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

Diagnostic Approach

Bronchiectasis is characterized by permanent bronchial dilatation, defined by:

• Bronchoarterial ratio >1
• Lack of airway tapering
• Airway visibility within 1cm of pleural surface 1

Consider investigation for bronchiectasis in patients with:

• Persistent production of mucopurulent/purulent sputum
• COPD with ≥2 exacerbations annually and previous P. aeruginosa culture
• Rheumatoid arthritis with chronic productive cough/recurrent infections
• Inflammatory bowel disease with chronic productive cough
• Cough persisting >8 weeks, especially with sputum production
• Asthma with severe or poorly-controlled disease 1

Diagnosis is confirmed with thin-section CT scan performed during clinically stable disease for optimal diagnostic accuracy 1.

Initial Management Algorithm

Step 1: Antibiotic Therapy

1. Obtain sputum sample for culture and sensitivity before starting antibiotics
2. Start empiric antibiotic therapy while awaiting culture results:
   • First-line: Amoxicillin-clavulanate 625mg three times daily for 14 days
   • Adjust based on previous or current sputum culture results 1

Step 2: Pathogen-Specific Antibiotic Selection

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
MRSA	Doxycycline 100mg BD	Vancomycin or Linezolid

Step 3: Airway Clearance Techniques

• Patient should be taught techniques by a trained respiratory physiotherapist
• Techniques include:
  • Active cycle of breathing
  • Autogenic drainage
  • Postural drainage
  • Device-assisted methods
• Perform once or twice daily
• Increase frequency during exacerbations 1
• Ensure adequate hydration to thin secretions 1

Step 4: Additional Initial Interventions

1. Pulmonary Rehabilitation: Recommended for patients with impaired exercise capacity 1
2. Bronchodilators: Consider for patients with significant breathlessness on an individual basis 1
3. Vaccinations:
   • Annual influenza vaccination for all patients
   • Pneumococcal vaccination for all patients 1
4. Self-Management Plan:
   • Patient education about the disease
   • Prompt treatment of exacerbations
   • Consider providing antibiotics for suitable patients to keep at home 1

Management of Comorbid Conditions

• Optimize control of asthma and allergies in patients with both conditions
• Monitor patients with co-morbid COPD more closely due to higher mortality risk
• Consider a trial of inhaled/oral corticosteroids in patients with inflammatory bowel disease 1

Common Pitfalls and Caveats

1. Failure to obtain sputum culture before starting antibiotics: This can lead to inappropriate antibiotic selection and potential resistance development.
2. Inadequate duration of antibiotic therapy: Standard course is 14 days, especially for P. aeruginosa infections 1.
3. Overlooking airway clearance techniques: These are essential components of management, not optional add-ons 1, 2.
4. Neglecting to identify underlying causes: Bronchiectasis may be associated with conditions requiring specific management, such as immunodeficiency, rheumatoid arthritis, or allergic bronchopulmonary aspergillosis 2.
5. Underestimating symptom burden: Patients with higher symptom scores have higher exacerbation rates, indicating the need for more aggressive management 3.

Follow-Up Recommendations

• Assess patients annually, more frequently in severe disease
• Perform pulse oximetry to screen for respiratory failure
• Record patient's weight and BMI at each clinic appointment
• Review by a respiratory physiotherapist within 3 months of initial assessment 1

The comprehensive approach to bronchiectasis management aims to reduce exacerbations, improve symptoms and quality of life, and halt disease progression 1, 4. Recent research confirms that patients with greater symptoms are at higher risk of exacerbations, emphasizing the importance of aggressive symptom management 3.