BMJ  2007;335:1089-1093 (24 November), doi:10.1136/bmj.39384.657118.80

Clinical Review

Treatment of bronchiectasis in adults

Pulmonary Department, University Medical Centre Groningen, University of Groningen, Postbox 30001, 9700 RB Groningen, Netherlands

Summary points Bronchiectasis refers to abnormal bronchial dilatation caused by a vicious cycle of transmural infection and inflammation Symptoms include chronic productive cough, wheeze, and dyspnoea; repeated respiratory infections may dominate the clinical picture Diagnosis is based on daily production of mucopurulent phlegm and dilated and thickened airways on computed tomography Diagnosis should lead to investigation and treatment of possible causes and associated conditions Acute exacerbations should be treated promptly with short courses of antibiotics Frequent exacerbations may be treated with prolonged and aerosolised antibiotics The role of mucolytics, anti-inflammatory agents, and bronchodilators is not clear Surgery is a possibility if the area of bronchiectasis is localised and symptoms are debilitating or life threatening

Patients with bronchiectasis usually need lifelong medical support from their doctor, especially given the frequent episodes of infection. This article focuses on the treatment of bronchiectasis in adults and does not include a discussion of bronchiectasis caused by cystic fibrosis. The prevalence of bronchiectasis not linked to cystic fibrosis is unclear, but every general practitioner in the United Kingdom probably has a few patients.

How do we diagnose bronchiectasis?

Bronchiectasis refers to the permanent abnormal dilatation of the central and medium sized bronchi as a result of a vicious cycle of transmural infection and inflammation with mediator release.¹ Symptoms include chronic productive cough, wheeze, and dyspnoea. Infective exacerbations are associated with worsening of symptoms and signs of pneumonia. Haemoptysis can occur, but amounts of blood are usually small, and serious haemoptysis requiring selective arteriography and embolisation or surgery is rare.

The most frequently used classification system distinguishes between cylindrical, varicose, and saccular or cystic bronchiectasis.^w1 Although insightful, this classification has no clinical or therapeutic uses. A modern clinical definition includes the daily production of mucopurulent phlegm and chest imaging that demonstrates dilated and thickened airways.^w2 The clinical suspicion of bronchiectasis can be confirmed by high resolution computed tomography. Characteristic findings include internal bronchial diameters greater than that of the adjacent pulmonary artery, lack of bronchial tapering, presence of bronchi within 1 cm of the costal pleura, presence of bronchi abutting the mediastinal pleura, and bronchial wall thickening.^w3

A diagnosis of bronchiectasis should prompt an investigation of possible causes and associated conditions (table 1), some of which can be treated.² Extrinsic factors, particularly childhood respiratory infections, were an important cause of permanent bronchial damage in the past. These days, especially in Western countries with early immunisation and widespread use of antibiotics, post-infectious damage is a less prominent cause of the disease, and intrinsic defects are more common causes. A study of 150 adults with bronchiectasis in the UK found that 53% of cases were idiopathic; 29% were post-infectious; 8% were caused by an immune defect, 7% by allergic bronchopulmonary aspergillosis, 4% by aspiration, 3% by Young's syndrome, 3% by cystic fibrosis, 3% by rheumatoid arthritis, 1.5% by ciliary dysfunction, and <1% by miscellaneous causes.³

How is it treated?

Bronchiectasis can be treated by pharmacological and non-pharmacological means (tables 2 and 3).^w4 The box shows an arbitrary step-up scheme that takes into account the level of evidence and safety risks.

Suggested step-up scheme for treating bronchiectasis Step 1: Inhaled fluticasone (500 µg twice daily) Step 2: Physical therapy including exercise training Step 3: Prolonged use of oral antibiotics. The choice of antibiotic should depend on sputum culture results, with a preference for clarithromycin

Antibiotics
Antibiotics are used to treat acute exacerbations, to prevent exacerbations, or to reduce the bacterial burden. In general, the outcome of treatment with antibiotics depends on the severity of the disease. In mild to moderate bronchiectasis the infection can be completely eradicated, whereas in severe disease the bronchial tree remains chronically colonised. Antibiotics with a high penetrance (macrolides, azalides, and quinolones) are recommended in severe cases because high concentrations of bacteria are located intraluminally in association with mucus, and because thickening and scarring of the bronchial wall may reduce local bioavailability. Pseudomonas aeruginosa is inherently resistant to most antibiotics at concentrations that are achieved in vivo. The organism is susceptible to (oral) quinolones,² but after one or two courses resistance may develop. Patients who are clinically unwell or do not respond to oral antibiotics should be admitted to hospital and given intravenous antibiotics.

Patients who relapse quickly might need prophylactic antibiotics. Three strategies have been described—a high oral dose for a prolonged period (at least four weeks), aerosolised antibiotics (for example, during alternate months), or regular pulsed courses of intravenous antibiotics (for example, two to three week courses with one or two months in between). Prolonged use of oral antibiotics for purulent bronchiectasis was investigated in a recent meta-analysis. It identified six trials that included 302 patients.⁵ The results of five studies were positive in terms of parameters pertaining to sputum, such as volume or purulence. However, no positive effects were seen on rates of exacerbation, lung function, or death. This contradicts the findings of a recent controlled study that investigated 500 mg of azithromycin given twice a week for six months in 30 patients.⁶ Pulmonary function tests did not change, but azithromycin significantly decreased the incidence of exacerbations compared with usual care (5 v 16). Inhalation of nebulised antibiotics might be a better route of administration because of its favourable benefit-risk ratio. Gentamicin 40 mg inhaled twice daily for three days improved sputum production, sputum neutrophil activity, airway obstruction, exercise capacity, and nocturnal desaturation compared with placebo.⁷ Tobramycin 300 mg inhaled twice daily for four weeks eradicated P auruginosa in 35% of patients and improved the medical condition of 62%.⁸ Ceftazidime 1 g and tobramycin 100 mg inhaled twice daily over 12 months decreased the number of hospital admissions and inpatient days.⁹

Flu vaccinations reduced the number of flu related exacerbations in chronic obstructive pulmonary disease,^w5 so vaccination might have a beneficial effect in bronchiectasis. However, randomised controlled trials of vaccination in patients with bronchiectasis are lacking.

Mucolytics
Mucolytics target hypersecretion or the physiochemical characteristics of sputum seen in bronchiectasis. They aim to improve tracheobronchial clearance. In one study, oral bromhexine (30 mg three times daily) was added to an antibiotic during acute infective exacerbations. It improved expectoration, the quantity and quality of sputum, and auscultatory findings.¹⁰ In another study, nebulised recombinant human DNase I (2.5 mg once or twice a day for two weeks) was given to patients with stable bronchiectasis. The study found no improvements in spirometry, quality of life, dyspnoea, safety, or ciliary transportability of the sputum.¹¹ In a large placebo controlled study, 349 patients with idiopathic bronchiectasis in a stable condition inhaled 2.5 mg recombinant human DNase I for 24 weeks. Pulmonary exacerbations were more frequent and the decline in FEV₁ (forced expiratory volume in one second) was greater in patients who received DNase than in controls. These results contrast greatly with the positive effects of this drug in cystic fibrosis.¹²

Inhaled mannitol may improve impaired mucociliary clearance by inducing an influx of fluid into the airways, and thereby changing the mucous rheology. One study found that mucociliary clearance was doubled in the central and intermediate lung regions of 11 patients with bronchiectasis directly after inhaling 300 mg mannitol.^w6 A follow-up study showed that these effects lasted for at least 24 hours.^w7 Inhalation of 400 mg mannitol once daily for 12 days improved the tenacity and hydration of sputum, as well as health status.^w8 Mannitol is therefore a promising new drug, especially as it is easier and more hygienic to inhale a dry powder than to use a nebuliser. Large randomised controlled studies are needed, however, to establish its efficacy and tolerability during long term administration.¹³

Anti-inflammatory agents
Inhaled corticosteroids may reduce inflammation and improve airway obstruction, as they do in asthma. To date, three randomised controlled studies have investigated this hypothesis.^w9-w11 Inhaled fluticasone decreased the density of leucocytes and concentrations of the inflammatory mediators interleukin 1β, interleukin 8, and leukotriene B4 in sputum.^w11 However, a systematic review found no significant improvements in lung function.¹⁴ Recently, a large study was published in which 86 patients inhaled fluticasone 500 µg twice daily or placebo for 12 months.¹⁵ Twenty four hour sputum volume improved significantly in patients treated with fluticasone, but no change was seen in the frequency of exacerbations, the purulence of sputum, or lung function. Systemic corticosteroids may be better at penetrating the bronchial wall and therefore be more effective, but data from randomised controlled trials are available only for bronchiectasis associated with cystic fibrosis.¹⁶

Leukotriene receptor antagonists are a new class of drugs that is effective in the treatment of asthma. These drugs may be of benefit in bronchiectasis because they inhibit neutrophil mediated inflammation. To date, no randomised controlled trials of these agents have been published, however.¹⁷

Non-steroidal anti-inflammatory drugs may also be of use because they inhibit neutrophil function and the release of neutrophil elastase. In a non-controlled open study, eight patients with stable bronchiectasis received 25 mg oral indometacin three times daily for four weeks.^w12 Indometacin had a pronounced effect on two of the three neutrophil functions studied—neutrophil chemotaxis and fibronectin degradation were inhibited by more than 50%. However, lung inflammation, sputum volume, and sputum quality did not change. Interestingly, high dose ibuprofen taken consistently for four years significantly slowed the progression of lung disease in patients with cystic fibrosis.^w13 Ibuprofen has not yet been investigated in non-cystic fibrosis bronchiectasis.

Macrolides suppress inflammation—independent of their antimicrobial actions—in airway diseases like asthma, chronic obstructive pulmonary disease, cystic fibrosis, and diffuse panbronchiolitis. Indeed, macrolides improved clinical status and lung function in a few small studies of bronchiectasis.^w14-w18 In addition, a randomised placebo controlled trial in children showed that three months of treatment with clarithromycin decreased the total number of leucocytes, proportion of neutrophils, and the concentration of interleukin 8 in bronchoalveolar lavage fluid.^w18 Because bacterial growth was not eliminated the authors suggested that direct anti-inflammatory effects of clarithromycin were responsible. This contradicts a randomised placebo controlled study in adults, however, which showed that eight weeks of low dose erythromycin did not reduce the number of leucocytes or the concentrations of interleukin 1, interleukin 8, tumour necrosis factor , or leukotriene B4 in sputum.^w15

Bronchodilators
The mechanisms of expiratory airflow obstruction in non-cystic fibrosis bronchiectasis are not clear, but may include excessive production of mucus, distortion of the bronchial wall, and constriction of smooth muscle. Increased bronchial hyper-reactivity and some reversibility of the airflow obstruction with an inhaled bronchodilator are common. As bronchiectasis may coexist with asthma or chronic obstructive pulmonary disease, some studies have a high degree of uncertainty as to whether airway obstruction is due to asthma, chronic obstructive pulmonary disease, or bronchiectasis (or a combination). Nevertheless, as many patients show signs of airway obstruction and hyper-responsiveness, they often receive bronchodilators.

One small Malaysian study gives some information about the reversibility of airway obstruction in bronchiectasis. It included 24 patients with confirmed bronchiectasis but no signs of an acute exacerbation. The study compared 400 µg fenoterol, followed by 5 mg fenoterol 30 minutes later, with 40 µg ipratropium, followed by 500 µg ipratropium.^w19 FEV₁ increased more than 15% in response to one or both bronchodilators in 11 patients—five responded to both, three to fenoterol alone, and three to ipratropium alone. This small study suggests a significant response to bronchodilators in a subset of patients.

Cochrane reviews found no randomised controlled trials on short acting β2 adrenergic agonists,¹⁸ long acting β2 adrenergic agonists,¹⁹ anticholinergic therapy,²⁰ or oral methylxanthines²¹ in patients with non-cystic fibrosis bronchiectasis. Good quality studies are therefore urgently needed in this field.

Bronchopulmonary hygiene physical therapy
Bronchopulmonary hygiene physical therapy is a form of chest physical therapy that aims to remove lung secretions in patients with acute and chronic airway diseases. Many active and passive techniques are available (table 2), and the technique chosen varies between institutes and physical therapists.^{w20 w21} The evidence in support of these techniques is variable and the literature is conflicting.^w20 Two systematic reviews found insufficient evidence to support or refute this form of therapy.^{22 23}

Exercise training
The role of pulmonary rehabilitation and inspiratory muscle training has been investigated in only one randomised controlled trial. It compared an eight week training programme of pulmonary rehabilitation alone, pulmonary rehabilitation plus inspiratory muscle training, and a control group.^w22 The authors concluded that pulmonary rehabilitation does improve exercise tolerance. Simultaneous inspiratory muscle training offered no additional benefit.

Surgery
If the area of bronchiectasis is localised and the patient's symptoms are debilitating or life threatening, surgical resection has long been thought to be of benefit. This assumption was based on several non-randomised controlled studies of uncertain value. A Cochrane review updated in 2002 found no randomised clinical trials—just case series or case-control studies.²⁴ The largest case-control study included pneumonectomy in 190 cases, lobectomy in 202 cases, bilobectomy in 23 cases, and lobectomy combined with segmental resection in 72 cases.²⁵ Overall mortality was 3.5%, and 71% of patients had no symptoms during follow-up (four months to 10 years). The authors therefore concluded that surgery was preferable to conventional medical treatment.

Conclusion

The general consensus is that acute exacerbations should be treated promptly with short courses of systemic antibiotics. In stable bronchiectasis, a high level of evidence exists for the use of prolonged and aerosolised antibiotics, but this form of treatment is mostly reserved for patients with frequent exacerbations. Because of the low level of evidence we cannot recommend the use of mucolytics, anti-inflammatory agents, or bronchopulmonary hygiene therapy on a routine basis. Surgery may be considered if the area of bronchiectasis is localised and the patient's symptoms are debilitating or life threatening. Well powered studies to investigate the effects of well defined treatment regimens on important short and long term outcomes of bronchiectasis are urgently needed.

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Web references w1-w22 are on bmj.com

Contributors: NHTtH selected the literature and wrote all versions of the article. HAMK and PJW commented on the various drafts of the manuscript. All authors discussed the grading the levels of evidence and recommendations. NHTtH is guarantor.

Competing interests: None declared.

Provenance and peer review: Commissioned; externally peer reviewed.

References

1. Cole PJ. Inflammation: a two-edged sword—the model of bronchiectasis. Eur J Respir Dis Suppl 1986;147:6-15.[Medline]
2. Wilson R. Bronchiectasis. In: Niederman MS, Sarosi GA, Glassroth J, eds. Respiratory infections. Philadelphia: Lippincott Williams and Wilkins, 2001:347-59.
3. Pasteur MC, Helliwell SM, Houghton SJ, Webb SC, Foweraker JE, Coulden RA, et al. An investigation into causative factors in patients with bronchiectasis. Am J Respir Crit Care Med 2000;162:1277-84.[Abstract/Free Full Text]
4. Harbour R, Miller J. A new system for grading recommendations in evidence based guidelines. BMJ 2001;323:334-6.[Free Full Text]
5. Evans DJ, Bara AI, Greenstone M. Prolonged antibiotics for purulent bronchiectasis. Cochrane Database Syst Rev 2003;(4):CD001392.
6. Cymbala AA, Edmonds LC, Bauer MA, Jederlinic PJ, May JJ, Victory JM, et al. The disease-modifying effects of twice-weekly oral azithromycin in patients with bronchiectasis. Treat Respir Med 2005;4:117-22.[CrossRef][Medline]
7. Lin HC, Cheng HF, Wang CH, Liu CY, Yu CT, Kuo HP. Inhaled gentamicin reduces airway neutrophil activity and mucus secretion in bronchiectasis. Am J Respir Crit Care Med 1997;155:2024-9.[Abstract]
8. Barker AF, Couch L, Fiel SB, Gotfried MH, Ilowite J, Meyer KC, et al. Tobramycin solution for inhalation reduces sputum Pseudomonas aeruginosa density in bronchiectasis. Am J Respir Crit Care Med 2000;162:481-5.[Abstract/Free Full Text]
9. Orriols R, Roig J, Ferrer J, Sampol G, Rosell A, Ferrer A, et al. Inhaled antibiotic therapy in non-cystic fibrosis patients with bronchiectasis and chronic bronchial infection by Pseudomonas aeruginosa. Respir Med 1999;93:476-80.[CrossRef][ISI][Medline]
10. Olivieri D, Ciaccia A, Marangio E, Marsico S, Todisco T, Del Vita M. Role of bromhexine in exacerbations of bronchiectasis. Double-blind randomized multicenter study versus placebo. Respiration 1991;58:117-21.[ISI][Medline]
11. Wills PJ, Wodehouse T, Corkery K, Mallon K, Wilson R, Cole PJ. Short-term recombinant human DNase in bronchiectasis. Effect on clinical state and in vitro sputum transportability. Am J Respir Crit Care Med 1996;154:413-7.[Abstract]
12. O'Donnell AE, Barker AF, Ilowite JS, Fick RB. Treatment of idiopathic bronchiectasis with aerosolized recombinant human DNase I. rhDNase Study Group. Chest 1998;113:1329-34.[ISI][Medline]
13. Wills P, Greenstone M. Inhaled hyperosmolar agents for bronchiectasis. Cochrane Database Syst Rev 2002;(1):CD002996.
14. Kolbe J, Wells A, Ram FS. Inhaled steroids for bronchiectasis. Cochrane Database Syst Rev 2000;(2):CD000996.
15. Tsang KW, Tan KC, Ho PL, Ooi GC, Ho JC, Mak J, et al. Inhaled fluticasone in bronchiectasis: a 12 month study. Thorax 2005;60:239-43.[Abstract/Free Full Text]
16. Lasserson T, Holt K, Greenstone M. Oral steroids for bronchiectasis (stable and acute exacerbations). Cochrane Database Syst Rev 2001;(4):CD002162.
17. Corless JA, Warburton CJ. Leukotriene receptor antagonists for non-cystic fibrosis bronchiectasis. Cochrane Database Syst Rev 2000;(4):CD002174.
18. Franco F, Sheikh A, Greenstone M. Short acting beta-2 agonists for bronchiectasis. Cochrane Database Syst Rev 2003;(3):CD003572.
19. Sheikh A, Nolan D, Greenstone M. Long-acting beta-2-agonists for bronchiectasis. Cochrane Database Syst Rev 2001;(4):CD002155.
20. Lasserson T, Holt K, Evans D, Greenstone M. Anticholinergic therapy for bronchiectasis. Cochrane Database Syst Rev 2001;(4):CD002163.
21. Steele K, Greenstone M, Lasserson JA. Oral methyl-xanthines for bronchiectasis. Cochrane Database Syst Rev 2001;(1):CD002734.
22. Jones AP, Rowe BH. Bronchopulmonary hygiene physical therapy for chronic obstructive pulmonary disease and bronchiectasis. Cochrane Database Syst Rev 2000;(2):CD000045.
23. Jones A, Rowe BH. Bronchopulmonary hygiene physical therapy in bronchiectasis and chronic obstructive pulmonary disease: a systematic review. Heart Lung 2000;29:125-35.[CrossRef][ISI][Medline]
24. Corless JA, Warburton CJ. Surgery vs non-surgical treatment for bronchiectasis. Cochrane Database Syst Rev 2000;(4):CD002180.
25. Dogan R, Alp M, Kaya S, Ayrancioglu K, Tastepe I, Unlu M, et al. Surgical treatment of bronchiectasis: a collective review of 487 cases. Thorac Cardiovasc Surg 1989;37:183-6.[ISI][Medline]