Management

The principles of management of bronchiectasis are outlined in table 1. There is a great lack of clinical trials in bronchiectasis to guide treatment. These therapeutic choices have been extrapolated from COPD or CF treatment regimes, with variable levels of success. Some small investigator-led randomised controlled trials have been published, but there are insufficient data to recommend definitive therapies based on robust clinical trials. Regular airway clearance is a logical treatment and is supported by some small studies. Airway clearance, undertaken once or twice daily using methods such as the active cycle of breathing technique or a resistance device such as Acapella (Smiths Medical) or Flutter (Axcan Scandipharm Inc.), is a reasonable regimen. Inhaled β2-agonists may be helpful in managing associated airflow obstruction. There is some evidence to support the use of inhaled corticosteroids to reduce sputum volume and possibly the frequency of exacerbations in patients with P. aeruginosa infection. There are strong published data supporting the use of macrolides in CF and oral macrolides may also be of value in reducing exacerbations in non-CF bronchiectasis. Three randomised placebo-controlled trials of macrolide treatment have demonstrated a reduction in pulmonary exacerbations and an improvement in lung function (FEV1). This treatment should be considered in all patients with bronchiectasis who have had two or more exacerbations in the previous year. The use of inhaled antibiotics has been extrapolated from CF data. In individuals in whom chronic P. aeruginosa infection is identified, long-term antibiotics are often used. There are no therapies licensed for use in this condition, but off- label colistin, gentamicin and tobramycin are frequently used. In patients with newly isolated P. aeruginosa, eradication regimes are frequently applied based on experience from CF.

Treatment of pulmonary exacerbations should include increased airway clearance and the commencement of antibiotics. Choice of antibiotic is largely empirical, though previous sputum bacteriology results can be useful in deciding. For the common organisms, such as H. influenzae, Moraxella catarrhalis, Staphylococcus aureus and Streptococcus pneuomoniae, oral antibiotics are usually sufficient. In contrast, for patients chronically infected with P. aeruginosa , combination therapy with an extended- action β-lactam and aminoglycoside is recommended. Surgery has a limited role in the management of bronchiectasis, mainly in localised disease. Occasionally, haemoptysis is sufficiently frequent or severe to warrant treatment by embolisation of the relevant bronchial artery or arteries.

Improving airway clearance Mechanical airway clearance (ACBT, PEP devices, autogenic drainage)
Inhaled hypertonic saline
Inhaled mannitol#
Reducing bronchoconstriction Short- and long-acting β2-agonists
Reducing inflammation Inhaled corticosteroids
Oral azithromycin#
Treating infection Oral antibiotics for exacerbations
Inhaled colistin/aminoglycoside for eradication or long-term suppression
Table 1 – Therapies for bronchiectasis. (Many of these therapies are used but none are approved by European Medicines Agency to support their long-term use in bronchiectasis.) ACBT: active cycle of breathing technique; PEP: positive expiratory pressure. #: recently reported phase 3 clinical trials.

See the entire Bronchiectasis Chapter