Medications for Bronchiectasis
When well, many patients do not require specific medications for bronchiectasis and may be maintained with an exercise and airway clearance regimen.
The following medications may be indicated:
Antibiotics are central to the management of bronchiectasis. The selection of the initial antibiotic approach should be driven by symptoms, symptom escalation, the presence of mucopurulent sputum and the availability of lower airway culture results from sputum (or where available or occasionally necessary, bronchoscopic sampling). Selection should be guided by previous antibiotic responses, allergy, drug tolerability, antibiotic susceptibility patterns and clinical severity.
Antibiotics (oral, intravenous or nebulised) can be used in three situations:
To attempt eradication of new airway isolates
To treat exacerbations
As a long term maintenance for suppression of chronic colinisation
The use of inhaled antibiotics is challenged by a poor evidence base. The addition of inhaled tobramycin to ciprofloxacin for the treatment of acute exacerbations of Pseudomonas Aeruginosa colonised bronchiectasis as an example revealed a superior microbiological response but no clinical superiority at 21 days when compared with ciprofloxacin and placebo and so further patient numbers may be required to confirm benefit (Bilton 2006).
A medium sized randomised trial of nebulised Colistin for acute exacerbations in Pseudomonas Aeruginosa colonised bronchiectasis has also failed to achieve the primary outcome of time to first exacerbation, although encouragingly there was benefit in those in whom a high level of treatment adherence was observed (Haworth 2014).
Through these trials we see a diversity of responses and outcomes that preclude population based treatment recommendations. There are however opportunities for interventions for the individual which should be carefully considered on a case by case basis with close monitoring of clinical effect. The selection of treatments will be based on clinical phenotype based on features including lung function, bronchodilator responsiveness, symptoms, exacerbation frequency and microbial colonisation.
The challenges in managing Pseudomonas Aeruginosa are described in the following review article (Wilson et al 2016) Challenges in managing Pseudomonas Aeruginosa
Eradication of new isolates. The isolation of haemophilus, Strep. pneumoniae, Staph aureus (not MRSA) and in some cases, new isolates of Pseudomonas aeruginosa should prompt an appropriate trial of antibiotics with eradicative intent.
Maintenance suppression of persisting microbial colonists. Once established in the airway long term colonists may be difficult to eradicate. A therapeutic trial of pathogen-targeted inhaled antibiotics (Tobramycin / Colistin) may be considered in those with established Pseudomonas aeruginosa colonisation and frequent exacerbation. See Correct use of Medications for the administration of antibiotics via a nebuliser.
Maintenance suppression of recurrent exacerbations. Long-term oral antibiotics should not be prescribed routinely. Azithromycin has been shown to have some immunomodulatory impacts on airway function in Pseudomonas colonised individuals. Some patients see sustained reduction in sputum production and reduction in exacerbation frequency. Macrolides (or other antibiotics) may be considered for a therapeutic trial over a limited period (eg, up to 12–24 months) in selected patients (eg, those with frequent exacerbations
Antibiotic use – mild to moderate exacerbation
Antibiotic use – severe exacerbation
Before commencing macrolide antibiotics it is appropriate to:
seek respiratory/infectious diseases specialist advice;
ensure non-tuberculous mycobacteria infection is excluded
perform ECG in adults for assessment of QT interval corrected for heart rate (macrolide induced QT prolongation).
Antibiotic strategies in bronchiectasis
Outpatient management of exacerbation. Oral antibiotics are prescribed for 10-14 days based on available airway microbiology results. Close follow-up to assess treatment response is necessary.
Inpatient management of exacerbation. Failure to respond to oral antibiotics, severe exacerbation or occasionally for relentless slow increase in symptoms or fall in lung function, may prompt admission (in-patient or hospital in the home) for intensified IV antibiotic therapy.
Agents which affect mucus flow include isotonic saline (0.9%), hypertonic saline (6%-7%) and mannitol, are currently not recommended for routine use in people with bronchiectasis. Patients who experience difficulty with sputum clearance or those having frequent exacerbations may benefit from a therapeutic trial.
Recombinant human deoxyribonuclease, used frequently in people with cystic fibrosis (CF), is contraindicated in non-CF bronchiectasis.
While bronchiectasis in CF and non-CF patients shares some similarities there are also significant differences. Some of these differences appear counterintuitive and so the simple grandfathering of treatments from the CF evidence base to non-CF bronchiectasis is inappropriate and may be potentially harmful.
Dornase, the recombinant DNase as an example has been evaluated in two trials showing no benefit in one trial and a worsening in FEV1 and increase in exacerbation frequency in the other in Dornase treated subjects (O’Donnell 1998, Wills 1996). In contrast, case reports however have suggested some benefit for Dornase treatment in primary ciliary dyskinesia (Desai 1995, El-Abiad 2007).
Inhaled bronchodilators should not be prescribed routinely but used only on an individual basis if significant reversibility has been identified. In vitro studies suggest salbutamol may have a positive impact on mucociliary function and ongoing use will be guided by patient benefit.
Inhaled and oral corticosteroids should not be prescribed routinely unless there is an established diagnosis of coexisting asthma or COPD. Indeed steroids may have a negative impact on local immune responses and frequently the challenge lies in trying to wean inhaled steroids from patients on steroid therapy prior to confirmation of a diagnosis of bronchiectasis.