Comprehensive Management of Bronchiectasis
The comprehensive management of bronchiectasis requires a multidimensional approach targeting chronic bronchial infection, inflammation, impaired mucociliary clearance, and structural lung damage to improve quality of life and prevent disease progression. 1
Diagnosis and Initial Evaluation
- High-resolution CT (HRCT) scanning is the gold standard for diagnosing bronchiectasis, defined by permanent bronchial dilatation with clinical symptoms of cough, sputum production, and/or recurrent respiratory infections 2
- Minimum testing should include chest CT scan, sweat test (to rule out cystic fibrosis), lung function tests, full blood count, immunological tests, and lower airway bacteriology 2
- Regular monitoring should be tailored to disease severity, with mild disease requiring annual assessment and moderate-severe disease requiring assessment every 6 months 2
Airway Clearance Techniques
- All patients with bronchiectasis should be taught and regularly use airway clearance techniques by a trained respiratory physiotherapist 1, 2
- Recommended techniques include active cycle of breathing, postural drainage, manual techniques, or mechanical devices, with sessions lasting 10-30 minutes, once or twice daily 3
- Consider intermittent positive pressure breathing or non-invasive ventilation during acute exacerbations to reduce work of breathing 3
Mucoactive Treatments
- Consider long-term mucoactive treatment for patients with difficulty expectorating sputum, poor quality of life, or failure of standard airway clearance techniques 3
- Consider humidification with sterile water or normal saline to facilitate airway clearance 3
- Do not routinely use recombinant human DNase (dornase alfa) in adults with non-CF bronchiectasis 3
Management of Exacerbations
- Treat exacerbations with 14 days of antibiotics, with selection based on previous sputum culture results 1, 3
- Obtain sputum samples for culture and sensitivity testing prior to starting antibiotics whenever possible 1
- Common pathogens and recommended antibiotics include 1:
- Streptococcus pneumoniae: Amoxicillin 500mg TID (14 days)
- Haemophilus influenzae (beta-lactamase negative): Amoxicillin 500mg TID (14 days)
- Haemophilus influenzae (beta-lactamase positive): Amoxicillin with clavulanic acid 625mg TID (14 days)
- Pseudomonas aeruginosa: Ciprofloxacin 500-750mg BID (14 days)
- Consider intravenous antibiotics for patients who are particularly unwell, have resistant organisms, or have failed to respond to oral therapy 1
Long-term Antibiotic Therapy
- For patients with ≥3 exacerbations per year, consider long-term antibiotic therapy 2, 3:
- 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
Pseudomonas Aeruginosa Eradication
- Offer eradication antibiotic treatment to patients with a new growth of P. aeruginosa (first isolation or regrowth after intermittently positive cultures) 1
- First-line treatment: ciprofloxacin 500–750 mg twice daily for 2 weeks 1
- Second-line treatment: IV anti-pseudomonal beta-lactam ± IV aminoglycoside for 2 weeks, followed by a 3-month course of nebulized colistin, gentamicin, or tobramycin 1
- Discuss with patients the potential risks and benefits of starting eradication treatment versus clinical observation 1
MRSA Eradication
- Offer eradication antibiotic treatment to patients with a new growth of methicillin-resistant S. aureus (MRSA) 1
Anti-inflammatory Treatments
- Do not routinely offer inhaled corticosteroids unless comorbid asthma or COPD is present 3
- Do not offer long-term oral corticosteroids without other indications, such as ABPA, chronic asthma, COPD, or inflammatory bowel disease 3
- For patients with allergic bronchopulmonary aspergillosis (ABPA) 1:
- Offer oral corticosteroids (initial dose of 0.5 mg/kg/day for 2 weeks)
- Wean steroids according to clinical response and serum IgE levels
- Consider itraconazole as a steroid-sparing agent for patients dependent on oral corticosteroids
Pulmonary Rehabilitation
- Offer pulmonary rehabilitation to patients with impaired exercise capacity 2, 3
- Pulmonary rehabilitation improves exercise capacity, reduces cough symptoms, and enhances quality of life 2
Immunizations
- Offer annual influenza immunization to all patients with bronchiectasis 3
- Offer pneumococcal vaccination to all patients with bronchiectasis 3
- Consider influenza vaccination in household contacts of patients with immune deficiency and bronchiectasis 3
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 3
- Video-assisted thoracoscopic surgery (VATS) is often preferred to better preserve lung function and reduce scarring compared to open surgery 3
- Emergency surgery in unstable patients with massive hemoptysis is associated with higher morbidity and mortality reaching 37% 3
Patient Self-Management
- Consider a patient self-management plan 1
- Ensure suitable patients have antibiotics to keep at home for prompt treatment of exacerbations 1
- Provide education on recognizing and managing exacerbations 1
Management of Associated Conditions
- Evaluate patients with bronchiectasis for symptoms of chronic rhinosinusitis 1
- Treat patients with bronchiectasis and symptoms of rhinosinusitis according to existing evidence-based treatment pathways 1
- Consider a trial of inhaled and/or oral corticosteroids in patients with bronchiectasis and inflammatory bowel disease (IBD) 1
- Ensure optimal control of asthma and allergies in patients with these comorbidities 1