What are the treatment options for bronchiectasis?

Treatment Options for Bronchiectasis

The comprehensive management of bronchiectasis should focus on airway clearance techniques, antibiotic therapy, anti-inflammatory treatment, and pulmonary rehabilitation to prevent exacerbations, reduce symptoms, and improve quality of life. 1

Airway Clearance Techniques

• Perform airway clearance techniques once or twice daily, taught by a respiratory physiotherapist 1
  • Active cycle of breathing
  • Autogenic drainage
  • Postural drainage
  • Device-assisted methods (flutter valves, positive expiratory pressure devices)
• Ensure adequate hydration to thin secretions 1
• Consider humidification with sterile water or normal saline to facilitate clearance 1
• Mucoactive treatments may be considered for patients with difficulty expectorating sputum 2
• Do not routinely use recombinant human DNase (rhDNase) in adults with non-CF bronchiectasis 2

Antibiotic Therapy

Acute Exacerbations

• Standard recommended duration is 14 days, particularly for P. aeruginosa infections 2
• Select antibiotics based on previous sputum culture results and severity of exacerbation 2
• Obtain sputum cultures before starting antibiotics when possible 1
• Consider intravenous antibiotics for:
  • Severe symptoms
  • Treatment failures
  • P. aeruginosa infections resistant to oral therapy 2

Long-term Antibiotic Therapy

• Consider for patients with ≥3 exacerbations per year 1
• Options include:
  • Long-term macrolides (e.g., azithromycin) 2
  • Inhaled antibiotics (e.g., colistin, gentamicin) for patients with P. aeruginosa infection 2
  • Cyclical IV antibiotics in patients with repeated infections (≥5/year) despite other treatments 2

P. aeruginosa Eradication

• Offer eradication therapy for new isolation of P. aeruginosa 1
• First-line treatment: ciprofloxacin 500-750 mg twice daily for 2 weeks 1
• P. aeruginosa infection is associated with a three-fold increase in mortality risk 2

Anti-inflammatory Treatment

• Inhaled corticosteroids should not be routinely offered without other indications such as ABPA, asthma, or COPD 1
• Two randomized short-term trials showed non-significant trends toward improved lung function but no effect on symptoms 2
• For allergic bronchopulmonary aspergillosis (ABPA):
  • Oral corticosteroids: Prednisolone 0.5 mg/kg/day for 1-2 weeks, then on alternate days for 6-8 weeks before tapering 2
  • Consider itraconazole as a steroid-sparing agent for steroid-dependent ABPA patients 1

Bronchodilators

• May be considered for symptom relief, especially in patients with reversible airflow obstruction 2, 1
• No randomized studies have validated their usefulness in managing cough, sputum production, or dyspnea specifically in bronchiectasis 2

Pulmonary Rehabilitation and Exercise

• Recommend regular exercise for patients with impaired exercise capacity 1
• Pulmonary rehabilitation may improve exercise capacity and reduce exacerbation frequency 1
• Annual clinical review by a respiratory physiotherapist is recommended 1

Vaccinations

• Offer annual influenza vaccination to all patients 2, 1
• Offer pneumococcal vaccination to all patients 2, 1
• Consider influenza vaccination for household contacts of immunodeficient patients 2

Management of Complications

Respiratory Failure

• Consider long-term oxygen therapy for patients with respiratory failure, using the same eligibility criteria as for COPD 2
• Consider domiciliary non-invasive ventilation with humidification for patients with respiratory failure associated with hypercapnia 2

Hemoptysis

• For minor hemoptysis: treat with appropriate oral antibiotics 1
• For major hemoptysis: use a multidisciplinary approach with respiratory physicians, interventional radiology, and thoracic surgeons 1
• Consider bronchial artery embolization as first-line treatment for persistent significant hemoptysis 1

Surgical Options

• Consider lung resection in patients with localized disease whose symptoms are not controlled by optimal medical treatment 2, 1
• Consider lung transplant referral in patients aged ≤65 years with FEV1 <30% and clinical instability 2
• Multidisciplinary assessment including a bronchiectasis physician, thoracic surgeon, and experienced anesthetist is essential before surgery 2

Monitoring and Follow-up

• Assess patients annually, more frequently in severe disease 1
• Perform pulse oximetry to screen for respiratory failure 1
• Send sputum for culture before and after eradication antibiotics 1
• Monitor for antibiotic resistance with repeat sensitivity testing 1
• Record patient's weight and BMI at each clinic appointment 2

Common Pitfalls and Caveats

• Failure to identify and treat underlying causes (immunodeficiency, ABPA, etc.)
• Inappropriate use of rhDNase, which may worsen lung function in non-CF bronchiectasis
• Inadequate duration of antibiotic therapy, particularly for P. aeruginosa infections
• Overuse of inhaled corticosteroids without specific indications
• Neglecting airway clearance techniques, which are fundamental to management