What are the differences in treatment between bronchiectasis and bronchitis?

Bronchiectasis vs Bronchitis: Key Treatment Differences

Bronchiectasis requires fundamentally different treatment than bronchitis, with the cornerstone being daily airway clearance techniques, longer antibiotic courses (14 days vs 5-7 days), and consideration for long-term prophylactic antibiotics in patients with frequent exacerbations—none of which are standard for simple bronchitis. 1, 2

Core Treatment Distinctions

Airway Clearance (Essential for Bronchiectasis, Not for Bronchitis)

All bronchiectasis patients with chronic productive cough must be taught airway clearance techniques by a trained respiratory physiotherapist, performing sessions 10-30 minutes once or twice daily. 1, 2 This includes:

• Chest percussion, vibration, and postural drainage 1
• Oscillatory positive expiratory pressure devices 1
• Mechanical high-frequency chest wall oscillation 1

This is not standard treatment for acute or chronic bronchitis, where cough typically resolves with the underlying infection or irritant removal.

Antibiotic Duration and Selection

Bronchiectasis exacerbations require 14 days of antibiotics (not the 5-7 days typical for bronchitis), with selection guided by previous sputum cultures. 1, 2, 3

For bronchiectasis, common pathogens and treatments include:

• Streptococcus pneumoniae: Amoxicillin 500mg TID for 14 days 1
• Haemophilus influenzae: Amoxicillin 500mg TID (beta-lactamase negative) or amoxicillin-clavulanate 625mg TID (beta-lactamase positive) for 14 days 1
• Pseudomonas aeruginosa: Ciprofloxacin 500-750mg BID for 14 days 1, 2

Obtain sputum cultures before starting antibiotics whenever possible in bronchiectasis—this is critical for guiding therapy and monitoring resistance patterns. 1, 2

Long-Term Prophylactic Antibiotics (Bronchiectasis Only)

For bronchiectasis patients with ≥3 exacerbations per year, consider long-term prophylactic antibiotics—a strategy never used in simple bronchitis. 1, 2

Treatment hierarchy:

• First-line for chronic P. aeruginosa infection: Long-term inhaled antibiotics (colistin, gentamicin, or tobramycin) 1, 3
• First-line for non-Pseudomonas infection: Macrolides (azithromycin 250mg three times weekly or 500mg three times weekly) 1, 2, 3
• Critical caveat: Exclude active nontuberculous mycobacterial (NTM) infection before starting macrolides 4, 3

P. aeruginosa infection in bronchiectasis is associated with three-fold increased mortality, seven-fold increased hospitalization risk, and one additional exacerbation per year. 2, 3

Mucoactive Therapy (Bronchiectasis-Specific)

Consider long-term mucoactive treatment (≥3 months) for bronchiectasis patients with difficulty expectorating sputum when standard airway clearance fails. 1, 2 Options include:

• Nebulized saline or hypertonic saline 1, 2
• Guaifenesin 2
• Humidification with sterile water 2

Critical warning: Do NOT use recombinant human DNase (dornase alfa) in non-CF bronchiectasis—it is contraindicated and may worsen outcomes. 1, 4

Bronchodilator Use

For bronchiectasis:

• Only use bronchodilators if there is documented airflow obstruction, bronchial hyperreactivity, or comorbid asthma/COPD 1
• Use before physiotherapy and inhaled antibiotics to optimize deposition 1
• Discontinue if no symptom improvement 3

For bronchitis, bronchodilators may provide symptomatic relief during acute episodes but are not routinely continued long-term unless COPD coexists.

Anti-Inflammatory Treatment Differences

Do NOT routinely use inhaled corticosteroids for bronchiectasis unless comorbid asthma or COPD is present. 2, 3 This contrasts with asthmatic bronchitis where inhaled corticosteroids are often first-line.

Never use long-term oral corticosteroids for bronchiectasis without specific indications like ABPA, chronic asthma, COPD, or inflammatory bowel disease. 2

Eradication Protocols (Bronchiectasis-Specific)

For new isolation of P. aeruginosa in bronchiectasis with clinical deterioration, offer eradication therapy:

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

For new MRSA isolation with clinical deterioration, offer eradication antibiotic treatment. 1

These eradication protocols have no equivalent in bronchitis management.

Monitoring and Follow-Up Differences

Bronchiectasis requires:

• Regular sputum culture monitoring to track pathogens and resistance patterns 4, 3
• Drug toxicity monitoring with long-term macrolides and inhaled aminoglycosides 4
• Annual influenza and pneumococcal vaccination 2
• Pulmonary rehabilitation for those with impaired exercise capacity 1, 3

Simple bronchitis requires none of these ongoing interventions.

Surgical Considerations (Bronchiectasis Only)

Surgery should be limited to bronchiectasis patients with localized disease and high exacerbation frequency despite optimal medical management. 1, 4, 3 Video-assisted thoracoscopic surgery (VATS) is preferred to preserve lung function. 2

Consider lung transplantation referral for bronchiectasis patients ≤65 years with FEV1 <30% and clinical instability or rapid deterioration. 2

Surgery has no role in bronchitis management.

Common Pitfalls

• Do not extrapolate CF bronchiectasis treatments to non-CF bronchiectasis—treatment responses differ significantly 2
• Do not use short antibiotic courses (5-7 days) for bronchiectasis exacerbations—this increases treatment failure risk 2, 3
• Do not start macrolides without excluding NTM infection—this can lead to macrolide resistance in undiagnosed NTM disease 4, 3
• Do not confuse chronic bronchitis with bronchiectasis—the latter requires CT confirmation showing permanent bronchial dilation 4, 3