What is the management approach for bronchiectasis?

Management of Bronchiectasis in Adults

The management of bronchiectasis centers on preventing exacerbations and reducing mortality through airway clearance techniques for all patients with productive cough, long-term antibiotics for frequent exacerbators (≥3 exacerbations/year), and pulmonary rehabilitation for those with impaired exercise capacity. 1, 2

Core Treatment Objectives

The primary goals are preventing exacerbations, reducing symptoms, improving quality of life, and halting disease progression, as exacerbations drive lung function decline, increased mortality, and healthcare costs. 3 Approximately 50% of European patients experience ≥2 exacerbations annually, with one-third requiring hospitalization. 3

Essential Non-Pharmacological Interventions

Airway Clearance Techniques (Strong Recommendation)

All patients with chronic productive cough or difficulty expectorating must be taught airway clearance techniques by a trained respiratory physiotherapist. 1, 2

• Sessions should last 10-30 minutes, performed once or twice daily. 1, 4
• Techniques include active cycle of breathing, postural drainage, and manual or mechanical devices. 1
• This is a strong recommendation applicable regardless of disease severity. 4

Pulmonary Rehabilitation (Strong Recommendation)

Pulmonary rehabilitation is strongly recommended for patients with impaired exercise capacity. 1, 2

• Consists of 6-8 weeks of supervised exercise training. 4
• Provides improved exercise capacity, reduced cough symptoms, enhanced quality of life, and decreased exacerbation frequency. 1
• Benefits are equivalent to those seen in severe COPD and other disabling respiratory diseases. 3

Pharmacological Management Algorithm

Acute Exacerbation Treatment

Treat all exacerbations with 14 days of antibiotics, selected based on previous sputum culture results. 1, 4

• Consider intravenous antibiotics for severe exacerbations or treatment failures. 1
• Common pathogens include Pseudomonas aeruginosa, Haemophilus influenzae, and Streptococcus pneumoniae. 4

Long-Term Antibiotic Therapy (For Frequent Exacerbators)

For patients with ≥3 exacerbations per year, initiate long-term antibiotic therapy. 1, 2

Decision pathway:

• If chronic Pseudomonas aeruginosa infection: Use long-term inhaled antibiotics (colistin or gentamicin) as first-line treatment. 1, 5
• If no Pseudomonas aeruginosa: Use macrolides (azithromycin 250 mg three times weekly) as first-line treatment. 1, 4

This represents a strong recommendation based on randomized controlled trial evidence demonstrating reduced exacerbation rates. 2, 6

Bronchodilator Therapy

Do not routinely prescribe bronchodilators for all patients. 1

• Consider long-acting bronchodilators only for patients with significant breathlessness, particularly those with chronic obstructive airflow limitation or comorbid asthma/COPD. 1, 4
• This is a conditional recommendation based on individual patient characteristics. 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

• Critical caveat: Do NOT use recombinant human DNase in non-CF bronchiectasis—this is contraindicated. 1, 7
• Nebulized saline may be used to loosen tenacious secretions. 5

Anti-Inflammatory Treatments

Do not routinely offer inhaled corticosteroids unless comorbid asthma or COPD is present. 1

• Do not offer long-term oral corticosteroids. 1
• This strong recommendation against routine use is based on lack of efficacy and potential harm in bronchiectasis without obstructive airway disease. 1

Diagnostic Workup Requirements

High-resolution CT (HRCT) is the gold standard for confirming permanent bronchial dilatation. 1, 7

Initial laboratory evaluation must include: 1

• Differential blood count
• Serum immunoglobulins (IgG, IgA, IgE, IgM)
• Testing for allergic bronchopulmonary aspergillosis
• Sputum culture for bacteria, mycobacteria, and fungi
• Prebronchodilator and postbronchodilator spirometry 5

Monitoring Strategy

Regular monitoring is essential, with frequency tailored to disease severity (minimum annually). 4

• Monitor sputum pathogens regularly, especially when using long-term antibiotics. 1, 7
• Monitor for drug toxicity, particularly with macrolides and inhaled aminoglycosides. 1, 7
• Annual assessment by respiratory physiotherapist to optimize airway clearance regimen. 1
• Perform pulse oximetry to screen for respiratory failure. 4

Surgical Intervention

Do not routinely recommend surgery for most patients. 1, 2

• Consider surgery only for patients with localized disease and high exacerbation frequency despite optimization of all other management aspects. 1, 7
• Surgery should be performed in centers with expertise in both medical and surgical management. 7
• Adequate cardiopulmonary reserve is required. 7

Common Pitfalls to Avoid

Critical errors in bronchiectasis management include:

• Using recombinant human DNase (contraindicated in non-CF bronchiectasis). 1, 7
• Prescribing inhaled corticosteroids routinely without asthma/COPD. 1
• Failing to teach airway clearance techniques to all patients with productive cough. 1, 2
• Undertreating exacerbations with <14 days of antibiotics. 1, 4
• Not considering long-term antibiotics in patients with ≥3 exacerbations annually, leading to progressive lung damage and increased mortality. 1, 5