What is the comprehensive management plan for patients with bronchiectasis?

Comprehensive Management Plan for Bronchiectasis

The comprehensive management of bronchiectasis should focus on preventing exacerbations, reducing symptoms, improving quality of life, and stopping disease progression through a structured approach targeting airway clearance, infection control, and inflammation reduction. 1

Airway Clearance Techniques

• Patients with chronic productive cough or difficulty expectorating sputum should be taught airway clearance techniques by a trained respiratory physiotherapist to perform once or twice daily 1
• Pulmonary rehabilitation is strongly recommended for patients with impaired exercise capacity to improve exercise tolerance and quality of life 1
• Consider long-term mucoactive treatment (≥3 months) for patients with difficulty expectorating sputum and poor quality of life where standard airway clearance techniques have failed 1
• Recombinant human DNase should NOT be offered to patients with bronchiectasis 1

Infection Management

Exacerbation Treatment

• Promptly treat exacerbations with antibiotics, with suitable patients having antibiotics to keep at home 1
• Obtain sputum cultures before starting antibiotics whenever possible 1, 2
• Standard antibiotic course is 14 days, especially for P. aeruginosa infections 1, 2
• Common first-line treatments by pathogen:
  • Streptococcus pneumoniae: Amoxicillin 500 mg three times daily for 14 days 1, 2
  • Haemophilus influenzae (beta-lactamase negative): Amoxicillin 500 mg three times daily for 14 days 1, 2
  • Haemophilus influenzae (beta-lactamase positive): Amoxicillin-clavulanate 625 mg three times daily for 14 days 1, 2
  • Pseudomonas aeruginosa: Ciprofloxacin 500-750 mg twice daily for 14 days 1, 2
• Consider intravenous antibiotics for patients who are particularly unwell, have resistant organisms, or have failed oral therapy 1

Chronic Infection Management

• For new isolation of P. aeruginosa, offer eradication antibiotic treatment:
  • First line: Ciprofloxacin 500-750 mg twice daily for 2 weeks
  • Second line: IV anti-pseudomonal 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 treatment 1
• For patients with ≥3 exacerbations per year, consider long-term antibiotic therapy:
  • Long-term macrolides (azithromycin, erythromycin) for patients not infected with P. aeruginosa 1, 2
  • For patients with chronic P. aeruginosa infection, consider inhaled antibiotics as first-line prophylaxis 1, 2

Bronchodilator Therapy

• Long-acting bronchodilators are 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

Immunizations

• Offer annual influenza immunization to all patients with bronchiectasis 1
• Offer polysaccharide pneumococcal vaccination to all patients 1
• Consider influenza vaccination in household contacts of patients with immune deficiency and bronchiectasis 1
• Consider 13-valent protein conjugate pneumococcal vaccine in patients who don't respond appropriately to standard polysaccharide vaccine 1

Management of Specific Conditions

• 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 patients with active ABPA using total IgE levels to assess treatment response 1

Advanced Management Options

• Consider lung resection in patients with localized disease whose symptoms are not controlled by optimized medical treatment 1
• Offer multidisciplinary assessment for surgical candidates, including evaluation by a bronchiectasis physician, thoracic surgeon, and experienced anesthetist 1
• Consider lung transplant referral in patients aged ≤65 years with FEV₁ <30% and significant clinical instability or rapid respiratory deterioration despite optimal management 1
• Consider earlier transplant referral in patients with poor lung function plus massive hemoptysis, severe pulmonary hypertension, ICU admissions, or respiratory failure 1

Respiratory Support

• Consider long-term oxygen therapy for patients with bronchiectasis and respiratory failure, using the same eligibility criteria as for COPD 1
• Consider domiciliary non-invasive ventilation with humidification for patients with bronchiectasis and hypercapnic respiratory failure, especially when associated with symptoms or recurrent hospitalization 1

Monitoring

• Record patient's weight and BMI at each clinic appointment 1
• Send sputum for culture and sensitivity immediately before and at each clinical attendance following antibiotics prescribed for bacterial eradication 1
• Monitor for disease progression with regular pulmonary function tests 3, 4

Common Pitfalls and Caveats

• Failure to identify and treat underlying causes of bronchiectasis can lead to continued disease progression 5, 3
• Inadequate airway clearance techniques can result in persistent symptoms despite appropriate antibiotic therapy 1
• Overuse of antibiotics without appropriate cultures can lead to antimicrobial resistance 1, 2
• Delaying eradication therapy for new P. aeruginosa isolation increases the risk of chronic infection 1
• Neglecting pulmonary rehabilitation can result in decreased exercise capacity and quality of life 1