Lung transplantation for non-cystic fibrosis bronchiectasis

Antibody Deficiency, Chronic Lung Disease, and Comorbid Conditions: A Case-Based Approach

New emerging pulmonary phenotypes associated with antibody deficiency, such as neutrophilic asthma, frequent exacerbations of chronic obstructive pulmonary disease, and unexplained interstitial lung disease, particularly in younger adults, are discussed in this review through a case-based approach. Also discussed in similar fashion are antibody deficiency syndromes that lead to end-stage lung disease and the indications for lung transplantation in primary immunodeficiency disease. These challenging cases require timely and individualized strategies for genetic and immunologic diagnosis, decisions about therapeutic approaches, and long-term monitoring.

Bilateral Lung Transplantation for Patients With Destroyed Lung and Asymmetric Chest Deformity

Background: Destroyed lung can cause mediastinal displacement and asymmetric chest deformity. Reports on bilateral lung transplantation (LT) to treat destroyed lung and asymmetric chest deformity are rare. This study presents our surgical experience of bilateral LT among patients with destroyed lung and asymmetric chest deformity.

Methods: Six patients with destroyed lung and asymmetric chest deformity who underwent bilateral LT at our center from 2005 to 2020 were included in the study. Demographic data, technical data, perioperative details, and short-term follow-up data were reviewed.

Results: Three patients underwent bilateral LT via anterolateral incisions in the lateral position without sternal transection, while three patients underwent bilateral LT via clam-shell incisions in the supine position with sternal transection. Only one patient required intraoperative extracorporeal membrane oxygenation. Four patients underwent size-reduced LT. In the other two patients, we restored the mediastinum by releasing mediastinal adhesions to ensure maximal preservation of the donor lung function. Patients in the lateral position group had a higher volume of blood loss, longer operation time, and longer postoperative in-hospital stay than those in the supine position group. However, these differences were not statistically significant. Postoperative computed tomography in the supine position group revealed that the donor lungs were well expanded and the mediastina were in their original positions.

Conclusions: Although bilateral LT in patients with destroyed lung and asymmetric chest deformity is high risk, with sufficient preoperative preparation and evaluation, it is safe and feasible to perform bilateral LT for selected patients. For patients without severe chest adhesions, releasing the mediastinal adhesions and restoring the mediastinum through a clam-shell incision in the supine position is a simple and effective method to maximally preserve the donor lung function without pneumonectomy or lobectomy.

The Deteriorating Patient: Therapies Including Lung Transplantation

In this review paper, we discuss the characteristics that define severe bronchiectasis and which may lead to deterioration of noncystic fibrosis bronchiectasis. These characteristics were used to establish the current severity scores: bronchiectasis severity index (BSI), FACED, and E-FACED (exacerbation frequency, forced expiratory volume in 1 second, age, colonization, extension and dyspnea score). They can be used to predict mortality, exacerbation rate, hospital admission, and quality of life. Furthermore, there are different treatable traits that contribute to severe bronchiectasis and clinical deterioration. When present, they can be a target of the treatment to stabilize bronchiectasis.One of the first steps in treatment management of bronchiectasis is evaluation of compliance to already prescribed therapy. Several factors can contribute to treatment adherence, but to date no real interventions have been published to ameliorate this phenomenon. In the second step, treatment in deteriorating patients with bronchiectasis should be guided by the predominant symptoms, for example, cough, sputum, difficulty expectoration, exacerbation rate, or physical impairment. In the third step, we evaluate treatable traits that could influence disease severity in the deteriorating patient. Finally, in patients who are difficult to treat despite maximum medical treatment, eligibility for surgery (when disease is localized), should be considered. In case of end-stage disease, the evaluation for lung transplantation should be performed. Noninvasive ventilation can serve as a bridge to lung transplantation in patients with respiratory failure.

ECG Abnormalities in Patients with Acute Exacerbation of Bronchiectasis and Factors Associated with High Probability of Abnormality

BACKGROUND

Bronchiectasis is an important reason for morbidity and mortality according to the last records that referred to high incidence rate of disease. Cardiovascular problems are common in pulmonary diseases, in general, and it can symptom by ECG abnormalities. The objective of this study was to define the most ECG abnormalities in patients with acute exacerbation of bronchiectasis and to study the correlation between the cardiac disorder and the other risk factors of the exacerbation.

MATERIALS AND METHODS

A prospective single-center observational cohort study was done at Aleppo University Hospital for patients with AEB between October 2017 and September 2018. They were divided into 2 groups (normal ECG vs. abnormal). Patients with COPD, cystic fibrosis, new diagnosis of ischemic accident through the last 6 months of the study, and treatment with macrolides or fluoroquinolones through the last 3 months of the study were excluded. We study the percent of abnormalities through the AEB and the percentage of the most common abnormalities.

RESULTS

67 patients were included in the study (44 males and 23 females) with a mean age of 52.85 ± 21.456. ECG abnormalities were recorded in 43 patients, and it was more common in men (67.44% of cases). Advanced age and survival state had a statistical significance (p = 0.003, 0.023), respectively, between the 2 groups. Right axis deviation (RAD) is the most common abnormality (23.3%) followed by sinus tachycardia (20.9%), and it is close to T-depression (18.6%). AF was the most common arrhythmia from all recorded arrhythmias (6.98% from all cases). Positive sputum cultures were recorded in 55.8%, and the most common isolated pathogen factor was Pseudomonas aeruginosa. Recurrent pneumonia was seen in 30.2% of all patients with abnormal ECG. We find a high prevalence of ECG abnormalities in patients with Oximetry (90-95%, 39.5%), and the opportunity for abnormalities is equal in the 2 age groups (45-59 and more than 75) that reflexed the possibility of cardiac disorders in any age in patients with AEB.

CONCLUSIONS

ECG abnormalities are common in AEB, and it can happen in any age and any value of Oximetry. It needs more attention because of the prognosis of the cardiac morbidity.

Lung transplantation for non-cystic fibrosis bronchiectasis in Turkey: Initial institutional experience

BACKGROUND/OBJECTIVE

Lung transplantation is a well-established treatment in patients who have bronchiectasis with diffuse involvement, and with a progressive decline in respiratory function despite maximal medical therapy. We have aimed to present pre-transplantation factors and our results of lung transplantation for non-cystic fibrosis bronchiectasis.

METHODS

Patients who underwent lung transplantation for non-cystic fibrosis bronchiectasis between the dates of December 2016 and July 2019 were included. The patients' clinical parameters, pulmonary function tests, microbiological results, cardiac parameters, intraoperative data, and lung transplant outcomes were assessed retrospectively.

RESULTS

Bilateral lung transplantation for bronchiectasis were performed in eleven patients. The mean age was 36.5 years (range 22-57 years). There were 4 (36.4%) female patients and 7 (63.6%) male patients. All patients had a high score as per the bronchiectasis severity index (BSI). The FACED score was moderate in six patients and severe in five patients. Preoperative colonization with Pseudomonas aeruginosa was observed in five patients. Hospital mortality was 18.2% (2/11). The 1-year mortality was 27.2% (3/11). Eight patients were alive. The mean follow-up period of patients with survival was 28.2 months (range 13-42 months). One patient was diagnosed with chronic lung allograft dysfunction (CLAD). The 3-year survival rates were 73%.

CONCLUSION

Lung transplantation for bronchiectasis with end-stage lung disease can improve the quality of life and increase survival in selected patients. Further studies are needed to identify the optimal time for lung transplantation referral due to the availability of limited data.

Outcomes Of Non-Cystic Fibrosis Related Bronchiectasis Post Lung Transplantation

BACKGROUND

Lung transplantation is a recognised treatment for end-stage lung disease due to bronchiectasis. Non-CF bronchiectasis and CF are often combined into one cohort, however outcomes for non-CF bronchiectasis patients varies between centres, and in comparison to those for CF.

AIMS

To compare lung transplantation mortality and morbidity of bronchiectasis (non-CF) patients to those with CF and other indications.

METHODS

Retrospective analysis of patients undergoing lung transplantation between 01 January 2008-31 December 2013. Time to and cause of lung allograft loss was censored on 01 April 2018. A case-note review was conducted on a sub-group of 78 patients, to analyse hospital admissions as a marker of morbidity.

RESULTS

341 patients underwent lung transplantation, 22 (6%) had bronchiectasis compared to 69 (20%) with CF. The 5-year survival for the bronchiectasis group was 32%, compared to CF 69%, obstructive lung disease (OLD) 64%, pulmonary hypertension 62% and ILD 55% (p = 0.008). Lung allograft loss due to CLAD with predominant infection was significantly higher in the bronchiectasis group at 2 years. The rate of acute admissions was 2.24 higher in the bronchiectasis group when compared to OLD (p = 0.01). Patients with bronchiectasis spent 45.81 days in hospital per person year after transplantation compared with 18.21 days for CF.

CONCLUSIONS

Bronchiectasis patients in this study had a lower 5-year survival and poorer outcomes in comparison to other indications including CF. Bronchiectasis should be considered a separate entity to CF in survival analysis. This article is protected by copyright. All rights reserved.

Managing Bronchiectasis: 13 Years of Experience from Sputum to Lung Transplantation

OBJECTIVES

Bronchiectasis and especially related mortality has gained growing interest in recent years. The aim of our retrospective study was to determine the factors which may influence and indicate mortality in our bronchiectasis patients throughout 13 years.

MATERIAL AND METHODS

Patients with ICD-10 code J47 depicting bronchiectasis between 1.1.2003 to 31.12.2015 were evaluated using database of our hospital.694 out of 1470 patients who had high-resolution computed tomography (HRCT) scan confirming the presence of bronchiectatic lesions were included.

RESULTS

Female/male ratio was 1.09. Mean age of the patients was 45.9±15.7 years. Sputum culture results were available in 365 (52.6%)of the patients. Pseudomonas aeruginosa was the leading pathogen, which was found in 68 (20.7%) patients. 28 (4%) patients have died during the 13 year period, and the overall survival was 125,3 months. In general 5 (4.4%) out of 112 patients who underwent surgery were lost, 3 of them belonging to the transplantation group. 3 out of 9 patients (33%) who underwent lung transplantation were lost within 3 years. There was no statistically significant difference in survival between patients who underwent surgery or not (p>0.05).In univariate Cox regression mortality analysis age, FEV1, P. aeruginosa, E.coli, hospitalisation and ICU admission had p value <0.01. When these factors were evaluated in the multivariate analysis, only P.aeruginosa reached statistical significance in predicting mortality.

CONCLUSION

Isolation of P.aeruginosa in a patient with bronchiectasis should be taken seriously. It can be suggested that eradication treatment according to guidelines will help reduce mortality of bronchiectasis worldwide. Surgery is still an option of treatment in severe bronchiectasis and lung transplantation may be a life-saving way of managing end-stage disease.

Noncystic fibrosis bronchiectasis management: opportunities and challenges

PURPOSE OF REVIEW

Noncystic fibrosis bronchiectasis is a challenging disease which carries a heavy healthcare burden and significant mortality and morbidity. This review highlights the challenges in the diagnosis of bronchiectasis and discusses the management strategies and research opportunities in this field.

RECENT FINDINGS

The challenges in the management of bronchiectasis appear to be multifactorial, arising from both etiological heterogeneity and disease-specific management. Frequent inflammation and infections not only lead to progressive respiratory failure but also increase the risk of cardiovascular complications. No therapies are approved specifically for adult bronchiectasis, but new guidelines and recent studies outline strategies for control of infection and inflammation and for prevention of frequent exacerbations to improve overall prognosis.

SUMMARY

Recent studies in the management of bronchiectasis are encouraging. Advances have been made in understanding both disease heterogeneity and best practices for care; interventions such as daily mucociliary clearance, eradication of colonized microbial organisms, and control of inflammation may result in favorable outcomes.

Noncystic Fibrosis Bronchiectasis: Evaluation of an Extensive Diagnostic Protocol in Determining Pediatric Lung Disease Etiology

Introduction: Pediatric noncystic fibrosis (CF) bronchiectasis has a variety of causes. An early and accurate diagnosis may prevent disease progression and complications. Current diagnostics and yield regarding etiology are evaluated in a pediatric cohort at a tertiary referral center. Methods: Available data, including high-resolution computed tomography (HRCT) characteristics, microbiological testing, and immunological screening of all children diagnosed with non-CF bronchiectasis between 2003 and 2017, were evaluated. Results: In 91% of patients [n = 69; median age 9 (3-18 years)] etiology was established in the diagnostic process. Postinfection (29%) and immunodeficiency (29%) were most common, followed by congenital anomalies (10%), aspiration (7%), asthma (6%), and primary ciliary dyskinesia (1%). HRCT predominantly showed bilateral involvement in immunodeficient patients (85%) and those with idiopathic bronchiectasis (83%). Congenital malformations (71%) were associated with unilateral disease. Completion of the diagnostic process often led to a change of treatment as started after initial diagnosis. Conclusion: Using a comprehensive diagnostic protocol, the etiology of pediatric non-CF bronchiectasis was established in more than 90% of patients. HRCT provides additional diagnostic information as it points to either a more systemic or a more localized etiology. Adequate diagnostics and data analysis allow treatment to be specifically adapted to prevent disease progression.

Brazilian consensus on non-cystic fibrosis bronchiectasis

Bronchiectasis is a condition that has been increasingly diagnosed by chest HRCT. In the literature, bronchiectasis is divided into bronchiectasis secondary to cystic fibrosis and bronchiectasis not associated with cystic fibrosis, which is termed non-cystic fibrosis bronchiectasis. Many causes can lead to the development of bronchiectasis, and patients usually have chronic airway symptoms, recurrent infections, and CT abnormalities consistent with the condition. The first international guideline on the diagnosis and treatment of non-cystic fibrosis bronchiectasis was published in 2010. In Brazil, this is the first review document aimed at systematizing the knowledge that has been accumulated on the subject to date. Because there is insufficient evidence on which to base recommendations for various treatment topics, here the decision was made to prepare an expert consensus document. The Brazilian Thoracic Association Committee on Respiratory Infections summoned 10 pulmonologists with expertise in bronchiectasis in Brazil to conduct a critical assessment of the available scientific evidence and international guidelines, as well as to identify aspects that are relevant to the understanding of the heterogeneity of bronchiectasis and to its diagnostic and therapeutic management. Five broad topics were established (pathophysiology, diagnosis, monitoring of stable patients, treatment of stable patients, and management of exacerbations). After this subdivision, the topics were distributed among the authors, who conducted a nonsystematic review of the literature, giving priority to major publications in the specific areas, including original articles, review articles, and systematic reviews. The authors reviewed and commented on all topics, producing a single final document that was approved by consensus.

Lung Transplantation for Cystic Fibrosis and Non-cystic Fibrosis Bronchiectasis: A Single-Center Experience

OBJECTIVES

Lung transplantation is a well-established treatment for selected patients with advanced cystic fibrosis (CF)- and non-cystic fibrosis (non-CF)--related bronchiectasis. Because the number of lung transplants performed for patients with non-CF bronchiectasis is much smaller than for patients with CF, little data is available regarding patient selection, choice of procedure, and outcomes.

METHODS

Between November 1997 and December 2013, 42 patients with CF and 33 patients with non-CF bronchiectasis underwent lung transplantation at the Rabin Medical Center, Israel. We analyzed and compared pretransplant evaluation data and short- and long-term results in both groups.

RESULTS

Median survival for the CF group in our study was 8.4 years, compared with 7.1 years for the non-CF group (P = .098), similarly to that reported by the International Society for Heart and Lung Transplantation Registry data. The main survival difference between groups was in the early postoperative period. Both groups achieved similar peak forced expiratory volume in 1 second values and had stable lung function at the 3-year follow-up. Biopsy-proven rates of acute cellular rejection were low for both groups. Rates of chronic lung allograft dysfunction development did not differ between CF and non-CF recipients.

CONCLUSION

Our institutional experience confirms that lung transplantation is feasible for non-CF bronchiectasis, and results are comparable to our CF cohort. The increased early mortality in this study occurred from 1999 to 2008 and was probably related to surgical techniques used at the time. Overall, 3-year and 5-year survival were comparable with the International Society for Heart and Lung Transplantation Registry data. Non-CF bronchiectasis patients achieved and maintained satisfactory lung function.

[Selection of lung transplant candidates in France in 2019]

INTRODUCTION

In 2015, the International Society for Heart and Lung Transplantation (ISHLT) published a consensus document for the selection of lung transplant candidates. In the absence of recent French recommendations, this guideline is useful in order to send lung transplant candidates to the transplantation centers and to list them for lung transplantation at the right time.

BACKGROUND

The main indications for lung transplantation in adults are COPD and emphysema, idiopathic pulmonary fibrosis and interstitial diseases, cystic fibrosis and pulmonary arterial hypertension (PAH). The specific indications for each underlying disease as well as the general contraindications have been reviewed in 2015 by the ISHLT. For cystic fibrosis, the main factors are forced expiratory volume in one second, 6-MWD, PAH and clinical deterioration characterized by increased frequency of exacerbations; for emphysema progressive disease, the BODE score, hypercapnia and FEV1; for PAH progressive disease or the need of specific intravenous therapy and NYHA classification. Finally, the diagnosis of fibrosing interstitial lung disease is usually a sufficient indication for lung transplantation assessment.

OUTLOOK AND CONCLUSION

These new recommendations, close to French practices, help clinicians to find the right time for referral of patients to transplantation centers. This is crucial for the prognosis of lung transplantation.

Outcomes of lung transplantation in adults with bronchiectasis

Background

Lung transplantation is a well-established treatment for end-stage non-cystic fibrosis bronchiectasis (BR), though information regarding outcomes of transplantation remains limited. Our results of lung transplantation for Br are reported here.

Methods

A retrospective review of case notes and transplantation databases was conducted for patients that had underwent lung transplantation for bronchiectasis at the Freeman Hospital between 1990 and 2013.

Results

Fourty two BR patients underwent lung transplantation, the majority (39) having bilateral sequential lung transplantation. Mean age at transplantation was 47.1 years. Pre-transplantation osteoporosis was a significant non-pulmonary morbidity (48%). Polymicrobial infection was common, with Pseudomonas aeruginosa infection frequently but not universally observed (67%). Forced expiratory volume in 1 second (% predicted) improved from a pre-transplantation mean of 0.71 L (22% predicted) to 2.56 L (79 % predicted) at 1-year post-transplantation. Our survival results were 74% at 1 year, 64% at 3 years, 61% at 5 years and 48% at 10 years. Sepsis was a common cause of early post-transplantation deaths.

Conclusions

Lung transplantation for end-stage BR is a useful therapeutic option, with good survival and lung function outcomes. Survival values were similar to other bilateral lung transplants at our centre. Pre-transplantation Pseudomonas infection is common.

Aberrant epithelial remodeling with impairment of cilia architecture in non-cystic fibrosis bronchiectasis

BACKGROUND

Aberrant epithelial remodeling and/or abnormalities in mucociliary apparatus in airway epithelium contribute to infection and inflammation. It is uncertain if these changes occur in both large and small airways in non-cystic fibrosis bronchiectasis (non-CF bronchiectasis). In this study, we aim to investigate the histopathology and inflammatory profile in the epithelium of bronchi and bronchioles in bronchiectasis.

METHODS

Excised lung tissue sections from 52 patients with non-CF bronchiectasis were stained with specific cellular markers and analyzed by immunohistochemistry and immunofluorescence to assess the epithelial structures, including ciliated cells and goblet cells morphology. Inflammatory cell counts and ciliary proteins expression levels of centrosomal protein 110 (CP110) and dynein heavy chain 5, axonemal (DNAH5) were assessed.

RESULTS

Epithelial hyperplasia is found in both bronchi and bronchioles in all specimens, including hyperplasia and/or hypertrophy of goblet cells. The median cilia length is longer in hyperplastic epithelium [bronchi: 8.16 (7.03-9.14) µm, P<0.0001; bronchioles: 7.46 (6.41-8.48) µm, P<0.0001] as compared to non-hyperplastic epithelium (bronchi: 5.60 µm; bronchioles: 4.89 µm). Hyperplastic epithelium is associated with overexpression of CP110 and decreased intensity of DNAH5 expression in both bronchial and bronchiolar epithelium. Though infiltration of neutrophils is predominant (63.0% in bronchi and 76.7% in bronchioles), eosinophilic infiltration is also present in the mucosa of bronchi (30.8%) and bronchioles (54.8%).

CONCLUSIONS

Aberrant epithelial remodeling with impaired mucociliary architecture is present in both large and small airways in patients with refractory non-CF bronchiectasis. Future studies should evaluate the interplay between these individual components in driving chronic inflammation and lung damage in patients.

A review of the etiology and clinical presentation of non-cystic fibrosis bronchiectasis: A tertiary care experience

INTRODUCTION

Non-cystic fibrosis(CF) bronchiectasis has been recognized in children for the past 200 years. Early childhood pneumonia and underlying conditions such as immunodeficiency, primary ciliary dyskinesia(PCD), and congenital lung pathology should be considered in the etiology. The aim of our study was to describe the clinical characteristics, laboratory, and radiological findings of a large population of patients with non-CF bronchiectasis at a tertiary center.

METHODS

We analyzed the clinical findings of 187 patients diagnosed with non-CF bronchiectasis over a period of 10 years (January 2005-December 2015) at the Hacettepe University Faculty of Medicine Department of Pediatric Pulmonology.

RESULTS

The median age at the time of diagnosis of non-CF bronchiectasis was 8 years (1-18 years). Consanguinity was positive in 59.4% (n = 111) of patients and 19.8% (n = 37) of patients had a positive family history for non-CF bronchiectasis. Common causes were PCD in 51.3% (n = 96), immunodeficiency in 15% (n = 28), history of tuberculosis in 5.9% (n = 11), post-infectious complication in 3.2% (n = 6) and other anomalies in 2.1% (n = 4) of patients. The frequency of pulmonary lobe involvement was as follows: 71.1% left-lower lobe, 59.4% right lower lobe, 54% right-middle lobe, 26.8% left lingula, 13.9% right upper lobe, and 9.6% left upper lobe.

CONCLUSIONS

Diagnosis of non-CF bronchiectasis is often delayed because of a failure to recognize the significance of symptoms. Through clinical investigation, including a HRCT scan of the chest, sweat test, studies of immune function, and ciliary function in a child with a prolonged suppurative cough, remains important. In Turkey, the most common causes of non-CF bronchiectasis are PCD and immunodeficiency, related to a high frequency of consanguinity.

The pharmacological treatment of bronchiectasis

INTRODUCTION

Until recently considered as a minor health problem, the role of bronchiectasis is now increasingly recognized. New specific drugs are being approved for treatment of bronchiectasis. Possibly they will offer better perspectives to bronchiectatic subjects with evolving course. Areas covered: We provide an overview of aetiopathogenesis, clinics and non-pharmacological management, extending the topic of pharmacological treatment. Present therapies were extrapolated from other chronic lung diseases, but newer promising specific drugs are being awaited. Therapy aims at improving mobilisation of bronchial secretions and, if any, reversing airflow obstruction. Antibiotics are indicated to treat exacerbations, eradicate or reduce sputum bacterial load. Expert commentary: Over the last years evidence is mounted that bronchiectatic subjects with accelerated course of disease should be referred to secondary and tertiary centres. This requires increased awareness on the role and the frequency of bronchiectasis in primary care. Long-term continuous or cyclical use of antibiotics is recommended to stabilize or improve the course of evolving disease. Macrolides are a currently preferred option. Inhaled antibiotics are gaining importance and are the object of ongoing research interest. Practical challenges of inhaled antibiotic treatment remain the need of defining the best therapeutic regimen and optimizing true adherence.

Diagnosis and management of bronchiectasis

KEY POINTS Following a diagnosis of bronchiectasis, it is important to investigate for an underlying cause. Goals of management are to suppress airway infection and inflammation, to improve symptoms and health-related quality of life. There are now validated scoring tools to help assess disease severity, which can help to stratify management. Good evidence supports the use of both exercise training and long-term macrolide therapy in long-term disease management.

Comorbidities and the risk of mortality in patients with bronchiectasis: an international multicentre cohort study

BACKGROUND

Patients with bronchiectasis often have concurrent comorbidities, but the nature, prevalence, and impact of these comorbidities on disease severity and outcome are poorly understood. We aimed to investigate comorbidities in patients with bronchiectasis and establish their prognostic value on disease severity and mortality rate.

METHODS

An international multicentre cohort analysis of outpatients with bronchiectasis from four European centres followed up for 5 years was done for score derivation. Eligible patients were those with bronchiectasis confirmed by high-resolution CT and a compatible clinical history. Comorbidity diagnoses were based on standardised definitions and were obtained from full review of paper and electronic medical records, prescriptions, and investigator definitions. Weibull parametric survival analysis was used to model the prediction of the 5 year mortality rate to construct the Bronchiectasis Aetiology Comorbidity Index (BACI). We tested the BACI as a predictor of outcomes and explored whether the BACI added further prognostic information when used alongside the Bronchiectasis Severity Index (BSI). The BACI was validated in two independent international cohorts from the UK and Serbia.

FINDINGS

Between June 1, 2006, and Nov 22, 2013, 1340 patients with bronchiectasis were screened and 986 patients were analysed. Patients had a median of four comorbidities (IQR 2-6; range 0-20). 13 comorbidities independently predicting mortality rate were integrated into the BACI. The overall hazard ratio for death conferred by a one-point increase in the BACI was 1·18 (95% CI 1·14-1·23; p<0·0001). The BACI predicted 5 year mortality rate, hospital admissions, exacerbations, and health-related quality of life across all BSI risk strata (p<0·0001 for mortality and hospital admissions, p=0·03 for exacerbations, p=0·0008 for quality of life). When used in conjunction with the BSI, the combined model was superior to either model alone (p=0·01 for combined vs BACI; p=0·008 for combined vs BSI).

INTERPRETATION

Multimorbidity is frequent in bronchiectasis and can negatively affect survival. The BACI complements the BSI in the assessment and prediction of mortality and disease outcomes in patients with bronchiectasis.

FUNDING

European Bronchiectasis Network (EMBARC).