What is the first‑line treatment strategy for an adult with bronchiectasis?

First-Line Treatment Strategy for Adult Bronchiectasis

All adults with bronchiectasis should be taught airway clearance techniques by a trained respiratory physiotherapist as the cornerstone of first-line therapy, performing sessions of 10-30 minutes once or twice daily. 1, 2

Core First-Line Management Components

1. Airway Clearance Techniques (Essential for All Patients)

• Teach airway clearance techniques to all patients with chronic productive cough or difficulty expectorating sputum through a trained respiratory physiotherapist 1, 2
• Sessions should last 10-30 minutes, performed once or twice daily, continuing until two clear huffs or coughs are completed 1, 2
• The most frequently used techniques include active cycle of breathing techniques, positive expiratory pressure devices, and gravity-assisted drainage 3
• Review patients within 3 months of initial assessment and annually thereafter to optimize their regimen 1

Common pitfall: Many clinicians underutilize physiotherapy referral. Airway clearance is not optional—it is the foundation of bronchiectasis management and should be initiated before escalating to pharmacological therapies. 1, 4

2. Mucoactive Therapy (Adjunctive to Airway Clearance)

• Consider mucoactive treatment for patients with difficulty expectorating sputum despite standard airway clearance techniques 1, 2
• Consider humidification with sterile water or normal saline to facilitate clearance 1
• Trial carbocysteine for 6 months and continue if there is ongoing clinical benefit 1
• Perform airway reactivity testing when initiating inhaled mucoactive treatments 1
• Never use recombinant human DNase (dornase alfa) in non-CF bronchiectasis—it is contraindicated 1, 2

3. Prompt Treatment of Exacerbations

• Treat all exacerbations with 14 days of antibiotics based on previous sputum culture results 1, 2, 5
• Obtain sputum for culture and sensitivity before starting antibiotics whenever possible 1
• First-line empiric choices based on common pathogens: 1
  • Streptococcus pneumoniae or Haemophilus influenzae: Amoxicillin 500mg three times daily for 14 days
  • Pseudomonas aeruginosa: Ciprofloxacin 500-750mg twice daily for 14 days
• Patients should have antibiotics at home for prompt self-initiation with a self-management plan 1

Critical pitfall: Never use antibiotic courses shorter than 14 days, especially with P. aeruginosa infection, as this increases treatment failure risk. 1, 5

4. Immunizations (Universal Recommendation)

• Offer annual influenza vaccination to all patients with bronchiectasis 1, 2
• Offer pneumococcal polysaccharide vaccination (23-valent) to all patients 1, 2
• Consider 13-valent protein conjugate pneumococcal vaccine in patients without appropriate serological response to standard vaccine 1

5. Bronchodilator Trial (For Symptomatic Patients)

• Offer a trial of long-acting bronchodilators (LABA, LAMA, or combination) for patients with significant breathlessness, particularly those with chronic airflow limitation 1, 2
• Use bronchodilators before physiotherapy and before inhaled antibiotics to optimize pulmonary deposition 1
• Discontinue if no symptom reduction is achieved 1

Important caveat: Do not routinely offer inhaled corticosteroids unless comorbid asthma or COPD is present. 1, 2

Stepwise Escalation Algorithm (Beyond First-Line)

Step 2: If ≥3 Exacerbations Per Year Despite First-Line Therapy

• Reassess physiotherapy technique and optimize airway clearance 1
• Consider trial of mucoactive treatment if not already prescribed 1

Step 3: If ≥3 Exacerbations Per Year Despite Step 2

For chronic Pseudomonas aeruginosa infection: 1

• First choice: Long-term inhaled colistin
• Second choice: Inhaled gentamicin
• Alternative: Azithromycin or erythromycin (if inhaled antibiotics contraindicated or not tolerated)

For patients without P. aeruginosa: 1

• Long-term macrolides (azithromycin 250mg three times weekly or erythromycin)
• Must rule out nontuberculous mycobacterial infection with at least one negative respiratory culture before starting macrolides 6, 5

Step 4: Pulmonary Rehabilitation

• All patients with impaired exercise capacity should participate in pulmonary rehabilitation programs consisting of 6-8 weeks of supervised exercise training 1, 2, 4
• This improves exercise capacity, reduces cough symptoms, enhances quality of life, and decreases exacerbation frequency 2

Special Considerations for New P. aeruginosa Isolation

• Offer eradication therapy for first isolation or regrowth of P. aeruginosa associated with clinical deterioration 1
• First-line: Ciprofloxacin 500-750mg twice daily for 2 weeks 1
• Second-line: IV antipseudomonal beta-lactam ± IV aminoglycoside for 2 weeks, followed by 3 months of nebulized colistin, gentamicin, or tobramycin 1

Monitoring and Follow-Up

• Send sputum for culture at each clinical visit to guide antibiotic selection 1
• Annual review minimum, with assessment of disease severity and optimization of all treatment components 1
• Patients with chronic P. aeruginosa, frequent exacerbations (≥3/year), or on long-term antibiotics should be followed in secondary care 1

Key principle: The British Thoracic Society and European Respiratory Society guidelines emphasize that treatment must be individualized based on disease severity, exacerbation frequency, and microbiology, but airway clearance remains the universal foundation. 1, 4