22nd February 2024

Management

Bronchiectasis leads to irreversible damage to the lung parenchyma, so management is predominantly aimed at preventing and slowing further deterioration. Treatment strategies focus on treating the underlying condition and any other coexisting comorbidities. These range from risk factor modification and regular physiotherapy to treating acute exacerbation with antibiotics and, in rare cases, surgical intervention. 

General management

Bronchiectasis patients need to address risk factors such as smoking cessation, engaging in pulmonary rehabilitation and medication adherence. There is evidence that regular exercise reduces exacerbation episodes. Healthy dietary consumption, including sources rich in Vitamin D, is beneficial.  Regular annual immunisations against influenza and pneumococcus have also had a positive impact in reducing hospitalisations. 

Pulmonary rehabilitation

Pulmonary rehabilitation should be offered to individuals with limited exercise tolerance due to shortness of breath (Modified Medical Research Dyspnoea Scale >1). This should incorporate exercises for strengthening and conditioning, dietary advice, and behavioural and psychological therapies. Regular exercise with dietary input ensures muscle strengthening which aids in breathing improvement during exacerbation episodes. Regular gravity-assisted postural drainage are effective techniques in sputum burden relief.

Medical management 

First line antibiotic agents consist of Penicillins such as Amoxicillin (or Doxycycline for Penicillin allergic patients). Sputum samples are an important component of investigations for suspected bronchiectasis with Pseudomonas Aeuruginosa, which is commonly identified as a source of bacterial colonisation. These exacerbation episodes will require a longer duration of intravenous antibiotics (minimum 2 weeks)

For non-Pseudomonas Aeruginosa colonised patients, Macrolides such as Azithromycin / Erythromycin should be considered as first line. Alternatively, Doxycycline can be used for patients allergic to Macrolides. 

Chronic colonisation of Pseudomonas will require broad-spectrum intravenous options such as Piperacillin/Tazobactam. Planned administration of intravenous antibiotics can be considered if more than >5 exacerbation episodes per year despite other treatments. Prophylactic oral antibiotics such as Azithromycin (250mg three times a day) are a pragmatic dose for patients with chronic colonisation. 

References

• Lonni S, Chalmers JD, Goeminne PC, et al. Etiology of Non-Cystic Fibrosis Bronchiectasis in Adults and Its Correlation to Disease Severity. Ann Am Thorac Soc 2015; 12:1764.
• Gibson RL, Burns JL, Ramsey BW. Pathophysiology and management of pulmonary infections in cystic fibrosis. Am J Respir Crit Care Med 2003; 168:918.