What is the treatment for bronchiectasis?

Treatment for Bronchiectasis

The cornerstone of bronchiectasis treatment includes airway clearance techniques, appropriate antibiotic therapy for exacerbations, and long-term antibiotic prophylaxis for patients with frequent exacerbations (≥3 per year), with macrolides being the preferred option for most patients. 1

Comprehensive Management Approach

Airway Clearance and Hydration

• Regular airway clearance techniques should be performed 1-2 times daily, taught by a respiratory physiotherapist 1
• Techniques include:
  • Active cycle of breathing
  • Autogenic drainage
  • Postural drainage
  • Device-assisted methods
• Ensure adequate hydration to thin secretions 1
• Consider hypertonic saline (6-7%) for patients with difficulty expectorating sputum 1
• Caution: Do not use recombinant human DNase (rhDNase) as it may be harmful in non-CF bronchiectasis 1

Antibiotic Therapy for Exacerbations

• A 14-day course of systemic antibiotics is standard for treating exacerbations 1
• Antibiotic selection should be guided by sputum culture results:

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
M. catarrhalis	Amoxicillin-clavulanate 625mg TID	Clarithromycin 500mg BD
P. aeruginosa	Ciprofloxacin 500-750mg BD	IV options 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) 1

Long-term Antibiotic Prophylaxis

For patients with ≥3 exacerbations per year:

1. For patients with P. aeruginosa infection:

   • First choice: Long-term inhaled antibiotic 2
   • If inhaled antibiotic is contraindicated, not tolerated, or not feasible: Long-term macrolide (azithromycin, erythromycin) 2
   • For high exacerbation frequency despite inhaled antibiotic: Consider adding macrolides 2

2. For patients without P. aeruginosa infection:

   • First choice: Long-term macrolide (azithromycin, erythromycin) 2
   • If macrolides are contraindicated, not tolerated, or ineffective: Consider oral antibiotic based on susceptibility and tolerance 2
   • If oral antibiotics are contraindicated, not tolerated, or ineffective: Consider inhaled antibiotic 2

Bronchodilators and Corticosteroids

• Use bronchodilators only in patients with significant breathlessness, airflow obstruction, or bronchial hyperreactivity 1
• Discontinue if no symptomatic improvement is observed 1
• The presence of bronchiectasis alone should not lead to withdrawal of inhaled corticosteroids from patients with established asthma or COPD 2
• For 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 1

Pulmonary Rehabilitation and Lifestyle Modifications

• Pulmonary rehabilitation is 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
• Encourage ongoing exercise and optimize nutrition, including vitamin D status 1
• Advise patients to avoid tobacco smoke and other pollutants 1

Vaccinations

• 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 clinic reviews every 3-6 months 1
• Regular monitoring should include:
  • Spirometry (FEV1 and FVC)
  • Sputum collection for microbiology
  • Pulse oximetry
  • Weight and BMI assessment
• More frequent monitoring for patients with severe disease 1
• Repeat chest CT scans only when clinically indicated to change management 1

Surgical Considerations

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

Common Pitfalls and Caveats

1. Failure to identify underlying causes: Always investigate for potential underlying etiologies such as immunodeficiency, ABPA, or autoimmune conditions 1, 3
2. Inadequate antibiotic duration: Exacerbations typically require longer antibiotic courses (14 days) than typical respiratory infections 1
3. Overuse of inhaled corticosteroids: These should be reserved for patients with coexisting asthma or COPD 2
4. Insufficient airway clearance education: Patients need proper training in airway clearance techniques for optimal benefit 1
5. Neglecting pulmonary rehabilitation: This is a key component of management that is often underutilized 1

The evidence supporting bronchiectasis management is growing, with recent research focusing on identifying phenotypes and endotypes to help find "treatable traits" and overcome disease complexity 4. While the heterogeneity of bronchiectasis presents challenges, a structured approach focusing on airway clearance, infection control, and reducing inflammation can significantly improve outcomes and quality of life for patients.