Editing Bronchiectasis (section)

==Management==
A comprehensive approach to the management of bronchiectasis is recommended.<ref name="Chalmers 1446–1462">{{Cite journal|last1=Chalmers|first1=James D.|last2=Aliberti|first2=Stefano|last3=Blasi|first3=Francesco|date=May 2015|title=Management of bronchiectasis in adults|journal=The European Respiratory Journal|volume=45|issue=5|pages=1446–62|doi=10.1183/09031936.00119114 |pmid=25792635|doi-access=free}}</ref> It is important to establish whether an underlying modifiable cause, such as immunoglobulin deficiency or [[alpha-1 antitrypsin deficiency]] is present.<ref name="Chalmers 1446–1462"/> The next steps include controlling [[infection]]s and bronchial secretions, relieving airway obstructions, removing affected portions of lung by surgery, and preventing [[Complication (medicine)|complications]].<ref>{{cite journal|last1=José|first1=RJ|last2=Brown|first2=JS|date=October 2014|title=Bronchiectasis |journal=British Journal of Hospital Medicine |volume=75|issue=Suppl 10 |pages=C146-51|doi=10.12968/hmed.2014.75.Sup10.C146|pmid=25289486}}</ref>

=== Airway clearance ===
The goal of [[airway clearance therapy]] is to loosen secretions and interrupt the cycle of inflammation and infection.<ref>{{Cite journal|last1=Flude|first1=Lizzie J.|last2=Agent|first2=Penny|last3=Bilton|first3=Diana|date=June 2012|title=Chest physiotherapy techniques in bronchiectasis|journal=Clinics in Chest Medicine|volume=33|issue=2|pages=351–361|doi=10.1016/j.ccm.2012.02.009 |pmid=22640850}}</ref> [[Airway clearance technique]]s improve difficulty breathing, cough, and help patients cough up phlegm and [[Mucus|mucus plug]]s.<ref>{{Cite journal|last1=Hill|first1=Adam T.|last2=Barker|first2=Alan F.|last3=Bolser|first3=Donald C.|last4=Davenport|first4=Paul|last5=Ireland|first5=Belinda|last6=Chang|first6=Anne B.|last7=Mazzone|first7=Stuart B.|last8=McGarvey|first8=Lorcan|date=April 2018|title=Treating Cough Due to Non-CF and CF Bronchiectasis With Nonpharmacological Airway Clearance: CHEST Expert Panel Report|journal=Chest|volume=153|issue=4|pages=986–993|doi=10.1016/j.chest.2018.01.014 |pmc=6689075|pmid=29355548}}</ref> Airway clearance usually uses an inhaled agent ([[hypertonic saline]]) with [[chest physiotherapy]], such as [[Chest wall oscillation|high-frequency chest wall oscillation]].<ref name="Mc2013" /> Many airway clearance techniques and devices exist. The choice of a technique or device is based on the frequency and tenacity of phlegm, patient comfort, cost, and the patient's ability to use the technique or device with minimal interference to their lifestyle.<ref name=":2">{{Cite journal|last1=McIlwaine|first1=Maggie|last2=Bradley|first2=Judy|last3=Elborn|first3=J. Stuart|last4=Moran|first4=Fidelma|date=January 2017|title=Personalising airway clearance in chronic lung disease|journal=European Respiratory Review|volume=26|issue=143|pages=160086|doi=10.1183/16000617.0086-2016 |pmid=28223396|pmc=9488523 |doi-access=free}}</ref>
The [[Active cycle of breathing|active cycle of breathing technique]] (ACBT), which can be employed with or without a flutter device, is beneficial in treating those with bronchiectasis.<ref>{{cite journal |last1=Athawale |first1=Vrushali |last2=Lalwani |first2=Lajwanti |last3=Mishra |first3=Gyanshankar |title=Comparison of the Active Cycle of Breathing Technique ( ACBT ) versus Active Cycle of Breathing Technique with Flutter in Bronchiectasis |journal=National Journal of Medical Research |date=2020 |volume=10 |issue=4 |pages=178–180 |doi=10.6084/M9.FIGSHARE.13727290 |url=http://njmr.in/home/download/828 |access-date=2021-09-05 |archive-date=2021-09-05 |archive-url=https://web.archive.org/web/20210905062421/http://njmr.in/home/download/828 |url-status=dead }}</ref> [[Mucoactive agent|Mucolytic agents]] such as [[dornase alfa]] are not recommended for individuals with non-CF bronchiectasis.<ref name=Mc2013/> [[Mannitol]] is a hyperosmolar agent that is thought to hydrate airway secretions, however, clinical trials with it have not demonstrated efficacy.<ref name=":2" />

=== Anti-inflammatories ===
The two most commonly used classes of [[anti-inflammatory]] therapies are [[macrolide]]s and [[corticosteroid]]s.<ref name=Mc2013/>

Despite also being antibiotics, macrolides exert [[immunomodulator]]y effects on the host inflammatory response without systemic suppression of the immune system.<ref name=Mc2013/> These effects include modifying mucus production, inhibition of [[biofilm]] production, and suppression of [[inflammatory mediator]]s.<ref name=":02"/> Three large multicenter, randomized trials have shown reduced rates of exacerbations and improved cough and dyspnea with use of macrolide therapy.<ref name="auto1">{{Cite journal|last1=Polverino|first1=Eva|last2=Goeminne|first2=Pieter C.|last3=McDonnell|first3=Melissa J.|last4=Aliberti|first4=Stefano|last5=Marshall|first5=Sara E.|last6=Loebinger|first6=Michael R.|last7=Murris|first7=Marlene|last8=Cantón|first8=Rafael|last9=Torres|first9=Antoni|last10=Dimakou|first10=Katerina|last11=De Soyza|first11=Anthony|date=September 2017|title=European Respiratory Society guidelines for the management of adult bronchiectasis|journal=The European Respiratory Journal|volume=50|issue=3|pages=1700629|doi=10.1183/13993003.00629-2017 |pmid=28889110|doi-access=free}}</ref> The impact of adverse effects of macrolides such as [[gastrointestinal symptom]]s, [[hepatotoxicity]], and increased [[antimicrobial resistance]] needs ongoing review and study.<ref name=Qi2014/>

[[Inhaled corticosteroid]] therapy can reduce sputum production and decrease airway constriction over a period of time, helping prevent progression of bronchiectasis.<ref name=":3"/> Long term use of high-dose inhaled corticosteroids can lead to adverse consequences such as [[cataract]]s and [[osteoporosis]].<ref name=Mc2013/> It is not recommended for routine use in children.<ref name="HILL201122">{{cite journal|last=Hill|first=Adam T|author2=Pasteur, Mark|author3=Cornford, Charles|author4=Welham, Sally|author5=Bilton, Diana|date=1 January 2011|title=Primary care summary of the British Thoracic Society Guideline on the management of non-cystic fibrosis bronchiectasis|journal=Primary Care Respiratory Journal|volume=20|issue=2|pages=135–40|doi=10.4104/pcrj.2011.00007|pmc=6549837|pmid=21336465}}</ref> One commonly used therapy is [[beclometasone dipropionate]].<ref>{{cite journal|vauthors=Elborn JS, Johnston B, Allen F, Clarke J, McGarry J, Varghese G|year=1992|title=Inhaled steroids in patients with bronchiectasis|journal=Respir Med|volume=86|issue=2|pages=121–4|doi=10.1016/S0954-6111(06)80227-1|pmid=1615177}}</ref>

=== Antibiotics ===
[[File:Zithromax (Azithromycin) tablets.jpg|thumb|[[Azithromycin]] is a [[macrolide]] commonly used in bronchiectasis.]]

[[Antibiotic]]s are used in bronchiectasis to eradicate [[Pseudomonas aeruginosa|''P. aeruginosa'']] or [[Mrsa|MRSA]], to suppress the burden of chronic bacterial colonization, and to treat exacerbations.<ref name=Mc2013/> The use of daily oral non-macrolide antibiotic treatment has been studied in small case series, but not in randomized trials.<ref name="auto1"/> The role of inhaled antibiotics in non-CF bronchiectasis has recently evolved with two society guidelines and a systematic review suggesting a therapeutic trial of inhaled antibiotics in patients with three or more exacerbations per year and ''P. aeruginosa'' in their sputum.<ref>{{Cite journal|last1=Chang|first1=Anne B.|last2=Bell|first2=Scott C.|last3=Torzillo|first3=Paul J.|last4=King|first4=Paul T.|last5=Maguire|first5=Graeme P.|last6=Byrnes|first6=Catherine A.|last7=Holland|first7=Anne E.|last8=O'Mara|first8=Peter|last9=Grimwood|first9=Keith|last10=extended voting group|date=2015-01-19|title=Chronic suppurative lung disease and bronchiectasis in children and adults in Australia and New Zealand Thoracic Society of Australia and New Zealand guidelines|journal=The Medical Journal of Australia|volume=202|issue=1|pages=21–23|doi=10.5694/mja14.00287 |pmid=25588439|doi-access=free|hdl=10072/132638|hdl-access=free}}</ref><ref>{{Cite journal|last1=Brodt|first1=Alessandra Monteiro|last2=Stovold|first2=Elizabeth|last3=Zhang|first3=Linjie|date=August 2014|title=Inhaled antibiotics for stable non-cystic fibrosis bronchiectasis: a systematic review|journal=The European Respiratory Journal|volume=44|issue=2|pages=382–393|doi=10.1183/09031936.00018414 |pmid=24925920|doi-access=free}}</ref> Options for inhaled antibiotics include aerosolized [[tobramycin]], inhaled [[ciprofloxacin]], aerosolized [[aztreonam]], and aerosolized [[colistin]].<ref name=":02" /> However, there arises a problem with inhaled antibiotic treatments, such as ciprofloxacin, of staying in the desired area of the infected lung tissues for sufficient time to provide optimal treatment.<ref name="ReferenceA">{{Cite journal |last1=Almurshedi |first1=Alanood S. |last2=Aljunaidel |first2=Hessah A. |last3=Alquadeib |first3=Bushra |last4=Aldosari |first4=Basmah N. |last5=Alfagih |first5=Iman M. |last6=Almarshidy |first6=Salma S. |last7=Eltahir |first7=Eram KD |last8=Mohamoud |first8=Amany Z. |date=2021-03-25 |title=Development of Inhalable Nanostructured Lipid Carriers for Ciprofloxacin for Noncystic Fibrosis Bronchiectasis Treatment |journal=International Journal of Nanomedicine |language=English |volume=16 |pages=2405–2417 |doi=10.2147/IJN.S286896 |pmc=8012696 |pmid=33814907 |doi-access=free }}</ref> To combat this and prolong the amount of time the antibiotic spends in the lung tissue, current study trials have moved to develop inhalable nanostructured lipid carriers for the antibiotics.<ref name="ReferenceA"/>

=== Bronchodilators ===
Some clinical trials have shown a benefit with inhaled [[bronchodilator]]s in certain people with bronchiectasis.<ref name=Mc2013/> In people with demonstrated bronchodilator reversibility on [[spirometry]], the use of inhaled bronchodilators resulted in improved dyspnea, cough, and quality of life without any increase in adverse events.<ref name="Pasteur i1–58"/> However, overall there is a lack of data to recommend use of bronchodilators in all patients with bronchiectasis.<ref>{{Cite journal|last1=Goyal|first1=Vikas|last2=Chang|first2=Anne B.|date=2014-06-10|title=Combination inhaled corticosteroids and long-acting beta2-agonists for children and adults with bronchiectasis|journal=The Cochrane Database of Systematic Reviews|volume=2017 |issue=6|pages=CD010327|doi=10.1002/14651858.CD010327.pub2 |pmc=6483496|pmid=24913725}}</ref>

=== Surgery ===
The primary role of [[surgery]] in the management of bronchiectasis is in localized disease to [[Segmental resection|remove segments of the lung]] or to control massive [[hemoptysis]].<ref name=":02" /> Additionally, surgery is used to remove an airway obstruction that is contributing to bronchiectasis. The goals are conservative, aiming to control specific disease manifestations rather than cure or eliminate all areas of bronchiectasis.<ref name=":12">{{Cite journal|last1=Agasthian|first1=T.|last2=Deschamps|first2=C.|last3=Trastek|first3=V. F.|last4=Allen|first4=M. S.|last5=Pairolero|first5=P. C.|date=October 1996|title=Surgical management of bronchiectasis|journal=The Annals of Thoracic Surgery|volume=62|issue=4|pages=976–978; discussion 979–980|doi=10.1016/0003-4975(96)00469-9 |pmid=8823075|doi-access=free}}</ref> Surgical case series have shown low operative mortality rate (less than 2%) and improvement of symptoms in the majority of patients selected to receive surgery.<ref>{{Cite journal|last1=Zhang|first1=Peng|last2=Jiang|first2=Gening|last3=Ding|first3=Jiaan|last4=Zhou|first4=Xiao|last5=Gao|first5=Wen|date=July 2010|title=Surgical treatment of bronchiectasis: a retrospective analysis of 790 patients|journal=The Annals of Thoracic Surgery|volume=90|issue=1|pages=246–250|doi=10.1016/j.athoracsur.2010.03.064 |pmid=20609785}}</ref> However, no randomized clinical trials have been performed evaluating the efficacy of surgery in bronchiectasis.<ref name=":12" />

=== Clinical trials ===
Results from a phase 2 clinical trial were published in 2018.{{r|BRENSOCATIB}} In a placebo-controlled, double-blind study conducted in 256 patients worldwide, patients who received [[Brensocatib]] reported prolonged time to the first exacerbation and also reduced rate of yearly exacerbation.{{r|BRENSOCATIB}}