What is the recommended treatment for bronchiectasis?

Treatment of Bronchiectasis

All adults with bronchiectasis must receive daily airway clearance techniques taught by a respiratory physiotherapist, 14-day antibiotic courses for every exacerbation, and escalation to long-term antibiotics or macrolides if experiencing ≥3 exacerbations per year. 1

Core Treatment Framework

The management of bronchiectasis targets four pathophysiologic pillars: chronic bronchial infection, inflammation, impaired mucociliary clearance, and structural lung damage. 1 Treatment intensity escalates based on exacerbation frequency and microbiology results, with airway clearance serving as the universal foundation regardless of disease severity. 1

Airway Clearance Techniques (Foundation for All Patients)

Every patient with chronic productive cough or difficulty expectorating must receive instruction from a trained respiratory physiotherapist. 1

• First-line techniques: Active cycle of breathing or oscillating positive expiratory pressure (PEP) devices, performed for 10-30 minutes once or twice daily until two clear huffs or coughs are achieved. 1
• Incorporate the forced-expiration (huff) maneuver with every session to mobilize mucus effectively. 1
• Use gravity-assisted positioning (modified postural drainage without head-down tilt) unless contraindicated by gastroesophageal reflux. 1
• Alternative methods (autogenic drainage, high-frequency chest-wall oscillation, intrapulmonary percussive ventilation) should be considered when standard techniques fail or are not tolerated. 1
• Review technique within 3 months of initiation and conduct annual reassessments to optimize the regimen. 1
• During hospitalizations for exacerbations, provide daily physiotherapy visits until airway clearance is optimized. 1

Mucoactive Therapy (Adjunct to Airway Clearance)

• Consider adding a mucoactive agent for patients who continue to have difficulty expectorating despite optimal airway clearance techniques. 1
• Humidification with sterile water or normal saline may facilitate sputum clearance. 1
• A 6-month trial of carbocysteine is reasonable; continue only if clinical benefit is observed. 1
• Recombinant human DNase (dornase alfa) is absolutely contraindicated in non-cystic fibrosis bronchiectasis because it worsens clinical outcomes. 1

Bronchodilator Therapy

• Offer a trial of long-acting bronchodilators (LABA, LAMA, or combination) for patients with significant breathlessness, especially those with chronic airflow limitation (FEV₁/FVC < 0.7). 1
• Administer bronchodilators before physiotherapy sessions and before inhaled antibiotics to improve pulmonary drug deposition and reduce bronchospasm risk. 1
• Discontinue bronchodilator therapy if no symptomatic improvement is observed after an adequate trial. 1

Management of Acute Exacerbations

Treat every exacerbation with a 14-day course of antibiotics—this duration is superior to shorter courses in reducing treatment failure and improving clinical outcomes. 1

• Select antibiotics based on the most recent sputum culture and sensitivity results obtained before therapy whenever possible. 1
• Obtain sputum for culture and sensitivity before starting antibiotics at every exacerbation. 1

Empiric Antibiotic Selection (When Cultures Unavailable)

• Amoxicillin 500mg TID for 14 days for Streptococcus pneumoniae or Haemophilus influenzae (beta-lactamase negative). 1
• Ciprofloxacin 500-750mg BID for 14 days for Pseudomonas aeruginosa. 1
• Consider intravenous antibiotics for patients who are particularly unwell, have resistant organisms, or have failed to respond to oral therapy. 1

Self-Management Strategy

• Patients should keep a supply of appropriate antibiotics at home and have a self-management plan for prompt self-initiation of therapy. 1

Pseudomonas Aeruginosa Eradication (First Isolation)

P. aeruginosa infection is associated with a three-fold increase in mortality risk, seven-fold increase in hospitalization risk, and one additional exacerbation per year. 1

• Offer eradication therapy when P. aeruginosa is first isolated or re-emerges with clinical deterioration. 1
• First-line eradication: Oral ciprofloxacin 500-750mg BID for 2 weeks. 1
• Second-line eradication: 2 weeks of intravenous antipseudomonal β-lactam ± aminoglycoside, followed by 3 months of nebulized colistin, gentamicin, or tobramycin. 1
• Do NOT attempt eradication for pathogens other than P. aeruginosa. 1

Long-Term Antibiotic Prophylaxis (≥3 Exacerbations Per Year)

Escalate to long-term antibiotics only after optimizing airway clearance and treating underlying causes. 1

For Chronic Pseudomonas aeruginosa Infection

• First-line: Long-term inhaled antibiotics (colistin or gentamicin). 1
• Administer a short-acting bronchodilator before inhaled antibiotics to reduce bronchospasm risk (observed in 10-32% of patients). 1
• Perform a supervised test dose with pre- and post-spirometry to assess tolerance before initiating chronic therapy. 1
• Second-line: Long-term macrolides (azithromycin 250mg three times weekly or erythromycin) if inhaled antibiotics are contraindicated, not tolerated, or ineffective. 1

For Patients Without Pseudomonas aeruginosa

• First-line: Long-term macrolides (azithromycin 250mg three times weekly or erythromycin). 1
• Confirm absence of nontuberculous mycobacterial infection before starting macrolides because macrolide monotherapy can promote macrolide-resistant NTM. 1
• Second-line: Oral non-macrolide antibiotics selected according to susceptibility testing if macrolides are unsuitable. 1

Monitoring Requirements for Long-Term Antibiotics

• Obtain comprehensive sputum analysis (bacteria, mycobacteria, fungi) before and after initiating chronic antibiotics to guide drug choice, monitor resistance patterns, and detect emergent pathogens. 1
• Ongoing drug-toxicity monitoring is required, especially for macrolides and inhaled aminoglycosides, to detect adverse effects such as ototoxicity or hepatic injury. 1

Pulmonary Rehabilitation

Patients with impaired exercise capacity should enroll in a supervised 6-8 week pulmonary rehabilitation program—this strong recommendation is supported by high-quality evidence showing improvements in exercise capacity, cough symptoms, quality of life, and a reduction in exacerbation frequency. 1

• Encourage regular physical exercise combined with the forced-expiration technique to further promote airway clearance. 1

Anti-Inflammatory Treatments

• Inhaled corticosteroids should NOT be routinely prescribed unless the patient has comorbid asthma or COPD. 1
• For patients with comorbid asthma or COPD, continue inhaled corticosteroids according to the respective disease guidelines; bronchiectasis diagnosis alone should not alter this approach. 1
• Do NOT offer long-term oral corticosteroids without specific indications such as allergic bronchopulmonary aspergillosis (ABPA), chronic asthma, COPD, or inflammatory bowel disease. 1
• Statins are NOT recommended for bronchiectasis treatment. 1

Immunizations

• Offer annual influenza vaccination to all patients with bronchiectasis. 1
• Offer pneumococcal vaccination to all patients—a single dose of 23-valent pneumococcal polysaccharide vaccine, with consideration of 13-valent pneumococcal conjugate vaccine in patients who do not achieve adequate serologic response. 1
• Consider influenza vaccination in household contacts of patients with immune deficiency and bronchiectasis. 1

Surgical Management

Surgery is NOT recommended except for localized disease with high exacerbation frequency that persists despite optimal medical management. 1

• Video-assisted thoracoscopic surgery (VATS) is preferred over open thoracotomy to preserve lung function and reduce postoperative scarring. 1
• Emergency surgery in unstable patients with massive hemoptysis is associated with higher morbidity and mortality reaching 37%. 1

Lung Transplantation Referral

Refer patients ≤65 years for lung transplantation when FEV₁ < 30% with significant clinical instability or rapid progressive respiratory decline despite optimal medical therapy. 1

• Consider earlier transplant referral with additional factors such as massive hemoptysis, severe secondary pulmonary hypertension, ICU admissions, or respiratory failure. 1

Diagnostic Work-Up (Essential for All New Diagnoses)

• Obtain a minimum test bundle that includes differential blood count, serum immunoglobulin levels (IgG, IgA, IgM), testing for allergic bronchopulmonary aspergillosis, and sputum culture for bacteria and mycobacteria at every clinical visit. 1
• Perform bronchoscopy with bronchial aspiration or wash in patients with localized disease or who cannot expectorate sputum, to exclude endobronchial lesions, foreign bodies, and to diagnose nontuberculous mycobacterial infection. 1
• Apply the Bronchiectasis Severity Index to guide management decisions and prognostication. 1

Monitoring and Follow-Up

• Obtain sputum for culture at every clinical visit to guide antibiotic selection. 1
• Conduct at least an annual comprehensive review to assess disease severity and optimize all treatment components. 1
• Patients with chronic P. aeruginosa infection, ≥3 exacerbations per year, or on long-term antibiotics should be followed in secondary-care services. 1

Critical Pitfalls to Avoid

• Do NOT extrapolate cystic fibrosis treatments to non-CF bronchiectasis—treatment responses are fundamentally different. 1
• Do NOT use recombinant human DNase in non-CF bronchiectasis under any circumstances. 1
• Do NOT prescribe inhaled corticosteroids routinely without comorbid asthma or COPD. 1
• Do NOT use antibiotic courses shorter than 14 days for exacerbations, as this increases treatment failure rates. 1