What inhaler regimen is recommended for a patient with bronchiectasis?

Inhaler Regimen for Bronchiectasis

Bronchodilators should not be used routinely in bronchiectasis unless the patient has significant breathlessness, airflow obstruction (FEV₁/FVC <0.7), or comorbid asthma/COPD. 1, 2

Core Principle: Bronchodilators Are NOT First-Line Therapy

• Do not prescribe long-acting bronchodilators (LABA/LAMA) routinely for bronchiectasis patients without symptomatic breathlessness, as there is no evidence supporting their use in this population. 1, 2

• Airway clearance techniques taught by a respiratory physiotherapist remain the cornerstone of treatment, not inhaled medications. 2, 3

When to Consider Bronchodilators

Indications for Short-Acting Bronchodilators

• Administer short-acting bronchodilators (SABA/SAMA) before airway clearance techniques to improve pulmonary deposition and prevent bronchoconstriction. 2

• Use short-acting bronchodilators before nebulized therapies (mucoactive agents, inhaled antibiotics) to optimize drug delivery and tolerability. 1, 2

Indications for Long-Acting Bronchodilators

• Offer a trial of long-acting bronchodilators only to patients with significant breathlessness, particularly those with chronic airflow obstruction (FEV₁/FVC <0.7). 1, 2

• Discontinue bronchodilators if no symptomatic improvement occurs after an adequate trial period. 1, 2

• Continue standard bronchodilator therapy in patients with comorbid asthma or COPD, as these conditions constitute clear indications regardless of bronchiectasis. 1, 2, 4

Inhaled Corticosteroids: Generally Contraindicated

• Do not prescribe inhaled corticosteroids routinely for bronchiectasis, as they increase risks of adrenal suppression, pneumonia, pharyngeal irritation, and dysphonia without improving exacerbation frequency or lung function beyond six months. 2, 3

• Continue inhaled corticosteroids only when the patient has documented asthma, COPD meeting treatment criteria, allergic bronchopulmonary aspergillosis (ABPA), or inflammatory bowel disease. 2, 4

• Never discontinue inhaled corticosteroids in a patient with confirmed asthma simply because bronchiectasis is present—asthma remains a clear indication. 4

The 2005 fluticasone study 5 showed some benefit in sputum volume reduction, particularly in patients with Pseudomonas aeruginosa infection, but this finding has not been replicated in larger trials and is contradicted by more recent high-quality evidence showing no benefit and increased adverse events. 2, 3

Nebulized Mucoactive Therapy

• Offer nebulized isotonic (0.9%) or hypertonic saline (≥3%) to patients with difficulty expectorating sputum, especially when secretions are viscous or there is sputum plugging. 2

• Perform an airway-reactivity challenge test before initiating hyperosmolar agents to identify potential bronchoconstriction. 2

• Pre-treat with a bronchodilator before nebulized saline in patients with severe airflow obstruction (FEV₁ <1 L) or documented bronchial hyperreactivity. 2

Long-Term Inhaled Antibiotics

• Reserve long-term inhaled antibiotics for patients with ≥3 exacerbations per year after optimal airway-clearance measures have been instituted. 2, 3

For Chronic Pseudomonas aeruginosa Infection

• First-line: Inhaled colistin (1 million units twice daily via I-neb). 2

• Second-line: Inhaled gentamicin if colistin is not tolerated. 2

• Avoid inhaled aminoglycosides if creatinine clearance <30 mL/min, and use with caution in patients with significant hearing loss or vestibular dysfunction. 2

Sequencing Multiple Inhaled Therapies

When multiple inhaled treatments are prescribed, follow this exact order: 1, 2, 3

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

Critical Pitfalls to Avoid

• Do not extrapolate cystic fibrosis data to non-CF bronchiectasis—treatment responses differ significantly. 3

• Never use recombinant human DNase (dornase alfa) in non-CF bronchiectasis, as it worsens clinical outcomes. 1, 2, 3

• Do not initiate long-term inhaled antibiotics without first optimizing airway-clearance strategies, as this is the foundation of management. 2, 3

• Avoid prescribing bronchodilators based solely on spirometric reversibility testing, as this does not predict clinical response in bronchiectasis. 1, 6

The evidence base for bronchodilators in bronchiectasis remains weak 6, with only one small methodologically limited trial 1 and no long-term observational studies demonstrating benefit. Despite this, bronchodilators are overused in real-world practice 6. The 2025 ERS guidelines 7 and recent JAMA review 8 reinforce that bronchodilators should be reserved for specific indications rather than used routinely.