Medication Summary
Corticosteroids, Inhaled
Class Summary
These agents may be beneficial in treating chronic inflammation in bronchiectasis. They elicit anti-inflammatory and immunosuppressive properties and cause profound and varied metabolic effects. They also modify the body's immune response to diverse stimuli.
Fluticasone (Flovent HFA, Flovent Diskus)
This agent inhibits bronchoconstriction mechanisms, produces direct smooth muscle relaxation, and may decrease the number and activity of inflammatory cells, in turn decreasing airway hyperresponsiveness. Fluticasone is available as an aerosol, Flovent HFA (44, 110, or 220 mcg/actuation); it is also available as Flovent powder for inhalation (Diskus) that delivers 50 mcg/actuation, 100 mcg/actuation, or 250 mcg/actuation.
Budesonide inhaled (Pulmicort Flexhaler, Pulmicort Respules)
Budesonide reduces inflammation in airways by inhibiting multiple types of inflammatory cells and decreasing production of cytokines and other mediators involved in bronchospasm. This agent is available as Pulmicort Flexhaler, powder for inhalation (90 mcg/actuation and 180 mcg/actuation; each actuation delivers 80 mcg and 160 mcg respectively) or Pulmicort Respules inhalation susp (0.25 mg/2 mL, 0.5 mg/2 mL, or 1 mg/2 mL). Nebulization has been used in children aged 1-8 y.
Bronchodilators
Class Summary
Bronchodilators act to decrease muscle tone in the small and large airways in the lungs, thereby increasing ventilation. Spirometry is recommended before and after use of an inhaled bronchodilator before beginning long-term therapy. If no response is noted, or if paradoxical bronchoconstriction occurs, these agents should be avoided.
Albuterol (Proventil HFA, Ventolin HFA, ProAir HFA)
Albuterol relaxes bronchial smooth muscle by action on beta2-receptors. It has little effect on cardiac muscle contractility.
Levalbuterol (Xopenex)
Levalbuterol is used for treatment or prevention of bronchospasm. It is a selective beta2-agonist agent. Albuterol is a racemic mixture, while levalbuterol contains only the active R-enantiomer of albuterol. The S-enantiomer does not bind to beta2-receptors, but it may be responsible for some of the adverse effects of racemic albuterol, including bronchial hyperreactivity and reduced pulmonary function during prolonged use.
Antibiotics
Class Summary
Systemic and inhaled antibiotics are used in bronchiectatic disease to prevent or treat exacerbations caused by bacterial colonization that result in airway inflammation and injury. Antibiotics are generally chosen based on organisms and sensitivities from sputum cultures. The antibiotics used more commonly are listed below.
Amoxicillin and clavulanic acid (Augmentin)
Amoxicillin inhibits bacterial cell wall synthesis by binding to penicillin-binding proteins. The addition of clavulanate inhibits beta-lactamase–producing bacteria.
The product is a good alternative antibiotic for patients who are allergic or intolerant to the macrolide class. It is usually well tolerated and provides good coverage against most infectious agents. It is not effective against Mycoplasma and Legionella species. For children older than 3 months, base dosing on the amoxicillin content. Because of different amoxicillin/clavulanic acid ratios in 250-mg tablet (250/125) versus the 250-mg chewable tablet (250/62.5), do not use the 250-mg tablet until the child weighs more than 40 kg.
Ciprofloxacin (Cipro)
Amoxicillin inhibits bacterial cell wall synthesis by binding to penicillin-binding proteins. The addition of clavulanate inhibits beta-lactamase–producing bacteria.
The product is a good alternative antibiotic for patients who are allergic or intolerant to the macrolide class. It is usually well tolerated and provides good coverage against most infectious agents. It is not effective against Mycoplasma and Legionella species. For children older than 3 months, base dosing on the amoxicillin content. Because of different amoxicillin/clavulanic acid ratios in 250-mg tablet (250/125) versus the 250-mg chewable tablet (250/62.5), do not use the 250-mg tablet until the child weighs more than 40 kg.
Trimethoprim and sulfamethoxazole (Bactrim DS, Septra DS)
This agent 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 treatment of acute and chronic bronchitic symptoms in patients with bronchiectasis.
Levofloxacin (Levaquin)
Fluoroquinolones should be used empirically in patients likely to develop exacerbations due to organisms resistant to other antibiotics. Levofloxacin is rapidly becoming a popular choice in pneumonia. This is the L stereoisomer of the D/L parent compound ofloxacin, the D form being inactive. It is good monotherapy, with extended coverage against pseudomonal species and excellent activity against pneumococcal species. It acts by inhibition of DNA gyrase activity. The oral form has bioavailability that reportedly is 99%.
Azithromycin (Zithromax, Zmax)
Azithromycin, a macrolide, has bacteriostatic properties due to prevention of mRNA translation and thus stopping bacterial protein synthesis by binding the bacterial 50S ribosomal subunit. At high doses, Azithromycin can be bactericidal. Clinical use as an anti-inflammatory drug takes advange of macrolide inhibition of cell function of macrophages and inflammatory cytokines. Some guidelines do caution against use without negative docuementation of nontuberculous mycobacteria (NTM) infection and normal electrocardiogram (ECG).
Inhaled antibiotics
Class Summary
These agents are indicated in bronchiectasis, specifically in patients with CF for Pseudomonas aeruginosa –positive sputum cultures.
Tobramycin (TOBI)
Tobramycin is an aminoglycoside specifically developed for administration with a nebulizer system. When inhaled, it is concentrated in airways, where it exerts antibacterial effect by disrupting protein synthesis. This agent is active against a wide range of gram-negative organisms, including P aeruginosa. It is indicated for the treatment of patients with CF and P aeruginosa infection.
Macrolides
- Posteroanterior chest radiograph of a child with bronchiectasis due to chronic aspiration.
- CT scan of the chest of a child with bronchiectasis due to chronic aspiration.
- Chest radiograph of a child with severe adenoviral pneumonia as an infant. The child has persistent symptoms of cough, congestion, and wheezing.
- Bronchoscopic bronchogram of the left lower lobe on a patient with history of adenoviral pneumonia, demonstrating cylindrical and varicose types of bronchiectasis.
- Bronchoscopic bronchogram of the right upper lobe of a patient with a history of adenoviral pneumonia, demonstrating saccular bronchiectasis.
