What are the treatment options for bronchiectasis?

Treatment Options for 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

Airway Clearance Techniques

• All patients with chronic productive cough or difficulty expectorating sputum should be taught airway clearance techniques by a trained respiratory physiotherapist, with sessions lasting 10-30 minutes, once or twice daily 1
• Consider intermittent positive pressure breathing or non-invasive ventilation during acute exacerbations to reduce work of breathing 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 1
• 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 2, 1

Antibiotic Therapy

For Exacerbations

• Treat exacerbations with 14 days of antibiotics, with selection based on previous sputum culture results 1
• Obtain sputum cultures before starting antibiotics whenever possible 1
• Common pathogens and recommended antibiotics include:
  • Streptococcus pneumoniae: Amoxicillin 500mg TID (14 days)
  • Haemophilus influenzae (beta-lactamase negative): Amoxicillin 500mg TID (14 days)
  • Pseudomonas aeruginosa: Ciprofloxacin 500-750mg BID (14 days) 1

Long-term Antibiotic Therapy

• Consider long-term antibiotics for patients with ≥3 exacerbations per year 1
• First-line treatments include:
  • Long-term inhaled antibiotics for patients with chronic Pseudomonas aeruginosa infection
  • Macrolides for patients without Pseudomonas aeruginosa infection 1, 3

Bronchodilators and Anti-inflammatory Treatments

• Suggest the use of bronchodilators in patients with significant breathlessness 2
• Appropriate inhalation device selection and inhaler technique training are recommended 2
• If treatment with bronchodilators does not result in a reduction in symptoms, it should be discontinued 2
• Do not routinely offer inhaled corticosteroids unless comorbid asthma or COPD is present 1
• Do not offer long-term oral corticosteroids without other indications, such as allergic bronchopulmonary aspergillosis (ABPA), chronic asthma, COPD, or inflammatory bowel disease 1

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 Options

• Surgery is not recommended for adult patients with bronchiectasis except in cases of localized disease and high exacerbation frequency despite optimization of all other aspects of bronchiectasis management 2
• The most frequent indication for surgery is recurrent infections with chronic symptoms such as productive cough, purulent sputum, and hemoptysis 2
• Video-assisted thoracoscopic surgery (VATS) is often preferred to better preserve lung function and reduce scarring compared to open surgery 2
• Surgery is the procedure of choice for massive hemoptysis refractory to bronchial artery embolization 2

Lung Transplantation

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

Treatment of Specific Pathogens

• For patients with MAC (Mycobacterium avium complex) infection, treatment with a macrolide (clarithromycin or azithromycin) with ethambutol and a rifamycin (rifabutin or rifampin) constitute first-line therapy for severe or progressive symptoms 2
• P. aeruginosa infection is associated with a three-fold increase in mortality risk, almost seven-fold increase in risk of hospital admission, and an average of one additional exacerbation per patient per year 2

Pitfalls and Caveats

• Bronchiectasis treatment should not be directly extrapolated from cystic fibrosis management, as treatment responses differ significantly 2
• Mortality is higher for patients with frequent and severe exacerbations, infection with Pseudomonas aeruginosa, and comorbidities such as COPD 4
• Long-term antibiotic regimens for MAC infections are often poorly tolerated, and patients frequently relapse 2
• Emergency surgery in unstable patients with massive hemoptysis is associated with higher morbidity and mortality reaching 37% 2