What is the treatment for asthma with bronchiectasis?

Treatment of Asthma with Bronchiectasis

Inhaled corticosteroids should be continued for asthma control in patients with coexisting bronchiectasis, as asthma represents a clear indication for their use despite the general recommendation against routine inhaled corticosteroids in bronchiectasis alone. 1

Core Treatment Principles

The management requires addressing both conditions simultaneously, recognizing that asthma is an established indication for treatments otherwise not recommended in bronchiectasis alone. 1

Asthma-Specific Therapies

• Continue inhaled corticosteroids as they have an established role in asthma management, even in the presence of bronchiectasis. 1

• Optimize asthma control using standard asthma guidelines, ensuring allergies are also well-managed. 1

• Use bronchodilators (short- or long-acting) as needed for breathlessness and before other inhaled therapies to optimize pulmonary deposition and tolerability. 1

• Pre-treat with bronchodilators before mucoactive treatments and inhaled antibiotics, especially given the bronchial hyper-reactivity present in asthma. 1

• For severe eosinophilic asthma with bronchiectasis, consider IL-5/5Ra targeted biologics (mepolizumab, reslizumab, benralizumab), as real-world evidence demonstrates significant reduction in exacerbations and oral corticosteroid requirements despite bronchiectasis being an exclusion criterion in phase 3 trials. 2

Bronchiectasis-Specific Management

Airway Clearance:

• All patients with chronic productive cough must be taught airway clearance techniques by a trained respiratory physiotherapist, performing 10-30 minute sessions once or twice daily. 1, 3

• Review airway clearance technique within 3 months of initial assessment and annually thereafter, or whenever clinical deterioration occurs. 1

Mucoactive Therapy:

• Consider a trial of mucoactive treatment (such as carbocysteine for 6 months) in patients with difficulty expectorating sputum. 1, 3

• Perform an airway reactivity challenge test when first administering inhaled mucoactive treatment, given the increased risk of bronchoconstriction in asthma patients. 1

• Do NOT use recombinant human DNase (dornase alfa), as it is contraindicated in non-CF bronchiectasis. 1, 3

Antibiotic Management:

For Exacerbations:

• Treat all exacerbations with 14 days of antibiotics, selecting based on previous sputum culture results. 1, 3

• Obtain sputum for culture and sensitivity before starting antibiotics whenever possible. 1, 3

• Common pathogens and first-line treatments include: Streptococcus pneumoniae (amoxicillin 500mg TID), Haemophilus influenzae (amoxicillin 500mg TID), and Pseudomonas aeruginosa (ciprofloxacin 500-750mg BID). 3

For Prevention:

• Consider long-term antibiotics if the patient experiences ≥3 exacerbations per year. 1, 3

• For chronic Pseudomonas aeruginosa infection, use inhaled colistin as first-line or inhaled gentamicin as second-line. 1, 3

• For patients without Pseudomonas, consider macrolides (azithromycin 250mg three times weekly). 3, 4

Monitoring and Follow-Up

• Assess patients annually at minimum, with more frequent monitoring in severe disease. 1, 4

• Perform pulse oximetry to screen for respiratory failure. 1, 4

• Obtain regular sputum cultures to monitor for pathogen emergence, particularly Pseudomonas aeruginosa (associated with three-fold increased mortality risk). 3

• Monitor for underlying causes including ABPA, which requires specific immunosuppression with corticosteroids ± antifungal agents. 1, 3

Critical Pitfalls to Avoid

• Do NOT discontinue inhaled corticosteroids simply because bronchiectasis is present—asthma remains a clear indication. 1

• Do NOT use shorter antibiotic courses for exacerbations; always use 14 days, particularly with Pseudomonas. 1, 3

• Do NOT extrapolate cystic fibrosis treatments to non-CF bronchiectasis, as treatment responses differ. 3

• Always pre-treat with bronchodilators before nebulized therapies in asthma patients to prevent bronchoconstriction. 1

Sequence of Multiple Inhaled Therapies

When using multiple inhaled treatments, administer in this order: 1

1. Short- or long-acting bronchodilators
2. Mucolytic/physiotherapy adjuncts
3. Airway clearance techniques
4. Inhaled antibiotics (if prescribed)