What is the management of bronchiectasis exacerbation?

Management of Bronchiectasis Exacerbation

Bronchiectasis exacerbations should be treated with a 14-day course of antibiotics, with the specific antibiotic selection based on prior sputum cultures and severity of the exacerbation. 1

Antibiotic Therapy

First-line approach:

• Duration: 14 days of antibiotics is the standard recommended duration 1, 2
• Specimen collection: Obtain sputum culture before starting antibiotics when possible 2
• Antibiotic selection:
  • Base on previous sputum microbiology results
  • Consider severity of exacerbation and patient's response to previous treatments
  • For Pseudomonas aeruginosa infections, more aggressive antibiotic therapy is warranted 2

Special considerations:

• Severe exacerbations: Consider intravenous antibiotics for severe symptoms or treatment failures 2
• Home supply: Suitable patients should have antibiotics at home for prompt treatment 2
• Treatment modification: Shorter courses may be appropriate for mild exacerbations, particularly with sensitive pathogens like S. pneumoniae, but evidence for shorter courses is lacking 1
• Treatment failure: If no improvement after 14 days, re-evaluate clinical condition and obtain new microbiological samples 1

Airway Clearance Techniques

• Essential component: Airway clearance should be intensified during exacerbations 2
• Techniques:
  • Active cycle of breathing
  • Autogenic drainage
  • Postural drainage
  • Device-assisted methods (flutter, acapella)
• Frequency: Sessions should last 10-30 minutes and continue until two clear huffs or coughs are completed 2
• Professional guidance: Techniques should be taught by a respiratory physiotherapist 2

Additional Supportive Measures

• Bronchodilators: May help with symptom relief, especially in patients with reversible airflow obstruction
• Hydration: Adequate fluid intake to help thin secretions
• Mucoactive agents: Consider for patients with difficulty expectorating sputum 1
• Oxygen therapy: As needed for hypoxemia

Management of Specific Pathogens

Pseudomonas aeruginosa

• If newly isolated during an exacerbation, consider eradication therapy after treating the acute exacerbation 1, 2
• First-line eradication: Ciprofloxacin
• Second-line: IV anti-pseudomonal beta-lactam ± aminoglycoside 2

Other pathogens

• Eradication therapy is not routinely recommended for non-P. aeruginosa pathogens 1

Post-Exacerbation Management

• Follow-up: Reassess clinical status after completion of antibiotics
• Preventive strategies: Consider long-term therapies for patients with ≥3 exacerbations per year:
  • Long-term macrolides (azithromycin, erythromycin) 1
  • Inhaled antibiotics for patients with chronic P. aeruginosa infection 1
  • Pulmonary rehabilitation to improve exercise capacity and potentially reduce exacerbation frequency 2

Common Pitfalls to Avoid

• Delayed treatment: Prompt treatment is essential to prevent disease progression 2
• Inadequate airway clearance: Failure to emphasize proper airway clearance techniques 2
• Inappropriate use of inhaled corticosteroids: Not routinely recommended unless specific indications exist 1, 2
• Use of recombinant human DNase: Not recommended in non-CF bronchiectasis 2
• Insufficient duration of antibiotics: Shorter courses may lead to treatment failure 1
• Failure to address underlying causes: Conditions like immunodeficiency or ABPA require specific management 2

Remember that the goal of exacerbation management is to reduce symptoms, improve quality of life, and prevent disease progression and future complications such as lung function decline 1.