What is the recommended management for a patient with bronchiectasis, elevated eosinophils, and potential mold exposure, who has normal Pulmonary Function Test (PFT) and 6-minute walk (6MW) results?

Management of Bronchiectasis with Elevated Eosinophils and Normal PFT/6MW

Despite normal pulmonary function tests and 6-minute walk results, this patient with bronchiectasis and elevated eosinophils requires active management including airway clearance techniques, pulmonary rehabilitation, and consideration of inhaled corticosteroids given the eosinophilic phenotype, while addressing the potential mold exposure as a trigger for allergic bronchopulmonary aspergillosis.

Immediate Diagnostic Priorities

Evaluate for Allergic Bronchopulmonary Aspergillosis (ABPA)

• Obtain total IgE and specific IgE or skin prick test to Aspergillus, as this is part of the mandatory minimum diagnostic panel for all bronchiectasis patients 1
• The combination of elevated eosinophils and mold exposure raises significant concern for ABPA, which fundamentally changes management 1
• If total IgE is elevated with positive Aspergillus testing suggesting active ABPA, initiate oral corticosteroid 0.5 mg/kg/day for 2 weeks 1

Obtain Baseline Sputum Microbiology

• Collect sputum for culture and sensitivity testing to identify pathogens, specifically Pseudomonas aeruginosa 1
• This should be done even in the absence of acute exacerbation, as routine sputum samples every 6-12 months are recommended for monitoring 2

Core Management Strategy

Airway Clearance Techniques (Mandatory for All Patients)

• All patients with bronchiectasis must be taught airway clearance techniques by a respiratory physiotherapist, regardless of disease severity or normal functional testing 1
• Teach active cycle of breathing technique in sitting position as first-line method 1
• Prescribe sessions of 10-30 minutes duration, performed once or twice daily 1
• The normal PFT and 6MW do not negate this requirement, as airway clearance prevents disease progression 2

Pulmonary Rehabilitation

• Initiate pulmonary rehabilitation even with normal exercise capacity, as it improves quality of life and reduces exacerbation frequency 2
• Pulmonary rehabilitation increases exercise capacity and can improve quality of life in individuals with bronchiectasis (Level 1+ evidence) 2
• Pulmonary rehabilitation can reduce frequency of exacerbations over a 12-month period and increase time to first exacerbation 2
• The program should include walking components, upper limb training, and education sessions tailored to bronchiectasis (airway clearance techniques, pathophysiology, inhaled therapy) 2

Eosinophilic Bronchiectasis-Specific Considerations

Inhaled Corticosteroid Trial

• Consider inhaled corticosteroids given the elevated eosinophils, as this represents eosinophilic bronchiectasis affecting approximately 20% of patients 3, 4
• Recent evidence demonstrates that ICS use is associated with reduced exacerbation frequency specifically in patients with elevated blood eosinophils (relative risk 0.70,95% CI 0.59 to 0.84, p<0.001) 5
• Eosinophilic bronchiectasis (defined as eosinophils ≥300 cells/μL without coexisting asthma) has been associated with better therapeutic response to inhaled corticosteroids and other anti-TH2 profile treatments 4
• After controlling for infection status, raised blood eosinophil counts are associated with shortened time to exacerbation (hazard ratio 3.99 for ≥300 cells/μL) 3

Important Caveat on ICS Use

• Current bronchiectasis guidelines advise against routine ICS use except in patients with associated asthma, ABPA, and/or COPD 5
• However, the 2025 European Respiratory Society guidelines acknowledge emerging evidence for eosinophilic phenotypes 6
• The decision to use ICS should weigh the potential benefit in eosinophilic disease against the lack of strong guideline support outside specific indications 5

Ongoing Monitoring Strategy

Regular Outpatient Follow-Up

• Review every 3-6 months in outpatient clinics to monitor general wellbeing, respiratory status, and detect complications 2
• Perform spirometry (FEV1 and FVC) at each visit when age-appropriate 2
• Obtain sputum samples every 6-12 months to identify new pathogens, specifically P. aeruginosa 2
• Perform pulse oximetry at each visit 2

Quality of Life Assessment

• Use the Quality of Life-Bronchiectasis (QOL-B) questionnaire as a validated tool for monitoring, focusing on respiratory symptoms, physical, role, emotional and social functioning 7

Criteria for Secondary Care Referral

Refer for ongoing secondary care management if any of the following develop 1:

• Chronic Pseudomonas aeruginosa, non-tuberculous mycobacteria, or MRSA colonization
• Deteriorating bronchiectasis with declining lung function
• Recurrent exacerbations (≥2 per year requiring antibiotics)
• ABPA diagnosis
• Advanced disease features

Environmental Intervention

• Address the mold exposure immediately through environmental remediation, as this may be driving the eosinophilic response and potential ABPA 1
• Consider referral to environmental health services or occupational medicine if workplace exposure

Key Pitfall to Avoid

The most critical error would be assuming normal PFT and 6MW results mean no intervention is needed. Bronchiectasis management is not driven by spirometry or exercise capacity alone—it is driven by preventing exacerbations, maintaining quality of life, and preventing disease progression 2, 6. The eosinophilic phenotype and potential ABPA require specific attention regardless of preserved lung function 3, 4.