Treatment of Bronchiectasis

Core Treatment Strategy

All patients with bronchiectasis should receive airway clearance techniques taught by a trained respiratory physiotherapist, with treatment escalation to long-term antibiotics reserved for those with ≥3 exacerbations per year after optimizing non-pharmacological management. 1, 2

Non-Pharmacological Management (Foundation for All Patients)

Airway Clearance Techniques

All patients with chronic productive cough or difficulty expectorating sputum must be taught airway clearance techniques by a trained respiratory physiotherapist, performed 10-30 minutes once or twice daily. 1, 2, 3
Techniques include active cycle of breathing, autogenic drainage, postural drainage, and may incorporate devices like flutter valves. 2, 3
Consider intermittent positive pressure breathing or non-invasive ventilation during acute exacerbations to reduce work of breathing. 2

Pulmonary Rehabilitation and Exercise

Patients with impaired exercise capacity should participate in pulmonary rehabilitation programs (6-8 weeks of supervised exercise training) and take regular exercise—this is a strong recommendation. 1, 3
Benefits include improved exercise capacity, reduced cough symptoms, enhanced quality of life, and decreased exacerbation frequency. 2, 4

Mucoactive Treatments

Consider long-term mucoactive treatment (≥3 months) for patients with difficulty expectorating sputum, poor quality of life, or failure of standard airway clearance techniques. 1, 2
Consider humidification with sterile water or normal saline to facilitate airway clearance. 2
Do NOT use recombinant human DNase (dornase alfa) in adults with non-CF bronchiectasis—this is a strong recommendation based on moderate quality evidence showing potential harm. 1, 2

Treatment of Acute Exacerbations

Antibiotic Selection and Duration

Treat all acute exacerbations with 14 days of antibiotics, selected based on previous sputum culture results. 2, 3, 4
Obtain sputum cultures before starting antibiotics whenever possible. 2, 3
Do NOT use shorter than 14-day courses unless specifically indicated for mild cases, as this increases risk of treatment failure. 3

Pathogen-Specific Antibiotic Choices

Streptococcus pneumoniae: Amoxicillin 500mg three times daily for 14 days. 2
Haemophilus influenzae (beta-lactamase negative): Amoxicillin 500mg three times daily for 14 days. 2
Pseudomonas aeruginosa: Ciprofloxacin 500-750mg twice daily for 14 days orally. 2, 3
Consider intravenous antibiotics for patients who are particularly unwell, have resistant organisms, or have failed to respond to oral therapy. 2

Long-Term Antibiotic Prophylaxis (For Frequent Exacerbators)

Patient Selection Criteria

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
Before initiating long-term antibiotics, obtain sputum cultures for bacteria, mycobacteria, and fungi to characterize pathogens. 1, 3

Treatment Algorithm Based on Pseudomonas Status

For Chronic Pseudomonas aeruginosa Infection:

First-line: Long-term inhaled antibiotics (colistin 1MU twice daily via I-neb, or gentamicin). 1, 2, 3, 4
Perform supervised test dose with pre- and post-spirometry due to 10-32% risk of bronchospasm; pre-treat with short-acting bronchodilator. 1
Second-line (if inhaled antibiotics contraindicated, not tolerated, or not feasible): Macrolides (azithromycin or erythromycin). 1
Third-line (if inadequate response to inhaled antibiotics alone): Combined oral and inhaled antibiotic treatment. 1

For Non-Pseudomonas Infection:

First-line: Long-term macrolides (azithromycin or erythromycin). 1, 2, 4
CRITICAL: Exclude active nontuberculous mycobacterial (NTM) infection before starting macrolides, as monotherapy increases risk of macrolide resistance in NTM. 1
Second-line (if macrolides contraindicated, not tolerated, or ineffective): Long-term targeted oral antibiotic based on antibiotic susceptibility and patient tolerance. 1
Third-line (if oral antibiotics contraindicated, not tolerated, or ineffective): Long-term inhaled antibiotics. 1

Monitoring During Long-Term Antibiotics

Careful characterization of sputum pathogens before and after implementation to direct antibiotic choices, monitor resistance patterns, and identify treatment-emergent organisms. 1
Drug toxicity monitoring is required, most notably with macrolides and inhaled aminoglycosides. 1

Bronchodilator Therapy

Do NOT routinely offer long-acting bronchodilators for all patients with bronchiectasis. 1, 4
Offer trial of long-acting bronchodilator therapy (LABA, LAMA, or combination) on an individual basis for patients with significant breathlessness, particularly those with chronic obstructive airflow limitation. 1, 2
Use bronchodilators before physiotherapy, inhaled mucoactive drugs, and inhaled antibiotics to increase tolerability and optimize pulmonary deposition. 1
The diagnosis of bronchiectasis should not affect the use of long-acting bronchodilators in patients with comorbid asthma or COPD—follow COPD or asthma guideline recommendations for these patients. 1, 2
If treatment with bronchodilators does not result in symptom reduction, discontinue therapy. 2

Anti-Inflammatory Treatments

Inhaled Corticosteroids

Do NOT routinely offer inhaled corticosteroids to adults with bronchiectasis unless they have comorbid asthma or COPD. 2, 3, 4
Do NOT offer long-term oral corticosteroids without other indications such as allergic bronchopulmonary aspergillosis (ABPA), chronic asthma, COPD, or inflammatory bowel disease. 2

Allergic Bronchopulmonary Aspergillosis (ABPA)

For patients with ABPA, immunosuppression with corticosteroids (with or without antifungal agents) is the mainstay of treatment. 2
Use tapering dose of corticosteroid with monitoring of total serum IgE every 6-8 weeks as a marker of disease activity. 2

Immunizations

Offer annual influenza immunization to all patients with bronchiectasis. 2, 3, 4
Offer pneumococcal vaccination to all patients with bronchiectasis. 2, 3
Consider influenza vaccination in household contacts of patients with immune deficiency and bronchiectasis. 2

Surgical Interventions

Do NOT offer surgical treatments except for patients with localized disease and high exacerbation frequency despite optimization of all other aspects of management. 1, 2, 3, 4
Video-assisted thoracoscopic surgery (VATS) is preferred over open surgery to better preserve lung function and reduce scarring. 2, 4
Emergency surgery in unstable patients with massive hemoptysis is associated with higher morbidity and mortality reaching 37%. 2

Lung Transplantation Referral

Consider transplant referral for patients aged ≤65 years if FEV1 <30% with significant clinical instability or rapid progressive respiratory deterioration despite optimal medical management. 2, 3, 4
Consider earlier transplant referral with additional factors such as massive hemoptysis, severe secondary pulmonary hypertension, ICU admissions, or respiratory failure. 2

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. 3

Critical Pitfalls to Avoid

Do NOT extrapolate treatments from cystic fibrosis bronchiectasis, as treatment responses are different. 2, 3
Do NOT use shorter than 14-day antibiotic courses for exacerbations, as this increases risk of treatment failure. 3
Do NOT start macrolides without first excluding active NTM infection. 1
Do NOT use recombinant human DNase in non-CF bronchiectasis. 1, 2
Recognize that Pseudomonas aeruginosa infection is associated with 3-fold increased mortality risk, 7-fold increased hospitalization risk, and one additional exacerbation per year—requiring aggressive management. 2, 4

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