bronchiectasis
BRONCHIECTASIS
Bronchiectasis is an irreversible pathologic dilatation or ectasia of the bronchi due to repeated airway infection and inflammation.
It enhances susceptibility to bronchial infection and increases inflammatory reaction which causes further lung damage.
Classic symptoms of of bronchiectasis are cough with chronic sputum production along with recurring infective exacerbations and hemoptysis.

Principles of Therapy

Goals of Treatment
  • Minimize both resp & generalized symptoms; maintain good quality of life
  • Reduce frequency & severity of acute exacerbations
  • Limit disease progression
  • Avoid or minimize adverse effects of treatment
  • Recognizing acute exacerbation generally depends upon symptomatic changes rather than any specific lab result
  • Identification of acute exacerbation may be difficult since the onset may be gradual w/ sputum volume increasing slowly over mth

Pharmacotherapy

Treatment of Acute Exacerbations
Antibiotics
  • One of the mainstays of treatment for bronchiectasis used to break the cycle of bacterial infection that leads to inflammation & further lung injury
  • Appropriate therapy for the treatment of exacerbations & chronic active disease
  • Most patients have chronic colonization of organisms which is the basis for empiric choice of antibiotic
  • Amoxicillin
    • First-line treatment for patients w/o previous bacteriological exams
    • Higher doses may be used for patients w/ H influenzae colonization
  • Quinolones
    • Eg Ciprofloxacin, Levofloxacin
    • May be used in patients w/ suspected Pseudomonas aeruginosa colonization
    • Reasonable therapeutic option for oral administration in ambulatory patients
  • Some authorities may choose empiric antibiotic therapy based on clinical parameters
    • FEV1/FVC of <60% & daily sputum >20 mL are independently associated w/ the presence of P aeruginosa
    • Patients w/ little sputum & good lung function may only require non-pseudomonal antibiotics
    • Suspected non-pseudomonal acute exacerbation: Consider treatment w/ IV cephalosporin, Amoxicillin/clavulanic acid or oral macrolides (Clarithromycin)
    • Suspected pseudomonal acute exacerbation: Consider treatment w/ Ciprofloxacin (1st-line), Ceftazidime, antipseudomonal Penicillins (Piperacillin/Tazobactam, Aztreonam, Meropenem), Colistin, or IV aminoglycoside (Gentamicin, Tobramycin)
    • Methicillin-sensitive Staph aureus exacerbation: Flucloxacillin, Clarithromycin
    • Methicillin-resistant Staph aureus exacerbation: oral Rifampicin + Trimethoprim, oral Rifampicin + Doxycycline, Vancomycin, or Linezolid
  • Duration of therapy is not well defined, but a minimum of 7-10 days has become a frequent practice
  • Sputum culture & sensitivity are indicated in patients who fail to respond to the initial antibiotic to help define antibiotic selection
Other Treatments
Bronchodilators
  • Beta2-agonists may be theoretically beneficial in bronchiectasis since they increase ciliary beat frequency in vitro
  • Administration prior to chest physiotherapy may help produce more sputum during clearance, & may help increase expiratory flow rates
Anti-Inflammatory Agents
  • Corticosteroids (Inhaled)
    • Use is controversial & may not be recommended by some authorities
    • May be beneficial since inflammation & neutrophilic mediator release play a major role in bronchiectasis
    • Small short-term studies suggest that regular use of inhaled corticosteroids may improve lung function & indices but not symptoms
    • Beclomethasone: Small short-term study showed that cough & sputum production may be reduced, & improvement in FEV1 & peak flow rates may occur
    • Fluticasone: Pilot study showed reduced sputum neutrophils & inflammatory cytokines
  • Corticosteroids (Nasal)
    • If present, allergic nasal symptoms may be controlled w/ topical corticosteroids
  • Corticosteroids (Systemic)
    • Not generally recommended
    • Systemic steroids can further depress host immunity, promote increased bacterial & fungal colonization, & perpetuate infection
Suppressive Antibiotic Therapies
  • It is thought that some organisms (eg P aeruginosa & H influenzae) stimulate neutrophilic & inflammatory mediator response in the airways
  • Bacterial pathogens are thought to have an active destructive role, therefore suppressive antibiotic therapies have been used in bronchiectasis patients
Intermittent IV Antibiotics
  • Some authorities recommend intermittent IV antibiotics for patients who have copious sputum production (>60 mL/day) when at steady state &/or who have frequent exacerbations (>6 episodes/yr)
  • May also be considered in preparation for major surgery including resection of a bronchiectatic region of lung & other procedures when pulmonary function may be compromised
  • Patients are hospitalized for 2-3 wk of antibiotics every 2-3 mth
    • IV Ceftazidime, Amoxicillin/clavulanic acid & quinolones have been used
    • Chest physiotherapy is administered & rest is encouraged
  • Some authorities have suggested that the intermittent IV antibiotics may decrease the cumulative hospitalizations frequency & the need for antibiotic therapy in the medium term
Aerosolized Antibiotics
  • May be considered in patients where bronchiectasis is due to CF
  • Tobramycin or Colistin may improve sputum volume, purulence & exacerbation frequency, sputum P aeruginosa & myeloperoxidase levels & general well-being
    • A dose of Tobramycin 300 mg inhaled 12 hrly via nebulizer is used in childn >6 yr & adults x 28 days on, followed by 28 days off for CF patients; this dose has been used in bronchiectasis patients
    • Colistin 0.5-1 MIU in childn <2 yr & 1-2 MIU in adults & childn >2 yr inhaled 12 hrly is used in CF patients
  • Inhaled Ceftazidime + Tobramycin given over 12 mth improves hospitalization frequency & duration but not lung function or antibiotic usage
  • Gentamicin is a treatment option in patients w/ Pseudomonas aeruginosa colonization
Low-Dose Macrolides
  • Long-term administration of low-dose Erythromycin can reduce sputum production in patients w/ bronchiectasis due to diffuse panbronchiolitis
  • May be given to patients w/ persistently copious sputum & frequent exacerbations despite inhaled corticosteroid therapy & at least 3 elective admissions for IV antibiotic therapy
  • Erythromycin inhibits resp mucous secretion by decreasing pulmonary macrophage mucous secretagogue production
    • Also reduces P aeruginosa exotoxin production which slows human resp ciliary beat in vitro & decreases P aeruginosa adherence to damaged airway in vitro
  • Low-dose macrolide therapy may be continued for 1-2 yr before stopping if there is clear clinical improvement, & withdrawn if no improvement after 3-4 mth of therapy

Non-Pharmacological Therapy

Bronchopulmonary Hygiene
  • One of the mainstays in the treatment of bronchiectasis; w/ unknown long-term effectiveness
  • Aid in removing secretions from the lower airway in patients w/ mucus hypersecretion & problems w/ expectoration
  • Systemic hydration enhanced by nebulization w/ saline remains a necessity in patients w/ mucous plugging & viscous secretions
  • Mucolytics (eg Acetylcysteine) alters characteristic of sputum & may aid expectoration of secretions
  • Mechanical Procedures
    • Consistent benefits are lacking from these techniques & will vary based on patient motivation & knowledge
    • Eg postural drainage w/ percussion & vibration, incentive spirometry, flutter & percussive ventilation devices
Chest Physiotherapy
  • Patients should learn different airway clearance techniques & exercises
    • Referral to a chest physiotherapist for a more tailored technique is recommended
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