Bronchiectasis: Drug Therapy

Therapeutic targets

• Treatment of the underlying disease, if applicable.
• Symptomatic therapy:
  • Secretolytic therapy – dissolving the viscous secretions in the bronchi (secretion drainage).
  • Anti-infective measures (directed against infection (with microorganisms)).
  • Antiobstructive therapy (directed against narrowing of the airways).
• Treatment of chronic inflammation (inflammation).
• Avoidance or reduction of exacerbations (disease relapses).
• Prevention of infections
• Improvement of the quality of life

Therapy recommendations

• Secretolytic therapy ((liquefaction of secretion).
  • Inhalation of hypertonic saline solution
  • Inhalation of hyperosmolar solutions has been particularly successful:
    • Mannitol
      • Advantage: longer half-life in the respiratory tract than other hyperosmolar solutions.
      • Disadvantage: Inhalation of mannitol leads to increased hyperresponsiveness (airway hypersensitivity).
• Antibiotic therapy (prior to this, pathogen diagnostics should be performed): in acute disease flare-ups with an increase in dyspnea (shortness of breath) and sputum volume, as well as a yellow-green or green color of the sputum (treatment duration: 7-10 days (14 days)).
  • If there is no microbiological result:
    • Broad-spectrum antibiotic
    • Note: Pseudomonads should be included as they are of prognostic relevance!
  • Oral therapy in the outpatient setting:
    • Fluoroquinolones: levofloxacin or ciprofloxacin.
    • Caveat: Ciprofloxacin is not sufficiently effective against pneumococci!
  • Oral therapy for pseudomonas infection (inpatient stay):
    • Pseudomonas-active substances: carbapenems, cephalosporins, ureidopenicillins.
    • Pseudomonas infections should be treated for 10-14 days!
  • Patients without Pseudomonas aeruginosa risk are treated with aminopenicillin + inhibitor or third-generation cephalosporins (treatment duration: 7 days).
  • Note: Antibiotic therapy outside of a disease flare is controversial. Neither the amount of germs nor the exacerbation rate could be reduced by a permanent oral antibiotic therapy.
  • However, in bronchiectasis with chronic bacterial colonization (= three exacerbations or more per year), long-term antibiotic treatment is required: macrolides are the antibiotics of first choice.
    • Macrolides can reduce the exacerbation frequency by half and prolong the time to the next exacerbation.
  • Inhaled antibiotics:
    • Indications:
      • Frequent exacerbations
      • Colonization with Pseudomonas aeruginosa and cystic fibrosis (CF) (synonym: cystic fibrosis).
      • Severe clinical picture
      • Note: Studies suggest relevance also in non-CF bronchiectasis.
    • Active ingredients:
      • Tobramycin: eradication (elimination of the germ) in 13-35% of cases; fewer symptoms; improvement in lung function; improved quality of life.
      • Colistin: increase in FEV1; eradication in 3 of 18 cases; improvement in lung function and quality of life; fewer hospitalizations were needed; fewer exacerbations
      • Aztreonam in patients with cystic fibrosis (CF) synonym: cystic fibrosis): fewer exacerbations and symptoms; improvement in lung function.
      • Gentamycin: resulted in eradication of Pseudomonas aeruginosa in one-third of cases and prolonged time to next exacerbation
• Antiobstructive therapy (for airway obstruction/constriction).
  • Parasympathetic drugs (anticholinergics).
  • Beta-sympathomimetics
• Treatment of chronic inflammation (inflammation) (chronic bacterial colonization).
  • Oral corticosteroids in acute disease flare-ups.
  • Inhaled steroids: reduced exacerbation rate (number of disease episodes) and sputum production in a study of patients with non-CF bronchiectasis (not caused by cystic fibrosis (CF)).
  • Macrolide antibiotics/macrolides (azithromycin):
    • They have antibacterial and anti-inflammatory (anti-inflammatory) effects by decreasing the production of proinflammatory cytokines.
    • They have few side effects.
    • In non-CF bronchiectasis, they led to a reduction in sputum volume and an improved 5-year survival rate in one study.
• Note: Long-term therapy with inhaled antibiotics and / or macrolides is indicated only if there is significant improvement in terms of sputum volume (sputum = sputum) within three months after initiation of therapy and the disease does not worsen.
• If allergic bronchopulmonary aspergillosis (ABPA) is present as a complication:
  • In the acute disease flare of ABPA: systemic steroids over a long period of time.
  • For relapse prophylaxis in pulmonary colonization: oral itraconazole continuous therapy.
• For underlying immune deficiency syndromes:
  • Hypogammaglobulinemia: substitution with immunoglobulins → 0.4 g/kg body weight every 4-6 weeks.