Management

The aims of bronchiectasis management are to reduce symptoms, reduce exacerbation frequency, preserve lung function and improve health related quality of life.

Patient education is of great importance as many patients have a high treatment burden with physiotherapy regimes, inhaled and oral therapy regimes and frequent hospital visits. Optimising treatment compliance, rapid recognition of exacerbations and appropriate use of complex therapies requires active patient engagement.

Patients should be advised to stop smoking as smoking will accelerate lung function decline and predispose to mortality. As with most other chronic illnesses, patients with bronchiectasis will be offered the annual influenza vaccination in accordance with national guidelines. 

Airway clearance

Despite limited evidence, airway clearance techniques are widely considered a key component of management. There is little high quality data comparing different techniques for effectiveness. The choice is therefore largely determined by patient choice and ease of use.

Chest physiotherapy

Chest clearance techniques include physiotherapy regimes such as Active Cycle of Breathing Technique and Postural Drainage with or without adjuncts such as positive airway pressure devices, (e.g “Flutter” devices providing oscillatory positive pressure), or high frequency chest wall oscillation.  Small, but significant improvements can be seen in exercise capacity, sputum volume and HRQOL in patients who use chest physiotherapy compared with control.  The availability of a physiotherapist or other health professional experience in teaching chest clearance techniques is invaluable for patient education.

Inhaled hyperosmolar agents

As an adjunct to standard chest physiotherapy, nebulized hypertonic saline can alter the mucus osmolality making it easier to clear.

Hypertonic saline can improve FEV₁ when used in combination with chest physiotherapy.[78] Recent trials of inhaled mannitol, another hyperosmolar agent, suggest it can increase sputum volume compared to placebo, although the overall significance of this to patients is not entirely clear.

DNase

The experience of recombinant DNase acts as a cautionary tale in extrapolating results in cystic fibrosis to patients with non-CF bronchiectasis. Despite being effective in selected patients with CF, DNase was shown to be potentially harmful in a randomised controlled trial in NCFBE, reducing FEV_1. It is therefore not advised for use in this group of patients, and highlights the different pathophysiology in NCFB, compared with CF associated bronchiectasis.