What is the management approach for bronchiectasis?

Management of Bronchiectasis

The management of bronchiectasis should target the four key components of the disease: chronic bronchial infection, inflammation, impaired mucociliary clearance, and structural lung damage through a comprehensive approach including airway clearance techniques, pulmonary rehabilitation, appropriate antibiotic therapy, and consideration of long-term antibiotics for frequent exacerbators. 1, 2

Airway Clearance Techniques

• All patients with chronic productive cough or difficulty expectorating sputum should be taught airway clearance techniques by a trained respiratory physiotherapist 1, 2
• Techniques include active cycle of breathing, postural drainage, and manual or mechanical devices 1
• Sessions should last 10-30 minutes, performed once or twice daily 1, 2
• Consider intermittent positive pressure breathing or non-invasive ventilation during acute exacerbations to reduce work of breathing 2

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, 2
• Consider humidification with sterile water or normal saline to facilitate airway clearance 2
• Do not use recombinant human DNase (dornase alfa) in adults with non-CF bronchiectasis as it may be harmful 1, 2

Pulmonary Rehabilitation

• Strongly recommended for patients with impaired exercise capacity 1, 3
• Provides improved exercise capacity, reduced cough symptoms, enhanced quality of life, and decreased frequency of exacerbations 1, 2
• Benefits are achieved in 6-8 weeks and maintained for 3-6 months 3

Management of Acute Exacerbations

• Treat exacerbations with 14 days of antibiotics 1, 2
• Select antibiotics based on previous sputum culture results 1, 2
• Obtain sputum cultures before starting antibiotics whenever possible 2
• Common pathogens and recommended antibiotics include:
  • Streptococcus pneumoniae: Amoxicillin 500mg TID (14 days) 2
  • Haemophilus influenzae (beta-lactamase negative): Amoxicillin 500mg TID (14 days) 2
  • Pseudomonas aeruginosa: Ciprofloxacin 500-750mg BID (14 days) 2
• Consider intravenous antibiotics for severe exacerbations or treatment failures 1, 2

Long-term Antibiotic Therapy

• Consider for patients with ≥3 exacerbations per year 1, 2
• First-line treatment options:
  • Long-term inhaled antibiotics for patients with chronic Pseudomonas aeruginosa infection 1, 2, 4
  • Macrolides for patients without Pseudomonas aeruginosa infection 1, 2, 4
• 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

Bronchodilator Therapy

• Not routinely recommended for all patients with bronchiectasis 1
• Consider long-acting bronchodilators for patients with significant breathlessness on an individual basis 1, 2
• If treatment with bronchodilators does not result in a reduction in symptoms, it should be discontinued 2

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, 2
• For patients with allergic bronchopulmonary aspergillosis (ABPA), use immunosuppression with corticosteroids, with or without antifungal agents 2

Immunizations

• Offer annual influenza immunization to all patients with bronchiectasis 2
• Provide pneumococcal vaccination to all patients with bronchiectasis 2
• Consider influenza vaccination in household contacts of patients with immune deficiency and bronchiectasis 2

Surgical Intervention

• Not routinely recommended for most patients with bronchiectasis 1, 2
• Consider for patients with localized disease and high exacerbation frequency despite optimization of all other aspects of bronchiectasis management 1, 2
• Video-assisted thoracoscopic surgery (VATS) is often preferred to better preserve lung function and reduce scarring compared to open surgery 2
• Emergency surgery in unstable patients with massive hemoptysis is associated with higher morbidity and mortality reaching 37% 2

Monitoring and Follow-up

• Regular monitoring of sputum pathogens, especially when using long-term antibiotics 1
• Monitor for drug toxicity, particularly with macrolides and inhaled aminoglycosides 1
• Annual assessment by respiratory physiotherapist to optimize airway clearance regimen 1

Pitfalls and Caveats

• Do not extrapolate treatments from cystic fibrosis bronchiectasis, as treatment responses are different 2
• Avoid recombinant human DNase (dornase alfa) in non-CF bronchiectasis as it may worsen outcomes 1, 2
• Consider the heterogeneity of bronchiectasis when planning treatment; what works for one patient may not work for another 5
• Recognize that P. aeruginosa infection requires more aggressive management due to its association with worse outcomes 2