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{{Bronchiectasis}}
{{Bronchiectasis}}
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{{CMG}} {{AE}} Saarah T. Alkhairy, M.D.


==Overview==
==Overview==
Along with treatment of bronchiectasis, it is important to treat the underlying condition if one is present. The medical therapy is divided into medical treatment and physiologic strategies. The medical treatment consists of patient   education, treatment of the acute exacerbations, prophylactic treatment, vaccination, and other therapies. The physiotherapy strategies focuses on airway clearance and [[pulmonary]] rehabilitation.
Along with treatment of bronchiectasis, it is important to treat the underlying condition if one is present. The medical therapy is divided into medical treatment and physiologic strategies. The medical treatment consists of patient education, treatment of the acute exacerbations, [[prophylactic]] treatment, [[vaccination]]  and other therapies. The physiotherapy strategies focuses on airway clearance and [[pulmonary]] rehabilitation.


==Bronchiectasis Medical Therapy==
==Bronchiectasis Medical Therapy==
===Medical Treatment===
===Medical Treatment===
====Patient  Education ====
====Patient  Education ====
*The patients should understand their diagnosis clearly.
*The patients should understand their diagnosis clearly
*Smoking cessation, regular exercise, and proper nutrition should be advised.
*Smoking cessation, regular exercise, and proper nutrition should be advised
*The patient should know how to self-manage acute exacerbations with a home supply of antibiotics.
*The patient should know how to self-manage acute exacerbations with a home supply of antibiotics


====Treatment of Acute Exacerbations====
====Treatment of Acute Exacerbations====
*Exacerbations can be defined as patients reporting four or more of the following symptoms: change in sputum production, increased dyspnea, increased cough, [[fever]] over 38 °C, increased wheezing, decreased exercise tolerance, [[fatigue]], [[malaise]], [[lethargy]], reduced [[pulmonary]] function, changes in chest sounds or radiographic changes consistent with a new infectious process.
*Exacerbations can be defined as patients reporting four or more of the following symptoms:  
*The mainstay of treatment is [[antibiotic]] therapy.
:*change in [[sputum]] production
*Once the sputum specimen is collected and sent for culture, a targeted antibiotic therapy is recommended.
:*[[dyspnea]]
*Colonization with a particular microorganism is graded as chronic if the same microorganism is detected in three or more consecutive cultures separated by at least 1 month over a period of 6 months.<ref name="pmid23728208">{{cite journal| author=McDonnell MJ, Ward C, Lordan JL, Rutherford RM| title=Non-cystic fibrosis bronchiectasis. | journal=QJM | year= 2013 | volume= 106 | issue= 8 | pages= 709-15 | pmid=23728208 | doi=10.1093/qjmed/hct109 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23728208  }} </ref>
:*[[cough]]
*Oral antibiotic therapy should be used first line for 10-14 days. [[Intravenous]] (IV) antibiotics may be needed if there has been: no response to oral antimicrobials, systemic deterioration or if pathogenic organisms sensitive only to IV agents are cultured. <ref name="pmid23728208">{{cite journal| author=McDonnell MJ, Ward C, Lordan JL, Rutherford RM| title=Non-cystic fibrosis bronchiectasis. | journal=QJM | year= 2013 | volume= 106 | issue= 8 | pages= 709-15 | pmid=23728208 | doi=10.1093/qjmed/hct109 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23728208  }} </ref>
:*[[fever]] > 38°C
*Here are suggested antibiotics with specific culture growth
:*wheezing
:*H. influenza type B
:*decreased exercise tolerance
::*[[Amoxicillin]] 1g tds × 2/52, [[Doxycycline]] 100mg bd × 2/52
:*[[fatigue]]
::* If β-lactamase-positive strain, [[Augmentin]] 625mg tds × 2/52
:*reduced [[pulmonary]] function
:*P. aeruginosa
:*changes in chest sounds  
::*[[Ciprofloxacin]] 750mg BD × 2/52
:*radiographic changes consistent with a new infection
::*If no response or resistant to above, consider IV alternatives for 2/52: Ceftazidime 2g tds × 2/52 IV, Tazocin 4.5g tds IV or Meropenem 1g tds IV
*The mainstay of treatment is [[antibiotic]] therapy
:*S. pneumoniae
*Once the [[sputum]] specimen is collected and sent for culture, a targeted [[antibiotic]] therapy is recommended.
::*[[Amoxicillin]] 1g tds × 2/52
*It is considered chronic if the same [[microorganism]] is detected in three or more consecutive cultures separated by at least 1 month over a period of 6 months.<ref name="pmid23728208">{{cite journal| author=McDonnell MJ, Ward C, Lordan JL, Rutherford RM| title=Non-cystic fibrosis bronchiectasis. | journal=QJM | year= 2013 | volume= 106 | issue= 8 | pages= 709-15 | pmid=23728208 | doi=10.1093/qjmed/hct109 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23728208  }} </ref>
:*M. catarrhalis
*[[Intravenous]] (IV) antibiotics may be needed if there has been: no response to oral antibiotics, systemic deterioration, or if the organism is sensitive only to IV agents<ref name="pmid23728208">{{cite journal| author=McDonnell MJ, Ward C, Lordan JL, Rutherford RM| title=Non-cystic fibrosis bronchiectasis. | journal=QJM | year= 2013 | volume= 106 | issue= 8 | pages= 709-15 | pmid=23728208 | doi=10.1093/qjmed/hct109 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23728208  }} </ref>
::*[[Augmentin]] 625mg tds × 2/52 or [[Ciprofloxacin]] 500mg BD × 2/52
*Allergic bronchopulmonary aspergillosis (ABPA)
:*S. aureus
:*Oral prednisone 0.5 to 1 mg/kg per day for two weeks followed by alternate day therapy tapered over three to six months
::*[[Flucloxacillin]] 1g qds × 2/52
:*A 16 week course of an antifungal agent, such as itraconazole or voriconazole, may be added in patients who require large doses of glucocorticoids
{| class="wikitable"
! Haemophilus influenzae type B
! Amoxicillin
! 1g three times daily for two weeks
|-
| Haemophilus influenzae type B
| Doxycycline
| 100mg twice daily for two weeks
|-
| Haemophilus influenzae type B (β-lactamase-positive strain)
| Augmentin
| 625mg three times daily for two weeks
|-
| Pseudomonas aeruginosa
| Ciprofloxacin
| 500-750mg twice daily for two weeks
|-
| If resistant to Pseudomonas aeruginosa
| Ceftazidime
| 2g three times daily for two weeks (IV)
|-
| If resistant to Pseudomonas aeruginosa
| Tazocin
| 4.5g three times daily IV
|-
| If resistant to Pseudomonas aeruginosa
| Meropenem
| 1g three times daily IV
|-
| Streptococcus pneumoniae
| Amoxicillin
| 1g threes times daily for two weeks
|-
| Moraxella catarrhalis
| Augmentin
| 625mg three times daily for two weeks
|-
| Moraxella catarrhalis
| Ciprofloxacin
| 500mg twice daily for two weeks
|-
| Staphylococcus aureus
| Flucloxacillin
| 1g once a day for two weeks
|}


====Prophylactic Treatment====
====Prophylactic Treatment====
*National guidelines recommend that patients suffering from three or more exacerbations per year, should be considered for long-term antibiotics.<ref name="pmid23728208">{{cite journal| author=McDonnell MJ, Ward C, Lordan JL, Rutherford RM| title=Non-cystic fibrosis bronchiectasis. | journal=QJM | year= 2013 | volume= 106 | issue= 8 | pages= 709-15 | pmid=23728208 | doi=10.1093/qjmed/hct109 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23728208  }} </ref>  
*National guidelines recommend that patients suffering from three or more exacerbations per year, should be considered for long-term antibiotics.<ref name="pmid23728208">{{cite journal| author=McDonnell MJ, Ward C, Lordan JL, Rutherford RM| title=Non-cystic fibrosis bronchiectasis. | journal=QJM | year= 2013 | volume= 106 | issue= 8 | pages= 709-15 | pmid=23728208 | doi=10.1093/qjmed/hct109 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23728208  }} </ref>  
*Macrolide daily or three times weekly
:**Macrolides exhibit anti-bacterial and immunomodulatory effects.<ref name="pmid23728208">{{cite journal| author=McDonnell MJ, Ward C, Lordan JL, Rutherford RM| title=Non-cystic fibrosis bronchiectasis. | journal=QJM | year= 2013 | volume= 106 | issue= 8 | pages= 709-15 | pmid=23728208 | doi=10.1093/qjmed/hct109 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23728208  }} </ref>
*Amoxicillin 500 mg twice daily or doxycycline 100 mg twice daily for patients who are not candidates for long-term macrolide administration


====Vaccination====
====Vaccination====
*There has been some evidence to support that the yearly influenza vaccine reduces morbidity, mortality, and healthcare costs with high-risk patients.
*There has been some evidence to support that the yearly influenza vaccine reduces morbidity, mortality, and healthcare costs with high-risk patients


====Other Therapies====
====Other Therapies====
*Inhaled [[mannitol]] and nebulized [[hypertonic]] 7% saline have demonstrated effectiveness in increased airways clearance and sputum yield.<ref name="pmid23728208">{{cite journal| author=McDonnell MJ, Ward C, Lordan JL, Rutherford RM| title=Non-cystic fibrosis bronchiectasis. | journal=QJM | year= 2013 | volume= 106 | issue= 8 | pages= 709-15 | pmid=23728208 | doi=10.1093/qjmed/hct109 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23728208  }} </ref>  
*Inhaled [[mannitol]] and nebulized [[hypertonic]] 7% saline for increased airways clearance and [[sputum]] yield<ref name="pmid23728208">{{cite journal| author=McDonnell MJ, Ward C, Lordan JL, Rutherford RM| title=Non-cystic fibrosis bronchiectasis. | journal=QJM | year= 2013 | volume= 106 | issue= 8 | pages= 709-15 | pmid=23728208 | doi=10.1093/qjmed/hct109 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23728208  }} </ref>  
 
*Inhaled [[corticosteroids]] show a significant decrease in [[sputum]] production and cough<ref name="pmid23728208">{{cite journal| author=McDonnell MJ, Ward C, Lordan JL, Rutherford RM| title=Non-cystic fibrosis bronchiectasis. | journal=QJM | year= 2013 | volume= 106 | issue= 8 | pages= 709-15 | pmid=23728208 | doi=10.1093/qjmed/hct109 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23728208  }} </ref>  
*Inhaled [[corticosteroids]] show a significant decrease in sputum production and cough.<ref name="pmid23728208">{{cite journal| author=McDonnell MJ, Ward C, Lordan JL, Rutherford RM| title=Non-cystic fibrosis bronchiectasis. | journal=QJM | year= 2013 | volume= 106 | issue= 8 | pages= 709-15 | pmid=23728208 | doi=10.1093/qjmed/hct109 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23728208  }} </ref>
*The combination of a long-acting beta2-agonists ([[LABA]]) with a conventional inhaled [[corticosteroids]] can improve the quality of life
 
*Macrolides exhibit anti-bacterial and immunomodulatory effects.<ref name="pmid23728208">{{cite journal| author=McDonnell MJ, Ward C, Lordan JL, Rutherford RM| title=Non-cystic fibrosis bronchiectasis. | journal=QJM | year= 2013 | volume= 106 | issue= 8 | pages= 709-15 | pmid=23728208 | doi=10.1093/qjmed/hct109 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23728208  }} </ref>  
*The combination of a long-acting beta2-agonists ([[LABA]]) with a conventional inhaled corticosteroids (IC) improved the quality of life.


== Physiotherapy Strategies==
== Physiotherapy Strategies==
====Airway Clearance====
====Airway Clearance====
*Postural Drainage
*Postural Drainage
Line 72: Line 118:
[[Category:Emergency medicine]]
[[Category:Emergency medicine]]


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Revision as of 13:42, 26 June 2015

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Saarah T. Alkhairy, M.D.

Overview

Along with treatment of bronchiectasis, it is important to treat the underlying condition if one is present. The medical therapy is divided into medical treatment and physiologic strategies. The medical treatment consists of patient education, treatment of the acute exacerbations, prophylactic treatment, vaccination and other therapies. The physiotherapy strategies focuses on airway clearance and pulmonary rehabilitation.

Bronchiectasis Medical Therapy

Medical Treatment

Patient Education

  • The patients should understand their diagnosis clearly
  • Smoking cessation, regular exercise, and proper nutrition should be advised
  • The patient should know how to self-manage acute exacerbations with a home supply of antibiotics

Treatment of Acute Exacerbations

  • Exacerbations can be defined as patients reporting four or more of the following symptoms:
  • change in sputum production
  • dyspnea
  • cough
  • fever > 38°C
  • wheezing
  • decreased exercise tolerance
  • fatigue
  • reduced pulmonary function
  • changes in chest sounds
  • radiographic changes consistent with a new infection
  • The mainstay of treatment is antibiotic therapy
  • Once the sputum specimen is collected and sent for culture, a targeted antibiotic therapy is recommended.
  • It is considered chronic if the same microorganism is detected in three or more consecutive cultures separated by at least 1 month over a period of 6 months.[1]
  • Intravenous (IV) antibiotics may be needed if there has been: no response to oral antibiotics, systemic deterioration, or if the organism is sensitive only to IV agents[1]
  • Allergic bronchopulmonary aspergillosis (ABPA)
  • Oral prednisone 0.5 to 1 mg/kg per day for two weeks followed by alternate day therapy tapered over three to six months
  • A 16 week course of an antifungal agent, such as itraconazole or voriconazole, may be added in patients who require large doses of glucocorticoids
Haemophilus influenzae type B Amoxicillin 1g three times daily for two weeks
Haemophilus influenzae type B Doxycycline 100mg twice daily for two weeks
Haemophilus influenzae type B (β-lactamase-positive strain) Augmentin 625mg three times daily for two weeks
Pseudomonas aeruginosa Ciprofloxacin 500-750mg twice daily for two weeks
If resistant to Pseudomonas aeruginosa Ceftazidime 2g three times daily for two weeks (IV)
If resistant to Pseudomonas aeruginosa Tazocin 4.5g three times daily IV
If resistant to Pseudomonas aeruginosa Meropenem 1g three times daily IV
Streptococcus pneumoniae Amoxicillin 1g threes times daily for two weeks
Moraxella catarrhalis Augmentin 625mg three times daily for two weeks
Moraxella catarrhalis Ciprofloxacin 500mg twice daily for two weeks
Staphylococcus aureus Flucloxacillin 1g once a day for two weeks

Prophylactic Treatment

  • National guidelines recommend that patients suffering from three or more exacerbations per year, should be considered for long-term antibiotics.[1]
  • Macrolide daily or three times weekly
    • Macrolides exhibit anti-bacterial and immunomodulatory effects.[1]
  • Amoxicillin 500 mg twice daily or doxycycline 100 mg twice daily for patients who are not candidates for long-term macrolide administration

Vaccination

  • There has been some evidence to support that the yearly influenza vaccine reduces morbidity, mortality, and healthcare costs with high-risk patients

Other Therapies

Physiotherapy Strategies

Airway Clearance

  • Postural Drainage
  • Autogenic Drainage
  • Active Cycle of Breathing Techniques
  • Positive Expiratory Pressure (PEP)
  • Oscillatory PEP devices
  • High-frequency chest wall percussion

Pulmonary Rehabilitation

  • Exercise training
  • Nutritional counseling
  • Educationof the patient's disease and how to manage it
  • Techniques on how to conserve energy
  • Strategies on breathing
  • Psychological counseling

References

  1. 1.0 1.1 1.2 1.3 1.4 1.5 McDonnell MJ, Ward C, Lordan JL, Rutherford RM (2013). "Non-cystic fibrosis bronchiectasis". QJM. 106 (8): 709–15. doi:10.1093/qjmed/hct109. PMID 23728208.

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