What is the initial management for patients with bronchiectasis?

Initial Management of Bronchiectasis

All patients with newly diagnosed bronchiectasis must immediately begin airway clearance techniques taught by a respiratory physiotherapist, performing sessions for 10-30 minutes once or twice daily, regardless of symptom severity or disease extent. 1, 2

Immediate Non-Pharmacological Interventions

Airway clearance is the cornerstone of initial management and should never be delayed. The active cycle of breathing technique in a sitting position is the recommended first-line method. 2, 3 This intervention has strong evidence (high quality) showing improved exercise capacity and quality of life, making it one of only two strong recommendations in bronchiectasis management. 1

• Consider manual techniques or assisted devices (such as Acapella) if the patient experiences fatigue or breathlessness during clearance attempts. 1, 2
• Humidification with sterile water or normal saline can facilitate mucus clearance in patients struggling with thick secretions. 3

Initial Diagnostic Workup

Obtain a comprehensive panel of tests at the initial visit to identify treatable underlying causes. 2 The British Thoracic Society mandates:

• Thin-section chest CT (diagnostic confirmation) 2
• Full blood count with differential 2
• Serum immunoglobulins (IgG, IgA, IgM, IgE) 2, 4
• Specific IgE or skin prick test to Aspergillus 2
• Sputum culture for bacteria, mycobacteria, and fungi 2, 4
• Pre- and post-bronchodilator spirometry 4

Management of Presenting Exacerbation (If Present)

If the patient presents with an acute exacerbation (increased cough, sputum volume/purulence, breathlessness, or systemic symptoms), start empiric oral antibiotics for 14 days immediately while awaiting culture results. 1, 2, 3

• First-line empiric choice: Amoxicillin-clavulanate 625 mg three times daily for 14 days 2
• Obtain sputum for culture before starting antibiotics, but do not delay treatment 1, 2
• Modify antibiotics at 48-72 hours if no clinical improvement, guided by culture and sensitivity results 2
• Consider intravenous antibiotics if the patient is severely unwell, has resistant organisms, or fails oral therapy 1, 2

Increase airway clearance frequency during exacerbations to facilitate sputum expectoration. 2

Pathogen-Specific Eradication Strategies

If Pseudomonas aeruginosa is isolated for the first time, offer eradication treatment immediately. 1, 2 This organism is associated with three-fold increased mortality, seven-fold increased hospitalization risk, and one additional exacerbation per year. 3

• First-line eradication: Ciprofloxacin 500-750 mg twice daily for 2 weeks 1, 2
• Second-line eradication: IV anti-pseudomonal beta-lactam ± IV aminoglycoside for 2 weeks, followed by 3 months of nebulized colistin, gentamicin, or tobramycin 1, 2

If methicillin-resistant Staphylococcus aureus (MRSA) is isolated for the first time, offer eradication therapy. 1, 2

If total IgE is elevated with positive Aspergillus testing suggesting allergic bronchopulmonary aspergillosis (ABPA), initiate oral corticosteroid 0.5 mg/kg/day for 2 weeks. 2, 3

Bronchodilator Therapy

Do not routinely prescribe long-acting bronchodilators for bronchiectasis alone. 1, 3 However, offer bronchodilators on an individual basis for patients with significant breathlessness, particularly those with comorbid asthma or COPD. 1

• Use bronchodilators before physiotherapy and before inhaled antibiotics to optimize pulmonary deposition and increase tolerability. 1
• If bronchodilators do not reduce symptoms, discontinue them. 1

Mucoactive Therapy

Consider long-term mucoactive treatment (≥3 months) only for patients with difficulty expectorating sputum and poor quality of life where standard airway clearance techniques have failed. 1, 3

Never prescribe recombinant human DNase (dornase alfa) in non-CF bronchiectasis. 1, 3 This is a strong recommendation based on moderate quality evidence showing potential harm.

Pulmonary Rehabilitation

Refer all patients with impaired exercise capacity to pulmonary rehabilitation immediately. 1, 3 This is the second strong recommendation in bronchiectasis management, supported by high-quality evidence showing improved exercise capacity, reduced cough symptoms, and enhanced quality of life. 1

• Standard programs consist of 6-8 weeks of supervised exercise training with review of airway clearance techniques. 1, 3
• One study demonstrated that pulmonary rehabilitation reduced exacerbation frequency (median 1 vs 2 exacerbations; p=0.012) and prolonged time to first exacerbation (8 vs 6 months; p=0.047) over 12 months. 1

Preventive Measures

Administer annual influenza vaccination and pneumococcal vaccination to all patients with bronchiectasis. 3

Determining Need for Ongoing Specialist Care

Refer for ongoing secondary care management if any of the following criteria are present: 2

• Chronic Pseudomonas aeruginosa, non-tuberculous mycobacteria, or MRSA colonization 2
• Deteriorating bronchiectasis with declining lung function 2
• Recurrent exacerbations (≥3 per year) 2
• ABPA 2
• Advanced disease (FEV1 <30%) 2
• Associated conditions requiring specialist input 2

Critical Pitfalls to Avoid

Do not extrapolate treatments from cystic fibrosis bronchiectasis, as treatment responses differ significantly. 3 The most notable example is DNase, which benefits CF patients but harms non-CF bronchiectasis patients.

Do not routinely prescribe inhaled corticosteroids unless comorbid asthma or COPD is documented. 3 There is no evidence supporting their use in bronchiectasis alone.

Do not delay airway clearance training until the patient is "stable." 2, 3 This intervention should begin at the first visit regardless of disease activity.

Long-term antibiotic therapy should only be considered after optimization of airway clearance and treatment of modifiable underlying causes. 1 Starting with antibiotics before establishing proper airway clearance is a common error that undermines long-term outcomes.