Intended for healthcare professionals

Rapid response to:

Clinical Review

Treatment of bronchiectasis in adults

BMJ 2007; 335 doi: https://doi.org/10.1136/bmj.39384.657118.80 (Published 22 November 2007) Cite this as: BMJ 2007;335:1089

Rapid Response:

Managing patients with bronchiectasis

Dear Editor

The review by ten Hacken and colleagues of treatment of
bronchiectasis in adult patients provides a very general overview and much
of the content sends the wrong message to Internists and GPs regarding the
management of such patients.

Firstly this paper fails to highlight the importance of collaboration
between the GP and a specialised respiratory service for this population.
As this is a secondary care diagnosis some indication of the symptoms and
clinical signs which differentiate bronchiectasis from COPD and asthma and
prompt referral would have been helpful.1,2 Many of the assessments and
interventions suggested should be initiated in a specialist respiratory
centre and then supported by the GP. Annual review at a respiratory centre
(and more frequently review as disease progresses) is necessary to ensure
appropriate investigations are undertaken and specific treatments, such as
immunoglobulin in deficient patients, for causes commenced, bacteriology
monitored, complex antibiotic regimes initiated and other aspects of this
disease monitored.

The antibiotic recommendations are confusing. Whilst available data
support the use of prolonged courses of antibiotics in selected patients
determined by bacteriology, the highlighted recommendation that
clarithromycin should be given preference for prolonged oral use is not
based on any evidence. This is particularly relevant as some geographical
areas suffer significant rates of macrolide resistant Haemophilus strains.
We think there is confusion in this paper between acute treatment with
antibacterial antibiotics and the role of long term macrolides where
therapeutic strategies are felt to be more anti-inflammatory rather than
antibacterial.

There are other comments with regard to the use of antibiotics which
we feel are very misleading and unhelpful in the community management of
bronchiectasis patients. It is implied that Pseudomoas aeruginosa is
inherently resistant to most antibiotics (implying no role for oral
ciprofloxacin) and the comment that prolonged or aerosolized antibiotics
are mostly reserved for patients with frequent exacerbations are
incorrect.

The section on inhaled antibiotics covers many of the available drugs
but does not include colistin which is frequently used by a large number
of patients for eradication of P aeruginosa. It would have been more
helpful to discuss the evidence supporting the various regimens and make
it clear that to assess benefit of prolonged antibiotics in individual
patients there needs to be a structured appraisal of micobiological
response (sputum cultures and sensitivities), inflammation, and markers
of disease control (exacerbation rates, symptom scores, quality of life).
A discussion on the doses of antibiotics and the need for higher doses in
patients with bronchiectasis would have been helpful to the readership of
this paper.

The suggestion of a stepped approached to therapy is arbitrary as
noted by the authors and is unhelpful and without an evidence base. The
suggestion that inhaled corticosteroids (ICS) should be the first step is
surprising as available studies are too short and too small to provide any
clear evidence to guide practice3. The largest such study suggests
patients infected with P aeruginosa gain the best response and ICS are not
a first step therapy.

The paper also suggests that the level of evidence for airway
clearance is 3 (Recommendation D). There is not a large number of studies
but the lack of good evidence from large studies for airway clearance does
not mean no evidence no benefit (as some readers will presume form the
article). There are a number of well designed short term studies (they are
not non analytical, case reports or case series!) and together they
provide evidence that airway clearance is important4,5. There is a clear
need for research in this field and the article should have called for
funded studies on airway clearance. Like many respiratory diseases the
technique chosen by the physiotherapists is based on detailed assessment
including patient choice and patient preference. This is one of the
keystones of secondary care for bronchiectasis and supports the role of
specialist clinics.

Yours truly,

Professor Stuart Elborn

Consultant Physician

Department Respiratory Medicine,
Belfast City Hospital

Dr Jackie Rendall

Consultant Physician

Department Respiratory Medicine,
Belfast City Hospital

Dr Judy Bradley

Reader in Physiotherapy

Adult CF Unit,
Belfast City Hospital

A De Soyza

Consultant Physician

Adult Bronchiectasis Unit,
Freeman Hospital, Newcastle upon Tyne

Dr Andrew M Jones

Consultant Respiratory Physician

Bradbury CF Unit Wythenshawe

Mary Dodd

Consultant Physiotherapist

Bradbury CF Unit Wythenshawe

Dr Diana Bilton

Consultant Physician / Honorary Senior Lecturer

Department of Respiratory Medicine,
The Royal Brompton Hospital

References

1. Bradley J, Lavery K, Rendall J, Elborn JS Managing bronchiectasis.
Practitioner 2006: 250; 1681: 194-207.

2. Lavery K, Bradley JM, Elborn JS. Bronchiectasis: challenges in
diagnosis and management. International Journal of Respiratory Care.
2005; 1(3)92-98.

3. Tsang KW et al. Inhaled fluticasone in bronchiectasis: a 12 month study
Thorax 2005;60:239-243.

4. Thompson CS, Harrison S, Ashley J, Day K, Smith DL. Randomised
crossover trial of the flutter device and ACBT in non CF broniectasis.
Thorax 2002; 57: 446-448.

5. Patterson J, Hewiit O, Kent L, Elborn JS, Bradley JM. Acapella versus
usual airway clearance during an acute exacerbation in bronchiectasis: a
randomized cross over trial. Chronic Respiratory Disease 2007; 4: 67-74.

Competing interests:
None declared

Competing interests: No competing interests

19 December 2007
Stuart Elborn
Consultant Physician
Judy Bradley, Jackie Rendall, Tony De Soyza, Andrew Jones, Mary Dodd, Di Bilton
Belfast City Hospital