What is the initial management for patients with bronchiectasis?

Initial Management of Bronchiectasis

The initial management for patients with bronchiectasis should include a 14-day course of antibiotics targeted at the most likely or previously cultured pathogens, with amoxicillin-clavulanate (625mg three times daily) as the empiric antibiotic of choice, along with airway clearance techniques taught by a trained respiratory physiotherapist to be performed once or twice daily. 1, 2

Diagnostic Approach

• Confirm diagnosis with thin-section CT scan showing:

  • Bronchial dilatation with bronchoarterial ratio >1
  • Lack of airway tapering
  • Airway visibility within 1cm of pleural surface 1

• Obtain sputum sample for culture and sensitivity before starting antibiotics 2, 1

• Begin empiric antibiotics while awaiting culture results 2

Antibiotic Management

First-line antibiotic therapy:

• Empiric therapy: Amoxicillin-clavulanate 625mg three times daily for 14 days 1
• Adjust based on previous or current sputum culture results 2

Pathogen-specific antibiotic regimens:

Pathogen	First-line Treatment	Alternative Treatment
Streptococcus pneumoniae	Amoxicillin 500mg TID	Doxycycline 100mg BD
Haemophilus influenzae (β-lactamase -)	Amoxicillin 500mg TID	Doxycycline 100mg BD
Haemophilus influenzae (β-lactamase +)	Amoxicillin-clavulanate 625mg TID	Doxycycline 100mg BD
Moraxella catarrhalis	Amoxicillin-clavulanate 625mg TID	Clarithromycin 500mg BD
Pseudomonas aeruginosa	Ciprofloxacin 500-750mg BD (14 days)	IV options (if oral fails): Ceftazidime, Piperacillin-tazobactam, Aztreonam, or Meropenem [2]
MRSA	Doxycycline 100mg BD	Vancomycin or Linezolid [2]

Caution: Standard antibiotic course is 14 days, especially for P. aeruginosa infections. Shorter courses may be considered only in mild bronchiectasis. 2

Airway Clearance Techniques

• Patients with chronic productive cough should be taught airway clearance techniques by a trained respiratory physiotherapist 2
• Techniques should be performed once or twice daily and include:
  • Active cycle of breathing
  • Autogenic drainage
  • Postural drainage
  • Device-assisted methods (e.g., Acapella, oscillating positive expiratory pressure) 2, 1
• Ensure adequate hydration to thin secretions 1
• Consider humidification with sterile water or normal saline to facilitate airway clearance 1

Additional Initial Management Components

• Pulmonary rehabilitation: Recommended for patients with impaired exercise capacity 2

  • Improves exercise tolerance, cough symptoms, and quality of life
  • May reduce exacerbation frequency 2

• Bronchodilators:

  • Not routinely recommended for all patients 2
  • Consider for patients with significant breathlessness on an individual basis
  • Use before physiotherapy and inhaled medications to optimize pulmonary deposition 2

• Self-management plan:

  • Provide patient education about disease
  • Ensure prompt treatment of exacerbations
  • Consider providing antibiotics for suitable patients to keep at home 2

Special Considerations

• Allergic Bronchopulmonary Aspergillosis (ABPA):

  • If present, offer oral corticosteroids (initial dose 0.5 mg/kg/day for 2 weeks)
  • Wean steroids according to clinical response and serum IgE levels 2

• Comorbid conditions:

  • Optimize control of asthma and allergies in patients with both conditions
  • Monitor patients with co-morbid COPD more closely as they have higher mortality risk 2
  • Consider trial of inhaled/oral corticosteroids in patients with inflammatory bowel disease 2

Monitoring

• Assess patients annually, more frequently in severe disease 2, 1
• Perform pulse oximetry to screen for respiratory failure 2
• Monitor weight and BMI at each clinic appointment 1
• Follow-up with respiratory physiotherapist within 3 months of initial assessment 1

By following this structured approach to initial management of bronchiectasis, focusing on antibiotic therapy and airway clearance techniques, clinicians can help reduce symptoms, prevent exacerbations, and improve quality of life for patients with this condition.