What is the management approach for bronchiectasis?

Management of Bronchiectasis in Adults

All patients with bronchiectasis and chronic productive cough must be taught airway clearance techniques by a trained respiratory physiotherapist, performing 10-30 minute sessions once or twice daily, and those with ≥3 exacerbations per year should receive long-term antibiotics—either inhaled antibiotics for chronic Pseudomonas aeruginosa infection or azithromycin 250 mg three times weekly for those without Pseudomonas. 1, 2

Initial Diagnostic Workup

Before initiating treatment, confirm the diagnosis and identify underlying causes:

• High-resolution CT (HRCT) is the gold standard for diagnosing bronchiectasis, demonstrating permanent bronchial dilatation 1
• Obtain differential blood count, serum immunoglobulins (IgG, IgA, IgE, IgM), testing for allergic bronchopulmonary aspergillosis, and sputum culture for bacteria, mycobacteria, and fungi 1, 3
• Perform prebronchodilator and postbronchodilator spirometry to assess airflow limitation 3

Core Non-Pharmacological Management

Airway Clearance Techniques (Mandatory for All Patients)

• Every patient with chronic productive cough or difficulty expectorating sputum must 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
• Annual reassessment by respiratory physiotherapist is required to optimize the airway clearance regimen 1

Pulmonary Rehabilitation

• Strongly recommended for all patients with impaired exercise capacity 1, 2
• Consists of 6-8 weeks of supervised exercise training 2
• Provides improved exercise capacity, reduced cough symptoms, enhanced quality of life, and decreased exacerbation frequency 1, 2

Pharmacological Management

Long-Term Antibiotic Therapy (For Frequent Exacerbators)

For patients with ≥3 exacerbations per year: 1, 2

• First-line for chronic Pseudomonas aeruginosa infection: Long-term inhaled antibiotics (colistin or gentamicin) 1, 3
• First-line for patients without Pseudomonas: Azithromycin 250 mg three times weekly 2, 3
• Monitor sputum pathogens regularly when using long-term antibiotics 1
• Monitor for drug toxicity, particularly with macrolides and inhaled aminoglycosides 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
• Nebulized saline can be used to loosen tenacious secretions 3
• Do not use recombinant human DNase in non-CF bronchiectasis 1

Bronchodilator Therapy

• Not routinely recommended for all patients 1
• Consider long-acting bronchodilators (β-agonists and antimuscarinic agents) for patients with significant breathlessness, particularly those with chronic obstructive airflow limitation or associated asthma 1, 2, 3

Anti-Inflammatory Treatments

• Do not routinely offer inhaled corticosteroids unless comorbid asthma or COPD is present 1, 3
• Do not offer long-term oral corticosteroids 1

Management of Acute Exacerbations

Exacerbations typically present with increased cough and sputum production and worsened fatigue: 3

• Treat all exacerbations with 14 days of antibiotics 1, 2
• Select antibiotics based on previous sputum culture results 1, 2
• Common pathogens include Streptococcus pneumoniae, Haemophilus influenzae, and Pseudomonas aeruginosa 2
• Consider intravenous antibiotics for severe exacerbations or treatment failures 1

Monitoring and Follow-Up

• Minimum annual assessments for all patients, with more frequent monitoring in severe disease 2
• Perform pulse oximetry to screen for respiratory failure 2
• Monitor sputum culture and sensitivity regularly, especially when using long-term antibiotics 1, 2
• Annual assessment by respiratory physiotherapist to optimize airway clearance regimen 1

Surgical Intervention

• Not routinely recommended for most patients 1, 2
• Consider only for patients with localized disease and high exacerbation frequency despite optimization of all other management aspects 1, 2
• Lung transplant may be considered for patients with severely impaired pulmonary function or frequent exacerbations 3

Common Pitfalls to Avoid

• Do not withhold airway clearance techniques from any patient with chronic productive cough—this is a cornerstone of management regardless of disease severity 1, 2
• Do not use inhaled corticosteroids routinely without documented asthma or COPD, as they lack evidence in bronchiectasis alone 1
• Do not delay long-term antibiotic therapy in patients meeting the ≥3 exacerbations per year threshold, as exacerbations are associated with progressive lung function decline 1, 3