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Bronchiectasis - Management
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What follow-up is recommended for people with bronchiectasis in primary care?
- All children with bronchiectasis should be followed up by a specialist.
- All adults with bronchiectasis should be offered an annual review in primary care. Ask about:
- Smoking.
- The number of exacerbations in the last year.
- Breathlessness associated with activities of daily living.
- Sputum volume and character.
- Send sputum for culture and sensitivity at annual review or if it has become persistently purulent between exacerbations — to assess for chronic bacterial colonization.
- Specialist follow up is required for adults with:
- Chronic colonization with Pseudomonas aeruginosa, opportunist mycobacteria, or meticillin-resistant Staphylococcus aureus (MRSA).
- Deteriorating symptoms.
- Three or more infective exacerbations a year.
- Bronchiectasis requiring long-term prophylactic antibiotics.
- Bronchiectasis associated with rheumatoid arthritis, immune deficiency, inflammatory bowel disease, primary ciliary dyskinesia, and allergic bronchopulmonary aspergillosis.
- Advanced disease.
- Ensure all people with bronchiectasis:
- Know how to recognize exacerbations and understand the condition. A patient information leaflet on bronchiectasis is available from the British Lung Foundation.
- Have a record of sputum cultures from previous exacerbations to guide future treatment of exacerbations.
- Have been taught an airway clearance technique by a physiotherapist — for daily use by people with a chronic productive cough, and intermittent use by people with a productive cough during exacerbations.
- Offer pulmonary rehabilitation to people with bronchiectasis and breathlessness associated with activities of daily living.
- Refer the person to a specialist to arrange this.
- People who have been advised to start antibiotics themselves for exacerbations should:
- Understand when it is appropriate to start treatment and the importance of collecting sputum before starting treatment.
- Have sputum collection pots and a repeat prescription for antibiotics.
- Offer immunization against Streptococcus pneumoniae and seasonal influenza. See CKS topics on Immunizations - pneumococcal and Immunizations - seasonal influenza.
- Offer people who smoke advice and support to help them stop — for further information, see the CKS topic on Smoking cessation.
- Do not routinely repeat chest X-rays.
- Routine annual spirometry is not recommended for people who are stable, with minimal exercise limitation, and who have few exacerbations.
Basis for recommendation
Recommendations on who should receive follow up in secondary care
Record of sputum cultures from previous exacerbations
- Experts consider that treatment of exacerbations is more likely to be effective when this is based on previous sputum culture results [British Thoracic Society, 2010].
- The recommendation to send sputum samples for analysis at annual review, when the person is clinically stable, is based on the opinion of a CKS expert reviewer.
Physiotherapy
- It is not possible, from the limited available evidence, to assess the effectiveness of physiotherapy for people with bronchiectasis.
- It is widely believed by experts that airway clearance techniques are an important component of managing bronchiectasis [British Thoracic Society, 2010].
Pulmonary rehabilitation
- Pulmonary rehabilitation is recommended for people with bronchiectasis associated with exercise limitation. This is based on limited evidence summarized by the British Thoracic Society [British Thoracic Society, 2010].
- A Cochrane systematic review showed that inspiratory muscle training improved exercise endurance and health-related quality of life [Bradley et al, 2002].
- Further evidence from a randomized controlled trial compared exercise capacity in three groups of people. The first group received 8 weeks of a high intensity pulmonary rehabilitation programme with inspiratory muscle training; the second group received pulmonary rehabilitation with sham inspiratory muscle training; and a control group received no rehabilitation.
- There was a statistically significant improvement in exercise capacity in both groups receiving pulmonary rehabilitation.
- This improvement was maintained in the group receiving additional inspiratory muscle training but not in the group that received sham inspiratory muscle training.
Immunization
- There is a lack of evidence on the benefit of vaccination in people with bronchiectasis [ten Hacken et al, 2007]. The recommendation to offer people with bronchiectasis immunization against seasonal influenza and Streptococcus pneumoniae is based on expert opinion from the British Thoracic Society [British Thoracic Society, 2010].
Smoking cessation advice
- Recommendations on smoking cessation advice are based on accepted good clinical practice.
Who should be followed-up in secondary care?
- Regular follow up in secondary care is recommended for:
- All children.
- Adults with bronchiectasis, with:
- Chronic colonization with Pseudomonas aeruginosa, opportunist mycobacteria, or meticillin-resistant Staphylococcus aureus (MRSA).
- Clinical deterioration with declining lung function.
- Three or more infective exacerbations a year.
- Requirement for long-term prophylactic antibiotics.
- Co-existing rheumatoid arthritis, immune deficiency, inflammatory bowel disease, primary ciliary dyskinesia, or allergic bronchopulmonary aspergillosis.
- Advanced disease — including those people who are being considered for transplantation.
- Secondary care follow up for adults with less severe disease is at the discretion of the specialist.
- Follow up is likely to be exclusively in primary care if the disease is stable, with minimal exercise limitation and few exacerbations.
- Follow up is usually shared between primary care and secondary care for people with intermediate disease severity.
Basis for recommendation
Recommendations on who should receive follow up in secondary care are based on the expert opinion of the British Thoracic Society [British Thoracic Society, 2010].
What treatments for bronchiectasis may be initiated in secondary care?
- All people with bronchiectasis should be referred to a respiratory physiotherapist for the teaching of an airway clearance technique.
- People with a chronic productive cough should use the technique every day.
- People who have a productive cough during exacerbations can use the technique intermittently (during an exacerbation).
- All people with bronchiectasis who have breathlessness associated with activities of daily living should be offered pulmonary rehabilitation.
- All people having three or more exacerbations a year, and those with fewer exacerbations causing significant morbidity, should be considered for long-term prophylactic treatment with antibiotics.
- Nebulized antibiotics should be considered in adults chronically colonized with Pseudomonas aeruginosa.
- Nebulized antibiotics should be considered in children with frequent recurrent exacerbations, or deteriorating bronchiectasis despite oral antibiotics, or if oral antibiotics are not appropriate.
- Long-term treatment with theophylline, aminophylline, inhaled beta2-agonists, or inhaled anticholinergic bronchodilators should only be prescribed after a trial of therapy has demonstrated improvement of symptoms or lung function.
- Lung resection surgery may be considered in people with localized disease when symptoms cannot be controlled by medical treatment.
Basis for recommendation
Physiotherapy
- It is not possible, from the limited available evidence, to assess the effectiveness of physiotherapy for people with bronchiectasis.
- It is widely believed by experts that airway clearance techniques are an important component of managing bronchiectasis [British Thoracic Society, 2010].
Pulmonary rehabilitation
- UK Guidelines recommend a number of techniques; such as postural drainage and pelvic floor muscle training [Bott et al, 2009].
- Pulmonary rehabilitation is recommended in individuals with bronchiectasis who are breathless during activities of daily living; based on limited evidence summarized by the British Thoracic Society [British Thoracic Society, 2010].
- A Cochrane systematic review showed that inspiratory muscle training improved exercise endurance and health-related quality of life [Bradley et al, 2002].
- Further evidence was provided from a randomized controlled trial that compared exercise capacity in three groups of people. The first group received 8 weeks of a high intensity pulmonary rehabilitation programme with inspiratory muscle training; the second group received pulmonary rehabilitation with sham inspiratory muscle training; and a control group received no rehabilitation.
- There was a statistically significant improvement in exercise capacity in both groups receiving pulmonary rehabilitation.
- This improvement was maintained in the group receiving additional inspiratory muscle training but not in the group that received sham inspiratory muscle training.
Prophylactic antibiotics
- Limited evidence from studies of long-term antibiotics suggest small clinical benefits, and no benefit in terms of exacerbation rate or lung function.
- Information on who should receive long-term antibiotics are based on the expert opinion of the British Thoracic Society [British Thoracic Society, 2010].
Bronchodilators
- Information on the use of bronchodilators are based on the expert opinion of the British Thoracic Society [British Thoracic Society, 2010].
- It is unclear from the limited available evidence whether bronchodilators are beneficial in bronchiectasis.
Lung resection surgery
What treatments are not recommended for bronchiectasis?
- These treatments should not be used for the treatment of bronchiectasis:
- Corticosteroids (inhaled or oral) — unless there is coexistent asthma.
- Mucolytics.
- Leukotriene receptor antagonists.
Basis for recommendation
Mucolytics
- There is insufficient evidence to determine whether mucolytics are of benefit for people with bronchiectasis.
- Experts recommend that these should not be routinely prescribed for the treatment of bronchiectasis [British Thoracic Society, 2010].
Inhaled corticosteroids
- There is insufficient evidence to determine whether inhaled corticosteroids are of benefit for people with bronchiectasis.
- Experts recommend that these should not be routinely prescribed for the treatment of bronchiectasis (unless there is coexistent asthma) [British Thoracic Society, 2010].
Oral corticosteroids
- There is insufficient evidence to determine whether oral corticosteroids are of benefit for people with bronchiectasis.
- Experts recommend that these should not be routinely prescribed for the treatment of bronchiectasis [British Thoracic Society, 2010].
Leukotriene receptor antagonists
- There is insufficient evidence to determine whether leukotriene receptor antagonists are of benefit for people with bronchiectasis.
- Experts recommend that these should not be routinely prescribed for the treatment of bronchiectasis [British Thoracic Society, 2010].
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