- Author: Ethan E Emmons, MD; Chief Editor: Zab Mosenifar, MD, FACP, FCCP more...
No specific medical therapy exists for the treatment of bronchiectasis. Pharmacologic therapy focuses on the treatment of infectious exacerbations that these patients commonly experience, most often in the form of an acute bronchitis-type syndrome.
The most widely accepted and commonly used medications in the treatment of acute infectious processes associated with bronchiectasis include antibiotics, beta-agonists, inhaled corticosteroids, and expectorants. Other more controversial medications have been previously mentioned in this article for completeness but are not discussed here.
These are the mainstays of treatment of patients with bronchiectasis and infectious exacerbations. The route of antibiotic administration varies with the overall clinical condition, with most patients doing well on outpatient regimens. Some patients benefit from a set regimen of antibiotic therapy, such as therapy for 1 week of every month.
The choice of antibiotic is provider dependent, but, in general, the antibiotic chosen should have a reasonable spectrum of coverage, including the most common gram-positive and gram-negative organisms. Treatment of the patient who is more ill or the patient with CF often requires intravenous anti-Pseudomonas species coverage with an aminoglycoside, most often in combination with an antipseudomonal synthetic penicillin or cephalosporin. Aerosolized tobramycin has been found effective in patients with cystic fibrosis (CF).
Clarithromycin is a semisynthetic macrolide antibiotic that reversibly binds to P site of 50S ribosomal subunit of susceptible organisms and may inhibit RNA-dependent protein synthesis by stimulating dissociation of peptidyl t-RNA from ribosomes, causing bacterial growth inhibition.
Azithromycin is an azalide, a subclass of the macrolide antibiotics. Following oral administration, it is absorbed rapidly and widely distributed throughout body. Its mechanism of action is interference with microbial protein synthesis.
Azithromycin is effective against a wide range of organisms, including the most common gram-positive and gram-negative organisms. It has additional coverage of so-called atypical infections, such as Chlamydia, Mycoplasma, and Legionella species. This agent is indicated for treatment of patients with mild-to-moderate infections, including acute bronchitic infections that may be observed with bronchiectasis.
Trimethoprim-sulfamethoxazole is a synthetic combination antibiotic. Each tab contains 80 mg of trimethoprim and 400 mg of sulfamethoxazole. It is rapidly absorbed after oral administration. The mechanism of action involves blockage of 2 consecutive steps in biosynthesis of nucleic acids and proteins needed by many microorganisms.
This agent provides coverage for common forms of both gram-positive and gram-negative organisms, including susceptible strains of Streptococcus pneumoniae and Haemophilus influenzae. It is indicated in the treatment of acute and chronic bronchitic symptoms in patients with bronchiectasis.
Doxycycline is a broad-spectrum, synthetically derived bacteriostatic antibiotic in the tetracycline class. It is an alternative agent for patients who cannot be given macrolides or penicillins.
Doxycycline is almost completely absorbed, concentrates in bile, and is excreted in urine and feces as a biologically active metabolite in high concentrations. It inhibits protein synthesis and, thus, bacterial growth by binding to 30S and possibly 50S ribosomal subunits of susceptible bacteria. It may block dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest.
Fluoroquinolones should be used empirically in patients likely to develop exacerbation due to resistant organisms to other antibiotics. Levofloxacin is rapidly becoming a popular choice in pneumonia. It is the L stereoisomer of the D/L parent compound ofloxacin, the D form being inactive.
This agent is good for monotherapy, with extended coverage against Pseudomonas species and excellent activity against pneumococcus. It acts by inhibition of DNA gyrase activity. Bioavailability of the oral form reportedly is 99%.
Tobramycin is an aminoglycoside specifically developed for administration with a nebulizer system. When inhaled, it is concentrated in airways, where it exerts an antibacterial effect by disrupting protein synthesis. Tobramycin is active against a wide range of gram-negative organisms, including P aeruginosa. It is indicated for treatment of patients with CF and P aeruginosa infection.
A water-soluble injectable antibiotic of aminoglycoside group, gentamicin acts by inhibiting normal protein synthesis; it is active against variety of pathogenic organisms, including P aeruginosa. For treatment of Pseudomonas species, it is often used in combination with an antipseudomonal synthetic penicillin or cephalosporin.
In patients with bronchiectasis, gentamicin (or other aminoglycosides) may be indicated in setting of severe respiratory tract infection or CF. Dosing regimens are numerous; adjust dose based on creatinine clearance (CrCl) and changes in volume of distribution. Gentamicin may be administered IV or IM.
Amikacin irreversibly binds to the 30S subunit of bacterial ribosomes; it blocks the recognition step in protein synthesis and causes growth inhibition. It is indicated for gram-negative bacterial coverage of infections resistant to gentamicin and tobramycin. Amikacin is effective against P aeruginosa. Use patient's ideal body weight (IBW) for dosage calculation. The same principles of drug monitoring for gentamicin apply to amikacin.
Inhaled Beta Agonist
Although no long-term studies have been performed with inhaled beta-agonists, these medications are routinely used in patients with bronchiectasis for multiple reasons. Bronchiectasis may cause an obstructive defect on pulmonary function testing that may respond to inhaled beta-agonists. Many older patients with bronchiectasis often have a concomitant illness, such as chronic obstructive pulmonary disease, that responds to inhaled beta-agonists.
Finally, in the acute infectious bronchitic exacerbation that occurs in patients with bronchiectasis, patients may develop transient obstructive airway physiology that may improve with an inhaled beta-agonist. Along these same lines, many patients are started on inhaled steroids for long-term airway stabilization, but the efficacy of these medications in bronchiectasis is questionable, and any effect simply may be secondary to the treatment of other concomitant obstructive airway diseases.
By relaxing the smooth muscles of the bronchioles in conditions associated with bronchitis, emphysema, asthma, or bronchiectasis, salmeterol can relieve bronchospasms. It also may facilitate expectoration.
Salmeterol has been shown to improve symptoms and morning peak flows. It may be useful when bronchodilators are used frequently. More studies are needed to establish the role for these agents.
The bronchodilating effect of salmeterol lasts >12 h. This agent is used on a fixed schedule in addition to regular use of anticholinergic agents. When salmeterol is administered at high or more frequent doses than recommended, the incidence of adverse effects is higher.
Albuterol is a relatively selective beta2-adrenergic bronchodilator that, when inhaled, relaxes bronchial smooth muscle and inhibits release of mediators of immediate hypersensitivity from cells, especially mast cells.
Albuterol is administered in a metered-dose aerosol unit for oral inhalation. It is indicated for prevention and relief of bronchospasm from any cause, including those observed in patients with bronchiectasis.
Studies suggest a benefit of inhaled corticosteroids in bronchiectasis, although the optimal dosing remains to be determined. No significant studies of oral steroid therapy in patients with bronchiectasis have been performed.
Beclomethasone inhibits bronchoconstriction mechanisms, produces direct smooth muscle relaxation, and may decrease the number and activity of inflammatory cells, in turn decreasing airway hyperresponsiveness. It is readily absorbed through the nasopharyngeal mucosa and GI tract. It has a weak hypothalamic-pituitary-adrenal (HPA) axis inhibitory potency when applied topically.
Various dose preparations are available and must be titrated in conjunction with other medications the patient is taking; most inhaled oral medications have an effect in 24 hours.
Fluticasone may decrease the number and activity of inflammatory cells, in turn decreasing airway hyperresponsiveness. It also has vasoconstrictive activity.
One of the hallmarks of bronchiectasis is a chronic, thick, viscid sputum production. In bronchiectasis, it is extremely difficult for the body's natural mucociliary clearance mechanisms to adequately clear the sputum produced. Although definitive evidence is lacking, expectorants are expected to increase respiratory tract fluid secretions and to help loosen phlegm and bronchial secretions.
By reducing the viscosity of secretions, expectorants increase the efficacy of the mucociliary clearance system. Expectorants are often marketed in combination with decongestants, which may provide some patients additional relief.
The product contains 600 mg of guaifenesin in a sustained-release formulation intended for oral administration. It increases respiratory tract fluid secretions and helps to loosen phlegm and bronchial secretions. Humibid LA and guaifenesin are indicated for patients with bronchiectasis complicated by tenacious mucus and/or mucous plugs.
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