Inhaler Management in Bronchiectasis

Indications for Bronchodilators

• Short‑acting bronchodilators (SABA/SAMA) should be administered before airway‑clearance techniques and nebulized therapies to improve pulmonary deposition and prevent bronchoconstriction in patients with bronchiectasis. 1
• Long‑acting bronchodilators (LABA/LAMA) are not recommended routinely for bronchiectasis alone. 2
• Long‑acting bronchodilators may be considered only for individuals with significant breathlessness despite other measures. 3
• In patients who have co‑existing asthma or COPD, standard bronchodilator therapy should be continued as these comorbidities constitute clear indications. 2

Use of Inhaled Corticosteroids (ICS)

• Routine prescription of inhaled corticosteroids for bronchiectasis is not advised. 3
• Continuation of inhaled corticosteroids is appropriate only when the patient has one of the following:
  
  • Asthma
  • COPD that meets treatment criteria
  • Allergic bronchopulmonary aspergillosis (ABPA)
  • Inflammatory bowel disease
• Inhaled corticosteroids carry notable risks in bronchiectasis, including adrenal suppression, pneumonia, pharyngeal irritation, and dysphonia. 1
• Discontinuing inhaled corticosteroids in a patient with documented asthma is contraindicated, even when bronchiectasis is present. 4
• Use of inhaled corticosteroids does not improve exacerbation frequency or lung‑function measures beyond six months and increases adverse events. 2

Nebulized Mucoactive Therapy

• Nebulized isotonic (0.9 %) or hypertonic saline (≥3 %) should be offered to patients who have difficulty expectorating sputum, especially when secretions are viscous or there is sputum plugging. 5
• An airway‑reactivity challenge test must be performed before initiating hyperosmolar agents to identify potential bronchoconstriction. 6
• Pre‑treatment with a bronchodilator is recommended before nebulized saline in patients with severe airflow obstruction (FEV₁ < 1 L) or documented bronchial hyper‑reactivity. 2

Long‑Term Inhaled Antibiotics

• Long‑term inhaled antibiotics are indicated only for patients experiencing ≥3 exacerbations per year after optimal airway‑clearance measures have been instituted. 7

Regimens for Chronic Pseudomonas aeruginosa Infection

• Safety monitoring for inhaled aminoglycosides:
  
  • Avoid if creatinine clearance < 30 mL/min. 7
  • Use with caution in patients with significant hearing loss or vestibular dysfunction. 7
  • Do not combine with other nephrotoxic medications. 7

Recombinant Human DNase

• Routine use of recombinant human DNase in adult bronchiectasis patients is not recommended. 3

Sequencing of Inhaled Therapies

Safety and Monitoring

• Perform a bronchodilator challenge test before starting nebulized hypertonic saline or mannitol to prevent severe bronchoconstriction. 6
• Do not initiate long‑term inhaled antibiotics without first optimizing airway‑clearance strategies. 7
• The threshold for initiating long‑term antibiotics may be lowered (< 3 exacerbations/year) in patients who remain symptomatic between exacerbations, have poor response to standard therapy, or are immunosuppressed. 7

Criteria for Escalating Inhaler Therapy

• ≥3 exacerbations per year despite optimal airway clearance. 7
• Documented chronic Pseudomonas aeruginosa infection. 7
• Viscous secretions unresponsive to standard airway‑clearance techniques. 5
• Co‑existing asthma or COPD that requires standard pharmacologic treatment. 2

Bronchodilator and Inhaled Therapy Recommendations for Non‑CF Bronchiectasis

Indications and Contra‑Indications for Bronchodilators

• Bronchodilators (short‑acting or long‑acting) should be reserved for patients who have clinically significant dyspnea, documented airflow obstruction (FEV₁/FVC < 0.7), or a comorbid diagnosis of asthma or COPD; routine use in all other bronchiectasis patients is not supported by evidence. (European Respiratory Society) 8
• Long‑acting bronchodilators (LABA/LAMA) are not recommended as first‑line therapy for bronchiectasis without symptomatic breathlessness, because no trial data demonstrate benefit in this population. (European Respiratory Society) 8
• Short‑acting bronchodilators should be administered immediately before airway‑clearance techniques or nebulized therapies (e.g., mucoactive agents, inhaled antibiotics) to improve pulmonary deposition and reduce the risk of bronchoconstriction. (European Respiratory Society) 8
• A therapeutic trial of long‑acting bronchodilators is appropriate only in patients with marked dyspnea and chronic airflow obstruction (FEV₁/FVC < 0.7); if no symptomatic improvement is observed after an adequate trial period, the agent should be discontinued. (European Respiratory Society) 8
• Patients who have a coexisting diagnosis of asthma or COPD should continue their established bronchodilator regimen, as these conditions constitute clear indications independent of bronchiectasis. (European Respiratory Society) 8
• Prescribing bronchodilators based solely on spirometric reversibility testing is discouraged because reversibility does not reliably predict clinical benefit in bronchiectasis. (European Respiratory Society) 8

Evidence Strength for Bronchodilator Use

• The overall evidence supporting bronchodilator efficacy in non‑CF bronchiectasis is weak; only one small, methodologically limited trial and no long‑term observational studies have shown benefit, indicating low‑quality evidence. (European Respiratory Society) 8

Recommended Sequencing of Multiple Inhaled Therapies

The above order is endorsed by the European Respiratory Society.* 8

Contra‑Indicated Inhaled Therapy

• Recombinant human DNase (dornase alfa) should never be used in non‑CF bronchiectasis, as randomized data demonstrate worsening of clinical outcomes. (Chest) 9