cases
• Long-term antibiotics, such as azithromycin 500mg three times weekly or ciprofloxacin 500-750mg twice daily, for patients with frequent exacerbations
• Mucolytics, like hypertonic saline (3-7%) or N-acetylcysteine, to help thin secretions

During acute exacerbations, targeted antibiotics based on sputum cultures are given for 10-14 days 1. Severe cases may require hospitalization for intravenous antibiotics, supplemental oxygen, and intensive airway clearance. Underlying conditions like immunodeficiency or GERD should be treated concurrently. Surgery is rarely needed but may be considered for localized disease unresponsive to medical management.

The use of long-term antibiotics, including macrolides such as azithromycin or erythromycin, has been shown to reduce the number of exacerbations, time to first exacerbation, sputum purulence, and breathlessness in adults with bronchiectasis 1. However, long-term antibiotic treatment is also associated with more adverse events and bacterial resistance.

In terms of specific treatment recommendations, the European Respiratory Society guidelines suggest:

• Long-term treatment with macrolides for adults with bronchiectasis and chronic P. aeruginosa infection
• Long-term treatment with an inhaled antibiotic for adults with bronchiectasis not infected with P. aeruginosa
• Long-term treatment with an oral antibiotic for adults with bronchiectasis not infected with P. aeruginosa in whom macrolides are contraindicated, not tolerated, or ineffective

Overall, the treatment of bronchiectasis requires a comprehensive approach that includes airway clearance techniques, medications, and management of underlying conditions to improve quality of life, reduce morbidity, and prevent mortality.

From the FDA Drug Label

Adult PatientsAcute Bacterial Exacerbations of Chronic Obstructive Pulmonary Disease In a randomized, double-blind controlled clinical trial of acute exacerbation of chronic bronchitis (AECB), azithromycin (500 mg once daily for 3 days) was compared with clarithromycin (500 mg twice daily for 10 days).

The treatment for bronchiectasis is not directly addressed in the provided drug label. However, azithromycin is used to treat acute bacterial exacerbations of chronic obstructive pulmonary disease and acute bacterial sinusitis, which may be related to bronchiectasis.

• The clinical cure rate for 3 days of azithromycin was 85% in the treatment of acute exacerbation of chronic bronchitis.
• The most common side effects were diarrhea, nausea, and abdominal pain. 2

From the Research

Treatment Overview

The treatment for bronchiectasis typically involves a combination of airway clearance techniques, medications, and lifestyle changes.

• Airway clearance techniques, such as nebulization of saline to loosen tenacious secretions, are used to help clear mucus from the airways 3.
• Regular exercise, participation in pulmonary rehabilitation, or both, are also recommended to help manage the condition 3.
• Inhaled bronchodilators (β-agonists and antimuscarinic agents) and inhaled corticosteroids may be prescribed for patients with bronchiectasis who have asthma or chronic obstructive pulmonary disease 3.

Management of Exacerbations

Exacerbations of bronchiectasis, which typically present with increased cough and sputum and worsened fatigue, should be treated with oral or intravenous antibiotics 3.

• Individuals with 3 or more exacerbations of bronchiectasis annually may benefit from long-term inhaled antibiotics (eg, colistin, gentamicin) or daily oral macrolides (eg, azithromycin) 3.
• Lung transplant may be considered for patients with severely impaired pulmonary function, frequent exacerbations, or both 3, 4.

Specific Treatments

Treatment for bronchiectasis may vary depending on the underlying cause of the condition.

• For example, bronchiectasis related to allergic bronchopulmonary aspergillosis (ABPA), immunodeficiencies with antibody production deficiency, primary ciliary dyskinesia, cystic fibrosis, and alpha-1-antitrypsin deficiency may require specific management 5.
• Identifying the cause of the bronchiectasis is crucial in determining the most effective treatment approach 5.

Future Directions

There is an urgent need to find new biomarkers to better stratify patients with bronchiectasis and develop more effective treatments 6.

• Future research should focus on biomarkers, omics technologies, endotypes, and new treatments toward a personalized medicine approach in the field of bronchiectasis 6.