What is the treatment for bronchiectasis?

Treatment of Bronchiectasis

The treatment of bronchiectasis should target the four key components of the disease: chronic bronchial infection, inflammation, impaired mucociliary clearance, and structural lung damage. 1, 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 2
• Techniques include active cycle of breathing, postural drainage, and manual or mechanical devices 2
• Sessions should last 10-30 minutes, once or twice daily 1, 2
• Consider intermittent positive pressure breathing or non-invasive ventilation during acute exacerbations to reduce work of breathing 1
• Patients should be reviewed by a respiratory physiotherapist within 3 months of initial assessment and annually thereafter 1

Mucoactive Treatments

• Consider long-term mucoactive treatment for patients with difficulty expectorating sputum, poor quality of life, or failure of standard airway clearance techniques 2
• Consider humidification with sterile water or normal saline to facilitate airway clearance 1
• Do not routinely use recombinant human DNase (dornase alfa) in adults with non-CF bronchiectasis 1, 2
• Consider pre-treatment with a bronchodilator prior to inhaled mucoactive treatments, especially in patients with asthma, bronchial hyperreactivity, or severe airflow obstruction 1

Antibiotic Therapy for Exacerbations

• Treat exacerbations with 14 days of antibiotics, with selection based on previous sputum culture results 2
• Obtain sputum cultures before starting antibiotics whenever possible 1
• Empirical antibiotics can be started while awaiting sputum microbiology results 1
• Common pathogens and recommended antibiotics include:
  • Streptococcus pneumoniae: Amoxicillin 500mg TID (14 days) 1
  • Haemophilus influenzae (beta-lactamase negative): Amoxicillin 500mg TID (14 days) 1
  • Haemophilus influenzae (beta-lactamase positive): Amoxicillin-clavulanate 625mg TID (14 days) 1
  • Pseudomonas aeruginosa: Ciprofloxacin 500-750mg BID (14 days) 1
• Consider intravenous antibiotics for severe exacerbations, treatment failures, or resistant organisms (particularly P. aeruginosa) 1

Long-term Antibiotic Therapy

• Consider long-term antibiotics for patients with ≥3 exacerbations per year 2
• First-line treatments include:
  • Long-term inhaled antibiotics for patients with chronic Pseudomonas aeruginosa infection 2
  • Macrolides for patients without Pseudomonas aeruginosa infection 2
• For new isolation of P. aeruginosa, offer eradication therapy:
  • First line: Ciprofloxacin 500-750mg BID for 2 weeks 1
  • Second line: IV antipseudomonal beta-lactam ± IV aminoglycoside for 2 weeks, followed by 3 months of nebulized colistin, gentamicin, or tobramycin 1
• For new isolation of MRSA, attempt eradication therapy 1

Anti-inflammatory Treatments

• Do not routinely offer inhaled corticosteroids unless comorbid asthma or COPD is present 1, 2
• Do not offer long-term oral corticosteroids without other indications (such as ABPA, chronic asthma, COPD, inflammatory bowel disease) 1
• For allergic bronchopulmonary aspergillosis (ABPA):
  • Offer oral corticosteroids (initial dose 0.5 mg/kg/day for 2 weeks, then wean according to clinical response and serum IgE levels) 1
  • Consider itraconazole as a steroid-sparing agent for patients dependent on oral corticosteroids 1
  • Monitor treatment response with total IgE levels 1

Bronchodilator Therapy

• Consider long-acting bronchodilators for patients with significant breathlessness on an individual basis 2
• In patients with airflow obstruction and/or bronchial hyperreactivity, bronchodilator therapy may be beneficial 1

Pulmonary Rehabilitation

• Strongly recommended for patients with impaired exercise capacity 2
• Provides improved exercise capacity, reduced cough symptoms, enhanced quality of life, and decreased frequency of exacerbations 2

Immunizations

• Offer annual influenza immunization to all patients with bronchiectasis 1
• Offer pneumococcal vaccination to all patients with bronchiectasis 1
• Consider influenza vaccination in household contacts of patients with immune deficiency and bronchiectasis 1

Surgical Intervention

• Consider surgical intervention for patients with localized disease and high exacerbation frequency despite optimization of all other aspects of bronchiectasis management 2
• Offer multidisciplinary assessment, including a bronchiectasis physician, a thoracic surgeon, and an experienced anesthetist for suitability for surgery 1

Lung Transplantation

• Consider transplant referral in bronchiectasis patients aged 65 years or less if the FEV1 is <30% with significant clinical instability or if there is rapid progressive respiratory deterioration despite optimal medical management 1
• Consider earlier transplant referral with additional factors: massive hemoptysis, severe secondary pulmonary hypertension, ICU admissions, or respiratory failure 1

Monitoring

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