What is the treatment for bronchiectasis?

Treatment 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 through a combination of airway clearance techniques, antibiotics, and anti-inflammatory treatments. 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
• Long-term mucoactive treatment should be considered for patients with difficulty expectorating sputum, poor quality of life, or failure of standard airway clearance techniques 1
• Humidification with sterile water or normal saline can facilitate airway clearance 1
• Do not routinely use recombinant human DNase (dornase alfa) in adults with non-CF bronchiectasis 1, 2

Antibiotic Therapy for Exacerbations

• Treat exacerbations with 14 days of antibiotics, with selection based on previous sputum culture results 3, 1
• Obtain sputum cultures before starting antibiotics whenever possible 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
  • Pseudomonas aeruginosa: Oral Ciprofloxacin 500mg BD (750mg BD in more severe infections) for 14 days 3, 1
  • MRSA: Vancomycin 1g BD (monitor serum levels) or Linezolid 600mg BD for 14 days 3
• Intravenous antibiotics should be considered when patients are particularly unwell, have resistant organisms, or have failed to respond to oral therapy (especially with P. aeruginosa) 3
• For P. aeruginosa requiring IV therapy, options include:
  • Monotherapy: Ceftazidime 2G TDS, Piperacillin-tazobactam 4.5G TDS, Aztreonam 2G TDS, or Meropenem 2G TDS 3
  • Combination therapy: The above can be combined with gentamicin, tobramycin, or Colistin 3

Long-term Antibiotic Therapy

• Consider long-term antibiotics for patients with ≥3 exacerbations per year 1, 2
• First-line treatments include:
  • Long-term inhaled antibiotics for patients with chronic Pseudomonas aeruginosa infection 1, 4
  • Macrolides (e.g., azithromycin) for patients without Pseudomonas aeruginosa infection 1, 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 1

Anti-inflammatory Treatments

• 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 ABPA, chronic asthma, COPD, or inflammatory bowel disease 1
• For patients with bronchiectasis and ABPA, the mainstay of treatment is immunosuppression with corticosteroids, with or without antifungal agents 3
• A tapering dose of corticosteroid is usually used with monitoring of total serum IgE every 6–8 weeks as a marker of ABPA disease activity 3

Bronchodilator Therapy

• Consider bronchodilators in patients with significant breathlessness, with appropriate inhalation device selection and inhaler technique training 1
• If treatment with bronchodilators does not result in a reduction in symptoms, it should be discontinued 1
• Inhaled bronchodilators (β-agonists and antimuscarinic agents) are indicated for patients with bronchiectasis who have asthma or chronic obstructive pulmonary disease 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 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 management 1
• Video-assisted thoracoscopic surgery (VATS) is often preferred to better preserve lung function and reduce scarring compared to open surgery 1
• Lung transplantation should be considered 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, 2

Special Considerations

• Caution with aminoglycosides in pregnancy, renal failure, elderly or on multiple other drugs 3
• For elderly patients (over 65 years) requiring vancomycin, use 500 mg every 12 hours or 1 g once daily 3
• Emergency surgery in unstable patients with massive hemoptysis is associated with higher morbidity and mortality reaching 37% 1