What inhaler regimen should be prescribed for an adult with bronchiectasis?

Inhaler Regimen for Bronchiectasis

Do not routinely prescribe inhaled corticosteroids or long-acting bronchodilators for bronchiectasis unless the patient has coexisting asthma or COPD. 1

Core Inhaler Strategy

Bronchodilators: Use Selectively, Not Routinely

• Short-acting bronchodilators (SABAs/SAMAs) should be used before airway clearance techniques and before nebulized therapies to optimize pulmonary deposition and prevent bronchoconstriction 1, 2
• Long-acting bronchodilators (LABAs/LAMAs) are NOT routinely recommended for bronchiectasis alone 1
• Consider long-acting bronchodilators only for patients with significant breathlessness on an individual basis 1
• If the patient has comorbid asthma or COPD, continue standard bronchodilator therapy as these conditions represent clear indications regardless of bronchiectasis diagnosis 1, 2

Inhaled Corticosteroids: Avoid Unless Specific Indications Exist

• Do NOT routinely offer inhaled corticosteroids for bronchiectasis 1
• Continue inhaled corticosteroids ONLY if the patient has:
  • Asthma 1, 2
  • COPD meeting treatment criteria 1, 2
  • Allergic bronchopulmonary aspergillosis (ABPA) 1
  • Inflammatory bowel disease 1
• Be aware that inhaled corticosteroids carry significant risks in bronchiectasis, including adrenal suppression, pneumonia, pharyngeal irritation, and dysphonia 1

Nebulized Therapies: The Foundation of Inhaler Treatment

Mucoactive Agents (Nebulized Saline)

• Consider nebulized isotonic (0.9%) or hypertonic saline (≥3%) for patients with difficulty expectorating sputum, particularly those with viscous secretions or sputum plugging 1
• Perform an airway reactivity challenge test before starting hyperosmolar agents to assess for bronchoconstriction 1
• Pre-treat with a bronchodilator before nebulized saline, especially in patients with severe airflow obstruction (FEV1 <1 liter) or bronchial hyperreactivity 1, 2
• If carbocysteine is prescribed, give a 6-month trial and continue only if there is ongoing clinical benefit 1

Nebulized Antibiotics: For High-Risk Patients Only

Consider long-term inhaled antibiotics ONLY for patients with ≥3 exacerbations per year after optimizing airway clearance 1, 3

For Chronic Pseudomonas aeruginosa Infection:

• First-line: Inhaled colistin 1 million units twice daily via I-neb device 1, 3
• Second-line: Inhaled gentamicin if colistin is not tolerated 1, 3
• Alternative: Azithromycin or erythromycin if inhaled antibiotics are not tolerated 1

Safety Monitoring for Inhaled Aminoglycosides:

• Avoid if creatinine clearance <30 mL/min 1
• Use with caution if significant hearing loss or balance issues exist 1
• Avoid concomitant nephrotoxic medications 1

Recombinant Human DNase: Do NOT Use

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

Proper Sequencing of Inhaled Therapies

When multiple inhaled therapies are prescribed, administer in this specific order: 1

1. Bronchodilator (if prescribed)
2. Mucoactive treatment (nebulized saline if prescribed)
3. Airway clearance technique (10-30 minutes)
4. Nebulized antibiotic (if prescribed)
5. Inhaled corticosteroid (only if asthma/COPD present)

Critical Pitfalls to Avoid

• Never discontinue inhaled corticosteroids in patients with documented asthma simply because bronchiectasis is present—asthma remains a clear indication 2
• Do not prescribe inhaled corticosteroids for bronchiectasis alone, as they increase adverse events without improving exacerbations or lung function beyond 6 months 1
• Always perform a bronchodilator challenge test before starting nebulized hypertonic saline or mannitol to prevent severe bronchoconstriction 1
• Do not start long-term inhaled antibiotics without first optimizing airway clearance techniques—this is the foundation of treatment 1, 3
• Recognize that the threshold for long-term antibiotics may be lower (<3 exacerbations/year) if the patient is symptomatic between exacerbations, responds poorly to treatment, or is immunosuppressed 1

When to Escalate Inhaler Therapy

Consider adding or intensifying inhaled therapies if: 1

• Patient has ≥3 exacerbations per year despite optimal airway clearance 1, 3
• Chronic Pseudomonas aeruginosa infection is documented 1, 3
• Patient has viscous secretions unresponsive to standard airway clearance 1
• Coexisting asthma or COPD requires standard treatment 1, 2