Diagnosis and Treatment of Bronchiectasis

Informatic analysis of the pulmonary microecology in non-cystic fibrosis bronchiectasis at three different stages

This study explored the impact of pulmonary microecological changes on disease progression in non-cystic fibrosis bronchiectasis (nCFB). A careful search of the NCBI BioProject database revealed the 16S rRNA-based microbiological testing results of 441 pulmonary sputum samples from patients in the relatively stable (baseline), acute exacerbation, or recovery stage. After preliminary analysis and screening, we selected 152 samples for further analyses, including determination of the operational taxonomic unit (OTU) distribution at the phylum, class, order, family and genus levels, community structure, alpha diversity, beta diversity, microbial multivariables, correlations, and community structure after the abundances of intragroup samples were averaged. The recovery group showed significant differences in pulmonary microbiological changes (P < 0.05) compared with the other groups. There were 30 differentially abundant OTUs, with 27 and 7 at the genus and phylum levels, respectively. The Chao1 value of the recovery group was comparable to that of the baseline group, and the Shannon and Simpson values of the recovery group were the highest. Rhodococcus in Actinobacteria was positively correlated with Ochrobactrum in Firmicutes. The differences in pulmonary microecological changes at different nCFB stages may serve as a biologically predictive indicator of nCFB progression.

Anxiety and depression as possible criteria in the treatment of bronchiectasis

Background

The aim of this study was to investigate the effect of bronchiectasis operation on anxiety and depression.

Methods

Between August 2014 and March 2019, a total of 167 patients with bronchiectasis (107 males, 60 females; mean age: 43.5±13.9 years; range, 18 to 84 years) who received medical (n=70) and surgical (n=97) treatment were retrospectively analyzed. Data including patients" characteristics, operation indication, operation type, and bronchiectasis localization were obtained from the electronic patient files. The patients were reached via phone calls and evaluated whether the operation provided a significant symptomatic improvement and whether the symptoms disappeared. The number of exacerbations/hospitalizations associated with bronchiectasis within the last year was also questioned. The anxiety and depression status of the patients in both groups was assessed by the Hospital Anxiety and Depression Scale.

Results

Eleven (15%) patients in the medical group and 10 (10%) patients in the surgical group had an anxiety score above 7. Twenty-one (30%) patients in the medical group and 10 (10%) patients in the surgical group had a depression score above 7. Both the anxiety and depression scores were significantly lower in the surgical group than the medical group (p<0.001). Annual exacerbation and annual hospitalization rates were also significantly lower in the surgical group (p<0.001).

Conclusion

Our study results suggest that patients with bronchiectasis treated medically rather than surgically are more prone to be anxious and depressive. The benefits of surgical treatment in patients with bronchiectasis is not limited to improving symptoms and decreasing the frequency of exacerbations/hospitalizations. We believe that surgical treatment also reduces anxiety and depression and improve the quality of life. While making a surgical decision, the anxiety/depression status of bronchiectasis patients should be considered.

Effectiveness of two high frequency chest wall oscillation techniques in patients with bronchiectasis: a randomized controlled preliminary study

BACKGROUND

Chest physiotherapy is an important tool in the treatment of bronchiectasis. High frequency chest wall oscillation (HFCWO) is a technique designed to create a global percussion of the lung which moves secretions and probably clears the peripheral bronchial tree. We propose the comparison between an existing device (SmartVest) and a new device (RespIn 11).

METHODS

Sixty patients were randomized into three groups: a group was treated with SmartVest, a group with RespIn 11, and a group with pharmacological therapy alone. Primary outcome measures included exacerbations at 3, 6 and 12 months after the end of treatment. Secondary outcome measures were pulmonary function testing, arterial blood gas analysis (ABG), and hematological examinations, cough, dyspnea, health and quality of life scores (Bronchiectasis Health Questionnaire [BHQ], Breathlessness, Cough, and Sputum Scale [BCSS], COPD Assessment Test [CAT], Leicester Cough Questionnaire [LCT]). A 5-point Likert scale was used to evaluate patient's preference.

RESULTS

Both patients in the HFCWO groups showed a significant improvement in the tests of dyspnea, cough and health and quality of life score evaluations (BHQ, BCSS, CAT, LCT) compared to the control group, but not in pulmonary function tests and ABG. Only RespIn 11 significantly reduced exacerbations in comparison with the control group. RespIn 11 also had a higher score regarding patients' preference.

CONCLUSIONS

The two machines have improved health and quality of life scores in patients with bronchiectasis. RespIn 11 also demonstrated a significant lowering of exacerbations and a better patient acceptance.

The economic burden of bronchiectasis - known and unknown: a systematic review

Background

The increasing prevalence and recognition of bronchiectasis in clinical practice necessitates a better understanding of the economic disease burden to improve the management and achieve better clinical and economic outcomes. This study aimed to assess the economic burden of bronchiectasis based on a review of published literature.

Methods

A systematic literature review was conducted using MEDLINE, Embase, EconLit and Cochrane databases to identify publications (1 January 2001 to 31 December 2016) on the economic burden of bronchiectasis in adults.

Results

A total of 26 publications were identified that reported resource use and costs associated with management of bronchiectasis. Two US studies reported annual incremental costs of bronchiectasis versus matched controls of US$5681 and US$2319 per patient. Twenty-four studies reported on hospitalization rates or duration of hospitalization for patients with bronchiectasis. Mean annual hospitalization rates per patient, reported in six studies, ranged from 0.3–1.3, while mean annual age-adjusted hospitalization rates, reported in four studies, ranged from 1.8–25.7 per 100,000 population. The average duration of hospitalization, reported in 12 studies, ranged from 2 to 17 days. Eight publications reported management costs of bronchiectasis. Total annual management costs of €3515 and €4672 per patient were reported in two Spanish studies. Two US studies reported total costs of approximately US$26,000 in patients without exacerbations, increasing to US$36,00–37,000 in patients with exacerbations. Similarly, a Spanish study reported higher total annual costs for patients with > 2 exacerbations per year (€7520) compared with those without exacerbations (€3892). P. aeruginosa infection increased management costs by US$31,551 to US$56,499, as reported in two US studies, with hospitalization being the main cost driver.

Conclusions

The current literature suggests that the economic burden of bronchiectasis in society is significant. Hospitalization costs are the major driver behind these costs, especially in patients with frequent exacerbations. However, the true economic burden of bronchiectasis is likely to be underestimated because most studies were retrospective, used ICD-9-CM coding to identify patients, and often ignored outpatient burden and cost. We present a conceptual framework to facilitate a more comprehensive assessment of the true burden of bronchiectasis for individuals, healthcare systems and society.

Electronic supplementary material

The online version of this article (10.1186/s12890-019-0818-6) contains supplementary material, which is available to authorized users.

Evaluation of obstructive sleep apnea in non-cystic fibrosis bronchiectasis: A cross-sectional study

The relationship between sleep disorders and bronchiectasis has not been well described. We hypothesize that, due to the irreversible dilatation of the bronchi, the presence of secretions, and airflow obstruction, patients with non-cystic fibrosis bronchiectasis may be predisposed to hypoxemia during sleep, or to symptoms that may lead to arousal. A cross-sectional observational study was performed involving 49 patients with a clinical diagnosis of non-cystic fibrosis bronchiectasis (NCFB). All patients underwent clinical evaluation, spirometry, and polysomnography, and were evaluated for the presence of excessive daytime sleepiness (EDS) and risk of obstructive sleep apnea (OSA). The mean age of the participants was 50.3 ± 13.6 years; 51.1% of patients were male and had a mean body mass index of 23.8 ± 3.4 kg/m². The mean total sleep time (TST) was 325.15 ± 64.22 min with a slight reduction in sleep efficiency (84.01 ± 29.2%). Regarding sleep stages, stage 1 sleep and REM sleep were abnormal. OSA was present in 40.82% of the patients. The mean arousal index was 5.6 ± 2.9/h and snoring was observed in 71.43% of the patients. The oxygen desaturation index (ODI) was 14.35 ± 15.36/h, mean minimum oxygen saturation (SpO₂ nadir) was 83.29 ± 7.99%, and mean TST with an SpO₂ less than 90% was 30.21 ± 60.48 min. EDS was exhibited by 53.06% of the patients and 55.1% were at high risk of developing OSA. The patients infected by Pseudomonas aeruginosa had higher apnea-hypopnea indices, ODI, and TST with SpO₂ < 90%, and lower values of SpO₂ nadir. Adult patients with clinically stable NCFB, especially those infected by Pseudomonas aeruginosa, display EDS and a high prevalence of OSA, associated with considerable oxygen desaturation during sleep.

Risk factors for multidrug-resistant pathogens in bronchiectasis exacerbations

BACKGROUND

Non-cystic fibrosis bronchiectasis is a chronic structural lung condition that courses with recurrent infectious exacerbations that lead to frequent antibiotic treatment making this population more susceptible to acquire pathogens with antibiotic resistance. We aimed to investigate risk factors associated with isolation of multidrug-resistant pathogens in bronchiectasis exacerbations.

METHODS

A prospective observational study was conducted in two tertiary-care hospitals, enrolling patients when first exacerbation appeared. Multidrug-resistance was determined according to European Centre of Diseases Prevention and Control classification.

RESULTS

Two hundred thirty three exacerbations were included and microorganisms were isolated in 159 episodes. Multidrug-resistant pathogens were found in 20.1% episodes: Pseudomonas aeruginosa (48.5%), methicillin-resistant Staphylococcus aureus (18.2%) and Extended spectrum betalactamase + Enterobacteriaceae (6.1%), and they were more frequent in exacerbations requiring hospitalization (24.5% vs. 10.2%, p: 0.016). Three independent multidrug-resistant risk factors were found: chronic renal disease (Odds ratio (OR), 7.60, 95% CI 1.92-30.09), hospitalization in the previous year (OR, 3.88 95% CI 1.37-11.02) and prior multidrug-resistant isolation (OR, 5.58, 95% CI 2.02-15.46). The proportion of multidrug-resistant in the 233 exacerbations was as follows: 3.9% in patients without risk factors, 12.6% in those with 1 factor and 53.6% if ≥2 risk factors.

CONCLUSIONS

Hospitalization in the previous year, chronic renal disease, and prior multidrug-resistant isolation are risk factors for identification multidrug-resistant pathogens in exacerbations. This information may assist clinicians in choosing empirical antibiotics in daily clinical practice.

Clinical impact of chronic obstructive pulmonary disease on non-cystic fibrosis bronchiectasis. A study on 1,790 patients from the Spanish Bronchiectasis Historical Registry

Background

Few studies have evaluated the coexistence of bronchiectasis (BE) and chronic obstructive pulmonary disease (COPD) in series of patients diagnosed primarily with BE. The aim of this study was to analyse the characteristics of patients with BE associated with COPD included in the Spanish Bronchiectasis Historical Registry and compare them to the remaining patients with non-cystic fibrosis BE.

Methods

We conducted a multicentre observational study of historical cohorts, analysing the characteristics of 1,790 patients who had been included in the registry between 2002 and 2011. Of these, 158 (8.8%) were registered as BE related to COPD and were compared to the remaining patients with BE of other aetiologies.

Results

Patients with COPD were mostly male, older, had a poorer respiratory function and more frequent exacerbations. There were no differences in the proportion of patients with chronic bronchial colonisation or in the isolated microorganisms. A significantly larger proportion of patients with COPD received treatment with bronchodilators, inhaled steroids and intravenous antibiotics, but there was no difference in the use of long term oral or inhaled antibiotherapy. During a follow-up period of 3.36 years, the overall proportion of deaths was 13.8%. When compared to the remaining aetiologies, patients with BE associated with COPD presented the highest mortality rate. The multivariate analysis showed that the diagnosis of COPD in a patient with BE as a primary diagnosis increased the risk of death by 1.77.

Conclusion

Patients with BE related to COPD have the same microbiological characteristics as patients with BE due to other aetiologies. They receive treatment with long term oral and inhaled antibiotics aimed at controlling chronic bronchial colonisation, even though the current COPD treatment guidelines do not envisage this type of therapy. These patients’ mortality is notably higher than that of remaining patients with non-cystic fibrosis BE.

Comparison of two prognostic scores (BSI and FACED) in a Spanish cohort of adult patients with bronchiectasis and improvement of the FACED predictive capacity for exacerbations

Bronchiectasis (BE) is a chronic and heterogeneous respiratory disease that requires a multidimensional scoring system to properly assess severity. The aim of this study was to compare the severity stratification by 2 validated scores (BSI and FACED) in a BE cohort and to determine their predictive capacity for exacerbations and hospitalizations. Moreover, we proposed a modified version of FACED which was created to better predict the risk of exacerbations in clinical practice. We performed a prospective cohort study including BE patients >18 years old with a follow-up period of 1-year. One-hundred eighty-two patients (40% males; mean age 68) were studied. Patients were stratified according to the number of exacerbations during the follow-up, and according to BSI and FACED scores. BSI classified most of our patients as severe 99 (54.4%) or moderate 47 (25.8%), while FACED mainly classified as mild 108 (59.3%) or moderate 61 (33.5%). BSI and FACED showed an area under ROC curve (AUC) for exacerbations of 0.808 and 0.734; and for hospitalizations (due to BE exacerbations) of 0.893 and 0.809, respectively. Subsequently, we modified FACED by adding previous exacerbations (Exa-FACED) and this new score classified patients as mild 48.4%, moderate 34.6% and severe 17.0%, with an improved AUC for exacerbations (0.760) and hospitalizations (0.820). Despite previous validations of BSI and FACED, they classified our patients very differently. As expected, FACED showed poor prognostic capacity for exacerbations. We support the Exa-FACED score to predict the risk future exacerbations for been easy to use in clinical practice.

Inhaled Antibiotics for Gram-Negative Respiratory Infections

Gram-negative organisms comprise a large portion of the pathogens responsible for lower respiratory tract infections, especially those that are nosocomially acquired, and the rate of antibiotic resistance among these organisms continues to rise. Systemically administered antibiotics used to treat these infections often have poor penetration into the lung parenchyma and narrow therapeutic windows between efficacy and toxicity. The use of inhaled antibiotics allows for maximization of target site concentrations and optimization of pharmacokinetic/pharmacodynamic indices while minimizing systemic exposure and toxicity. This review is a comprehensive discussion of formulation and drug delivery aspects, in vitro and microbiological considerations, pharmacokinetics, and clinical outcomes with inhaled antibiotics as they apply to disease states other than cystic fibrosis. In reviewing the literature surrounding the use of inhaled antibiotics, we also highlight the complexities related to this route of administration and the shortcomings in the available evidence. The lack of novel anti-Gram-negative antibiotics in the developmental pipeline will encourage the innovative use of our existing agents, and the inhaled route is one that deserves to be further studied and adopted in the clinical arena.