What is the recommended management of bronchiectasis?

Management of Bronchiectasis in Adults

All adults with bronchiectasis should receive airway clearance techniques taught by a respiratory physiotherapist, and those with impaired exercise capacity must participate in pulmonary rehabilitation, while long-term macrolide antibiotics are indicated for patients with ≥3 exacerbations per year after optimizing these foundational therapies. 1, 2, 3

Foundational Non-Pharmacological Management

Airway Clearance Techniques (ACTs)

• Teach all patients with chronic productive cough or difficulty expectorating sputum an airway clearance technique by a trained respiratory physiotherapist, performed once or twice daily for 10-30 minutes. 1, 3
• Techniques include active cycle of breathing, postural drainage, and mechanical devices (e.g., Acapella) that modify expiratory flow to increase mucus clearance. 1, 3
• ACTs increase sputum volume, reduce cough impact on quality of life, and may reduce peripheral airway obstruction and inflammatory cells in sputum. 1

Pulmonary Rehabilitation

• All patients with impaired exercise capacity must participate in a pulmonary rehabilitation program with regular exercise tailored to symptoms, physical capability, and disease characteristics. 1, 3
• This is a strong recommendation based on high-quality evidence showing clear improvements in exercise capacity, reduced cough symptoms, enhanced quality of life, and decreased exacerbation frequency. 1
• Benefits are achieved in 6-8 weeks and maintained for 3-6 months. 1

Acute Exacerbation Management

Antibiotic Duration and Selection

• Treat all acute exacerbations with 14 days of antibiotics, regardless of severity or causative organism. 4, 2, 3
• Select antibiotics based on previous sputum culture results and antibiotic susceptibility testing. 4, 2, 3
• For Pseudomonas aeruginosa: ciprofloxacin 500mg twice daily for 14 days. 2
• For Haemophilus influenzae or Streptococcus pneumoniae: amoxicillin for 14 days. 2
• For E. coli: fluoroquinolones, amoxicillin-clavulanate, or trimethoprim-sulfamethoxazole based on susceptibility patterns. 4

Route of Administration

• Oral antibiotics are first-line for most exacerbations. 4, 2
• Switch to intravenous antibiotics for severe exacerbations, treatment failures after oral therapy, or acutely deteriorating patients. 4, 2, 3

Extension Beyond 14 Days

• Extend treatment beyond 14 days only if the patient has not returned to baseline clinical state by day 14. 4
• Re-evaluate clinically and obtain new sputum culture at day 14 if extending treatment. 4

Long-Term Prophylactic Antibiotic Therapy

Indications and Prerequisites

• Consider long-term antibiotics only for patients with ≥3 exacerbations per year, and only after optimizing airway clearance techniques and treating modifiable underlying causes. 1, 2, 3
• Before initiating, exclude active nontuberculous mycobacterial (NTM) infection, as macrolide monotherapy increases macrolide resistance in NTM. 2, 3

First-Line Long-Term Antibiotic Selection

For patients WITH chronic Pseudomonas aeruginosa infection:

• Long-term inhaled antibiotics are first-line. 3, 5
• Perform supervised test dose with pre- and post-spirometry due to 10-32% risk of bronchospasm. 2

For patients WITHOUT Pseudomonas aeruginosa infection:

• Long-term macrolide therapy (azithromycin or erythromycin) is first-line. 1, 2, 3
• The EMBRACE study demonstrated azithromycin for 6 months significantly reduced exacerbations (RR 0.38,95% CI 0.26-0.54). 2
• Minimum treatment duration is 6 months with regular reassessment to determine ongoing clinical benefit. 2, 3

If macrolides are contraindicated, not tolerated, or ineffective:

• Consider long-term oral non-macrolide antibiotics selected based on antibiotic susceptibility and patient tolerance. 1
• If oral prophylaxis is contraindicated, not tolerated, or ineffective, use long-term inhaled antibiotics. 1

Monitoring During Long-Term Antibiotics

• Perform regular sputum culture and sensitivity monitoring to track resistance patterns and identify treatment-emergent organisms. 2, 3
• Monitor for drug toxicity, particularly with macrolides and inhaled aminoglycosides. 2, 3
• Annual assessment by respiratory physiotherapist to optimize airway clearance regimen. 3

Discontinuation Considerations

• Consider discontinuation if exacerbation frequency decreases to <3 per year consistently, significant adverse effects or resistance patterns emerge, or loss of clinical benefit despite adequate adherence. 2

Mucoactive Treatment

• Offer long-term mucoactive treatment (≥3 months) to patients with difficulty expectorating sputum and poor quality of life where standard airway clearance techniques have failed to control symptoms. 1, 3
• Do NOT offer recombinant human DNase to adults with bronchiectasis (strong recommendation based on moderate quality evidence). 1, 3

Bronchodilator Therapy

• Do NOT routinely offer long-acting bronchodilators for all patients with bronchiectasis. 1, 3
• Offer long-acting bronchodilators for patients with significant breathlessness on an individual basis. 1, 3
• Use bronchodilators before physiotherapy, inhaled mucoactive drugs, and inhaled antibiotics to increase tolerability and optimize pulmonary deposition. 1
• The diagnosis of bronchiectasis should not affect the use of long-acting bronchodilators in patients with comorbid asthma or COPD. 1

Surgical Intervention

• Do NOT offer surgical treatments except for patients with localized disease and high exacerbation frequency despite optimization of all other aspects of bronchiectasis management. 1, 3

Initial Diagnostic Workup

• High-resolution CT (HRCT) scanning is the gold standard for diagnosing bronchiectasis. 3
• Initial workup should include differential blood count, serum immunoglobulins, testing for allergic bronchopulmonary aspergillosis, and sputum culture for bacteria, mycobacteria, and fungi. 3

Common Pitfalls to Avoid

• Never start long-term antibiotics before optimizing airway clearance and treating underlying causes – this is a critical sequence emphasized repeatedly in the guidelines. 1, 2
• Never use recombinant human DNase – this is a strong recommendation against its use based on moderate quality evidence. 1, 3
• Never initiate macrolides without excluding NTM infection first – macrolide monotherapy increases resistance. 2, 3
• Never treat acute exacerbations for less than 14 days as standard practice – this is the evidence-based duration regardless of organism. 4, 2