What are the European Respiratory Society (ERS) guidelines for managing bronchiectasis?

European Respiratory Society Guidelines on Bronchiectasis Management

The 2017 ERS guidelines provide comprehensive, evidence-based recommendations for managing adult bronchiectasis, focusing on nine key clinical areas: investigation of underlying causes, treatment of exacerbations, pathogen eradication, long-term antibiotic therapy, anti-inflammatory treatments, mucoactive drugs, bronchodilators, surgical interventions, and respiratory physiotherapy. 1

Scope and Patient Population

The ERS guidelines apply specifically to adults with clinically significant bronchiectasis, defined by both:

• Permanent bronchial dilatation visible on high-resolution CT scanning 1
• Clinical syndrome of cough, sputum production, and/or recurrent respiratory infections 1

Excluded populations include cystic fibrosis bronchiectasis, children with bronchiectasis, primary immunodeficiencies requiring disease-specific therapy, and non-tuberculous mycobacterial infections. 1

Core Treatment Goals

Management aims to achieve three primary outcomes:

• Reduce exacerbations (the major determinant of healthcare costs, lung function decline, and mortality) 1
• Reduce symptoms (cough, sputum production, breathlessness) 1
• Improve quality of life (which is impaired to levels equivalent to severe COPD and idiopathic pulmonary fibrosis) 1

Key Recommendations by Treatment Category

Respiratory Physiotherapy

Airway clearance techniques (ACTs) should be taught to and regularly used by all patients with bronchiectasis. 1, 2 The evidence shows significant increases in sputum volume, though the quality of evidence is limited by small study sizes and methodological issues. 1

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

• Improved exercise capacity 1
• Reduced cough symptoms 1
• Enhanced quality of life 1
• Possible reduction in exacerbations (median 1 vs 2 exacerbations over 12 months, p=0.012) 1
• Longer time to first exacerbation (8 vs 6 months, p=0.047) 1

Benefits are achieved within 6-8 weeks and maintained for 3-6 months. 1

Acute Exacerbation Management

Treat acute exacerbations with 14 days of antibiotics, with selection guided by previous sputum cultures. 2 Obtain sputum samples for culture and sensitivity testing before starting antibiotics whenever possible. 2

Long-term Antibiotic Therapy

For patients with ≥3 exacerbations per year, consider long-term antibiotic therapy:

• Inhaled colistin for chronic Pseudomonas aeruginosa infection 2
• Macrolides for non-Pseudomonas infections 2

Mucoactive Treatments

Mucoactive treatments such as humidification with sterile water or normal saline should be considered to facilitate airway clearance. 2 However, recombinant human DNase (rhDNase) should NOT be used in non-CF bronchiectasis. 2

Routine Monitoring

All patients require routine monitoring to identify disease progression, pathogen emergence, and modify treatment when necessary. 2 Monitoring frequency should be:

• Annual assessment for mild disease 2
• Every 6 months for moderate-severe disease 2

Preventive Measures

Ensure all patients receive:

• Pneumococcal vaccination 1, 2
• Seasonal influenza vaccination 1, 2
• Optimization of nutrition, including vitamin D status 1
• Encouragement of regular exercise 1

Evidence Quality and Recommendation Strength

The majority of recommendations in this guideline are conditional and based on low-quality evidence. 1 The ERS used the GRADE approach to define evidence quality and recommendation levels. 1

Strong recommendations indicate that most informed patients would choose the recommended course of action, while conditional (weak) recommendations indicate that different choices may be appropriate for different patients, requiring shared decision-making. 1

Implementation Priorities

Research priorities identified include:

• Larger controlled studies with clinical outcomes (exacerbations, cough, quality of life) 1
• Studies combining physiotherapy training with mucoactive agents like hypertonic saline 1
• Role of pulmonary rehabilitation on exacerbations 1
• Long-term compliance with interventions (>12 months) 1

Clinical Application Framework

All recommendations must be interpreted within the clinical context, taking into account:

• Patient values and preferences 1
• History of exacerbations 1
• Quality of life 1
• Disease severity 1
• Underlying aetiology 1

These factors significantly impact long-term patient outcomes and should guide individualized treatment decisions. 1