What is the treatment for bronchiectasis?

Treatment of Bronchiectasis

The treatment of bronchiectasis should include a 14-day course of antibiotics for exacerbations, airway clearance techniques taught by a respiratory physiotherapist to be performed once or twice daily, and pulmonary rehabilitation for patients with impaired exercise capacity. 1, 2

Initial Management

Antibiotic Therapy

• Obtain sputum sample for culture and sensitivity before starting antibiotics 2
• Begin empiric antibiotic therapy while awaiting culture results
  • First-line empiric choice: Amoxicillin-clavulanate 625mg three times daily 2
• Standard antibiotic course is 14 days, especially important for P. aeruginosa infections 1, 2
• Adjust antibiotics based on culture results:

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	IV options if oral fails
MRSA	Doxycycline 100mg BD	Vancomycin or Linezolid

Airway Clearance

• All patients with chronic productive cough should be taught airway clearance techniques by a trained respiratory physiotherapist 1, 2
• Techniques include:
  • Active cycle of breathing
  • Autogenic drainage
  • Postural drainage
  • Device-assisted methods (flutter, acapella)
• Perform once or twice daily, increasing frequency during exacerbations 1
• Ensure adequate hydration to thin secretions 2

Long-Term Management

Pulmonary Rehabilitation

• Strongly recommended for patients with impaired exercise capacity 1
• Benefits include:
  • Improved exercise tolerance
  • Reduced cough symptoms
  • Better quality of life
  • Potential reduction in exacerbation frequency 2

Long-Term Antibiotic Therapy

• Consider for patients with ≥3 exacerbations per year 1, 2
• Options include:
  • Long-term macrolides (azithromycin, erythromycin) for patients not infected with P. aeruginosa 1
  • Inhaled antibiotics for patients with chronic P. aeruginosa infection 1
  • For P. aeruginosa infection with high exacerbation frequency despite inhaled antibiotics, consider macrolides in addition to or in place of inhaled antibiotics 1

Mucoactive Agents

• Consider for patients with difficulty expectorating sputum and poor quality of life when standard airway clearance techniques have failed 1
• Do not offer recombinant human DNase to patients with bronchiectasis (strong recommendation) 1

Bronchodilators

• Not routinely recommended for all patients 1
• Consider for patients with significant breathlessness on an individual basis 1
• Use before physiotherapy, mucoactive drugs, and inhaled antibiotics to optimize pulmonary deposition 1

Prevention Strategies

Vaccinations

• Annual influenza vaccination for all patients 2
• Pneumococcal vaccination for all patients 2

Eradication of New Pathogens

• Offer eradication antibiotic treatment for new isolation of P. aeruginosa 1
• Eradication treatment is not recommended for new isolation of pathogens other than P. aeruginosa 1

Special Considerations

Comorbid Conditions

• Diagnosis of bronchiectasis should not affect the use of inhaled corticosteroids in patients with comorbid asthma or COPD 1
• Diagnosis of bronchiectasis should not affect the use of long-acting bronchodilators in patients with comorbid asthma or COPD 1

Surgical Options

• Not recommended for most patients 1
• May be considered only for patients with localized disease and high exacerbation frequency despite optimization of all other aspects of management 1

Follow-Up

• Assess patients annually, more frequently in severe disease 2
• Monitor for respiratory failure with pulse oximetry 2
• Review by respiratory physiotherapist within 3 months of initial assessment 2

Common Pitfalls to Avoid

• Using recombinant human DNase (strongly contraindicated in non-CF bronchiectasis) 1
• Prescribing inhaled corticosteroids without comorbid asthma or COPD 1
• Short antibiotic courses (<14 days) for exacerbations, especially with P. aeruginosa 1, 2
• Neglecting airway clearance techniques, which are fundamental to management 1, 2
• Failing to offer eradication therapy for new P. aeruginosa isolation 1