Summary of PICO questions and recommendations
| Question | Title | Recommendations |
| Question 1 | Is standardised testing for the cause of bronchiectasis beneficial when compared with no standardised testing? | We suggest the minimum bundle of aetiological tests in adults with a new diagnosis of bronchiectasis (conditional recommendation, very low quality of evidence) is: 1) Differential blood count 2) Serum immunoglobulins (total IgG, IgA, IgM) 3) Testing for allergic bronchopulmonary aspergillosis It is expected that sputum culture is undertaken for monitoring purposes of bacterial infection. Mycobacterial culture may be helpful in selected cases where non-tuberculous mycobacteria are suspected as an aetiological cause of bronchiectasis. Additional tests may be appropriate in response to specific clinical features, or in patients with severe or rapidly progressive disease. |
| Question 2 | Are courses of 14–21 days of systemic antibiotic therapy compared to shorter courses (<14 days) beneficial for treating adult bronchiectasis patients with an acute exacerbation? | We suggest acute exacerbations of bronchiectasis should be treated with 14 days of antibiotics (conditional recommendation, very low quality of evidence). It is possible that shorter or longer courses of antibiotics may be appropriate in some cases, depending on specific clinical conditions (such as exacerbation severity, patient response to treatment, or microbiology). |
| Question 3 | Is an eradication treatment beneficial for treating bronchiectasis patients with a new isolate of a potentially pathogenic microorganism in comparison to no eradication treatment? | We suggest that adults with bronchiectasis with a new isolation of P. aeruginosa should be offered eradication antibiotic treatment (conditional recommendation, very low quality of evidence). We suggest not offering eradication antibiotic treatment to adults with bronchiectasis following new isolation of pathogens other than P. aeruginosa (conditional recommendation, very low quality of evidence). |
| Question 4 | Is long-term (≥3 months) anti-inflammatory treatment compared to no treatment beneficial for treating adult bronchiectasis patients? | We suggest not offering treatment with inhaled corticosteroids to adults with bronchiectasis (conditional recommendation, low quality of evidence). We recommend not offering statins for the treatment of bronchiectasis (strong recommendation, low quality of evidence). We suggest that the diagnosis of bronchiectasis should not affect the use of inhaled corticosteroids in patients with comorbid asthma or chronic obstructive pulmonary disease (best practice advice, indirect evidence). |
| Question 5 | Is long-term antibiotic treatment (≥3 months) compared to no treatment beneficial for treating adult bronchiectasis patients? | We suggest offering long-term antibiotic treatment for adults with bronchiectasis who have three or more exacerbations per year (conditional recommendation, moderate quality of evidence). All subsequent recommendations refer to patients with three or more exacerbations per year. We suggest long-term treatment with an inhaled antibiotic for adults with bronchiectasis and chronic P. aeruginosa infection (conditional recommendation, moderate quality of evidence). We suggest macrolides (azithromycin, erythromycin) for adults with bronchiectasis and chronic P. aeruginosa infection in whom an inhaled antibiotic is contraindicated, not tolerated or not feasible (conditional recommendation, low quality of evidence). We suggest macrolides (azithromycin, erythromycin) in addition to or in place of an inhaled antibiotic, for adults with bronchiectasis and chronic P. aeruginosa infection who have a high exacerbation frequency despite taking an inhaled antibiotic (conditional recommendation, low quality of evidence). We suggest long-term macrolides (azithromycin, erythromycin) for adults with bronchiectasis not infected with P. aeruginosa (conditional recommendation, moderate quality of evidence). We suggest long-term treatment with an oral antibiotic (choice based on antibiotic susceptibility and patient tolerance) for adults with bronchiectasis not infected with P. aeruginosa in whom macrolides are contraindicated, not tolerated or ineffective (conditional recommendation, low quality of evidence). We suggest long-term treatment with an inhaled antibiotic for adults with bronchiectasis not infected with P. aeruginosa in whom oral antibiotic prophylaxis is contraindicated, not tolerated or ineffective (conditional recommendation, low quality of evidence). Long-term antibiotic therapy should be considered only after optimisation of general aspects of bronchiectasis management (airway clearance and treating modifiable underlying causes). |
| Question 6 | Is long-term mucoactive treatment (≥3 months) compared to no treatment beneficial for treating adult bronchiectasis patients? | We suggest offering long-term mucoactive treatment (≥3 months) in adult patients with bronchiectasis who have difficulty in expectorating sputum and poor quality of life and where standard airway clearance techniques have failed to control symptoms (weak recommendation, low quality of evidence). We recommend not offering recombinant human DNase to adult patients with bronchiectasis (strong recommendation, moderate quality of evidence). |
| Question 7 | Is long-term bronchodilator treatment (≥3 months) compared to no treatment beneficial for adult bronchiectasis patients? | We suggest not routinely offering long-acting bronchodilators for adult patients with bronchiectasis (conditional recommendation, very low quality of evidence). We suggest offering long acting bronchodilators for patients with significant breathlessness on an individual basis (weak recommendation, very low quality of evidence). We suggest using bronchodilators before physiotherapy, including inhaled mucoactive drugs, as well as before inhaled antibiotics, in order to increase tolerability and optimise pulmonary deposition in diseased areas of the lungs (good practice point, indirect evidence). We suggest that the diagnosis of bronchiectasis should not affect the use of long acting bronchodilators in patients with comorbid asthma or chronic obstructive pulmonary disease (good practice point, indirect evidence) [95, 96]. |
| Question 8 | Are surgical interventions more beneficial compared to standard (non-surgical) treatment for adult bronchiectasis patients? | We suggest not offering surgical treatments for adult patients with bronchiectasis with the exception of patients with localised disease and a high exacerbation frequency despite optimisation of all other aspects of their bronchiectasis management (weak recommendation, very low quality of evidence). |
| Question 9 | Is regular physiotherapy (airway clearance and/or pulmonary rehabilitation) more beneficial than control (no physiotherapy) in adult bronchiectasis patients? | We suggest that patients with chronic productive cough or difficulty to expectorate sputum should be taught an airway clearance technique by a trained respiratory physiotherapist to perform once or twice daily (weak recommendation, low quality of evidence). We recommend that adult patients with bronchiectasis and impaired exercise capacity should participate in a pulmonary rehabilitation programme and take regular exercise. All interventions should be tailored to the patient's symptoms, physical capability and disease characteristics (strong recommendation, high quality of evidence). |