What are the guidelines for managing bronchiectasis?

Management Guidelines for Bronchiectasis

The management of bronchiectasis should follow evidence-based guidelines that focus on reducing exacerbations, improving symptoms, enhancing quality of life, and preventing disease progression through a structured approach to diagnosis, monitoring, and treatment. 1

Diagnosis and Initial Evaluation

• High-resolution CT (HRCT) scanning is the gold standard for diagnosing bronchiectasis, defined by permanent bronchial dilatation with clinical symptoms of cough, sputum production, and/or recurrent respiratory infections 1, 2

• A minimum panel of tests should be performed for all patients with suspected or confirmed bronchiectasis, including: 1

  • Chest CT scan (to diagnose bronchiectasis)
  • Sweat test (to exclude cystic fibrosis)
  • Lung function tests (in those who can perform spirometry)
  • Full blood count
  • Immunological tests (total IgG, IgA, IgM, IgE and specific antibodies to vaccine antigens)
  • Lower airway bacteriology

• Additional testing should be considered based on clinical presentation, including: 1

  • In-depth immunological assessments (in consultation with immunologist)
  • Diagnostic bronchoscopy with bronchoalveolar lavage
  • Tests for airway aspiration
  • Primary ciliary dyskinesia testing
  • Gastro-oesophageal disease evaluation
  • Testing for allergic bronchopulmonary aspergillosis

Routine Monitoring

• All patients with bronchiectasis should undergo routine monitoring to identify disease progression, pathogen emergence, and modify treatment when necessary 1

• Monitoring frequency should be tailored to disease severity: 1

  • Mild disease: Annual assessment of BMI, exacerbation history, sputum culture, MRC dyspnea score, spirometry, and oxygen saturation
  • Moderate-severe disease: Assessment every 6 months for exacerbation history, sputum culture, MRC dyspnea score, and oxygen saturation; annual assessment for BMI and spirometry

Airway Clearance Techniques

• All patients with bronchiectasis should be taught and regularly use airway clearance techniques 1, 2

• Techniques may include active cycle of breathing, postural drainage, manual techniques, or mechanical devices with sessions lasting 10-30 minutes until two clear huffs or coughs are completed 2

• Pulmonary rehabilitation should be offered to patients with impaired exercise capacity, as it improves exercise capacity, reduces cough symptoms, and enhances quality of life 1, 2

Management of Exacerbations

• Acute exacerbations of bronchiectasis should be treated with 14 days of antibiotics (conditional recommendation) 1, 3

• Obtain sputum samples for culture and sensitivity testing prior to starting antibiotics whenever possible 3

• Antibiotic selection should be guided by previous sputum cultures: 3

  • For Streptococcus pneumoniae: Amoxicillin 500 mg three times daily for 14 days
  • For Haemophilus influenzae (beta-lactamase negative): Amoxicillin 500 mg three times daily for 14 days
  • For Haemophilus influenzae (beta-lactamase positive): Amoxicillin-clavulanate 625 mg three times daily for 14 days
  • For Pseudomonas aeruginosa: Ciprofloxacin 500-750 mg twice daily for 14 days

• Consider intravenous antibiotics for severe exacerbations, treatment failures, or resistant organisms 3, 2

Long-term Management Strategies

• For patients with ≥3 exacerbations per year, consider long-term antibiotic therapy: 3, 2

  • For chronic P. aeruginosa infection: Inhaled colistin as first-line prophylaxis
  • For non-Pseudomonas infections: Macrolides as first-line treatment

• Mucoactive treatments: 2

  • Consider humidification with sterile water or normal saline to facilitate airway clearance
  • Do not use recombinant human DNase (rhDNase) in non-CF bronchiectasis

• Anti-inflammatory treatments: 2

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

Special Considerations

• For patients with new isolation of P. aeruginosa, consider eradication antibiotic treatment 3

• Ensure all patients are fully immunized according to national immunization programs, including pneumococcal and seasonal influenza vaccines 1

• Optimize nutrition, including vitamin D status 1

• Encourage regular exercise on an ongoing basis, as short periods of exercise training are unlikely to have long-term effects 1

• Provide psychological support and education on equipment use and care 1

Monitoring Treatment Response

• Assess clinical response to treatments, including symptoms of cough, sputum volume, purulence, and systemic symptoms 3

• For patients on IV aminoglycosides, monitor renal function and drug levels 3

• Regular monitoring of sputum pathogens before and after implementation of long-term antibiotics 2

• Monitor for drug toxicity, especially with macrolides and inhaled aminoglycosides 2

• Consider annual assessment by respiratory physiotherapist to optimize airway clearance regimen 2