- Chronic respiratory disease defined by recurrent bronchial infection and abnormal permanently dilated airways.
- Can occur at any age, but more common in women and age > 60.
- Is a heterogenous disease with many causative or contributing factors, including:
- Cystic fibrosis
- Pulmonary infection
- Chronic obstructive pulmonary disease
- Immune deficiency
- Airway obstruction
- Rheumatoid arthritis
- Inflammatory bowel disease
- Connective tissue disorders
- Primary ciliary dyskinesia
- Allergic bronchopulmonary aspergillosis
- Present with new undiagnosed bronchiectasis, or more typically an acute exacerbation of existing bronchiectasis.
- Bronchiectasis exacerbations are currently understood to be caused by pulmonary infections, typically bacterial, but also non-tuberculosis mycobacterial, viral, and fungal.
- This summary will not address the treatment of acute exacerbations of bronchiectasis due to cystic fibrosis, allergic bronchopulmonary aspergillosis, and non-tuberculosis mycobacteria.
- 14-day course of antibiotics is usual, although shorter courses may be used for milder exacerbations.
- Empiric antibiotics should be started based on previous sputum microbiology.
- Sputum culture and sensitivity should be acquired before initiation of therapy to guide antibiotic choice in the case of poor response to empiric treatment. A blood culture is recommended for patients with respiratory distress or a fever ≥38°C.
- It is recommended that patients already taking long-term antibiotics continue to do so throughout treatment if possible.
Afebrile, clinically stable patients can be treated as outpatients with oral antibiotics.
- Streptococcus pneumoniae: Amoxicillin (500mg TID).
- Beta-lactamase negative Haemophilus influenzae: Amoxicillin (500-1000mg TID).
- Beta-lactamase positive Haemophilus influenzae: Amoxicillin/clavulanate (625mg TID).
- Moraxella Catarrhalis: Amoxicillin/clavulanate (625mg TID).
- MSSA: Flucloxacillin (500mg QID).
- MRSA: Doxycycline (100mg BID), rifampin (<50kg: 450mg QD; >50kg: 600mg QD), trimethoprim (200mg BID).
- Coliforms (Klebsiella, Enterobacter, etc.): Ciprofloxacin (500-750mg BID).
- Quinolone sensitive Pseudomonas aeruginosa: Ciprofloxacin (500-750mg BID).
Intravenous antibiotics if severe exacerbations (see criteria for admission below), resistant organisms, or poor response to oral antibiotics (typically patients with Pseudomonas infection).
- MRSA: Vancomycin (1gm BID monitored appropriately), Teicoplanin (400mg QD).
- Hemophilus Influenzae or Coliforms: Ceftriaxone (2gm QD).
- Quinolone resistant Pseudomonas aeruginosa: Cefepime (2gm BID), ceftazidime (2gm TID), piperacillin/tazobactam (4gm piperacillin with 0.5gm tazobactam TID), aztreonam (2gm TID), meropenem (2gm TID).
- Any of the above can be combined with gentamicin, tobramycin, or colistin if necessary.
Consider testing for viral infection in an acute exacerbation of bronchiectasis. Exacerbations instigated by influenza should be treated with appropriate antiviral therapy.
Consider using an inhaled bronchodilator (e.g. salbutamol) prior to airway clearance therapy, especially in those who also have asthma and COPD.
There is no evidence to recommend the use of systemic corticosteroids in the treatment of acute bronchiectasis exacerbations, although they are commonly used.
- Increased airway clearance therapy (respiratory physiotherapy), including postural drainage and manual techniques.
- Pre-existing maintenance therapy should be continued throughout the duration of treatment (long-term antibiotic therapy, airway clearance therapy, mucoactive agents, pulmonary rehabilitation, and comorbidity management.)
Criteria For Hospital Admission
People when presenting with the following should be considered for admission:
- Respiratory rate ≥25/minute
- Fever ≥38°C
- Resistance to oral antibiotics
Quality Of Evidence?
We are highly confident that the true effect lies close to that of the estimate of the effect. There is a wide range of studies included in the analyses with no major limitations, there is little variation between studies, and the summary estimate has a narrow confidence interval.
We consider that the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. There are only a few studies and some have limitations but not major flaws, there are some variations between studies, or the confidence interval of the summary estimate is wide.
When the true effect may be substantially different from the estimate of the effect. The studies have major flaws, there is important variations between studies, of the confidence interval of the summary estimate is very wide.
Evidence-based clinical practice guidelines are lacking for bronchiectasis. Recommendations are made primarily on expert opinion, with very little, or no, scientific evidence. Evidence that does exist is typically low-quality or extrapolated from relevant higher-quality studies.
The purpose of this document is to provide health care professionals with key facts and recommendations for the diagnosis and treatment of patients in the emergency department. This summary was produced by the BC Emergency Medicine Network and uses the best available knowledge at the time of publication. However, healthcare professionals should continue to use their own judgment and take into consideration context, resources and other relevant factors. The BC Emergency Medicine Network is not liable for any damages, claims, liabilities, costs or obligations arising from the use of this document including loss or damages arising from any claims made by a third party. The BC Emergency Medicine Network also assumes no responsibility or liability for changes made to this document without its consent.
Last Updated Aug 09, 2021
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