What are the management options for bronchiectasis?

Management of Bronchiectasis in Adults

The comprehensive management of bronchiectasis should include airway clearance techniques, pulmonary rehabilitation, appropriate antibiotic therapy for exacerbations, and consideration of long-term antibiotics for patients with frequent exacerbations, with treatment tailored to specific pathogens identified in sputum cultures. 1, 2

Diagnostic Evaluation

• High-resolution CT (HRCT) scanning is the gold standard for diagnosing bronchiectasis, confirming permanent bronchial dilatation 2
• Initial diagnostic workup should include:
  • Differential blood count 1
  • Serum immunoglobulins (total IgG, IgA, and IgM) 1
  • Testing for allergic bronchopulmonary aspergillosis (ABPA) 1, 2
  • Sputum culture for bacteria, mycobacteria, and fungi 2
  • Pre- and post-bronchodilator spirometry 3

Management of Acute Exacerbations

• Treat exacerbations with 14 days of antibiotics 2
• Obtain sputum culture prior to initiating antibiotics to guide therapy 2
• Select antibiotics based on previous sputum culture results 2
• Consider intravenous antibiotics for severe exacerbations or treatment failures 2

Airway Clearance Techniques

• All patients with chronic productive cough or difficulty expectorating sputum should be taught airway clearance techniques by a trained respiratory physiotherapist 1
• Techniques may include:
  • Active cycle of breathing techniques 2
  • Postural drainage 2
  • Manual techniques or mechanical devices that modify expiratory flow 1
• Sessions should last 10-30 minutes and be performed once or twice daily 1, 2
• Benefits include increased sputum volume and reduced impact of cough on quality of life 1

Pulmonary Rehabilitation

• Strongly recommended for patients with impaired exercise capacity 1
• Pulmonary rehabilitation provides:
  • Improved exercise capacity 1
  • Reduced cough symptoms 2
  • Enhanced quality of life 2
  • Decreased frequency of exacerbations 1
  • Longer time to first exacerbation 1
• Regular exercise should be maintained after formal rehabilitation program 2

Mucoactive Treatments

• Consider long-term mucoactive treatment (≥3 months) for patients with:
  • Difficulty expectorating sputum 1
  • Poor quality of life 1
  • Failure of standard airway clearance techniques to control symptoms 1
• Do NOT use recombinant human DNase (rhDNase) in non-CF bronchiectasis as it may increase exacerbation rates 1, 2
• Consider humidification with sterile water or normal saline to facilitate airway clearance 2

Long-term Antibiotic Therapy

• Consider long-term antibiotics for patients with ≥3 exacerbations per year 1, 2
• For patients with chronic Pseudomonas aeruginosa infection:
  • First-line: Long-term inhaled antibiotics (e.g., colistin) 1, 2
  • Alternative: Macrolides (azithromycin, erythromycin) if inhaled antibiotics are contraindicated, not tolerated, or not feasible 1
  • Consider combination therapy (inhaled plus macrolide) for patients with high exacerbation frequency despite inhaled antibiotics 1
• For patients without Pseudomonas aeruginosa infection:
  • First-line: Long-term macrolides (azithromycin, erythromycin) 1, 2
  • Alternative: Long-term oral antibiotics based on antibiotic susceptibility if macrolides are contraindicated, not tolerated, or ineffective 1
  • Consider inhaled antibiotics if oral antibiotic prophylaxis is contraindicated, not tolerated, or ineffective 1
• Prior to starting macrolides, exclude active nontuberculous mycobacterial (NTM) infection to prevent development of macrolide resistance 1
• Regular monitoring of sputum pathogens before and after implementation of long-term antibiotics is essential 2

Bronchodilator Therapy

• Not routinely recommended for all patients with bronchiectasis 1
• Consider long-acting bronchodilators for patients with significant breathlessness on an individual basis 1
• Use bronchodilators before physiotherapy, inhaled mucoactive drugs, and inhaled antibiotics to increase tolerability and optimize pulmonary deposition 1
• Continue long-acting bronchodilators in patients with comorbid asthma or COPD 1

Anti-inflammatory Treatments

• Do not routinely offer inhaled corticosteroids unless comorbid asthma or COPD is present 2
• Do not offer long-term oral corticosteroids 2

Surgical Intervention

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

Monitoring and Follow-up

• Regular monitoring of sputum pathogens, especially when using long-term antibiotics 2
• Monitor for drug toxicity, particularly with macrolides and inhaled aminoglycosides 1, 2
• Annual assessment by respiratory physiotherapist to optimize airway clearance regimen 2