Screening for primary immune deficiency among patients with bronchiectasis

INTRODUCTION

To assess frequency and methods of PID (primary immune deficiency) screening among patients with bronchiectasis by pneumologists in clinical practice.

METHODS

All the patients hospitalized in the department of pneumology of the Poitiers University Hospital between April 2013 and April 2020 with a diagnosis of bronchiectasis on chest computerized tomography were included. Patients aged 70 and over and those with already known PID were excluded. Primary endpoint was the proportion of patients having had serum immunoglobulin (Ig) assay and serum protein electrophoresis (SPE) analysis. Secondary endpoints were factors associated with prescription of SPE and/or Ig assay, proportion of patients with newly diagnosed PID and their characteristics and factors associated with repeated courses of antibiotics.

RESULTS

Among the 133 patients included, 43% had SPE+Ig assay, 34% SPE only and 23% neither. The proportion of patients with asthma was higher in the "SPE+Ig assay" group (33.3%) compared to the "SPE only" (11.1%) and the "Neither SPE nor Ig assay" groups (6.4%) (P=0.002). Four patients were newly diagnosed for PID of whom 3 had subclass IgG deficiency. Factors associated with repeated courses of antibiotics were generalized bronchiectasis (P=0.02) and asthma (P=0.04).

CONCLUSION

PID is underscreened by pneumologists among patients with bronchiectasis. Association of SPE+Ig assay+IgG subclass assay appears as the most accurate combination.

Decrease in Readmissions after Hospitalisation for COPD Exacerbation through a Home Care Model

Objective

To decrease readmissions at 30 and 90 days post-discharge from a hospital admission for chronic obstructive pulmonary disease exacerbation (COPDE) through the home care model of the Ambulatory Chronic Respiratory Care Unit (ACRCU), increase patient survival at one year, and validate our readmission risk scale (RRS).

Materials and methods

This was an observational study, with a prospective data collection and a retrospective data analysis. A total of 491 patients with a spirometry diagnosis of chronic obstructive pulmonary disease (COPD) requiring hospitalisation for an exacerbation were included in the study. Subjects recruited within the first year (204 cases) received conventional care (CC). In the following year a home care (HC) programme was implemented and of those recruited that year (287) 104 were included in the ACRCU, administered by a specialised nurse.

Results

In the group of patients included in the home care model of the Ambulatory Chronic Respiratory Care Unit (ACRCU) a lower number of readmissions was observed at 30 and 90 days after discharge (30.5% vs. 50%, p = 0.012 and 47.7% vs. 65.2%, p = 0.031, respectively) and a greater one-year survival (85.3% vs. 59.1%, p < 0.001). The validation of our RRS revealed that the tool's capacity to predict readmissions at both 30 and 90 days was not high (AUC = 0.69 and AUC = 0.66, respectively).

Conclusions

The inclusion of exacerbator or fragile COPD patients in the ACRCU could achieve a decrease in readmissions and an increase in survival. The number of episodes of exacerbation within the 12 months prior to the hospital admission is the variable that best predicts the risk of readmission.

Critical appraisal of international adult bronchiectasis guidelines using the AGREE II tool

BACKGROUND

Guidelines aim to standardize and optimize diagnosis and management. We evaluated the quality of evidence supporting recommendations from different international adult guidelines on bronchiectasis, and classified with the GRADE system.

METHODS

Quality of eligible clinical practice guidelines was assessed for six domains using the AGREE II tool, with ≥ 80% rating as excellent.

RESULTS

Seven guidelines (283 recommendations) were analyzed, and four of them were considered "recommended for use" (three reported after 2017 as excellent). Overall, 144 (50.9%) recommendations were based on low-quality evidence, representing 81.5% in diagnosis and 36.2% in therapy. In contrast, 5/92 (5.4%) and 40/191 (20.9%) recommendations regarding diagnostic and treatment (respectively) were based on high-quality evidence. Quality agreement ratings were significantly (p< 0.05) higher for guidelines delivered after 2015, progressing from 27.7% to 58.3%, qualifying as excellent. Highest scores were documented in the domains of "scope and purpose" followed by "clarifying of presentation" and "editorial independence".

CONCLUSION

Updated guidelines reported after 2017 improved quality, although well-designed randomized clinical trials remain an unmet need. AGREE II quality assessment identified four guidelines qualified as recommended for use. Improvements are required in stakeholder involvement and applicability.

Inhaled antibiotics for treatment of adults with non-cystic fibrosis bronchiectasis: A systematic review and meta-analysis

BACKGROUND

Inhaled antibiotics (IA) in non-cystic fibrosis bronchiectasis (NCFB) are recommended by some clinical practice guidelines for prevention or treatment of NCFB exacerbations.

METHODS

We performed a systematic review and meta-analysis to evaluate the efficacy and safety of IA use for treatment of adults with NCFB and Pseudomonas aeruginosa chronic bronchial infection. The search was performed in the Cochrane Library, PubMed, and Web of Science databases from 2000 to 2019. Studies of IA for treatment of stable or exacerbated NCFB adults (≥18 years) with P. aeruginosa infection were considered eligible. PROSPERO Registration number: CRD42019136154.

RESULTS

Twelve trials (2476 participants) were included. IA therapy increased P. aeruginosa eradication from sputum in patients with exacerbations (OR: 3.19, 95%CI: 1.70-5.99) with similar effects on stable patients (OR: 7.22, 95%CI: 2.81-18.59), and a trend to reduced emergence of new respiratory pathogens (OR: 0.58, 95%CI: 0.28-1.18). IA achieved significant reduced exacerbation rates (RR: 0.90; 95%CI: 0.82-0.98) in stable patients, with a number needed to treat (NNT) of 59, but no significant changes in FEV₁, mortality, hospitalizations or quality of life were identified. In stable patients, IA use increased antimicrobial resistance (RR: 2.10, 95%CI: 1.35-3.27) at the end of therapy, with a number needed to treat of 6.

CONCLUSIONS

IA therapy achieved a statistically significant eradication of P. aeruginosa from sputum, with a 10% reduction of exacerbations in stable patients. This effect has to be balanced with significant increases in antimicrobial resistance. Our meta-analysis failed to show a significant benefit in terms of patient-centered outcomes.

Airway Clearance and Mucoactive Therapies

The respiratory system is constantly exposed to external pathogens but has different and effective defense systems. The pathophysiology of bronchiectasis affects the defense system considerably in that alterations occur in the airway that reduce its effectiveness in mucociliary clearance and the greater presence of mucins leads to the accumulation of more adherent and viscous mucus. One of the pillars of treatment of this disease should be improvement of mucociliary clearance and a decrease in the adherence and viscosity of the mucus. To this end, the mobilization of secretions must be increased through effective respiratory physiotherapy techniques, which can be manual and/or instrumental. The properties of mucus can be modified to improve its mobilization through the use of a mucoactive agent. Despite the increase in the number and quality of studies, the evidence for these treatments remains scarce, although their application is recommended in all guidelines.

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.

Antimicrobial Resistance in Common Respiratory Pathogens of Chronic Bronchiectasis Patients: A Literature Review

Non-cystic fibrosis bronchiectasis is a chronic disorder in which immune system dysregulation and impaired airway clearance cause mucus accumulation and consequent increased susceptibility to lung infections. The presence of pathogens in the lower respiratory tract causes a vicious circle resulting in impaired mucociliary function, bronchial inflammation, and progressive lung injury. In current guidelines, antibiotic therapy has a key role in bronchiectasis management to treat acute exacerbations and chronic infection and to eradicate bacterial colonization. Contrastingly, antimicrobial resistance, with the risk of multidrug-resistant pathogen development, causes nowadays great concern. The aim of this literature review was to assess the role of antibiotic therapy in bronchiectasis patient management and possible concerns regarding antimicrobial resistance based on current evidence. The authors of this review stress the need to expand research regarding bronchiectasis with the aim to assess measures to reduce the rate of antimicrobial resistance worldwide.

Pharmacotherapeutic management of bronchial infections in adults: non-cystic fibrosis bronchiectasis and chronic obstructive pulmonary disease

INTRODUCTION

Effective management of both acute and chronic bronchial infections is mandatory due to their high frequency rate, the relevant morbidity and mortality and the significant burden to health care systems, especially with the aging of population. Bacteria are the main causative pathogens, followed by viruses, and less commonly by fungi. The clinical evaluation of new therapeutic associations is mandatory to cope with the increases in resistance, in association with better infection control and antimicrobial policies.

AREAS COVERED

The authors searched Medline for any article published in English language up until March 1, 2020 that concerns the treatment of acute exacerbations and chronic infections in chronic obstructive respiratory disease and bronchiectasis.

EXPERT OPINION

As acute exacerbations are a main common and detrimental event in patients with COPD and bronchiectasis, effective antimicrobial therapies and regimens should be optimized. The development of new molecules or combination regimens is vital to patients with severe and/or difficult-to-treat infections. Moreover, chronic infection control is mandatory in these patients to their improve quality of life, respiratory function and prognosis as well as for reducing health care costs.

Systemic Inflammation during and after Bronchiectasis Exacerbations: Impact of Pseudomonas aeruginosa

Bronchiectasis is a chronic structural disease associated with exacerbations that provoke systemic inflammation. We aimed to evaluate the systemic acute proinflammatory cytokine and its biomarker profiles during and after exacerbations and its relationship with the severity of episode, microbiological findings, and the bronchiectasis severity index. This prospective observational study compared exacerbation and stable groups. Cytokine (interleukins (IL)-17a, IL-1β, IL-6, IL 8; tumor necrosis factor-alpha (α)) and high-sensitivity C-reactive protein (hsCRP) levels were determined by multiplex analysis on days 1, 5, 30, and 60 in the exacerbation group and on day 1 in the stable group. We recruited 165 patients with exacerbations, of which 93 were severe (hospitalized). Proinflammatory systemic IL-17a, IL-1β, IL-8, and tumor necrosis factor-α levels increased similarly on days 1 and 5 in severe and non-severe episodes, but on day 30, IL-17a, IL-8, and IL-6 levels were only increased for severe exacerbations. The highest IL-17a level occurred in patients with chronic plus the acute isolation of Pseudomonas aeruginosa. At 30 days, severe exacerbations were independently associated with higher levels of IL-17 (Odds ratio (OR) 4.58), IL-6 (OR 4.89), IL-8 (OR 3.08), and hsCRP (OR 6.7), adjusted for age, the bronchiectasis severity index, and treatment duration. Exacerbations in patients with chronic P. aeruginosa infection were associated with an increase in IL-17 and IL-6 at 30 days (ORs 7.47 and 3.44, respectively). Severe exacerbations elicit a higher systemic proinflammatory response that is sustained to day 30. Patients with chronic P. aeruginosa infection had impaired IL-17a reduction. IL-17a could be a useful target for measuring systemic inflammation.

Hospitalizations for Community-Acquired and Non-Ventilator-Associated Hospital-Acquired Pneumonia in Spain: Influence of the Presence of Bronchiectasis. A Retrospective Database Study

To examine and compare in-hospital mortality (IHM) of community-acquired pneumonia (CAP) and non-ventilator hospital-acquired pneumonia (NV-HAP) among patients with or without bronchiectasis (BQ) using propensity score matching. A retrospective observational epidemiological study using the Spanish Hospital Discharge Records, 2016–17. We identified 257,455 admissions with CAP (3.97% with BQ) and 17,069 with NV-HAP (2.07% with BQ). Patients with CAP and BQ had less comorbidity, lower IHM, and a longer mean length of hospital stay (p < 0.001) than non-BQ patients. They had a higher number of isolated microorganisms, including Pseudomonas aeruginosa. In patients with BQ and NV-HAP, no differences were observed with respect to comorbidity, in-hospital mortality (IHM), or mean length of stay. P. aeruginosa was more frequent (p = 0.028). IHM for CAP and NV-HAP with BQ was 7.89% and 20.06%, respectively. The factors associated with IHM in CAP with BQ were age, comorbidity, pressure ulcers, surgery, dialysis, and invasive ventilation, whereas in NV-HAP with BQ, the determinants were age, metastatic cancer, need for dialysis, and invasive ventilation. Patients with CAP and BQ have less comorbidity, lower IHM and a longer mean length of hospital stay than non-BQ patients. However, they had a higher number of isolated microorganisms, including Pseudomonas aeruginosa. In patients with BQ and NV-HAP, no differences were observed with respect to comorbidity, in-hospital mortality, or mean length of stay, but they had a greater frequency of infection by P. aeruginosa than non-BQ patients. Predictors of IHM for both types of pneumonia among BQ patients included dialysis and invasive ventilation.

[Effects of high frequency chest wall oscillatory (HFCWO) therapy on gas exchange and ventilation in healthy participants]

INTRODUCTION

Chest physiotherapy is an essential part of the treatment of respiratory diseases with increased respiratory secretion and ineffective cough. To date, there have been no studies on the effect of high frequency chest wall oscillatory (HFCWO) therapy on respiratory muscle strength, ventilation and gas exchange. The aim of this study was therefore to assess these three factors in healthy participants.

METHODS

Respiratory muscle strength was measured before and immediately after HFCWO therapy in 25 healthy participants. During the treatment, we continuously measured ventilation parameters, gas exchange, oxygen saturation and heart rate. All participants underwent HFCWO sessions twice (with 24hours difference) with the same procedure. Symptoms during the session and discomfort were measured with the visual analog scale (VAS).

RESULTS

HFCWO therapy produced a change in breathing pattern with increased ventilation associated with altered gas exchange. Heart rate also increased, with no changes in oxygenation. There was no effect, either beneficial or deleterious, on the strength of respiratory muscles. Up to 20% of participants reported substantial discomfort (VAS≥5/10) during the session.

CONCLUSIONS

This study shows that, during the application of HFCWO therapy in healthy participants, ventilation and heart rate increased. However, there were undesirable effects on gas exchange with a high degree of intolerance among volunteers, with no effects on respiratory muscle strength.

Characterization of the severity of dyspnea in patients with bronchiectasis: correlation with clinical, functional, and tomographic aspects

OBJECTIVE

To characterize a population of patients with bronchiectasis, correlating clinical, radiological, and functional aspects with the severity of dyspnea.

METHODS

This was a cross-sectional study involving adult patients with HRCT-confirmed bronchiectasis, categorized according to the severity of dyspnea (as being mildly or severely symptomatic, on the basis of the modified Medical Research Council scale). We correlated the severity of dyspnea with clinical parameters, functional parameters (spirometry values, lung volumes, and DLCO), and CT parameters.

RESULTS

We evaluated 114 patients, 47 (41%) of whom were men. The median age (interquartile range) was 42 years (30-55 years). The most common form was idiopathic bronchiectasis. Of the 114 patients, 20 (17.5%) were colonized with Pseudomonas aeruginosa and 59 (51.8%) were under continuous treatment with macrolides. When we applied the Exacerbation in the previous year, FEV1, Age, Colonization, Extension, and Dyspnea score, the severity of dyspnea was categorized as moderate in 54 patients (47.4%), whereas it was categorized as mild in 50 (43.9%) when we applied the Bronchiectasis Severity Index. The most common lung function pattern was one of obstruction, seen in 95 patients (83.3%), and air trapping was seen in 77 patients (68.7%). The prevalence of an obstructive pattern on spirometry was higher among the patients with dyspnea that was more severe, and most functional parameters showed reasonable accuracy in discriminating between levels of dyspnea severity.

CONCLUSIONS

Patients with bronchiectasis and dyspnea that was more severe had greater functional impairment. The measurement of lung volumes complemented the spirometry data. Because bronchiectasis is a complex, heterogeneous condition, a single variable does not seem to be sufficient to provide an overall characterization of the clinical condition.

Eradication of Pseudomonas aeruginosa with inhaled colistin in adults with non-cystic fibrosis bronchiectasis

The persistent isolation of Pseudomonas aeruginosa in the airways of non-cystic fibrosis bronchiectasis (NCFB) patients is associated with a worsening of the symptoms, increase of exacerbations, poor quality of life and functional impairment. The objective of this study was the analysis of the eradication rate of P. aeruginosa in the sputum of patients with NCFB treated with inhaled colistin and the effects of the treatment in the exacerbations. This was a prospective, cohort, study of 67 NCFB patients treated with inhaled colistin at the Hospital of A Coruña (Spain). We recorded dyspnoea, exacerbations, lung function and sputum cultures of P. aeruginosa in the patients. The mean age of the patients was 67.25 ± 14.6 years (59.7% male). The percentages of eradication of P. aeruginosa in sputum at 3, 6, 9 and 12 months were 61.2%, 50.7%, 43.3% and 40.3%, respectively. We observed a significant decrease in exacerbations after 1 year of colistin treatment (1.98 ± 3.62) versus the previous year (3.40 ± 4.21, p < 0.001). We conclude that treatment with inhaled colistin in patients with NCFB and P. aeruginosa in sputum can achieve high rates of eradication even in patients with several previous positive cultures, as well as a significant decrease of exacerbations and hospital admissions.

Nebulized hypertonic saline in noncystic fibrosis bronchiectasis: a comprehensive review

Bronchiectasis occurs as a result of a vicious circle consisting of an impaired mucociliary transport system, inflammation, and infection and repair of the airways. Damage to the mucociliary system prevents secretion elimination and facilitates bacterial growth and bronchial inflammation. To facilitate mucociliary clearance, current guidelines recommend the use of hypertonic saline (HS) solutions in patients with bronchiectasis not secondary to cystic fibrosis (CF), although the evidence of efficacy in this pathology is sparse. A high percentage of patients with CF and bronchiectasis tolerate HS solutions, but often patients report cough, dyspnoea, throat irritation, or salty taste after inhalation. These adverse effects negatively impact adherence to treatment, which sometimes must be discontinued. Some studies have shown that the addition of hyaluronic acid increases the tolerability of HS solutions, both in patients with CF and in bronchiectasis of other etiologies. We aimed to review the benefits and safety of HS solutions in patients with bronchiectasis. The reviews of this paper are available via the supplemental material section.

RIBRON: The spanish Online Bronchiectasis Registry. Characterization of the First 1912 Patients

INTRODUCTION

The SEPAR Spanish Bronchiectasis Registry (RIBRON) began as a platform for the collection of longitudinal data on patients with this disease. The objective of this study is to describe its operation and to analyze the characteristics of bronchiectasis patients according to sex.

METHODS

A total of 1912 adult patients diagnosed with bronchiectasis in 43 centers were included between February 2015 and 2019. All patients had complete data consisting of at least 79 basic required variables, controlled by an external audit.

RESULTS

Mean age was 67.6 (15.2) years; 63.9% were women. The most common symptom was productive cough (78.3%) which was mucopurulent-purulent in 45.9% of cases. The most common etiology was post-infectious (40.4%), while 18.5% were idiopathic. Pseudomonas aeruginosa was the most frequently isolated microorganism (40.4%), of which 25.6% were associated with chronic infection. The annual number of mild-to-moderate/severe exacerbations was 1.62 (1.9)/0.59 (1.3). Half of the patients (50%) presented with airflow obstruction (17% severe). The most frequent radiological localization was lower lobes. The average FACED/E-FACED/BSI values were 2.06 (1.7)/2.67 (2.2)/7.8 (4.5), respectively. Overall, 66.7% of patients were taking inhaled corticosteroids, 19.2% macrolides, and 19.5% inhaled antibiotics. Women presented a less severe profile than men in clinical and functional terms, and a similar infectious, radiological and therapeutic profile.

CONCLUSIONS

RIBRON represents an excellent map of the characteristics of bronchiectasis in our country. Two thirds of patients are women who presented lower disease severity as a specific characteristic.

The Efficacy of Therapeutic Respiratory Muscle Training Interventions in People with Bronchiectasis: A Systematic Review and Meta-Analysis

Background: Respiratory muscle dysfunction is an important health problem with high morbidity and mortality and associated costs in patients with bronchiectasis (BC). The aim of this study was to analyse the effects of therapeutic respiratory muscle training (RMT) interventions on improving sputum clearance, ventilator function, muscle strength and functional capacity in BC. Methods: Systematic review and meta-analysis were conducted following PRISMA guidelines. Two independent investigators searched using several electronic databases. The methodological quality of nine studies was assessed using the PEDro scale. Study selection/eligibility criteria: The following were included: randomised controlled trials, randomised crossover trials and pilot studies of patients with BC that used the intervention as RMT (inspiratory/expiratory) and evaluations of respiratory muscle strength (maximal expiratory pressure/maximal inspiratory pressure). This systematic review was registered in PROSPERO (CRD42017075101). Nine studies were included, five of which obtained an A recommendation grade, three with B, and one with C. Study quality was poor to good (mean PEDro Score of 6.375 out of 10). Studies had small sample sizes (8–98). Results show improvements on PImax in favour of therapeutic respiratory muscle training intervention (MD = 6.08; 95% CI = 1.38, 10.77; p < 0.01; I² = 92%). However, high heterogeneity was identified on meta-analysis.

Hot topics and current controversies in non-cystic fibrosis bronchiectasis

Non-cystic fibrosis bronchiectasis (NCFB) is a neglected and orphan disease with poor advances through the 20th century. However, its prevalence is rising and with this come new challenges for physicians. Few guidelines are available to guide clinicians on how to diagnose and manage patients with NCFB. Many areas of debate persist, and there is lack of consensus about research priorities most needed to advance patient care and improve clinical outcomes. In this review, we highlight the current hot topics in NCFB and present updated evidence to inform the critical areas of controversy.

Non-cystic fibrosis bronchiectasis (NCFB) is a neglected and orphan disease with poor advances through the 20th century. Physicians should understand available data to provide evidence-based treatments to patients suffering from NCFB.http://bit.ly/2kBGVsx

Duration of antibiotic therapy in non-cystic fibrosis bronchiectasis

Purpose of review

a)We conducted a review of the current evidence relating to antibiotic duration in the short and long-term management of non-cystic fibrosis bronchiectasis.

Recent findings

b)In non-cystic fibrosis pulmonary exacerbations, evidence is primarily based on expert consensus and recent guidelines recommend antibiotic durations of approximately 14 days. Chronic antibiotics (oral or inhaled) are recommended in patients with frequent exacerbations or with chronic Pseudomonas aeruginosa airways infection. Macrolides are the best studied therapies for long-term use with evidence for effect limited to a 12 month duration. Encouragingly, there are increased efforts to develop registries and conduct larger population level studies to improve patient care.

Summary

c)There is a paucity of evidence for optimal antibiotic strategies in exacerbations and chronic maintenance in persons with non-cystic fibrosis bronchiectasis. Rationally designed studies which utilize a registry and population-based approach will be critical to build evidence-based strategies to optimize management of non-cystic fibrosis bronchiectasis.

The biology of pulmonary exacerbations in bronchiectasis

Bronchiectasis is a heterogeneous chronic disease. Heterogeneity characterises bronchiectasis not only in the stable state but also during exacerbations, despite evidence on clinical and biological aspects of bronchiectasis, exacerbations still remain poorly understood.Although the scientific community recognises that bacterial infection is a cornerstone in the development of bronchiectasis, there is a lack of data regarding other trigger factors for exacerbations. In addition, a huge amount of data suggest a primary role of neutrophils in the stable state and exacerbation of bronchiectasis, but the inflammatory reaction involves many other additional pathways. Cole's vicious cycle hypothesis illustrates how airway dysfunction, airway inflammation, infection and structural damage are linked. The introduction of the concept of a "vicious vortex" stresses the complexity of the relationships between the components of the cycle. In this model of disease, exacerbations work as a catalyst, accelerating the progression of disease. The roles of microbiology and inflammation need to be considered as closely linked and will need to be investigated in different ways to collect samples. Clinical and translational research is of paramount importance to achieve a better comprehension of the pathophysiology of bronchiectasis, microbiology and inflammation both in the stable state and during exacerbations.

Nebulized Colistin And Continuous Cyclic Azithromycin In Severe COPD Patients With Chronic Bronchial Infection Due To Pseudomonas aeruginosa: A Retrospective Cohort Study

Introduction

Long-term use of nebulized or oral antibiotics is common in the treatment of cystic fibrosis and non-cystic fibrosis bronchiectasis. To date, however, few studies have focused on the use of nebulized antibiotics in COPD patients. The aims of this study are: to establish whether a combination of nebulized colistin plus continuous cyclic azithromycin in severe COPD patients with chronic bronchial infection due to Pseudomonas aeruginosa reduces the frequency of exacerbations, and to assess the effect of this treatment on microbiological sputum isolates.

Material and methods

A retrospective cohort was created for the analysis of patients with severe COPD and chronic bronchial infection due to P. aeruginosa treated with nebulized colistin at the Respiratory Day Care Unit between 2005 and 2015. The number and characteristics of COPD exacerbations (ECOPD) before and up to two years after the introduction of nebulized colistin treatment were recorded.

Results

We analyzed 32 severe COPD patients who received nebulized colistin for at least three months (median 17 months [IQR 7-24]). All patients but one received combination therapy with continuous cyclic azithromycin (median 24 months [IQR 11-30]). A significant reduction in the number of ECOPD from baseline of 38.3% at two years of follow-up was observed, with a clear decrease in P. aeruginosa ECOPD (from 59.5% to 24.6%) and a P. aeruginosa eradication rate of 28% over the two-year follow-up.

Conclusion

In patients with severe COPD and chronic bronchial infection due to P. aeruginosa, combination therapy with nebulized colistin and continuous cyclic azithromycin significantly reduced the number of ECOPD, with a marked decrease in P. aeruginosa sputum isolates.

Bronchiectasis: Experience of Surgical Management at Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia

Background

Bronchiectasis is one of the major health problems in Ethiopia. We analyzed the outcome of surgery done for bronchiectasis in a resource-limited setup.

Methods

A retrospective cross-sectional analysis of 22 patients who underwent surgery for bronchiectasis in Tikur Anbessa specialized hospital (TASH) during the period 2012 – 2017 were done.

Results

There were 13(59%) female and 9(41%) male patients with a mean age of 34.1 +/−16.9 years. The mean duration of symptoms was 2.2 years. Blood streak sputum, 13(59%), dyspnea, 9(49.9%), fetid sputum, 8(36.4%), dry cough, 6(27.3%), chest pain, 6(27.3%) and massive hemoptysis 3(13.6%) were the main presenting symptoms. In 20(91%) of the patients, previous history of TB treatment was identified. Recurrent childhood infection, 1(4.5%), and tumor obstruction, 1(4.5%), were also seen. Bronchiectasis was left sided in 12(54.5%), right-sided in 7(31.8%) and bilateral in 3(13.6%) patients. The disease affected multiple lung lobes in 9(40.9%), left lower lobe in 6(27.3%) and left upper lobe in 3(13.6%) cases. Indications for surgery were the failure of medical management in 10(45.5%), destroyed lung in 9(40.9%), and massive hemoptysis in 3(13.6%) cases. The procedures performed were lobectomy in 14(63.6%) and pneumonectomy in 8(36.4%) cases. Postoperative complications occurred in 5(22.7%) patients with one (4.5%) death. On the other hand, 77.3% of operated patients had significant improvement compared to their preoperative symptoms.

Conclusions

In a resource-limited setup like TASH, localized bronchiectasis can be treated surgically with an acceptable result. Proper selection and preparation with complete resection of the involved segments are needed for maximum control of symptoms and better outcomes.

Bronchiectasis and cough: An old relationship in need of renewed attention

Bronchiectasis is an increasingly recognised respiratory condition with limited therapeutic options and a complex spectrum of clinical manifestations that invariably includes chronic cough. As the primary presentation of bronchiectasis in most cases, chronic cough and its mechanistic underpinnings are of central importance but remain poorly understood in this setting. Bronchiectasis is also increasingly identified as an underlying cause of chronic cough highlighting the interrelationship between the two conditions that share overlapping clinical features. Several therapeutic approaches have illustrated positive effects on bronchiectasis-associated cough, however, more focused treatment of heterogeneous cough subtypes may yield better outcomes for patients. A current challenge is the identification of bronchiectasis and cough endophenotypes that may allow improved patient stratification and more targeted therapeutic matching of the right treatment to the right patient. Here we discuss the complex disease phenotypes of bronchiectasis and their interrelationship with cough while considering current and emerging treatment options. We discuss some key cough promoters in bronchiectasis including infection, allergy and immune dysfunction.

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.

Paediatric and adult bronchiectasis: Monitoring, cross-infection, role of multidisciplinary teams and self-management plans

Bronchiectasis is a chronic lung disease associated with structurally abnormal bronchi, clinically manifested by a persistent wet/productive cough, airway infections and recurrent exacerbations. Early identification and treatment of acute exacerbations is an integral part of monitoring and annual review, in both adults and children, to minimize further damage due to infection and inflammation. Common modalities used to monitor disease progression include clinical signs and symptoms, frequency of exacerbations and/or number of hospital admissions, lung function (forced expiratory volume in 1 s (FEV₁ )% predicted), imaging (radiological severity of disease) and sputum microbiology (chronic infection with Pseudomonas aeruginosa). There is good evidence that these monitoring tools can be used to accurately assess severity of disease and predict prognosis in terms of mortality and future hospitalization. Other tools that are currently used in research settings such as health-related quality of life (QoL) questionnaires, magnetic resonance imaging and lung clearance index can be burdensome and require additional expertise or resource, which limits their use in clinical practice. Studies have demonstrated that cross-infection, especially with P. aeruginosa between patients with bronchiectasis is possible but infrequent. This should not limit participation of patients in group activities such as pulmonary rehabilitation, and simple infection control measures should be carried out to limit the risk of cross-transmission. A multidisciplinary approach to care which includes respiratory physicians, chest physiotherapists, nurse specialists and other allied health professionals are vital in providing holistic care. Patient education and personalized self-management plans are also important despite limited evidence it improves QoL or frequency of exacerbations.

Bronchiectasis

Bronchiectasis is an important clinical syndrome because of its increasing prevalence, substantial economic burden on health care, and associated morbidity. Until recently, the disease was considered an orphan and essentially neglected from a therapeutic standpoint, but many recent advances have been made in the field. Several national registries have formed to provide databases from which to study patients with bronchiectasis. Experts published a consensus definition of a bronchiectasis-specific exacerbation that will serve as a unified definition for future clinical trials. Several inhaled antibiotic trials aimed at reducing exacerbation frequency have been completed. Researchers have investigated nonculture techniques, such as 16S ribosomal RNA (rRNA) and whole genome sequencing, to characterize the microbiological characteristics. Studies of anti-Pseudomonas antibodies are providing interesting insight into varying host responses to chronic Pseudomonas infection. After three successful trials demonstrating that macrolides reduce exacerbations in bronchiectasis, other antiinflammatory agents have been investigated, and a trial of a novel antiinflammatory drug is ongoing. A relatively robust study has been published in airway clearance, a therapy that is accepted universally as beneficial but that has never been accompanied by strong evidence. To build on the successes with bronchiectasis thus far, investigators must develop better definitions of phenotypes of bronchiectasis. In this regard, clinical tools have been developed to quantify disease severity and predict prognosis. Studies of different clinical phenotypes of bronchiectasis in patients with bronchiectasis have been published. With continued advances in the field of bronchiectasis, there is hope that evidenced-based therapies will become available.

Alpha-1 antitrypsin deficiency as a common treatable mechanism in chronic respiratory disorders and for conditions different from pulmonary emphysema? A commentary on the new European Respiratory Society statement

BACKGROUND

The European Respiratory Society recently published an important statement reviewing available evidence on diagnosis and treatment of lung disease associated to alpha-1 antitrypsin deficiency (AATD). Several issues on this topic still remain unresolved and subject of interpretation according to different standard procedures and healthcare systems worldwide. The purpose of this commentary is to offer a critical contribution to most of these controversial issues in light of an Italian perspective for the management of this disease.

MAIN BODY

The clinical spectrum of AATD lung disease might include different manifestations and the traditional paradigm of a younger emphysematous patient has been revealing insufficient. Targeting with appropriate testing only COPD patients might be considered a limited approach leading to underestimation of the real prevalence of the disease. Several reports have suggested the association between AATD and other chronic respiratory conditions, as asthma and bronchiectasis. A deeper evaluation of clinical, radiological, microbiological and functional variables is, therefore, needed in order to investigate different phenotypes in AATD patients. In addition, a new line of translational research in AATD might focus on the development of personalized therapeutic regimens taking into account the patient clinical profile and needs.

CONCLUSIONS

Over the past years, AATD has been interpreted as a common mechanism of inflammatory disequilibrium and tissue damage across different conditions. Future research is gradually pointing toward this new paradigm by expanding the evidence of the role of AAT as a potent immunomodulatory and anti-inflammatory drug in conditions different from pulmonary emphysema.

[Bronchiectasis]

Bronchiectasis is defined as irreversible dilatation of the bronchial lumen. Bronchiectasis not due to cystic fibrosis is the third most common chronic inflammatory disease of the airway, after asthma and chronic obstructive pulmonary disease (CPOD). The pathogenesis of the disease is characterised by chronic dilatation, with irreversible and usually progressive destruction of the bronchial wall as a consequence of the vicious pathogenic circle described by E. Cole, of infection, inflammation, injury to the mucociliary system, and cyclical repair of the airway. The disease can have different causes, and usually presents with cough and chronic expectoration, and repeated, acute, infectious exacerbations. Suspected diagnosis is clinical, and must be confirmed by high resolution computerised tomography. The treatment comprises diverse regimens aimed at controlling infection and bronchial inflammation. Nutritional aspects should be considered as part of treatment, as well as the management of secretions, muscle training and the management of complications and comorbidities.

Bronchiectasis: Treatment decisions for pulmonary exacerbations and their prevention

Interest in bronchiectasis has increased over the past two decades, as shown by the establishment of disease-specific registries in several countries, the publication of management guidelines and a growing number of clinical trials to address evidence gaps for treatment decisions. This review considers the evidence for defining and treating pulmonary exacerbations, the approaches for eradication of newly identified airway pathogens and the methods to prevent exacerbations through long-term treatments from a pragmatic practice-based perspective. Areas for future studies are also explored. Watch the video abstract.

When and how ruling out cystic fibrosis in adult patients with bronchiectasis

Background

Bronchiectasis is the final result of different processes and most of the guidelines advocate for a careful evaluation of those etiologies which might be treated or might change patients’ management, including cystic fibrosis (CF).

Main body

CFTR mutations have been reported with higher frequency in bronchiectasis population. Although ruling out CF is considered as a main step for etiological screening in bronchiectasis, CF testing lacks of a standardized approach both from a research and clinical point of view. In this review a list of most widely used tests in CF is provided.

Conclusions

Exclusion of CF is imperative for patients with bronchiectasis and CFTR testing should be implemented in usual screening for investigating bronchiectasis etiology. Physicians taking care of bronchiectasis patients should be aware of CFTR testing and its limitations in the adult population. Further studies on CFTR expression in human lung and translational research might elucidate the possible role of CFTR in the pathogenesis of bronchiectasis.

Nutritional status and muscle dysfunction in chronic respiratory diseases: stable phase versus acute exacerbations

Nutritional abnormalities are frequent in different chronic respiratory diseases such as chronic obstructive pulmonary disease (COPD), bronchiectasis, cystic fibrosis (CF), interstitial fibrosis and lung cancer, having important clinical consequences. However, nutritional abnormalities often remained underdiagnosed due to the relative lack of awareness of health professionals. Therefore, systematic anthropometry or even better, assessment of body composition, should be performed in all patients with chronic respiratory conditions, especially following exacerbation periods when malnutrition becomes more accentuated. Nutritional abnormalities very often include the loss of muscle mass, which is an important factor for the occurrence of muscle dysfunction. The latter can be easily detected with the specific assessment of muscle strength and endurance, and also negatively influences patients' quality of life and prognosis. Both nutritional abnormalities and muscle dysfunction result from the interaction of several factors, including tobacco smoking, low physical activity-sedentarism, systemic inflammation and the imbalance between energy supply and requirements, which essentially lead to a negative balance between protein breakdown and synthesis. Therapeutic approaches include improvements in lifestyle, nutritional supplementation and training. Anabolic drugs may be administered in some cases.

Body Composition Measurement in Bronchiectasis: Comparison between Bioelectrical Impedance Analysis, Skinfold Thickness Measurement, and Dual-Energy X-ray Absorptiometry before and after Pulmonary Rehabilitation

BACKGROUND

In individuals with bronchiectasis, fat-free mass depletion may be common despite a low prevalence of underweight and is considered a risk factor for increased morbidity and mortality. Techniques to adequately estimate fat-free mass and its changes over time are needed.

OBJECTIVE

The purpose of this study was to assess agreement among values obtained with three different body composition techniques: skinfold thickness measurement (STM), bioelectrical impedance analysis (BIA), and dual-energy x-ray absorptiometry (DXA).

DESIGN

The study was a secondary analysis of data from a randomized controlled trial.

PARTICIPANTS/SETTING

A respiratory rehabilitation program was administered for 3 months to individuals with bronchiectasis from the bronchiectasis unit of the Regional University Hospital in Malaga, Spain, from September 2013 to September 2014. Individuals with a body mass index (calculated as kg/m²) >18.5 who were aged 65 years or younger and those with a body mass index >20 who were older than 65 years were included.

MAIN OUTCOME MEASURES

At baseline and at 3 and 6 months, body composition was determined by DXA and STM.

STATISTICAL ANALYSES PERFORMED

Statistical concordance was assessed with the intraclass correlation coefficient (ICC), kappa coefficient, and the degree of agreement using the Bland Altman method. For comparison of the quantitative variables at baseline vs at 3 months and 6 months, the paired sample t test (or the Wilcoxon test) was used.

RESULTS

Thirty participants were included. Strong agreement was observed between body composition values determined by BIA and DXA in fat mass (ICC: 0.92) and fat-free mass (ICC: 0.87). Strong agreement was observed between STM and DXA in the values for fat-free mass (ICC: 0.91) and fat mass (ICC: 0.94), and lower agreement was observed for the longitudinal data and in the regional values. The mean difference between fat-free mass determined by BIA and DXA was + 4.7 with a standard deviation of 2.4 kg in favor of BIA. The mean difference between fat-free mass determined by STM and DXA was +2.3 with a standard deviation of 2.7 kg in favor of STM. Six individuals were classified as having a low fat-free mass index (20%) by DXA vs four by STM (13%; kappa: 0.76) and only two by BIA (6.6%; kappa: 0.44) compared with DXA.

CONCLUSIONS

Despite good statistical agreement among values obtained with DXA, STM, and BIA, the study findings indicate that STM and BIA, above all, tended to overestimate fat-free mass compared with DXA.

Bronchiectasis in severe asthma: Clinical features and outcomes

BACKGROUND

Bronchiectasis is increasingly being identified in patients with severe asthma and could contribute to disease severity.

OBJECTIVE

To determine the prevalence of bronchiectasis in a population of patients with severe asthma and to better characterize the clinical features of these patients and their outcomes.

METHODS

We retrospectively reviewed the medical files of 184 subjects with confirmed severe asthma who had undergone high-resolution thoracic computed tomography and compared the characteristics and outcomes of subjects with and without bronchiectasis.

RESULTS

Bronchiectasis was identified in 86 patients (47%). These patients had concomitant hypersensitivity to nonsteroidal anti-inflammatory drugs (odds ratio [OR] 2.24, 95% confidence interval [CI] 1.00-5.03) and gastroesophageal reflux disease (OR 1.89, 95% CI 1.05-3.41) more frequently than subjects without bronchiectasis, but had less atopic dermatitis (OR 0.188, 95% CI 0.04-0.88). Subjects with bronchiectasis were more frequently hospitalized for asthma exacerbations (OR 2.09, 95% CI 1.08-4.05) and had higher blood eosinophil levels (464 vs 338; P = .005) than subjects without bronchiectasis.

CONCLUSION

Our study suggests that in subjects with severe asthma, the presence of bronchiectasis is associated with more frequent hospitalizations, concomitant gastroesophageal reflux disease, hypersensitivity to nonsteroidal anti-inflammatory drugs, and higher blood eosinophil counts. Bronchiectasis could represent an additional phenotypic feature of severe eosinophilic asthma.

Identification of Pseudomonas aeruginosa and airway bacterial colonization by an electronic nose in bronchiectasis

RATIONALE

Airway colonization by Potentially Pathogenic Microorganisms (PPM) in bronchiectasis is associated with worse clinical outcomes. The electronic nose is a non-invasive technology capable of distinguishing volatile organic compounds (VOC) in exhaled breath. We aim to explore if an electronic nose can reliably discriminate airway bacterial colonization in patients with bronchiectasis.

METHODS

Seventy-three clinically stable bronchiectasis patients were included. PPM presence was determined using sputum culture. Exhaled breath was collected in Tedlar bags and VOC breath-prints were detected by the electronic nose Cyranose 320^®. Raw data was reduced to three factors with principal component analysis. Univariate ANOVA followed by post-hoc least significant difference test was performed with these factors. Patients were then classified using linear canonical discriminant analysis. Cross-validation accuracy values were defined by the percentage of correctly classified patients.

RESULTS

Forty-one (56%) patients were colonized with PPM. Pseudomonas aeruginosa (n = 27, 66%) and Haemophilus influenzae (n = 7, 17%) were the most common PPM. VOC breath-prints from colonized and non-colonized patients were significantly different (accuracy of 72%, AUROC 0.75, p < 0.001). VOC breath-prints from Pseudomonas aeruginosa colonized patients were significantly different from those of patients colonized with other PPM (accuracy of 89%, AUROC 0.97, p < 0.001) and non-colonized patients (accuracy 73%, AUROC 0.83, p = 0.007).

CONCLUSIONS

An electronic nose can accurately identify VOC breath-prints of clinically stable bronchiectasis patients with airway bacterial colonization, especially in those with Pseudomonas aeruginosa.

Clinical Determinants of Incremental Shuttle Walk Test in Adults with Bronchiectasis

INTRODUCTION

Exercise capacity is impaired in patients with bronchiectasis. Incremental shuttle walk test (ISWT) stresses cardiorespiratory system physiologically to symptom-limited maximal exercise capacity. The purpose of this study was to investigate the clinical determinants of ISWT in adults with non-cystic fibrosis (CF) bronchiectasis.

METHODS

Forty-one clinically stable bronchiectasis patients aged 18-72 years (27 females, 14 males) participated in the study. Subjects' demographics and physical characteristics were recorded. Bronchiectasis Severity Index was used to identify disease severity. Pulmonary function test was performed. Dyspnea perception was assessed using the modified Medical Research Council Dyspnea Scale. Maximum inspiratory and expiratory pressures were measured. Peripheral muscle strength using a hand held dynamometer was measured. ISWT was performed to determine exercise capacity. Fatigue Severity Scale, Hospital Anxiety and Depression Scale, Leicester Cough Questionnaire were used to determine fatigue, psychosocial status, and quality of life.

RESULTS

Patients' mean ISWT distance was 469.5 m. The ISWT distance was significantly related with age (r = - 0.472), height (r = 0.469), gender (r = 0.520), FEV₁ (r = 0.651), and FVC (r = 0.545, p < 0.05). Quadriceps muscle strength was higher in males (p = 0.001) as compared to females. Age and gender were identified as independent predictors of the ISWT, explaining 42% of variance in ISWT distance (r = 0.649, r² = 0.421, F_(2,38) = 13.794, p < 0.001).

CONCLUSION

The clinical determinants of ISWT in clinically stable patients with non-CF bronchiectasis are age and gender. Pulmonary function, dyspnea perception, muscle strength, disease severity, fatigue, psychosocial factors, and health-related quality of life seems to have an independent effect on ISWT in this group of patients with bronchiectasis.

RESPIRE 1: a phase III placebo-controlled randomised trial of ciprofloxacin dry powder for inhalation in non-cystic fibrosis bronchiectasis

We evaluated the efficacy and safety of ciprofloxacin dry powder for inhalation (DPI) in patients with non-cystic fibrosis bronchiectasis, two or more exacerbations in the previous year and pre-defined bacteria in sputum.

In this phase III, double-blind, placebo-controlled trial, patients were randomised 2:1 to twice-daily ciprofloxacin DPI 32.5 mg or placebo in two treatment regimens consisting of on/off treatment cycles of 14 or 28 days for 48 weeks. The primary end-points were time to first exacerbation and frequency of exacerbations.

A total of 416 patients were randomised to the 14-day on/off regimen (ciprofloxacin DPI (n=137) and placebo (n=68)) or the 28-day on/off regimen (ciprofloxacin DPI (n=141) and placebo (n=70)). Ciprofloxacin DPI 14 days on/off significantly prolonged time to first exacerbationversuspooled placebo (median time >336versus186 days; hazard ratio 0.53, 97.5% CI 0.36–0.80; p=0.0005) and reduced the frequency of exacerbations compared with matching placebo by 39% (mean number of exacerbations 0.6versus1.0; incidence rate ratio 0.61, 97.5% CI 0.40–0.91; p=0.0061). Outcomes for ciprofloxacin DPI 28 days on/off were not statistically significantly different from placebo. The safety profile of ciprofloxacin DPI was favourable.

Ciprofloxacin DPI was well tolerated and has the potential to be an effective treatment option in non-cystic fibrosis bronchiectasis.

RESPIRE 2: a phase III placebo-controlled randomised trial of ciprofloxacin dry powder for inhalation in non-cystic fibrosis bronchiectasis

We evaluated the efficacy and safety of ciprofloxacin dry powder for inhalation (DPI) in patients with non-cystic fibrosis bronchiectasis, two or more exacerbations in the previous year and predefined sputum bacteria.

Patients were randomised 2:1 to twice-daily ciprofloxacin DPI 32.5 mg or placebo in 14- or 28-day on/off treatment cycles for 48 weeks. Primary end-points were time to first exacerbation and frequency of exacerbations. Enrolling countries and α level split (0.049 and 0.001 for 14- and 28-day cycles, respectively) differed from RESPIRE 1.

Patients were randomised to ciprofloxacin DPI (14 days on/off (n=176) or 28 days on/off (n=171)) or placebo (14 days on/off (n=88) or 28 days on/off (n=86)). The exacerbation rate was low across treatment arms (mean±sd 0.6±0.9). Active treatment showed trends to prolonged time to first exacerbation (ciprofloxacin DPI 14 days on/off: hazard ratio 0.87, 95.1% CI 0.62–1.21; p=0.3965; ciprofloxacin DPI 28 days on/off: hazard ratio 0.71, 99.9% CI 0.39–1.27; p=0.0511) and reduced frequency of exacerbations (ciprofloxacin DPI 14 days on/off: incidence rate ratio 0.83, 95.1% CI 0.59–1.17; p=0.2862; ciprofloxacin DPI 28 days on/off: incidence rate ratio 0.55, 99.9% CI 0.30–1.02; p=0.0014), although neither achieved statistical significance. Ciprofloxacin DPI was well tolerated.

Trends towards clinical benefit were seen with ciprofloxacin DPI, but primary end-points were not met.