What is the treatment for bronchiectasis?

Treatment of Bronchiectasis

The treatment of bronchiectasis should target four key components: 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, 2
• Techniques may include active cycle of breathing, postural drainage, manual techniques, or mechanical devices 2
• 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, 2
• Do not routinely use recombinant human DNase (dornase alfa) in adults with non-CF bronchiectasis 1, 2

Pulmonary Rehabilitation

• Patients with impaired exercise capacity should participate in pulmonary rehabilitation programs and take regular exercise 3, 2
• Pulmonary rehabilitation can improve exercise capacity, reduce cough symptoms, and enhance quality of life 2
• Regular exercise should be maintained after formal rehabilitation 2

Antibiotic Therapy for Exacerbations

• Treat exacerbations with 14 days of antibiotics, with selection based on previous sputum culture results 3, 2
• Obtain sputum cultures before starting antibiotics whenever possible 1, 2
• 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: Ciprofloxacin 500-750mg BID (14 days) 3, 1
• Consider intravenous antibiotics for patients who are particularly unwell, have resistant organisms, or have failed to respond to oral therapy (especially with P. aeruginosa) 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 (e.g., colistin) for patients with chronic Pseudomonas aeruginosa infection 1, 2
  • Macrolides 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 3, 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, or inflammatory bowel disease 1
• For patients with allergic bronchopulmonary aspergillosis (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 disease activity 3

Bronchodilators

• 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

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

Monitoring and Follow-up

• 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
• Annual assessment by respiratory physiotherapist to optimize airway clearance regimen 2

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 1
• Video-assisted thoracoscopic surgery (VATS) is often preferred to better preserve lung function and reduce scarring compared to open surgery 1
• Consider lung 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

Pitfalls and Caveats

• Do not extrapolate treatments from cystic fibrosis bronchiectasis, as treatment responses are different 3
• Avoid recombinant human DNase (dornase alfa) as it may worsen outcomes in non-CF bronchiectasis 1, 2
• Emergency surgery in unstable patients with massive hemoptysis is associated with higher morbidity and mortality reaching 37% 1
• P. aeruginosa infection requires aggressive management due to its association with worse outcomes 3, 1