What is the treatment for bronchiectasis?

Treatment of Bronchiectasis

The cornerstone of bronchiectasis treatment is a comprehensive approach focusing on airway clearance techniques, appropriate antibiotic therapy, and pulmonary rehabilitation to prevent exacerbations, reduce symptoms, improve quality of life, and halt disease progression. 1

Airway Clearance Techniques

Airway clearance is fundamental in bronchiectasis management:

• Regular airway clearance techniques should be performed 1-2 times daily, including:
  • Active cycle of breathing
  • Autogenic drainage
  • Postural drainage
  • Device-assisted methods (e.g., oscillating positive expiratory pressure devices) 1, 2
• Adequate hydration is essential to thin secretions 1
• Hypertonic saline (6-7%) should be considered for patients with difficulty expectorating sputum 1, 2
• Do not use recombinant human DNase (rhDNase) as it may be harmful in non-CF bronchiectasis 1, 2

Antibiotic Therapy

Acute Exacerbations

• 14-day course of systemic antibiotics is the standard for treating exacerbations, particularly for P. aeruginosa infections 1, 2
• First-line empiric therapy: Amoxicillin-clavulanate 625mg TID 1
• Adjust based on sputum culture results using the following guide:

Pathogen	First-line Treatment	Alternative Treatment
S. pneumoniae	Amoxicillin 500mg TID	Doxycycline 100mg BD
H. influenzae (β-lactamase -)	Amoxicillin 500mg TID	Doxycycline 100mg BD
H. influenzae (β-lactamase +)	Amoxicillin-clavulanate 625mg TID	Doxycycline 100mg BD
P. aeruginosa	Ciprofloxacin 500-750mg BD	IV antibiotics if oral fails
MRSA	Doxycycline 100mg BD	Vancomycin or Linezolid

• Consider IV antibiotics when patients are particularly unwell, have resistant organisms, or have failed oral therapy (especially with P. aeruginosa) 2

Long-term Antibiotic Therapy

• Consider long-term antibiotics for patients with ≥3 exacerbations per year 1
• Macrolides (azithromycin, erythromycin) are preferred for long-term therapy 1
• Inhaled antibiotics (colistin, gentamicin, tobramycin) should be considered for chronic bronchial infection that doesn't respond to oral antibiotics, causes side effects, or involves P. aeruginosa or other resistant bacteria 3, 4

Bronchodilators and Anti-inflammatory Therapy

• Bronchodilators should be used in patients with significant breathlessness, airflow obstruction, or bronchial hyperreactivity 2, 1
• Discontinue bronchodilators if no symptomatic improvement is observed 2
• Do not routinely use bronchodilators in patients without symptomatic breathlessness 2
• For patients with allergic bronchopulmonary aspergillosis (ABPA), offer oral corticosteroids at an initial dose of 0.5 mg/kg/day for 2 weeks, then wean according to clinical response and serum IgE levels 2

Pulmonary Rehabilitation and Lifestyle Modifications

• Pulmonary rehabilitation is strongly recommended for patients with impaired exercise capacity 1
• Regular exercise should be encouraged on an ongoing basis 1
• Optimize nutrition, including vitamin D status 1
• Avoid tobacco smoke and other pollutants 1

Vaccination and Prevention

• Annual influenza vaccination for all patients 1
• Pneumococcal vaccination for all patients 1
• Consider influenza vaccination for household contacts of immunodeficient patients 1

Monitoring and Follow-up

• Outpatient reviews every 3-6 months with:
  • Spirometry (FEV1 and FVC)
  • Sputum collection for microbiology
  • Pulse oximetry 1
• Annual clinical review for patients followed in secondary care, with monitoring frequency tailored to disease severity 1
• Record weight and BMI at each clinic appointment 1

Surgical Options

• Surgery is not recommended for most patients with bronchiectasis 1
• Consider surgery only for patients with localized disease and high exacerbation frequency despite optimization of all other aspects of management 2, 1

Common Pitfalls and Caveats

1. Avoid recombinant human DNase (rhDNase) as it may be harmful in non-CF bronchiectasis, unlike in cystic fibrosis 1, 2
2. Don't underestimate the importance of airway clearance - this is fundamental to management
3. Don't assume all bronchiectasis patients need bronchodilators - only use if symptomatic benefit is demonstrated
4. Remember that 14-day antibiotic courses are standard for exacerbations, particularly for P. aeruginosa infections
5. Consider underlying causes that may require specific treatment (e.g., ABPA, immunodeficiency, rheumatoid arthritis)

By following this comprehensive approach to bronchiectasis management, clinicians can help prevent exacerbations, reduce symptoms, improve quality of life, and potentially slow disease progression in patients with this chronic respiratory condition.