What is the management approach for bronchiectasis?

Management Approach for Bronchiectasis

The comprehensive management of bronchiectasis should focus on preventing exacerbations, reducing symptoms, improving quality of life, and halting disease progression through airway clearance techniques, appropriate antibiotic therapy, and pulmonary rehabilitation. 1

Diagnosis

• Gold standard: High-resolution CT (HRCT) scan with sensitivity and specificity exceeding 90% 1
• Supporting tests:
  • Spirometry (may show obstructive, restrictive, or mixed patterns)
  • Sputum culture to identify pathogens (common: H. influenzae, S. pneumoniae, P. aeruginosa, S. aureus)
  • Blood tests (elevated CRP, neutrophilia, inflammatory markers)

Core Treatment Strategies

1. Airway Clearance Techniques

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

2. Pulmonary Rehabilitation

• Strongly recommended for patients with impaired exercise capacity 2, 1
• Benefits include:
  • Improved exercise tolerance
  • Reduced cough symptoms
  • Better quality of life
  • Potential reduction in exacerbation frequency (median 1 vs 2; p=0.012) 2
  • Longer time to first exacerbation (8 vs 6 months; p=0.047) 2
• Exercise should be encouraged on an ongoing basis 1

3. Antibiotic Therapy

• For exacerbations:

  • 14-day course of systemic antibiotics is standard 1
  • Consider IV antibiotics when patients are particularly unwell, have resistant organisms, or have failed oral therapy 1

• Long-term antibiotic therapy for patients with ≥3 exacerbations per year 1:

  For patients with P. aeruginosa infection:

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

  For patients without P. aeruginosa infection:

  • First choice: Long-term macrolide (azithromycin, erythromycin)
  • If macrolides contraindicated/not tolerated: Oral antibiotic based on susceptibility
  • If oral antibiotics contraindicated/not tolerated: Inhaled antibiotic

4. Bronchodilator Therapy

• Use bronchodilators in patients with significant breathlessness, airflow obstruction, or bronchial hyperreactivity 1
• Discontinue if no symptomatic improvement is observed 1
• Do not routinely use in patients without symptomatic breathlessness 1, 3
• Despite guideline recommendations, bronchodilators are often overused in real-world practice 3

5. Prevention Strategies

• Annual influenza vaccination for all patients 1
• Pneumococcal vaccination for all patients 1
• Consider influenza vaccination for household contacts of immunodeficient patients 1
• Avoid tobacco smoke and other pollutants 1

Management of Specific Conditions

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 1

Monitoring and Follow-up

• Regular lung function monitoring (spirometry for FEV1 and FVC) 1
• Sputum culture and pulse oximetry 1
• Outpatient clinic reviews every 3-6 months 1
• Repeat chest CT scans only when clinically indicated 1
• Record patient's weight and BMI at each clinic appointment 1
• Review by a respiratory physiotherapist within 3 months of initial assessment 1

Advanced Disease Management

• Consider surgery only for patients with localized disease and high exacerbation frequency despite optimization of all other aspects of management 1
• For patients with deteriorating clinical status:
  • Assess for new infections
  • Evaluate for possible comorbidities
  • Consider hospitalization for intravenous antibiotics and intensified airway clearance 1
• Consider lung transplantation for patients with severely impaired pulmonary function or frequent exacerbations 4

Prognosis

• Bronchiectasis is associated with:
  • Higher mortality risk (3-fold increase)
  • Higher hospitalization risk (7-fold increase)
  • Average of one additional exacerbation per patient per year 1
  • Up to 30% mortality at 1-year follow-up after exacerbation, particularly with comorbid COPD 1

Common Pitfalls to Avoid

1. Overuse of bronchodilators in patients without airflow obstruction or symptoms 3
2. Using rhDNase which can be harmful in non-CF bronchiectasis 1
3. Inadequate duration of antibiotics during exacerbations (should be 14 days) 1
4. Failure to identify underlying etiologies that may require specific treatment 4
5. Neglecting airway clearance techniques, which are fundamental to management 2, 1