Management

Management should be shared between a respiratory physician and primary care practitioners.

Requires an explanation of condition and aetiological factors to the patient.

The management of bronchiectasis may include encouraging smoking cessation, vaccination against influenza (annually) and pneumococcus, physiotherapy, antibacterial therapy, surgery, oxygen, ventilation and rehabilitation.

Treatment:

• physiotherapy which includes airway clearance techniques and exercise
  • postural drainage or gravity-assisted positioning (where not contraindicated) to enhance the effectiveness of an airway clearance technique
    • patients are encouraged to 'tip' for at least 10 minutes three times a day
    • required for a week or two after an upper respiratory tract infection in milder cases
    • may be employed indefinitely in severe cases
  • simple airway clearance techniques like active cycle of breathing techniques and oscillating positive expiratory devices – used in non-cystic fibrosis-related bronchiectasis
  • sterile water inhalation and nebulisation of normal saline or beta 2 agonists may be used to enhance the effectiveness of airway clearance techniques
  • effectiveness and acceptability of airway clearance techniques should be reviewed by a respiratory therapist after 3 months (1)
  • exercise - for people with limitations in daily activities due to breathlessness
• airway drug therapy
  • recombinant human DNase should not be used (in adults or in children) routinely
  • beta 2 agonists and anticholinergic bronchodilators could be considered on individual basis
  • inhaled steroids should not be routinely used in children or in adults (unless they have other indications e.g. asthma, COPD, inflammatory bowel disease) (1)
• antibiotics:
  • consider long-term antibiotics in patients who experience three or more exacerbations per year
  • antimicrobial stewardship is important
• inhaled and oral steroids:
  • are essential in bronchopulmonary aspergillosis
  • are useful in other cases of bronchiectasis to reduce sputum volume
  • oral steroids
    • are sometimes given with antibacterial therapy to help decrease inflammation
    • if required for longer than 2 weeks, the dose is tapered according to resolution of symptoms
      
• surgery:
  • resection is potentially curative for localised bronchiectasis, but should only be considered in the few patients who have failed to respond to optimal medical management, or when symptoms are severe (e.g. massive haemoptysis or lung abscess), and then only if the patient has no evidence of the underlying conditions typically associated with more generalised bronchiectasis (3)
  • an alternative approach (to resection) is bronchial artery embolisation in patients with haemoptysis, particularly in those not fit for open surgery.

Reference:

1. Hill AT, Sullivan AL, Chalmers JD, et al British Thoracic Society guideline for bronchiectasis in adults. BMJ Open Respiratory Research 2018;5:e000348. doi: 10.1136/bmjresp-2018-000348
2. Bott J et al. Guidelines for the physiotherapy management of the adult, medical, spontaneously breathing patient. Thorax. 2009;64 Suppl 1:i1-51
3. Pasteur MC et al. British Thoracic Society guideline for non-CF bronchiectasis. Thorax. 2010;65 Suppl 1:i1-58