Management of Bronchiectasis in Adults

Introduction to Management

• The European Respiratory Society recommends comprehensive management of bronchiectasis, including airway clearance techniques, pulmonary rehabilitation, appropriate antibiotic therapy for exacerbations, and consideration of long-term antibiotics for patients with frequent exacerbations, with treatment tailored to specific pathogens identified in sputum cultures 1, 2

Diagnostic Evaluation

• High-resolution CT (HRCT) scanning is the gold standard for diagnosing bronchiectasis, confirming permanent bronchial dilatation, as recommended by the European Respiratory Society 3
• Initial diagnostic workup should include differential blood count, serum immunoglobulins, testing for allergic bronchopulmonary aspergillosis, and sputum culture for bacteria, mycobacteria, and fungi, according to the European Respiratory Society guidelines 3

Management of Acute Exacerbations

• The European Respiratory Society recommends treating exacerbations with 14 days of antibiotics, with selection based on previous sputum culture results, and consideration of intravenous antibiotics for severe exacerbations or treatment failures 2

Airway Clearance Techniques

• The European Respiratory Society recommends that all patients with chronic productive cough or difficulty expectorating sputum should be taught airway clearance techniques by a trained respiratory physiotherapist, with techniques including active cycle of breathing, postural drainage, and manual or mechanical devices, and sessions lasting 10-30 minutes, once or twice daily 4, 5

Pulmonary Rehabilitation

• The European Respiratory Society strongly recommends pulmonary rehabilitation for patients with impaired exercise capacity, which provides improved exercise capacity, reduced cough symptoms, enhanced quality of life, and decreased frequency of exacerbations 4, 5

Mucoactive Treatments

• The European Respiratory Society recommends considering long-term mucoactive treatment for patients with difficulty expectorating sputum, poor quality of life, or failure of standard airway clearance techniques, and advises against using recombinant human DNase in non-CF bronchiectasis 6

Long-term Antibiotic Therapy

• The European Respiratory Society recommends considering long-term antibiotics for patients with ≥3 exacerbations per year, with first-line treatment including long-term inhaled antibiotics for patients with chronic Pseudomonas aeruginosa infection, and macrolides for patients without Pseudomonas aeruginosa infection 7

Bronchodilator Therapy

• The European Respiratory Society does not routinely recommend bronchodilator therapy for all patients with bronchiectasis, but suggests considering long-acting bronchodilators for patients with significant breathlessness on an individual basis 4, 5

Anti-inflammatory Treatments

• The European Respiratory Society advises against routinely offering inhaled corticosteroids unless comorbid asthma or COPD is present, and against offering long-term oral corticosteroids 2

Surgical Intervention

• The European Respiratory Society does not routinely recommend surgical intervention for most patients with bronchiectasis, but suggests considering it for patients with localized disease and high exacerbation frequency despite optimization of all other aspects of bronchiectasis management 4, 5

Monitoring and Follow-up

• The European Respiratory Society recommends regular monitoring of sputum pathogens, especially when using long-term antibiotics, and monitoring for drug toxicity, particularly with macrolides and inhaled aminoglycosides, as well as annual assessment by respiratory physiotherapist to optimize airway clearance regimen 2, 6