What is the standard of care for bronchiectasis?

Standard of Care for Bronchiectasis

The standard of care for bronchiectasis requires regular outpatient monitoring every 3-6 months with routine sputum cultures, pulmonary function testing, and targeted antibiotic therapy for exacerbations, along with daily airway clearance techniques. 1

Diagnosis and Initial Assessment

• Diagnosis is confirmed by non-contrast chest CT showing dilated airways, often with airway thickening and mucus plugging 2
• Initial evaluation should include:
  • Complete blood count with differential
  • Immunoglobulin quantification (IgG, IgA, IgE, IgM)
  • Sputum cultures for bacteria, mycobacteria, and fungi
  • Pre- and post-bronchodilator spirometry 2

Routine Monitoring

Frequency and Setting

• Outpatient clinic reviews every 3-6 months 1
• More frequent monitoring for severe disease 1
• Specialist clinic referral for patients with:
  • Chronic Pseudomonas aeruginosa, NTM, or MRSA colonization
  • Declining lung function
  • Recurrent exacerbations (≥3 per year)
  • Patients on long-term antibiotic therapy
  • Associated conditions (rheumatoid arthritis, immune deficiency, etc.)
  • Advanced disease 1

Routine Tests

• Lung function (spirometry for FEV1 and FVC) 1
• Sputum collection for culture every 6-12 months 1
• Pulse oximetry to screen for respiratory failure 1
• Baseline chest X-ray as comparator for future deterioration 1

Management Strategies

Airway Clearance

• Daily airway clearance techniques are a cornerstone of management 2, 3
• Options include:
  • Postural drainage
  • Active cycle of breathing techniques
  • Oscillating positive expiratory pressure devices
  • High-frequency chest wall oscillation 2
• Nebulized saline (isotonic or hypertonic) to loosen secretions 2, 3

Pharmacological Management

Antibiotics for Exacerbations

• Exacerbations present with increased cough, sputum production, and worsened fatigue 2
• Collect sputum for culture before starting antibiotics 1
• Start empirical antibiotics based on previous sputum bacteriology while awaiting results 1
• Standard course is 14 days, especially for P. aeruginosa infections 1
• Shorter courses may be appropriate for mild bronchiectasis 1
• Consider IV antibiotics when:
  • Patient is particularly unwell
  • Organisms are resistant
  • Failed response to oral therapy 1

Long-term Antibiotic Therapy

• Consider for patients with ≥3 exacerbations per year 2
• Options include:
  • Inhaled antibiotics (colistin, gentamicin) 2
  • Daily oral macrolides (azithromycin) 2
• Monitor for antibiotic resistance with regular sputum cultures 1

Eradication Therapy for New Pathogens

• For new P. aeruginosa isolation:
  • First line: ciprofloxacin 500-750mg twice daily for 2 weeks
  • Second line: IV antipseudomonal beta-lactam ± aminoglycoside for 2 weeks, followed by 3 months of nebulized colistin, gentamicin, or tobramycin 1
• For new MRSA isolation, attempt eradication due to infection control concerns 1

Bronchodilators and Anti-inflammatory Therapy

• Not routinely recommended for all patients 4
• Consider in patients with:
  • Coexisting asthma or COPD
  • Demonstrated airflow obstruction
  • Symptomatic benefit 1, 2

Management of Comorbidities

• Allergic bronchopulmonary aspergillosis (ABPA):
  • Oral corticosteroids (initial dose 0.5 mg/kg/day for 2 weeks)
  • Consider itraconazole as steroid-sparing agent
  • Monitor total IgE levels to assess treatment response 1
• Rhinosinusitis: Evaluate and treat according to evidence-based pathways 1
• Asthma and allergies: Ensure optimal control 1
• COPD: Monitor closely as these patients have higher mortality risk 1

Advanced Care Considerations

Respiratory Failure Management

• Consider long-term oxygen therapy using COPD eligibility criteria 1
• Consider non-invasive ventilation with humidification for hypercapnic respiratory failure 1

Surgical Options

• Consider lung resection for localized disease not controlled by medical treatment 1
• Require multidisciplinary assessment including bronchiectasis physician, thoracic surgeon, and anesthetist 1
• Consider transplant referral in patients ≤65 years with FEV1 <30% and clinical instability or rapid progression 1

Common Pitfalls and Caveats

1. Delayed recognition of exacerbations: Prompt treatment is essential to prevent lung function decline and deterioration in quality of life 2

2. Inadequate sputum sampling: Upper airway swabs are unreliable for predicting lower airway pathogens; obtain spontaneous or induced sputum when possible 1

3. Overuse of bronchodilators: Despite guideline recommendations against routine use, bronchodilators are often prescribed even without airway obstruction 4

4. Insufficient infection control: While individual segregation is not routinely required, standard infection control procedures should be followed, particularly when facilities are shared with CF patients 1

5. Neglecting reversible causes: In some cases, bronchiectasis may be reversible with early identification and treatment of underlying causes 1