Treatment

• Provide supportive treatment and oxygen therapy as needed.

• Optimize mucoactive agents

• Optimize airway clearance techniques.

• Obtain a new sputum culture and start empiric antibiotic therapy, based on the most recent sputum culture.

• Tailor antibiotics to the most recent sputum culture once available and preferably complete 14 days of therapy.

Acute exacerbations are defined as acute deterioration or worsening local symptoms and/or additional systemic symptoms such as fever or malaise. Exacerbations are associated with increased inflammation and progressive damage to the lungs.

Management goals are to stop or delay disease progression, reduce exacerbation frequency (goal ≤ 2 per year), achieve symptom control, and improve the patient's quality of life.

Approach

• General measures

  • Educate the patient regarding prognosis and the use of long-term medications.

  • Promote lifestyle changes like regular exercise and smoking cessation.

  • Educate the patient on airway clearance techniques.

    • Bronchopulmonary hygiene and chest physiotherapy: e.g., cupping and clapping, postural drainage, directed cough, hydration

    • Pulmonary rehabilitation: may improve exercise capacity and respiratory symptoms

  • Administer vaccinations (i.e., seasonal influenza vaccine, pneumococcal vaccine).

  • Consider treatment with mucoactive agents, bronchodilators, or corticosteroids if airway clearance is difficult.

  • Provide specific treatment for the underlying cause if identified.

• Disease progression

  • Consider long-term antibiotic therapy for bronchiectasis with ≥ 3 exacerbations per year.

• Advanced disease

  • Invasive procedures: not routinely indicated

Perform a careful reassessment of patients who are progressively deteriorating (i.e., patients with increased frequency and/or severity of exacerbations, frequent hospital admissions, worsening symptoms, rapid decline in lung function). Identify the cause of bronchiectasis if still unknown, and exclude any comorbidities or exacerbating conditions such as new pathogen colonization.

For patients with bronchiectasis and chronic productive cough or difficulty expectorating, consider referral to a trained respiratory physiotherapist for airway clearance techniques.

• The goal is to suppress bacterial growth and to reduce symptoms and exacerbations as a measure of secondary prevention in patients with ≥ 3 exacerbations per year. Antibiotic therapy should be administered for at least 3 months and may be extended based on clinical response and tolerability.

• Before starting treatment, obtain new sputum cultures with an antibiogram and consult an infectious diseases specialist.

• Surgical resection of bronchiectatic lung or lobectomy: indicated in pulmonary hemorrhage, inviable bronchus, and poor control of symptoms despite optimal medical therapy in unilateral bronchiectasis with well-localized disease

• Pulmonary artery embolization: indicated in pulmonary hemorrhage

• Lung transplantation: Consider for severe disease or rapid disease progression.

• Recurrent bronchopulmonary infections → chronic obstructive pulmonary disease → respiratory failure and cor pulmonale

• Pulmonary hemorrhage (massive hemoptysis)

• Lung abscess