What is the treatment for bronchiectasis?

Treatment of Bronchiectasis

Bronchiectasis treatment should target four key components: chronic bronchial infection, inflammation, impaired mucociliary clearance, and structural lung damage, with management intensity escalating based on exacerbation frequency. 1

Initial Diagnostic Workup

Before initiating treatment, obtain the following minimum bundle of tests 2:

• Differential blood count
• Serum immunoglobulins (total IgG, IgA, IgM)
• Testing for allergic bronchopulmonary aspergillosis (ABPA)
• Sputum culture for bacterial pathogens (essential for monitoring and guiding antibiotic selection) 2

Additional mycobacterial cultures should be obtained when non-tuberculous mycobacteria are suspected as the underlying cause 2.

Airway Clearance Techniques (Foundation of Treatment)

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

• Sessions should last 10-30 minutes, once or twice daily 1
• Techniques include active cycle of breathing, autogenic drainage, and may incorporate devices like flutter valves 2
• Consider intermittent positive pressure breathing or non-invasive ventilation during acute exacerbations to reduce work of breathing 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

• Humidification with sterile water or normal saline can facilitate airway clearance 1
• Do NOT routinely use recombinant human DNase (dornase alfa) in adults with non-CF bronchiectasis, as it may worsen outcomes 1, 3

Treatment of Acute Exacerbations

Treat all acute exacerbations with 14 days of antibiotics, selected based on previous sputum culture results. 2, 1, 4

Antibiotic Selection by Pathogen:

For patients WITHOUT Pseudomonas aeruginosa:

• Streptococcus pneumoniae: Amoxicillin 500mg-1g three times daily for 14 days 4
• Haemophilus influenzae (beta-lactamase negative): Amoxicillin 500mg three times daily for 14 days 4
• Haemophilus influenzae (beta-lactamase positive): Amoxicillin-clavulanate 625mg three times daily for 14 days 4
• Moraxella catarrhalis: Amoxicillin-clavulanate 625mg three times daily for 14 days 4
• Staphylococcus aureus (MSSA): Flucloxacillin 500mg four times daily for 14 days 4

For patients WITH Pseudomonas aeruginosa:

• Oral therapy: Ciprofloxacin 500mg twice daily (750mg twice daily in severe infections) for 14 days 1, 4
• IV therapy for severe cases: Ceftazidime 2g three times daily, piperacillin-tazobactam 4.5g three times daily, aztreonam 2g three times daily, or meropenem 2g three times daily for 14 days 4

Critical Management Points:

• Obtain sputum for culture BEFORE starting antibiotics whenever possible 4
• Start empirical therapy immediately while awaiting results 4
• Modify antibiotics based on culture results if no clinical improvement by day 14 4

Long-Term Antibiotic Prophylaxis

Offer long-term antibiotic treatment ONLY to patients with ≥3 exacerbations per year after optimizing airway clearance and treating underlying causes. 2, 3

For Chronic Pseudomonas aeruginosa Infection:

First-line: Inhaled antibiotics 2, 3

• Inhaled colistin 1MU twice daily via I-neb 2
• Nebulized gentamicin 2
• Nebulized liposomal ciprofloxacin 2

Second-line: Macrolides (if inhaled antibiotics contraindicated, not tolerated, or ineffective) 2

• Azithromycin or erythromycin 2
• Can be used in addition to inhaled antibiotics for high exacerbation frequency despite inhaled therapy 2

For Patients WITHOUT Pseudomonas aeruginosa:

First-line: Macrolides (azithromycin or erythromycin) 2, 3

Second-line: Other oral antibiotics (if macrolides contraindicated, not tolerated, or ineffective) 2

• Choice based on antibiotic susceptibility and patient tolerance 2

Third-line: Inhaled antibiotics (if oral prophylaxis contraindicated, not tolerated, or ineffective) 2

Monitoring for Long-Term Antibiotics:

• Review every 6 months for efficacy, toxicity, and continuing need 3
• Monitor sputum culture regularly, recognizing that in vitro resistance may not affect clinical efficacy 3

Eradication Therapy for New Pathogens

For new isolation of Pseudomonas aeruginosa, offer eradication treatment: 2, 4

• Ciprofloxacin 500-750mg twice daily for 2 weeks 4

For new isolation of MRSA with clinical deterioration: 4

• Oral doxycycline 100mg twice daily for 14 days 4

Do NOT offer eradication treatment for new isolation of pathogens other than P. aeruginosa or MRSA. 2

Anti-Inflammatory Treatments

Do NOT routinely offer inhaled corticosteroids to adults with bronchiectasis unless they have comorbid asthma or COPD. 2, 1, 3

• The presence of bronchiectasis alone should not lead to withdrawal of inhaled corticosteroids from patients with established asthma or COPD 2
• Do NOT offer long-term oral corticosteroids without other indications such as ABPA, chronic asthma, COPD, or inflammatory bowel disease 1
• Do NOT offer statins for bronchiectasis treatment 2, 4

Special Case - ABPA:

For allergic bronchopulmonary aspergillosis, use immunosuppression with corticosteroids, with or without antifungal agents, using a tapering dose with monitoring of total serum IgE every 6-8 weeks 1

Bronchodilators

Use bronchodilators in patients with significant breathlessness, with appropriate inhalation device selection and technique training. 1

• Discontinue if no reduction in symptoms occurs 1
• Bronchodilators are particularly indicated for patients with comorbid asthma or COPD 5

Pulmonary Rehabilitation and Exercise

Patients with impaired exercise capacity should participate in pulmonary rehabilitation programs and take regular exercise to improve exercise capacity, reduce cough symptoms, and enhance quality of life. 1, 5

Immunizations

Offer annual influenza immunization to all patients with bronchiectasis. 1

Offer pneumococcal vaccination to all patients with bronchiectasis. 1

Consider influenza vaccination in household contacts of patients with immune deficiency and bronchiectasis 1

Surgical Considerations

Surgery is NOT recommended except in cases of localized disease with high exacerbation frequency despite optimization of all other management aspects. 1

• Video-assisted thoracoscopic surgery (VATS) is preferred over open surgery to preserve lung function and reduce scarring 1
• Emergency surgery for massive hemoptysis carries mortality rates reaching 37% 1

Lung Transplantation Referral

Consider transplant referral for patients aged ≤65 years if: 1

• FEV1 <30% with significant clinical instability, OR
• Rapid progressive respiratory deterioration despite optimal medical management

Consider earlier referral with additional factors: 1

• Massive hemoptysis
• Severe secondary pulmonary hypertension
• ICU admissions
• Respiratory failure

Patient Self-Management

Provide patients with a self-management plan that includes prompt treatment of exacerbations, antibiotics to keep at home, and clear instructions on when to initiate treatment. 4

Critical Pitfalls to Avoid

• Do NOT extrapolate treatments from cystic fibrosis bronchiectasis, as treatment responses differ 1
• Do NOT use shorter than 14-day antibiotic courses for exacerbations unless specifically indicated for mild cases 2, 4
• Do NOT use inhaled corticosteroids for exacerbations unless comorbid asthma or COPD is present 4
• Re-evaluate patients who fail to respond by day 14: obtain repeat sputum culture, reassess for non-infectious causes, and consider antibiotic change with broader coverage 4