What are the treatment and prevention options for bronchiectasis?

Bronchiectasis Treatment and Prevention

The comprehensive management of bronchiectasis requires a targeted approach addressing chronic infection, inflammation, and impaired mucociliary clearance through antibiotic therapy, airway clearance techniques, and treatment of underlying causes to reduce exacerbations and improve quality of life. 1

Diagnosis and Initial Assessment

• Confirm bronchiectasis with high-resolution CT scanning of the chest 1
• Identify underlying causes through:
  • Complete blood count with differential
  • Serum immunoglobulin testing (IgG, IgA, IgE, IgM)
  • Testing for allergic bronchopulmonary aspergillosis (ABPA)
  • Sputum cultures for bacteria, mycobacteria, and fungi
  • Spirometry (pre and post-bronchodilator) 2, 3

Treatment of Exacerbations

Antibiotic Therapy

• Treat exacerbations with a 14-day course of antibiotics 2
• Select antibiotics based on:
  • Previous sputum culture results
  • Severity of exacerbation
  • Patient's clinical response 1
• Obtain sputum cultures before starting antibiotics when possible 1
• Consider intravenous antibiotics for:
  • Severe symptoms
  • Treatment failures
  • P. aeruginosa infections resistant to oral therapy 1, 2

Management During Exacerbations

• Intensify airway clearance techniques 2
• Ensure adequate hydration to thin secretions 2
• Provide oxygen therapy if hypoxemia is present 2
• Consider bronchodilators for symptom relief, especially with reversible airflow obstruction 2

Chronic Management

Airway Clearance

• All patients should perform airway clearance techniques once or twice daily 2
• Techniques should be taught by a respiratory physiotherapist and may include:
  • Active cycle of breathing
  • Autogenic drainage
  • Postural drainage
  • Device-assisted methods (flutter valve, positive expiratory pressure) 1, 2
• Sessions should last 10-30 minutes until two clear huffs or coughs are completed 2

Infection Control and Prevention

P. aeruginosa Eradication

• For new isolation of P. aeruginosa, offer eradication therapy:
  • First-line: Ciprofloxacin 500-750 mg 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, 2

Long-term Antibiotic Therapy

• Consider for patients with ≥3 exacerbations per year:
  • Long-term macrolides (e.g., azithromycin)
  • Inhaled antibiotics (e.g., colistin, gentamicin) 2, 3
• Monitor for antibiotic resistance with repeat sensitivity testing 1

Anti-inflammatory Treatments

• Do not routinely offer inhaled corticosteroids unless there are specific indications such as asthma or COPD 2, 3
• Consider oral corticosteroids for patients with active ABPA (initial dose 0.5 mg/kg/day for 2 weeks, then wean) 1
• Consider itraconazole as a steroid-sparing agent for steroid-dependent ABPA patients 1

Mucoactive Agents

• Consider for patients with difficulty expectorating sputum 2
• Do not use recombinant human DNase (rhDNase) in non-CF bronchiectasis as it may worsen outcomes 2

Prevention Strategies

Vaccinations

• Offer annual influenza vaccination to all patients 1
• Offer pneumococcal vaccination to all patients 1
• Consider influenza vaccination for household contacts of immunodeficient patients 1

Pulmonary Rehabilitation

• Recommend for patients with impaired exercise capacity 2
• Regular exercise improves exercise tolerance and may reduce exacerbation frequency 2, 3

Management of Comorbidities

• Ensure optimal control of asthma and allergies 1
• Monitor patients with co-morbid COPD closely as they have higher mortality risk 1
• Assess patients with autoimmune conditions for autoimmune-related lung disease 1
• Refer patients requiring disease-modifying antirheumatic drugs (DMARDs) to a chest physician 1

Follow-up and Monitoring

• Assess patients annually, more frequently in severe disease 1
• Perform pulse oximetry to screen for respiratory failure 1, 2
• Review by a respiratory physiotherapist within 3 months of initial assessment 2
• Send sputum for culture before and after eradication antibiotics 1

Management of Complications

Hemoptysis

• For minor hemoptysis (≤10 mL/24 hours): treat with appropriate oral antibiotics 1
• For major hemoptysis: use multidisciplinary approach with respiratory physicians, interventional radiology, and thoracic surgeons 1
• Consider bronchial artery embolization as first-line treatment for persistent significant hemoptysis 1

Severe Disease

• Consider lung transplant referral in patients:
  • Aged ≤65 years with FEV1 <30% and clinical instability
  • With poor lung function and additional factors like massive hemoptysis, severe pulmonary hypertension, or respiratory failure 1

Localized Disease

• Consider lung resection in patients with localized disease whose symptoms are not controlled by optimal medical treatment 1
• Require multidisciplinary assessment including bronchiectasis physician, thoracic surgeon, and experienced anesthetist 1

Pitfalls and Caveats

• Failure to identify and treat underlying causes can lead to poor outcomes 2
• P. aeruginosa infection is associated with three-fold increase in mortality risk and should be aggressively managed 1
• Some patients may respond to antibiotics despite in vitro resistance 1
• Bronchiectasis in the context of COPD has higher mortality (up to 30% at 1-year follow-up after exacerbation) 1
• Avoid recombinant human DNase as it may worsen outcomes in non-CF bronchiectasis 2

By implementing this comprehensive approach to bronchiectasis management, clinicians can help reduce exacerbations, improve quality of life, and potentially slow disease progression in affected patients.