What is the recommended nebulisation therapy for a patient with bronchiectasis?

Nebulisation Therapy in Bronchiectasis

Nebulised antibiotics should be considered for patients with bronchiectasis who have frequent exacerbations (≥3 per year) despite optimal airway clearance and oral antibiotics, while nebulised bronchodilators are only indicated when demonstrable airflow obstruction or bronchospasm is present. 1, 2

Nebulised Antibiotics

Indications for Long-Term Nebulised Antibiotics

• Consider a therapeutic trial of long-term nebulised antibiotics when oral antibiotics combined with regular postural drainage have been unsuccessful in controlling background symptoms, severity of acute exacerbations, or risk of disease progression 1

• Patients with ≥3 exacerbations annually requiring antibiotics are candidates for long-term inhaled antibiotics (such as colistin or gentamicin) 2

• Nebulised antibiotics should be used as an adjunct to regular postural drainage, not as monotherapy, and should supplement (not replace) oral or intravenous antibiotics during acute exacerbations 1

Monitoring and Assessment

• Carefully assess changes in purulent sputum volume, patient well-being between exacerbations, and the severity and frequency of exacerbations to evaluate treatment efficacy 1

• Dosing and frequency should follow protocols similar to those used in cystic fibrosis patients 1

Critical Safety Considerations

• Use special filters or venting systems to prevent exposure of personnel and family members to nebulised antibiotics 3

• Separate compressors should be used for patients colonized with Pseudomonas aeruginosa and Burkholderia cepacia to prevent cross-contamination 3

Nebulised Bronchodilators

When to Use Bronchodilators

• Nebulised bronchodilator therapy is indicated only in a small number of patients with bronchiectasis who have demonstrable airflow obstruction or bronchospasm 1

• The need should be evaluated using the same criteria as for patients with asthma and COPD, including objective spirometry demonstrating reversibility 1

• Inhaled bronchodilators (β-agonists and antimuscarinic agents) are specifically indicated for bronchiectasis patients who have comorbid asthma or COPD 2

Important Caveat

Despite guideline recommendations, bronchodilators are frequently overused in real-world bronchiectasis patients even without documented airflow obstruction 4. Do not prescribe bronchodilators routinely without objective evidence of reversible airflow obstruction 1.

Mucoactive Agents via Nebulisation

Hypertonic Saline

• Consider nebulised hypertonic saline (3-7%, 4-5 mL) to reduce sputum viscosity and facilitate mucus clearance 1, 2

• Always precede hypertonic saline with nebulised salbutamol to minimize bronchospasm risk 1

• The first dose should be administered under supervision to assess for adverse reactions 1

Isotonic Saline

• Consider humidification with sterile water or normal saline to facilitate airway clearance 1

• Nebulised saline or terbutaline given as adjunct to chest physiotherapy may enhance mucus clearance 3, 5

rhDNase (Dornase Alfa)

• Do not routinely use recombinant human DNase in adults with bronchiectasis 1

• This recommendation differs from cystic fibrosis, where rhDNase has established benefit 1, 3

N-Acetylcysteine

• N-acetylcysteine is NOT recommended as controlled trials show little or no benefit and it may cause bronchoconstriction 3

Technical Requirements for Nebulisation

Equipment Specifications

• Use a high-capacity nebulizer system with 6-8 L/min flow rate to achieve optimal particle sizes of 2-5 μm and minimize treatment time 3, 5

• Jet nebulizers or breath-enhanced open vent nebulizers are preferred for optimal delivery 3

• The compressor should be matched with the nebuliser to ensure adequate output with appropriate particle size for each drug class 1

Critical Safety Protocols

• Mucolytic drugs should be administered separately from other nebulised medications, as mixing may be hazardous and ineffective 3

• Never use water as a diluent for nebulisation—it may cause bronchoconstriction 5

• Nebulisers require proper cleaning between uses to prevent bacterial aerosolization and transmission 5

Service Organization and Patient Assessment

Referral and Assessment

• Patients should be referred to a centralised nebuliser service for assessment before establishing long-term treatment 1

• Assessment should be performed by a respiratory physician or appropriately trained specialist 1

Follow-Up Requirements

• Individuals with bronchiectasis followed in secondary care should be assessed by a respiratory physiotherapist within 3 months of initial assessment and as part of annual clinical review 1

• Any deterioration in condition (increased exacerbation frequency or worsening symptoms) requires airway clearance technique review 1

Service Components

The nebuliser service should provide: compressor and nebuliser equipment with disposables, emergency replacement equipment, repair and maintenance systems, patient and staff education, detailed assessment schemes, and standard written instructions including emergency contact numbers 1

Common Pitfalls to Avoid

• Do not prescribe nebulised bronchodilators without objective evidence of airflow obstruction or bronchospasm 1, 4

• Do not use nebulised antibiotics as monotherapy—they must be combined with regular airway clearance techniques 1

• Do not mix multiple medications in the same nebuliser, as this reduces efficacy and may cause adverse reactions 3

• Do not prescribe rhDNase routinely for non-CF bronchiectasis despite its established role in cystic fibrosis 1