Unlike some diseases, bronchiectasis is treated by controlling its signs and symptoms, not necessarily by treating the disease itself. This is due to the fact that few patients respond to direct treatment and are better served by controlling infection and reducing inflammation to overall improve bronchial hygiene. Four main categories of interventions serve to treat bronchiectasis: pharmacological intervention, medical devices, surgery, and pulmonary rehabilitation. While research in and refinement of surgery and pulmonary rehabilitation are ongoing, the most cutting-edge advances in treatment are from the pharmacological and medical device fields.
One requirement for a diagnosis of bronchiectasis is an infection in the lungs that is associated with cough and sputum production, according to “Treatment of Bronchiectasis in Adults,” published in UpToDate. When the cause of infection is bacterial, antibiotics can be administered to clear bacterial colonization of the lungs. The American Journal of Respiratory and Critical Care Medicine study “Short- and Long-Term Antibiotic Treatment Reduces Airway and Systemic Inflammation in Non-Cystic Fibrosis Bronchiectasis” identified that high airway bacterial loads can increase inflammation in the airways and increase the risk for exacerbations. The team, led by Dr. James D. Chalmesr at The Queen’s Medical Research Institute, then investigated how antibiotics improve airway inflammation and found that either short-term or long-term antibiotics reduce inflammation.
Viral infections can also increase the risk of pulmonary exacerbations in adults with bronchiectasis. In the study “The Role of Viral Infection in Pulmonary Exacerbations of Bronchiectasis in Adults: A Prospective Study,” which was published in Chest, a team from The First Affiliated Hospital of Zhengzhou University determined that half of patients who experience an exacerbation test positive for a viral infection. These are most commonly coronavirus, rhinovirus, and influenza A/B. Unfortunately, viral infections are difficult to treat, as they do not respond to antibiotics that kill bacterial infections.
Bacterial infections are most commonly treated with antibiotics, and a specialized class of antibiotics known as macrolides are undergoing clinical trials. Within this category of drugs is erythromycin, tested in “The Bronchiectasis and Low-Dose Erythromycin Study (BLESS).” Patients treated with erythromycin experienced modest improvements in the rate of exacerbations, rate of decline in forced expiratory volume in one second (FEV1), and sputum production. On the other hand, azithromycin is a macrolide that most likely is not effective in treating bronchiectasis. Two studies, “Azithromycin for Prevention of Exacerbations in Non-Cystic Fibrosis Bronchiectasis (EMBRACE): A Randomized, Double-blind, Placebo-controlled Trial,” and “Effect of Azithromycin Maintenance Treatment on Infectious Exacerbations among Patients with Non-Cystic Fibrosis Bronchiectasis: The BAT Randomized Controlled Trial,” each noted no improvements in lung function of patients treated with azithromycin. In fact, during the BAT trial, colonization of resistant organisms was more than three times greater in azithromycin-treated patients than in placebo patients.
Nonmacrolide antibiotics are already in use today and can be inhaled or orally dosed. Aerosolized tobramycin, indicated primarily for cystic fibrosis, has been tested in bronchiectasis and was found to decrease colonization of Pseudomonas aeruginosa and modestly lowered the rate of hospitalizations. However, treatment did not change FEV1 or exacerbation rate, and complications such as bacterial resistance or even death occurred. Other inhaled antibiotics include gentamicin, aztreonam, ciprofloxacin, and cloistin. While most of these antibiotics were noneffective in patients with bronchiectasis, ciprofloxacin significantly reduced sputum bacterial load compared to placebo, motivating future studies in safety and efficacy of treatment.
More than pharmacological interventions are being pursued for bronchiectasis treatment. In children, external percussion vests and airway oscillating devices have been used to treat bronchiectasis. These methods for respiratory physiotherapy are proven to help patients with cystic fibrosis by helping patients remove mucus from their airways. The article “Current Devices of Respiratory Physiotherapy,” published in the journal Hippokratia, lists positive expiratory pressure, high frequency chest wall oscillation, oral high frequency oscillation, and intrapulmonary ventilation as the most common means to administer respiratory physiotherapy.
“Multiple studies have shown that high frequency chest wall compressive vests [are] an effective therapy for airway clearance for patients with conditions such as cystic fibrosis and bronchiectasis,” stated a report from Harvard Pilgrim Health Care. “Randomized controlled trials demonstrated improvements in pulmonary function values, sputum production, antibiotic use, and/or frequency of hospitalization.”
As with medications, airway clearance devices such as compressive vests don’t always fit patients’ health needs and lifestyles. However, when choosing a device, clinicians should consider not only the effectiveness of the device, but also the required usage, mobility, convenience and comfort as well, since patient compliance is key to the success of airway clearance devices.
One of the main advantages to respiratory physiotherapy is the gift of independence for patients with bronchiectasis. Many of the devices can be used without an assistant, allowing children to receive treatment in the comfort of their own homes.
Just as not all medications are suitable for all patients, not all respiratory physiotherapy techniques are suitable for all patients. Physicians must determine if it is safe for a patient to start treatment. Physicians may prescribe treatment if patients will benefit from improved airway clearance and if external chest manipulation is ideal to enhance mucus transport and drain fluid from the bronchi.
While bronchiectasis is considered to be a complex disease that is cumbersome to manage, treatments are improving. Off-label or expensive medications may soon be less common to treat bronchiectasis, and treatments such as respiratory physiotherapy may decrease patient reliance on medications, decreasing the risk for side effects and the threat of bacterial resistance.
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