What is the treatment for bronchiectasis?

Treatment of Bronchiectasis

All patients with bronchiectasis and chronic productive cough must be taught airway clearance techniques by a trained respiratory physiotherapist, performing 10-30 minute sessions once or twice daily—this is the cornerstone of therapy regardless of disease severity. 1, 2, 3

Non-Pharmacological Management (First-Line for All Patients)

Airway Clearance Techniques

• Airway clearance is the single most important intervention to prevent mucus stasis, progressive lung damage, and exacerbations 1, 3
• Techniques include active cycle of breathing, postural drainage, and manual or mechanical devices 3
• All patients with difficulty expectorating sputum should receive instruction from a trained respiratory physiotherapist 4, 2
• Consider nebulized sterile water or normal saline to facilitate airway clearance and address mucus plugging 1, 2

Pulmonary Rehabilitation

• Strongly recommended for patients with impaired exercise capacity, consisting of 6-8 weeks of supervised exercise training 1, 3
• Benefits include improved exercise capacity, reduced cough symptoms, enhanced quality of life, and decreased exacerbation frequency 4, 3
• Regular exercise should be encouraged for all patients 2

Pharmacological Management

Bronchodilators

• Offer a trial of long-acting bronchodilator therapy (LABA, LAMA, or combination) in patients with significant breathlessness, particularly those with chronic obstructive airflow limitation 4, 1, 2
• Select appropriate inhalation device and ensure proper inhaler technique training 1, 2
• If treatment does not reduce symptoms, discontinue the bronchodilator 2
• Reversibility testing may help identify co-existing asthma but is not required to predict benefit from bronchodilators 4
• Follow COPD or asthma guideline recommendations for patients with these comorbidities 4

Antibiotic Therapy for Acute Exacerbations

• Treat all exacerbations with 14 days of antibiotics based on previous sputum culture results 1, 2, 3
• Obtain sputum cultures before starting antibiotics whenever possible 2, 3
• Common pathogens and first-line treatments include:
  • Streptococcus pneumoniae: Amoxicillin 500mg TID for 14 days 2
  • Haemophilus influenzae (beta-lactamase negative): Amoxicillin 500mg TID for 14 days 2
  • Pseudomonas aeruginosa: Ciprofloxacin 500-750mg BID for 14 days 2
• Consider intravenous antibiotics for patients who are particularly unwell, have resistant organisms, or have failed oral therapy 2

Long-Term Antibiotic Therapy

• Consider long-term antibiotics ONLY for patients with ≥3 exacerbations per year, and only after optimizing airway clearance and treating modifiable underlying causes 1, 2, 3
• For patients with chronic Pseudomonas aeruginosa infection: First-line is long-term inhaled antibiotics (colistin or gentamicin) 2, 3
• For patients without Pseudomonas aeruginosa infection: First-line is macrolides (azithromycin or erythromycin) 2, 3
• P. aeruginosa infection is associated with three-fold increased mortality risk, seven-fold increased hospitalization risk, and one additional exacerbation per year 1, 2, 3

Anti-Inflammatory Treatments

• Do NOT routinely offer inhaled corticosteroids unless comorbid asthma or COPD is present 1, 2, 3
• Do NOT offer long-term oral corticosteroids without specific indications (ABPA, chronic asthma, COPD, inflammatory bowel disease) 1, 2
• For allergic bronchopulmonary aspergillosis (ABPA): Immunosuppression with corticosteroids, with or without antifungal agents, is the mainstay of treatment 2

Mucoactive Treatments

• Consider long-term mucoactive treatment for patients with difficulty expectorating sputum, poor quality of life, or failure of standard airway clearance techniques 2
• Do NOT use recombinant human DNase (dornase alfa) in non-CF bronchiectasis—it may worsen outcomes 1, 2

Immunizations (Mandatory for All Patients)

• Annual influenza vaccination is mandatory for all bronchiectasis patients 1, 2, 3
• Pneumococcal vaccination is recommended for all bronchiectasis patients 1, 2, 3
• Consider influenza vaccination in household contacts of patients with immune deficiency 2

Surgical Intervention

• Surgery is NOT recommended except for localized disease with high exacerbation frequency despite optimal medical management 1, 2, 3
• Video-assisted thoracoscopic surgery (VATS) is preferred over open surgery to better preserve lung function and reduce scarring 2, 3
• Emergency surgery for massive hemoptysis is associated with mortality reaching 37% 2

Lung Transplantation

• Consider transplant referral for patients aged ≤65 years if FEV1 is <30% with significant clinical instability or rapid progressive respiratory deterioration despite optimal medical management 2, 3
• Consider earlier referral with additional factors such as massive hemoptysis, severe secondary pulmonary hypertension, ICU admissions, or respiratory failure 2

Monitoring and Follow-Up

• Annual assessments are recommended for mild disease, with more frequent monitoring if disease progresses 1
• Regular sputum culture and sensitivity monitoring should be performed, especially when using long-term antibiotics 3
• Monitor for drug toxicity, particularly with macrolides and inhaled aminoglycosides 3
• Pulse oximetry should be used to screen for respiratory failure 1
• Annual assessment by respiratory physiotherapist to optimize airway clearance regimen 3

Critical Pitfalls to Avoid

• Do NOT extrapolate treatments from cystic fibrosis bronchiectasis—treatment responses differ significantly 1, 2
• Do NOT use long-term antibiotics for mild disease without frequent exacerbations (<3 per year) 1
• Do NOT routinely use inhaled corticosteroids as monotherapy 1, 2
• The 2006 ACCP guideline 4 recommended against aerosolized antibiotics in idiopathic bronchiectasis, but this has been superseded by more recent evidence showing benefit in patients with chronic P. aeruginosa infection and frequent exacerbations 1, 2, 3