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Listen to audio content from CHEST about diagnosing and treating bronchiectasis.
Addressing the 4 drivers of bronchiectasis may help manage its chronic and progressive nature1-3
Goals in the management of bronchiectasis include disrupting the vicious vortex by addressing chronic airway infection, reducing chronic airway inflammation, enhancing mucociliary clearance, and preventing further lung destruction.2-4
Expert commentary: Addressing the vicious vortex of bronchiectasis
Show transcript
It’s important to take a multimodal treatment approach when you’re dealing with a patient with bronchiectasis, because there’s so many factors that are involved. We want to identify the potential etiology, the potential comorbidities to try to reduce the progression of the bronchiectasis. We want to try to reduce inflammation. You know, oftentimes, you know with airway clearance being a mainstay of that management, we want to try to treat infections and, you know, treat exacerbations and try to prevent exacerbations to really try to hinder the vicious vortex and prevent further progression of their bronchiectasis.
You know, we have multiple ways we can treat our patients with bronchiectasis, and if we reflect back on the vicious cycle and the vicious vortex, there are multiple places we can intervene to try to improve our patients’ symptoms and achieve all the objectives that we are trying to achieve. So we ought to be focusing on all the areas of the vortex to be able to optimize the management of our patients. And I know it’s hard to do that, but I think it’s important.
Targeting 1 aspect is not going to break the cycle in most patients, because it’s not just infection, or not just noninfectious inflammation, or not just problems with clearance of secretions. They all feed back on each other. So if you treat the retained mucus with airway clearance but you don’t treat the infection, you’re going to have an incomplete response. And vice versa, if you treat the infection and you don’t treat, say, underlying cause of inflammation, you’re still going to have dysfunction, ongoing inflammation, and all the negative effects of that.
Yeah, and a key part of what you’re describing there is people need to understand this is a chronic condition. This is not like an acute pneumonia and antibiotics, it’s all going to be gone and they’re done. They’re going to have it for the rest of their lives. And so chronic illness requires chronic therapies, and so you need to have some kind of daily regimen to manage that.
Bronchiectasis requires a multimodal treatment plan4,5
All 4 drivers of bronchiectasis should be targeted with a tailored approach to help address the interdependent modalities that may lead to devastating effects like exacerbations and disease progression.4-6
Focusing on 1 disease driver in isolation only affects 1 pathway of the disease and thus may yield only a limited clinical response.4,6
Investigate and treat underlying etiologies
Because bronchiectasis often appears alongside other diseases, patients should be assessed to identify potentially treatable underlying causes and comorbid conditions.7-9
- Airway abnormalities
- Allergic bronchopulmonary aspergillosis
- Aspiration syndromes
- Asthma
- Autoimmune disorders and connective tissue diseases
- Congenital disorders
- COPD
- Immunodeficiencies
- Post-infectious bronchiectasis
Managing the primary drivers of bronchiectasis
- For acute exacerbations, treat with 14 days of antibiotics
- For chronic airway infections, use long-term oral or inhaled antibiotics
- For new growth of Pseudomonas aeruginosa, use intravenous or nebulized antibiotics
- Active cycle of breathing
- Forced expiration (huff)
- Positive-expiratory-pressure (PEP) devices
- Percussion
- High-frequency chest-wall-oscillation (HFCWO) vests
- Pulmonary rehabilitation
It’s important to conduct routine sputum collection to identify pathogens causing infection, with susceptibility testing to guide antibiotic choice based on resistance patterns.2,7
Based on these results, antibiotic treatment for chronic or acute airway infections should be tailored to each patient’s needs2,3,7:
In the US, the common bacteria causing pulmonary infections in bronchiectasis patients include nontuberculous mycobacteria (NTM), Pseudomonas aeruginosa, Staphylococcus aureus, Haemophilus influenzae, and Moraxella catarrhalis. There are also fungal pathogens found in cultures such as Aspergillus species and Scedosporium apiospermum.10
There are limited options to treat chronic airway inflammation in bronchiectasis. The inflammatory response is currently managed with oral or inhaled steroids and macrolide antibiotics.2,3
Because of their immunosuppressive qualities, extended use of steroids may be detrimental to patients with bronchiectasis who are already susceptible to airway infections. Experts studying this disease do not recommend inhaled corticosteroids for treating patients with bronchiectasis in the absence of comorbid COPD or asthma.2,11,12
Impaired mucociliary clearance, which can cause further bacteria colonization, may be treated using airway clearance techniques and mucoactive therapies.2,13
Airway clearance can facilitate more effective sputum clearance to help improve symptoms and long-term outcomes.13 Various airway clearance techniques may lead to fewer respiratory symptoms, greater sputum expectoration, and improved quality of life in patients with bronchiectasis.14
Airway clearance techniques may involve the use of devices and/or breathing exercises, including2,12,13:
If prescribing mucoactive therapies for bronchiectasis, the main groups include expectorants, mucoregulators, mucolytics, and mucokinetics.12
While airway clearance and mucoactive therapies are management options, for some patients they may not be sufficient alone to treat bronchiectasis.2,13,15
Options for addressing the effects of lung destruction may include pulmonary rehabilitation (eg, physical activity or exercise) or surgery.2
We want to hear from you
What kinds of treatments do you most often use as maintenance therapy to manage inflammation in bronchiectasis?
An active management plan is important for your bronchiectasis patients
A comprehensive management approach addressing all 4 primary drivers of bronchiectasis can help target all potentially interdependent aspects of the disease. The objectives of bronchiectasis management are to reduce exacerbations, preserve lung function, and improve the patient’s quality of life.2,4,5
Creating an action plan with your bronchiectasis patients can help them prepare for future exacerbations. That plan may include education about exacerbations and how to appropriately take action.
Resources
Video library
Explore scientific information and expert commentary on a variety of topics about bronchiectasis.
Expert commentary: The impact of exacerbations on patients with bronchiectasis
Show transcript
Exacerbations are important for a lot of reasons. One is because patients feel poorly when they have them, and we would therefore like to try and prevent them, or treat them rapidly when they occur. So, we believe that exacerbations are part of what drives the ongoing inflammation and progression of bronchiectasis.
And a lot of that is why we’re trying to prevent these events, to try and prevent that progression of disease. But something we learned is, we tend to focus on the acute things, like the cough and the sputum production, and we measure things like missed days of work or school; and those are all important. But the other thing is these are systemic events. And even though their symptoms of cough or chest complaints may improve rapidly, we actually now have data that show that their physical functioning takes weeks before they recover. And that’s not unlike any other kind of lung infection. And that’s a factor I think we have to pay attention to.
You know, one of the reasons we want to prevent exacerbations is we know they’re associated with some bad outcomes, worsening quality of life, and, very importantly, disease progression, and even mortality. So we really need to focus on preventing these exacerbations for our patients.
When patients have bronchiectasis exacerbations, it may lead to, you know, frequent outpatient visits, frequent hospitalizations, if not treated appropriately, you know, worsening symptoms, worsening quality of life. Oftentimes, they’re trying to help themselves, right? So it leads to more time consumed at home with medical, you know, using certain medications or certain devices. It’s just very cumbersome for the patient when they’re faced with exacerbations. You want to, you know, try to optimize quality of life as best possible for these patients. You know, you want to prevent any sort of worsening lung function from exacerbations or any sort of, you know, worsening inflammation and worsening bronchiectasis, right? So I think it’s very important to identify these exacerbations and treat it appropriately early.
Helpful links
Airway clearance techniques and their benefits
Explore a publication with examples of airway clearance techniques, mucoactive therapies, and pulmonary rehabilitation in bronchiectasis.
Patient advocacy groups and professional societies
The American Thoracic Society accelerates global innovation in the advancement of respiratory health through multidisciplinary collaboration, education, and advocacy.
The goal of Bronchiectasis and NTM 360 is to address the unmet needs of the bronchiectasis and nontuberculous mycobacterial (NTM) lung disease communities.
Bronchiectasis Info and Research was developed to provide information and support to patients with bronchiectasis by promoting early diagnosis, improved treatments, and research.
Through advocacy, education, and research, the American Lung Association improves the lives of people living with bronchiectasis.
The CHEST Foundation aims to champion lung health through clinical research and patient education.
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