What is the initial management for bronchiectasis?

Initial Management for Bronchiectasis

The initial management of bronchiectasis should focus on airway clearance techniques taught by a respiratory physiotherapist, with patients performing these techniques once or twice daily to improve mucus clearance and reduce infection risk. 1

Diagnosis Confirmation and Evaluation

Before initiating treatment, bronchiectasis must be confirmed with:

• Thin-section CT scan showing dilated airways with airway thickening and mucus plugging 2
• Baseline investigations to identify underlying causes:
  • Complete blood count
  • Serum immunoglobulins (IgG, IgA, IgM)
  • Testing for allergic bronchopulmonary aspergillosis (ABPA)
  • Sputum cultures for bacteria, mycobacteria, and fungi
  • Spirometry (pre and post-bronchodilator) 1, 2

Core Management Strategies

1. Airway Clearance

Airway clearance is the cornerstone of initial management:

• A trained respiratory physiotherapist should teach appropriate airway clearance techniques 1
• Techniques may include:
  • Active cycle of breathing
  • Autogenic drainage
  • Postural drainage
  • Device-assisted methods (flutter, Acapella, positive expiratory pressure devices) 1
• Sessions should last 10-30 minutes and continue until two clear huffs or coughs are completed 1
• Regular physical exercise should be encouraged to promote airway clearance 1

2. Mucoactive Treatments

• Consider a trial of mucoactive treatment in patients who have difficulty expectorating sputum 1
• Options include:
  • Nebulized saline (normal or hypertonic) to loosen secretions 2
  • Consider humidification with sterile water or normal saline to facilitate clearance 1
• Important: Do NOT use recombinant human DNase (strong recommendation) as it may worsen outcomes 1

3. Bronchodilators

• Not routinely recommended for all patients with bronchiectasis 1
• Consider for patients with:
  • Significant breathlessness 1
  • Coexisting asthma or COPD 1, 3
  • Airflow obstruction (FEV1/FVC <0.7) 1
• Use before physiotherapy and before inhaled medications to optimize deposition 1
• Discontinue if no symptomatic improvement 1

4. Management of Exacerbations

• Prompt treatment of exacerbations is essential 1
• Suitable patients should have antibiotics to keep at home 1
• Standard antibiotic course is 14 days, especially for P. aeruginosa infections 1
• Obtain sputum cultures before starting antibiotics when possible 1
• Consider intravenous antibiotics for severe exacerbations or treatment failures 1

5. Pulmonary Rehabilitation

• Recommend pulmonary rehabilitation for patients with impaired exercise capacity 1, 4
• Regular exercise improves exercise tolerance and may reduce exacerbation frequency 1, 4

Special Considerations

Pseudomonas aeruginosa Infection

If P. aeruginosa is newly isolated:

• Offer eradication antibiotic treatment 1
• First-line: Ciprofloxacin 500-750mg twice daily for 2 weeks
• Second-line: IV anti-pseudomonal beta-lactam ± aminoglycoside for 2 weeks, followed by 3 months of nebulized colistin, gentamicin, or tobramycin 1

Hemoptysis Management

• For minor hemoptysis (≤10ml/24hrs): Treat with appropriate oral antibiotics 1
• For major hemoptysis: Multidisciplinary approach involving respiratory physicians, interventional radiology, and thoracic surgeons 1

Follow-up and Monitoring

• Review by a respiratory physiotherapist within 3 months of initial assessment 1
• Annual clinical review for patients followed in secondary care 1
• Tailor monitoring frequency to disease severity 1
• Perform pulse oximetry to screen for respiratory failure 1

Common Pitfalls to Avoid

1. Overuse of inhaled corticosteroids - Do not routinely offer these unless there are specific indications like ABPA, asthma, or COPD 1
2. Inappropriate use of recombinant human DNase - This is contraindicated in non-CF bronchiectasis 1
3. Delayed treatment of exacerbations - Prompt treatment is essential to prevent disease progression 1, 2
4. Inadequate airway clearance education - Patients need proper instruction from a trained physiotherapist 1
5. Failure to identify and treat underlying causes - Addressing conditions like immunodeficiency or ABPA is crucial 1, 2

By implementing these evidence-based strategies early in the management of bronchiectasis, clinicians can help reduce symptoms, prevent exacerbations, and potentially slow disease progression.