Bronchiectasis medical therapy: Difference between revisions
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*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> | *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> | ||
*[[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> | *[[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> | ||
*Allergic bronchopulmonary aspergillosis (ABPA) | *[[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 | :*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 | :*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" | {| class="wikitable" | ||
! Haemophilus influenzae type B | ! '''Culture Growth''' | ||
! '''Antibiotics''' | |||
! '''Dosage''' | |||
|- | |||
| '''''Haemophilus influenzae'' type B''' | |||
| [[Amoxicillin]] | |||
| 1g three times daily for two weeks | |||
|- | |- | ||
| Haemophilus influenzae type B | | '''''Haemophilus influenzae'' type B''' | ||
| Doxycycline | | [[Doxycycline]] | ||
| 100mg twice daily for two weeks | | 100mg twice daily for two weeks | ||
|- | |- | ||
| Haemophilus influenzae type B (β-lactamase-positive strain) | | '''''Haemophilus influenzae'' type B (β-lactamase-positive strain)''' | ||
| Augmentin | | [[Augmentin]] | ||
| 625mg three times daily for two weeks | | 625mg three times daily for two weeks | ||
|- | |- | ||
| Pseudomonas aeruginosa | | ''Pseudomonas aeruginosa'' | ||
| Ciprofloxacin | | [[Ciprofloxacin]] | ||
| 500-750mg twice daily for two weeks | | 500-750mg twice daily for two weeks | ||
|- | |- | ||
| If resistant to Pseudomonas aeruginosa | | '''If resistant to ''Pseudomonas aeruginosa''''' | ||
| Ceftazidime | | [[Ceftazidime]] | ||
| 2g three times daily for two weeks (IV) | | 2g three times daily for two weeks (IV) | ||
|- | |- | ||
| If resistant to Pseudomonas aeruginosa | | '''If resistant to ''Pseudomonas aeruginosa''''' | ||
| Tazocin | | [[Tazocin]] | ||
| 4.5g three times daily IV | | 4.5g three times daily IV | ||
|- | |- | ||
| If resistant to Pseudomonas aeruginosa | | '''If resistant to ''Pseudomonas aeruginosa''''' | ||
| Meropenem | | [[Meropenem]] | ||
| 1g three times daily IV | | 1g three times daily IV | ||
|- | |- | ||
| Streptococcus pneumoniae | | '''''Streptococcus pneumoniae''''' | ||
| Amoxicillin | | [[Amoxicillin]] | ||
| 1g threes times daily for two weeks | | 1g threes times daily for two weeks | ||
|- | |- | ||
| Moraxella catarrhalis | | '''''Moraxella catarrhalis''''' | ||
| Augmentin | | [[Augmentin]] | ||
| 625mg three times daily for two weeks | | 625mg three times daily for two weeks | ||
|- | |- | ||
| Moraxella catarrhalis | | '''''Moraxella catarrhalis''''' | ||
| Ciprofloxacin | | [[Ciprofloxacin]] | ||
| 500mg twice daily for two weeks | | 500mg twice daily for two weeks | ||
|- | |- | ||
| Staphylococcus aureus | | '''''Staphylococcus aureus''''' | ||
| Flucloxacillin | | [[Flucloxacillin]] | ||
| 1g once a day for two weeks | | 1g once a day for two weeks | ||
|} | |} | ||
| Line 80: | Line 88: | ||
====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 | *[[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> | :**[[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 | *[[Amoxicillin]] 500 mg twice daily or doxycycline 100 mg twice daily for patients who are not candidates for long-term macrolide administration | ||
====Vaccination==== | ====Vaccination==== | ||
| Line 90: | Line 98: | ||
====Other Therapies==== | ====Other Therapies==== | ||
*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 [[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 | *The combination of a long-acting beta2-agonists ([[LABA]]) with a conventional inhaled [[corticosteroids]] can improve the quality of life | ||
== | == Physiotherapy Strategies== | ||
====Airway Clearance==== | ====Airway Clearance==== | ||
*Postural Drainage | *Postural Drainage | ||
| Line 100: | Line 108: | ||
*Positive Expiratory Pressure (PEP) | *Positive Expiratory Pressure (PEP) | ||
*Oscillatory PEP devices | *Oscillatory PEP devices | ||
*High-frequency chest wall percussion | *High-frequency chest wall [[percussion]] | ||
====Pulmonary Rehabilitation==== | ====Pulmonary Rehabilitation==== | ||
*Exercise training | *Exercise training | ||
*Nutritional counseling | *Nutritional counseling | ||
* Educationof the patient's disease and how to manage it | *Educationof the patient's disease and how to manage it | ||
*Techniques on how to conserve energy | *Techniques on how to conserve energy | ||
*Strategies on breathing | *Strategies on breathing | ||
Revision as of 13:51, 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:
- 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
| Culture Growth | Antibiotics | Dosage |
|---|---|---|
| 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
- Inhaled mannitol and nebulized hypertonic 7% saline for increased airways clearance and sputum yield[1]
- Inhaled corticosteroids show a significant decrease in sputum production and cough[1]
- The combination of a long-acting beta2-agonists (LABA) with a conventional inhaled corticosteroids can improve the quality of life
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