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

Endotypes of Exacerbation in Bronchiectasis: An Observational Cohort Study

Rationale: Bronchiectasis is characterized by acute exacerbations, but the biological mechanisms underlying these events are poorly characterized. Objectives: To investigate the inflammatory and microbial characteristics of exacerbations of bronchiectasis. Methods: A total of 120 patients with bronchiectasis were enrolled and presented with acute exacerbations within 12 months. Spontaneous sputum samples were obtained during a period of clinical stability and again at exacerbation before receipt of antibiotic treatment. A validated rapid PCR assay for bacteria and viruses was used to classify exacerbations as bacterial, viral, or both. Sputum inflammatory assessments included label-free liquid chromatography-tandem mass spectrometry and measurement of sputum cytokines and neutrophil elastase activity. 16 s rRNA sequencing was used to characterize the microbiome. Measurements and Main Results: Bronchiectasis exacerbations showed profound molecular heterogeneity. At least one bacterium was identified in 103 samples (86%), and a high bacterial load (total bacterial load > 107 copies/g) was observed in 81 patients (68%). Respiratory viruses were identified in 55 (46%) patients, with rhinovirus being the most common virus (31%). PCR testing was more sensitive than culture. No consistent change in the microbiome was observed at exacerbation. Exacerbations were associated with increased neutrophil elastase, proteinase-3, IL-1β, and CXCL8. These markers were particularly associated with bacterial and bacterial plus viral exacerbations. Distinct inflammatory and microbiome profiles were seen between different exacerbation subtypes, including bacterial, viral, and eosinophilic events in both hypothesis-led and hypothesis-free analysis using integrated microbiome and proteomics, demonstrating four subtypes of exacerbation. Conclusions: Bronchiectasis exacerbations are heterogeneous events with contributions from bacteria, viruses, and inflammatory dysregulation.

Five-Year Outcomes among U.S. Bronchiectasis and NTM Research Registry Patients

Rationale: Nontuberculous mycobacteria (NTM) are prevalent among patients with bronchiectasis. However, the long-term natural history of patients with NTM and bronchiectasis is not well described. Objectives: To assess the impact of NTM on 5-year clinical outcomes and mortality in patients with bronchiectasis. Methods: Patients in the Bronchiectasis and NTM Research Registry with ⩾5 years of follow-up were eligible. Data were collected for all-cause mortality, lung function, exacerbations, hospitalizations, and disease severity. Outcomes were compared between patients with and without NTM at baseline. Mortality was assessed using Cox proportional hazards models and the log-rank test. Measurements and Main Results: In total, 2,634 patients were included: 1,549 (58.8%) with and 1,085 (41.2%) without NTM at baseline. All-cause mortality (95% confidence interval) at Year 5 was 12.1% (10.5%, 13.7%) overall, 12.6% (10.5%, 14.8%) in patients with NTM, and 11.5% (9.0%, 13.9%) in patients without NTM. Independent predictors of 5-year mortality were baseline FEV1 percent predicted, age, hospitalization within 2 years before baseline, body mass index, and sex (all P < 0.01). The probabilities of acquiring NTM or Pseudomonas aeruginosa were approximately 4% and 3% per year, respectively. Spirometry, exacerbations, and hospitalizations were similar, regardless of NTM status, except that annual exacerbations were lower in patients with NTM (P < 0.05). Conclusions: Outcomes, including exacerbations, hospitalizations, rate of loss of lung function, and mortality rate, were similar across 5 years in patients with bronchiectasis with or without NTM.

Biomarkers in bronchiectasis

Bronchiectasis is a heterogeneous disease with multiple aetiologies and diverse clinical features. There is a general consensus that optimal treatment requires precision medicine approaches focused on specific treatable disease characteristics, known as treatable traits. Identifying subtypes of conditions with distinct underlying biology (endotypes) depends on the identification of biomarkers that are associated with disease features, prognosis or treatment response and which can be applied in clinical practice. Bronchiectasis is a disease characterised by inflammation, infection, structural lung damage and impaired mucociliary clearance. Increasingly there are available methods to measure each of these components of the disease, revealing heterogeneous inflammatory profiles, microbiota, radiology and mucus and epithelial biology in patients with bronchiectasis. Using emerging biomarkers and omics technologies to guide treatment in bronchiectasis is a promising field of research. Here we review the most recent data on biomarkers in bronchiectasis.

Airway clearance management in people with bronchiectasis: data from the European Bronchiectasis Registry (EMBARC)

BACKGROUND

International guidelines recommend airway clearance management as one of the important pillars of bronchiectasis treatment. However, the extent to which airway clearance is used for people with bronchiectasis in Europe is unclear. The aim of the study was to identify the use of airway clearance management in patients with bronchiectasis across different countries and factors influencing airway clearance use.

METHODS

This was a prospective observational study using data from the European Multicentre Bronchiectasis Audit and Research Collaboration (EMBARC) Registry between January 2015 and April 2022. Prespecified options for airway clearance management were recorded, including airway clearance techniques, devices and use of mucoactive drugs.

RESULTS

16 723 people with bronchiectasis from 28 countries were included in the study. The mean age was 67 years (interquartile range 57-74 years, range 18-100 years) and 61% were female. 72% of the participants reported daily sputum expectoration and 52% (95% CI 51-53%) of all participants reported using regular airway clearance management. Active cycle of breathing technique was used by 28% of the participants and airway clearance devices by 16% of participants. The frequency of airway clearance management and techniques used varied significantly between different countries. Participants who used airway clearance management had greater disease severity and worse symptoms, including a higher daily sputum volume, compared to those who did not use it regularly. Mucoactive drugs were also more likely to be used in participants with more severe disease. Access to specialist respiratory physiotherapy was low throughout Europe, but particularly low in Eastern Europe.

CONCLUSIONS

Only a half of people with bronchiectasis in Europe use airway clearance management. Use of and access to devices, mucoactive drugs and specialist chest physiotherapy appears to be limited in many European countries.

Bacteriophages for bronchiectasis: treatment of the future?

PURPOSE OF REVIEW

Bronchiectasis is a chronic respiratory disease characterized by dilated airways, persistent sputum production and recurrent infective exacerbations. The microbiology of bronchiectasis includes various potentially pathogenic microorganisms including Pseudomonas aeruginosa which is commonly cultured from patients' sputum. P. aeruginosa is difficult to eradicate and frequently exhibits antimicrobial resistance. Bacteriophage therapy offers a novel and alternative method to treating bronchiectasis and can be used in conjunction with antibiotics to improve patient outcome.

RECENT FINDINGS

Thirteen case reports/series to date have successfully used phages to treat infections in bronchiectasis patients, however these studies were constrained to few patients ( n  = 32) and utilized personalized phage preparations and adjunct antibiotics. In these studies, phage therapy was delivered by inhalation, intravenously or orally and was well tolerated in most patients without any unfavourable effects. Favourable clinical or microbiological outcomes were seen following phage therapy in many patients. Longitudinal patient follow-up reported regrowth of bacteria and phage neutralization in some studies. There are five randomized clinical controlled trials ongoing aiming to use phage therapy to treat P. aeruginosa associated respiratory conditions, with limited results available to date.

SUMMARY

More research, particularly robust clinical trials, into how phages can clear respiratory infections, interact with resident microbiota, and how bacteria might develop resistance will be important to establish to ensure the success of this promising therapeutic alternative.

Bronchiectasis-associated infections and outcomes in a large, geographically diverse electronic health record cohort in the United States

BACKGROUND

Bronchiectasis is a pulmonary disease characterized by irreversible dilation of the bronchi and recurring respiratory infections. Few studies have described the microbiology and prevalence of infections in large patient populations outside of specialized tertiary care centers.

METHODS

We used the Cerner HealthFacts Electronic Health Record database to characterize the nature, burden, and frequency of pulmonary infections among persons with bronchiectasis. Chronic infections were defined based on organism-specific guidelines.

RESULTS

We identified 7,749 patients who met our incident bronchiectasis case definition. In this study population, the organisms with the highest rates of isolate prevalence were Pseudomonas aeruginosa with 937 (12%) individuals, Staphylococcus aureus with 502 (6%), Mycobacterium avium complex (MAC) with 336 (4%), and Aspergillus sp. with 288 (4%). Among persons with at least one isolate of each respective pathogen, 219 (23%) met criteria for chronic P. aeruginosa colonization, 74 (15%) met criteria for S. aureus chronic colonization, 101 (30%) met criteria for MAC chronic infection, and 50 (17%) met criteria for Aspergillus sp. chronic infection. Of 5,795 persons with at least two years of observation, 1,860 (32%) had a bronchiectasis exacerbation and 3,462 (60%) were hospitalized within two years of bronchiectasis diagnoses. Among patients with chronic respiratory infections, the two-year occurrence of exacerbations was 53% and for hospitalizations was 82%.

CONCLUSIONS

Patients with bronchiectasis experiencing chronic respiratory infections have high rates of hospitalization.

The clinical characteristics of non-cystic fibrosis bronchiectasis patients with positive serum tumor markers: a retrospective study

BACKGROUND

Serum tumor markers (STM), extensively used for the diagnosis, monitoring and prognostic assessment of tumors, can be increased in some non-malignant lung diseases. To date, there is a paucity of studies regarding the clinical characteristics of non-cystic fibrosis bronchiectasis patients with positive STMs.

OBJECTIVE

To investigate the clinical characteristics and indicators of bronchiectasis with positive STMs.

METHODS

The clinical data of 377 bronchiectasis patients was retrospectively collected from January 2017 to December 2019 from Beijing Chaoyang Hospital. Patients were divided into the STM negative group, the single STM positive group and the ≥2 STMs positive group according to the number of the positive STMs. The clinical characteristics are described and compared separately. The multivariate logistic regression analysis model was used to investigate the indicators regarding positive STMs.

RESULTS

Patients in the ≥2 STMs positive group were older (P = 0.015), had higher mMRC scores (P < 0.001) and developed higher fever (P = 0.027). Additionally, these patients also had lower Albumin/Globulin Ratio (A/G), albumin (ALB), prealbumin (PAB) (P < 0.001, P < 0.001, P < 0.001, respectively) and higher CRP, ESR and Fbg (P < 0.001, P < 0.001 and P < 0.001, respectively). Age (OR 1.022, 95%CI 1.003-1.042; P = 0.026) and the number of affected lobes (OR 1.443, 95%CI 1.233-1.690; P < 0.001) were independently associated with one and ≥ 2 positive STMs in bronchiectasis patients.

CONCLUSION

The ≥2 positive STMs are associated with a higher inflammation status and severer radiologic manifestations in bronchiectasis patients.

Impact of Pseudomonas aeruginosa on resource utilization and costs in patients with exacerbated non-cystic fibrosis bronchiectasis

AIMS

Non-cystic fibrosis bronchiectasis (NCFB) is a chronic progressive respiratory disorder occurring at a rate ranging from 4.2 to 278.1 cases per 100,000 persons, depending on age, in the United States. For many patients with NCFB, the presence of Pseudomonas aeruginosa (PA) makes treatment more complicated and typically has worse outcomes. Management of NCFB can be challenging, warranting a better understanding of the burden of illness for NCFB, treatments applied, healthcare resources used, and subsequent treatment costs. Comparing patients diagnosed with exacerbated NCFB, with or without PA on antibiotic utilization, treatments, and healthcare resources utilization and costs was the purpose of this study.

MATERIALS AND METHODS

This was a retrospective cohort study of commercial claims from IQVIA's PharMetrics Plus database (January 1,2006-December 31, 2020). Study patients with a diagnosis of NCFB were stratified into two groups based on the presence or absence of PA, then followed to identify demographic characteristics, comorbid conditions, antibiotic treatment regimen prescribed, healthcare resources utilized, and costs of care.

RESULTS

The results showed that patients with exacerbated NCFB who were PA+ had significantly more oral antibiotic fills per patient per year, more inpatient admissions with a longer length of stay, and more outpatient encounters than those who were PA-. For costs, PA+ patients also had significantly greater total healthcare costs per patient when compared to those who were PA-.

CONCLUSION

Exacerbated NCFB with PA+ was associated with increased antibiotic usage, greater resource utilization, and increased costs. The major contributor to the cost differences was the use of inpatient services. Treatment strategies aimed at reducing the need for inpatient treatment could lessen the disparities observed in patients with NCFB.

The Economic Burden of Bronchiectasis: A Systematic Review

BACKGROUND

Bronchiectasis, a previously neglected condition, now has renewed research interest. There are a few systematic reviews that have reported on the economic and societal burden of bronchiectasis in adults, but none have reported on children. We undertook this systematic review to estimate the economic burden of bronchiectasis in children and adults.

RESEARCH QUESTION

What is the health care resource utilization and economic burden of bronchiectasis in adults and children?

STUDY DESIGN AND METHODS

We performed a systematic review identifying publications from Embase, PubMed, Web of Science, Cochrane (trials, reviews, and editorials), and EconLit about the economic burden and health care utilization in adults and children with bronchiectasis between January 1, 2001, and October 10, 2022. We used a narrative synthesis approach and estimated aggregate costs for several countries.

RESULTS

We identified 53 publications reporting on the economic burden and/or health care utilization of people with bronchiectasis. Total annual health care costs per adult patient ranged from 2021 $3,579 to $82,545 USD and were predominantly driven by hospitalization costs. Annual indirect costs including lost income because of illness (reported in only five studies) ranged from $1,311 to $2,898 USD. Total health care costs in children with bronchiectasis were $23,687 USD annually in the one study that estimated them. Additionally, one publication found that children with bronchiectasis missed 12 school days per year. We estimated aggregate annual health care costs for nine countries, ranging from $101.6 million per year in Singapore to $14.68 billion per year in the United States. We also estimated the aggregate cost of bronchiectasis in Australian children to be $17.77 million per year.

INTERPRETATION

This review highlights the substantial economic burden of bronchiectasis for patients and health systems. To our knowledge, it is the first systematic review to include the costs for children with bronchiectasis and their families. Future research to examine the economic impact of bronchiectasis in children and economically disadvantaged communities, and to further understand the indirect burden of bronchiectasis on individuals and the community, is needed.

Bronchiectasis in Europe: data on disease characteristics from the European Bronchiectasis registry (EMBARC)

BACKGROUND

Bronchiectasis is a heterogeneous, neglected disease with few multicentre studies exploring the causes, severity, microbiology, and treatment of the disease across Europe. This aim of this study was to describe the clinical characteristics of bronchiectasis and compare between different European countries.

METHODS

EMBARC is an international clinical research network for bronchiectasis. We report on a multicentre, prospective, observational, non-interventional, cohort study (the EMBARC registry) conducted across 27 European countries and Israel. Comprehensive clinical data were collected from adult patients (aged ≥18 years) at baseline and annual follow-up visits using electronic case report form. Data from individual countries were grouped into four regions (the UK, northern and western Europe, southern Europe, and central and eastern Europe according to modified EU EuroVoc classification). Follow-up data were used to explore differences in exacerbation frequency between regions using a negative binomial regression model.

FINDINGS

Between Jan 12, 2015, and April 12, 2022, 16 963 individuals were enrolled. Median age was 67 years (IQR 57-74), 10 335 (60·9%) participants were female and 6628 (39·1%) were male. The most common cause of bronchiectasis in all 16 963 participants was post-infective disease in 3600 (21·2%); 6466 individuals (38·1%) were classified as idiopathic. Individuals with bronchiectasis experienced a median of two exacerbations (IQR 1-4) per year and 4483 (26·4%) patients had a hospitalisation for exacerbation in the previous year. When examining the percentage of all isolated bacteria, marked differences in microbiology were seen between countries, with a higher frequency of Pseudomonas aeruginosa and lower Haemophilus influenzae frequency in southern Europe, compared with higher H influenzae in the UK and northern and western Europe. Compared with other regions, patients in central and eastern Europe had more severe bronchiectasis measured by the Bronchiectasis Severity Index (51·3% vs 35·1% in the overall cohort) and more exacerbations leading to hospitalisations (57·9% vs 26·4% in the overall cohort). Overall, patients in central and eastern Europe had an increased frequency of exacerbations (adjusted rate ratio [RR] 1·12, 95% CI 1·01-1·25) and a higher frequency of exacerbations leading to hospitalisations (adjusted RR 1·71, 1·44-2·02) compared with patients in other regions. Treatment of bronchiectasis was highly heterogeneous between regions.

INTERPRETATION

Bronchiectasis shows important geographical variation in causes, microbiology, severity, and outcomes across Europe.

FUNDING

European Union-European Federation of Pharmaceutical Industries and Associations Innovative Medicines Initiative.

TRANSLATIONS

For the Arabic, French, German, Greek, Hebrew, Irish, Russian and Spanish translations of the abstract see Supplementary Materials section.

Pulmonary exacerbations in insured patients with bronchiectasis over 2 years

Background

Patients with bronchiectasis experience persistent symptoms and frequent pulmonary exacerbations; this study investigated the frequency of exacerbations and all-cause hospitalisation.

Methods

This longitudinal, retrospective, claims database study (IBM® MarketScan®) identified patients aged ≥18 years from 1 July 2015 through 30 September 2018. Exacerbations were identified by bronchiectasis inpatient claim or a healthcare interaction, followed by antibiotic prescription within 7 days. Patients with ≥36 months of continuous health plan enrolment (12 months preceding the first bronchiectasis claim, i.e., baseline period and ≥24 months of follow-up) were included. Patients with cystic fibrosis at baseline were excluded. A multivariable logistic regression model identified baseline factors associated with having ≥2 exacerbations over the 2-year follow-up period.

Results

In total, 14 798 patients with bronchiectasis were identified; 64.5% were female, 82.7% were aged ≥55 years and 42.7% had ≥2 exacerbations at baseline. Having ≥2 exacerbations after 2 years was positively associated with chronic macrolide use, long-acting β2 agonist use, gastro-oesophageal reflux disease, heart failure and Pseudomonas aeruginosa. Frequent exacerbations (≥2) at baseline were significantly associated with greater likelihood of experiencing ≥2 exacerbations during the first and second year's follow-up (unadjusted odds ratios 3.35 (95% CI 3.1-3.6) and 2.96 (95% CI 2.8-3.2), respectively). The proportion of patients experiencing ≥1 all-cause hospitalisation cumulatively increased from 41.0% in the first year of follow-up to 51.1% over 2 years' follow-up.

Conclusion

Frequent exacerbations in patients with bronchiectasis may increase the likelihood of future exacerbations over 2 years of follow-up, with increased hospitalisation rates over time.

Healthcare costs and resource utilisation in bronchiectasis, asthma and COPD

Direct healthcare costs for patients with asthma are less than half (-52%) and for patients with COPD are 41% higher if compared to those of patients with bronchiectasis. The leading expense items in bronchiectasis are hospitalisations and antibiotics. https://bit.ly/3Iq8AUP.

Towards development of evidence to inform recommendations for the evaluation and management of bronchiectasis

Bronchiectasis (BE) is a chronic condition characterized by airway dilation as a consequence of a variety of pathogenic processes. It is often associated with persistent airway infection and an inflammatory response resulting in cough productive of purulent sputum, which has an adverse impact on quality of life. The prevalence of BE is increasing worldwide. Treatment guidelines exist for managing BE, but they are generally informed by a paucity of high-quality evidence. This review presents the findings of a scientific advisory board of experts held in the United States in November 2020. The main focus of the meeting was to identify unmet needs in BE and propose ways to identify research priorities for the management of BE, with a view to developing evidence-based treatment recommendations. Key issues identified include diagnosis, patient evaluation, promoting airway clearance and appropriate use of antimicrobials. Unmet needs include effective pharmacological agents to promote airway clearance and reduce inflammation, control of chronic infection, clinical endpoints to be used in the design of BE clinical trials, and more accurate classification of patients using phenotypes and endotypes to better guide treatment decisions and improve outcomes.

Phage Therapy Administration Route, Regimen, and Need for Supplementary Antibiotics in Patients with Chronic Suppurative Lung Disease

Antimicrobial resistance is leading to increased mortality, posing risk to those with chronic suppurative lung disease (CSLD). One therapeutic option may be to target treatment-resistant bacteria using viruses (bacteriophages [phages]). Currently, patients receiving phage therapy on compassionate grounds may not be receiving optimal treatment as there is no defined approach for phage use. This review aims to explore administration route, regimen, and need for supplementary antibiotics in phage therapy to treat bacterial infection in CSLD. Twelve articles totaling 18 participants included details of numerous phage administration routes with varying regimens. All articles reported an initial reduction of bacterial load or an improvement in patient symptoms, highlighting the potential of phage therapy in CSLD. Fifteen out of 18 used supplementary antibiotics. Standardized protocols informed by high-quality research are necessary to ensure safe and effective phage therapy. In the interim, systematic recording of information within case reports may be useful.

Do Patients with Bronchiectasis Have an Increased Risk of Developing Lung Cancer? A Systematic Review

BACKGROUND

Initial evidence supports the hypothesis that patients with non-cystic fibrosis bronchiectasis (NCFB) have a higher risk of lung cancer. We systematically reviewed the available literature to define the characteristics of lung malignancies in patients with bronchiectasis and the characteristics of patients who develop bronchiectasis-associated lung cancer.

METHOD

This study was performed based on the PRISMA guidelines. The review protocol was registered in PROSPERO.

RESULTS

The frequency rates of lung cancer in patients with NCFB ranged from 0.93% to 8.0%. The incidence rate was 3.96. Cancer more frequently occurred in the elderly and males. Three studies found an overall higher risk of developing lung cancer in the NCFB population compared to the non-bronchiectasis one, and adenocarcinoma was the most frequently reported histological type. The effect of the co-existence of NCFB and COPD was unclear.

CONCLUSIONS

NCFB is associated with a higher risk of developing lung cancer than individuals without NCFB. This risk is higher for males, the elderly, and smokers, whereas concomitant COPD's effect is unclear.

Pilot Evaluation of a Management Toolkit for Airway Clearance Therapy in Bronchiectasis (IMPACT BE)

Background

Airway clearance therapies (ACTs) are recommended as an integral part of the management of non-cystic fibrosis bronchiectasis (BE) to prevent inflammation, mucus accumulation, and infection that occur because of ineffective secretion clearance. Adherence to ACTs is low, in part because of perceived burden and a lack of standardization of education and training programs for patients. Poor adherence is associated with more frequent exacerbations, worse health outcomes, and worse quality of life. Structured educational programs increase adherence to ACT among people with cystic fibrosis and may show similar results for people with BE.

Objective

This pilot study evaluated the feasibility, clinical utility, sustainability, and expert opinions of this educational program addressing gaps in ACT knowledge and skills in people with BE.

Methods

The Individual Management of Patient Airway Clearance Therapy- Bronchiectasis (IMPACT BE) was implemented in nine BE centers with 100 patients. Qualitative and quantitative data were collected from patients and providers.

Results

The IMPACT BE program demonstrated good uptake in a clinic setting by multidisciplinary team members, with improvements in medical teams' evaluation of their ability to provide education to patients. All healthcare teams indicated that this program could become a sustainable part of their clinic. Qualitative responses from patients indicated the program was comprehensive and easy to use.

Conclusion

In this pilot study, IMPACT BE was found to be useful in teaching airway clearance to people with BE. The open-access toolkit was well received by both patients and a diverse array of providers in a clinic setting.

Reliability and Validity of Computerized Adventitious Respiratory Sounds in People with Bronchiectasis

Background: Computerized adventitious respiratory sounds (ARS), such as crackles and wheezes, have been poorly explored in bronchiectasis, especially their measurement properties. This study aimed to test the reliability and validity of ARS in bronchiectasis. Methods: Respiratory sounds were recorded twice at 4 chest locations on 2 assessment sessions (7 days apart) in people with bronchiectasis and daily sputum expectoration. The total number of crackles, number of wheezes and wheeze occupation rate (%) were the parameters extracted. Results: 28 participants (9 men; 62 ± 12 y) were included. Total number of crackles and wheezes showed moderate within-day (ICC 0.87, 95% CI 0.74−0.94; ICC 0.86, 95% CI 0.71−0.93) and between-day reliability (ICC 0.70, 95% CI 0.43−0.86; ICC 0.78, 95% CI 0.56−0.90) considering all chest locations and both respiratory phases; wheeze occupation rate showed moderate within-day reliability (ICC 0.86, 95% CI 0.71−0.93), but poor between-day reliability (ICC 0.71, 95% CI 0.33−0.87). Bland−Altman plots revealed no systematic bias, but wide limits of agreement, particularly in the between-days analysis. All ARS parameters correlated moderately with the amount of daily sputum expectoration (r > 0.4; p < 0.05). No other significant correlations were observed. Conclusion: ARS presented moderate reliability and were correlated with the daily sputum expectoration in bronchiectasis. The use of sequential measurements may be an option to achieve greater accuracy when ARS are used to monitor or assess the effects of physiotherapy interventions in this population.

Self-management programmes for adult patients with bronchiectasis: a systematic review and realist synthesis

PURPOSE

Self-management for patients with bronchiectasis has been identified as an important component that could potentially empower patients to manage their condition and improve their quality of life. Evidence was reviewed to investigate what self-management programmes work, why and in what circumstances.

METHODS

A systematic review and realist synthesis were conducted. A comprehensive database search was performed on seven databases for evidence published up to July 2021. Leading candidate self-management programmes identified from the systematic review became the focus of the realist synthesis. A realist logic of analysis was applied to produce explanatory context-mechanism-outcome configurations. These explanations were consolidated into programme theories drawing on health behaviour change theory.

RESULTS

By synthesising the data from eight eligible articles, programme theories articulated how three different self-management programmes work that included: (i) education and action planning, (ii) education and airway clearance techniques (ACT) and, (iii) education, exercise and ACT. Patient characteristics and collaborative partnership between healthcare professionals and patients were identified as important contexts that influenced the improvement in self-efficacy, health-related quality of life, and exercise capacity.

CONCLUSIONS

This review contributes to a better understanding of how the complex interaction between contexts and mechanisms can improve outcomes of clinical interest.IMPLICATIONS FOR REHABILITATIONThis evidence synthesis has identified potentially important combinations of interventions to be considered in self-management programmes for adults with bronchiectasis.Collaborative partnership between patient and healthcare professionals should be considered to improve short-term self-efficacy.Targeting self-management programmes to increase short-term health-related quality of life and exercise capacity should consider the context of patient characteristics.

Risk Factors of Incident Lung Cancer in Patients with Non-Cystic Fibrosis Bronchiectasis: A Korean Population-Based Study

BACKGROUND

Patients with non-cystic fibrosis bronchiectasis have an increased risk of lung cancer, followed by higher mortality in this population. Because the risk factors of lung cancer have not been well identified, this study aimed to investigate the risk factors of lung cancer in individuals with newly diagnosed bronchiectasis.

METHODS

This cohort study using the Korean National Health Insurance Service database identified 7425 individuals with incident bronchiectasis among those who participated in the health screening exam in 2009. The cohort was followed from baseline to the date of incident: lung cancer, death, or until the end of the study period. We investigated the risk factors of lung cancer in participants with bronchiectasis using the Cox-proportional hazard models.

RESULTS

During median 8.3 years of follow-up duration, 1.9% (138/7425) developed lung cancer. In multivariable analyses, significant factors associated with increased risk of incident lung cancer included: males (adjusted hazard ratio [HR] = 3.54, 95% confidence interval [CI] = 2.17-5.79) than females, the overweight (adjusted HR = 1.55, 95% CI = 1.03-2.35) than the normal weight, current smokers (adjusted HR = 3.10, 95% CI = 2.00-4.79) than never smokers, participants living in the rural area (adjusted HR = 2.54, 95% CI = 1.68-3.85) than those living in the metropolitan area. Among comorbidities, chronic obstructive pulmonary disease was associated with an increased risk of lung cancer (adjusted HR = 1.46, 95% CI = 1.01-2.13) in participants with bronchiectasis. In contrast, mild alcohol consumption was associated with reduced risk of lung cancer (adjusted HR = 0.47, 95% CI = 0.29-0.74) in those with bronchiectasis.

CONCLUSION

This Korean population-based study showed that males, current smoking, overweight, living in rural areas, and comorbid chronic obstructive pulmonary disease are associated with increased risk of lung cancer in individuals with bronchiectasis.

Non-Cystic Fibrosis Bronchiectasis Increases the Risk of Lung Cancer Independent of Smoking Status

Rationale

It remains unclear whether non-cystic fibrosis bronchiectasis increases the risk of lung cancer, because smoking history was not considered in previous studies.

Objectives

To evaluate whether participants with bronchiectasis have a higher risk of incident lung cancer than those without bronchiectasis with information on smoking status.

Methods

This was a population-based cohort study of 3,858,422 individuals who participated in the 2009 National Health Screening Program. We evaluated the incidence of lung cancer in participants with bronchiectasis (n = 65,305) and those without bronchiectasis (n = 3,793,117). We followed the cohort up until the date of lung cancer diagnosis, date of death, or December 2018. Cox proportional hazard regression models were used to evaluate the relative risk of lung cancer between participants with bronchiectasis and those without bronchiectasis.

Results

The incidence of lung cancer in participants with bronchiectasis was significantly higher than in those without bronchiectasis (2.1 vs. 0.7 per 1,000 person-years; P < 0.001), with an adjusted hazard ratio (aHR) of 1.22 (95% confidence interval [CI], 1.14–1.30) in the model adjusting for potential confounders and accounting for the competing risk of mortality. Regardless of smoking status, the risk of lung cancer was significantly higher in participants with bronchiectasis than in those without bronchiectasis (aHR, 1.28 [95% CI, 1.17–1.41] for never-smokers; aHR, 1.26 [95% CI, 1.10–1.44] for ever-smokers). Although bronchiectasis did not increase the risk of lung cancer among participants with chronic obstructive pulmonary disease (COPD), it significantly increased the risk of lung cancer in participants without COPD (aHR, 1.19 [95% CI, 1.09–1.31]).

Conclusions

The presence of bronchiectasis was associated with a higher risk of lung cancer after considering the smoking status.

Increasing prevalence and burden of bronchiectasis in urban Chinese adults, 2013-2017: a nationwide population-based cohort study

Background

While the prevalence and disease burden of bronchiectasis are increasing, data in the world’s largest population are lacking. We aimed to investigate the prevalence and disease burden of bronchiectasis in Chinese adults.

Methods

We conducted a population-based study using data between 2013 and 2017 from the national databases of Urban Employee Basic Medical Insurance and Urban Resident Basic Medical Insurance in China. Data from over 380 million patients aged 18 years and older during the study period were analyzed, and a total of 383,926 bronchiectasis patients were identified. Primary outcomes included the age- and sex-specific prevalence of bronchiectasis. Annual visits and hospitalizations, as well as annual costs were also calculated.

Results

The prevalence of bronchiectasis in Chinese adults increased 2.31-fold, from 75.48 (62.26, 88.69) per 100,000 in 2013 to 174.45 (137.02, 211.88) per 100,000 in 2017. The increase was more remarkable for patients aged over 50 years in both genders. The per-capita total cost and hospitalization cost of patients with bronchiectasis increased 2.18-fold and 1.83-fold from 2013 to 2017, respectively, mostly driven by non-bronchiectasis costs. The average annual hospitalization ranged from 1.20 to 1.24 times during the 5 years.

Conclusion

The prevalence and disease burden of bronchiectasis in Chinese urban adults ≥ 18 years had increased significantly between 2013 and 2017.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12931-022-02023-8.

Effect of exercise-based pulmonary rehabilitation in patients with bronchiectasis: A meta-analysis

OBJECTIVE

We aimed to assess the effectiveness of exercise training in patients with bronchiectasis in terms of exercise capacity, pulmonary function, and quality of life.

METHODS

PubMed, Embase, and the Cochrane Library were searched for randomized controlled trials (RCTs) examining pulmonary rehabilitation to treat bronchiectasis, and the search timeline was from inception through November 2020. Two researchers independently screened the literature, extracted data, evaluated the risk of bias in the included studies, and used Review Manager 5.3 software to perform the meta-analysis. The primary outcomes were incremental shuttle walk distance (ISWD) and 6-minute walk distance (6-MWD) at 8 weeks. The secondary outcomes were forced expiratory volume in 1 second (FEV1), St. George's Respiratory Questionnaire (SGRQ) score, and Leicester Cough Questionnaire (LCQ) score at 8 weeks.

RESULTS

A total of five RCTs with a total of 198 patients were included. A pooled analysis showed that improvements in ISWD (mean difference [MD] = 92.47 m, 95% confidence interval [CI] 49.87, 135.08; P < 0.0001), 6-MWD (MD = 31.01 m, 95% CI 1.60, 60.42; P = 0.04), and FEV1 (MD = 0.08 L, 95% CI 0.04, 0.12; P = 0.0002) in the pulmonary rehabilitation group were more marked than in the control group. There was no significant difference between the two groups in terms of the improvement in SGRQ and LCQ scores.

CONCLUSIONS

Pulmonary rehabilitation improves exercise capacity and pulmonary function (specifically FEV1) in patients with bronchiectasis. However, due to limitations in the number and quality of current studies, the above conclusions need to be verified in future research.

Criteria and definitions for the radiological and clinical diagnosis of bronchiectasis in adults for use in clinical trials: international consensus recommendations

Bronchiectasis refers to both a clinical disease and a radiological appearance that has multiple causes and can be associated with a range of conditions. Disease heterogeneity and the absence of standardised definitions have hampered clinical trials of treatments for bronchiectasis and are important challenges in clinical practice. In view of the need for new therapies for non-cystic fibrosis bronchiectasis to reduce the disease burden, we established an international taskforce of experts to develop recommendations and definitions for clinically significant bronchiectasis in adults to facilitate the standardisation of terminology for clinical trials. Systematic reviews were used to inform discussions, and Delphi processes were used to achieve expert consensus. We prioritised criteria for the radiological diagnosis of bronchiectasis and suggest recommendations on the use and central reading of chest CT scans to confirm the presence of bronchiectasis for clinical trials. Furthermore, we developed a set of consensus statements concerning the definitions of clinical bronchiectasis and its specific signs and symptoms, as well as definitions for chronic bacterial infection and sustained culture conversion. The diagnosis of clinically significant bronchiectasis requires both clinical and radiological criteria, and these expert recommendations and proposals should help to optimise patient recruitment into clinical trials and allow reliable comparisons of treatment effects among different interventions for bronchiectasis. Our consensus proposals should also provide a framework for future research to further refine definitions and establish definitive guidance on the diagnosis of bronchiectasis.

Development of a core outcome set and outcome measurement set for physiotherapy trials in adults with Bronchiectasis (COS-PHyBE study): A protocol

Background

Bronchiectasis is a chronic respiratory disease characterised by airways widening and recurrent infections, resulting in episodes of chronic cough, sputum expectoration, and dyspnoea. This leads to deterioration in daily function, repeated hospital admissions and poor quality of life. The prevalence and mortality related to bronchiectasis is increasing worldwide with growing economic burden on healthcare systems. Physiotherapy for bronchiectasis aims to decrease accumulation of sputum, dyspnoea, and improve exercise capacity and daily function. A robust evidence base to support physiotherapy in bronchiectasis is currently lacking. This is partly because of inconsistency and poor reporting of outcomes in available studies.

A core outcome set is the minimum acceptable group of outcomes that should be used in clinical trials for a specific condition. This decreases research waste by improving consistency and reporting of key outcomes and facilitates the synthesis of study outcomes in systematic reviews and guidelines.

The aim of the study is therefore to develop a core outcome set and outcome measurement set for physiotherapy research in adults with bronchiectasis. This will ensure outcomes important to key stakeholders are consistently used and reported in future research.

Methods and analysis

This project will use the COMET Initiative and COSMIN guidelines of core outcome set development and will include three phases. In the first phase, a comprehensive list of outcomes will be developed using systematic review of reported outcomes and qualitative interviews with patients and physiotherapists. Then consensus on key outcomes will be established in phase two using a Delphi survey and a consensus meeting. Finally, in phase three, we will identify appropriate instruments to measure the core outcomes by evaluating the psychometric properties of available instruments and a stakeholders’ meeting to establish consensus.

Ethics

The study was reviewed and has received ethical approval from the health-related Research Ethics Committee- Edge Hill University (ETH2021-0217).

Registration

This study is registered with the COMET database. https://www.comet-initiative.org/Studies/Details/1931.

The full systematic review protocol is registered in PROSPERO under the number CRD42021266247.

Utility of a personalised Bronchiectasis Action Management Plan (BAMP) for children with bronchiectasis: protocol for a multicentre, double-blind parallel, superiority randomised controlled trial

INTRODUCTION

Bronchiectasis is no longer considered rare or irreversible in children, yet it remains relatively under-researched and neglected in respiratory health globally. Bronchiectasis (including chronic suppurative lung disease) causes substantial morbidity for patients and significant impact on caregivers, especially during acute respiratory exacerbations. In other chronic respiratory diseases (eg, asthma), empowering consumers with an individualised plan for management of acute exacerbations improves clinical outcomes. However, in the absence of any such data specific to bronchiectasis, action management plans are rarely currently used in children or adults with bronchiectasis. We hypothesise that providing an individualised bronchiectasis action management plan (BAMP) to children with bronchiectasis reduces non-scheduled doctor consultations, compared with not having a BAMP.

METHODS AND ANALYSIS

This multicentre, parallel, double-blind, randomised trial involving three urban Australian hospitals commenced in June 2018 and will include 198 children, aged <19 years with bronchiectasis who had 2 or more exacerbations in the previous 18 months. Children will be randomised to having an individualised BAMP or standard care (a decoy clinic letter). Primary caregivers will then be followed up monthly for 12 months. The primary outcome is the rate of acute non-scheduled doctor visits for respiratory exacerbations by 12 months. The main secondary outcomes are cough-specific quality of life scores at 6 and 12 months, overall exacerbation rate over 12 months, and proportion of children who received timely influenza vaccination by 30 May annually.

ETHICS AND DISSEMINATION

The Human Research Ethics Committees of the Northern Territory Department of Health and Menzies School of Heath Research and Queensland Children's Hospital approved the study. The results of the trial will be submitted for publication and the BAMP made available free online.

TRIAL REGISTRATION NUMBER

Australia and New Zealand Clinical Trials Register ACTRN12618000604202.

The contribution of Pseudomonas aeruginosa infection to clinical outcomes in bronchiectasis: a prospective cohort study

OBJECTIVES

The impact of Pseudomonas aeruginosa on the prognosis of bronchiectasis remains controversial. This study aimed to explore the prognostic value of P. aeruginosa in adult patients with bronchiectasis in central-southern China.

PATIENTS AND METHODS

This prospective cohort study enrolled 1,234 patients with bronchiectasis between 2013 and 2019. The independent impact of P. aeruginosa on all-cause mortality, annual exacerbations, and hospitalizations was assessed.

RESULTS

P. aeruginosa was isolated from 244 patients (19.8%). A total of 188 patients died over a follow-up period of 16 (1-36) months. Patients with P. aeruginosa had a longer disease course, poorer lung function, more lung lobe involvement, and more severe Bronchiectasis Severity Index (BSI) stage than those without P. aeruginosa. The independent impact of P. aeruginosa was observed on frequent hospitalizations but not on mortality and frequent exacerbations. Moderate- or high-risk comorbidities increased the risk of mortality (hazard ratio [HR]: 1.93, 95% confidence interval [CI]: 1.26-2.95), and this effect was magnified by the presence of P. aeruginosa (HR: 2.11, 95% CI: 1.28-3.48).

CONCLUSIONS

P. aeruginosa infection acts as a marker of disease severity as well as predictor of frequent hospitalizations. P. aeruginosa had no independent effect on all-cause mortality. P. aeruginosa combined with moderate- or high-risk comorbidities posed an increased risk of mortality. The management of comorbidities may be a critical target during the treatment of P. aeruginosa infection in bronchiectasis.KEY MESSAGE:P. aeruginosa increased the risk of frequent hospitalizations; however, it had no independent impact on all-cause mortality.P. aeruginosa combined with moderate- or high-risk comorbidities posed an increased risk of mortality.The management of comorbidities may be a critical target during the treatment of P. aeruginosa infection in bronchiectasis.

Evaluating hemoptysis hospitalizations among patients with bronchiectasis in the United States: a population-based cohort study

Background

The burden of hospitalizations and mortality for hemoptysis due to bronchiectasis is not well characterized. The primary outcome of our study was to evaluate in-hospital mortality in patients admitted with hemoptysis and bronchiectasis, as well as the rates of bronchial artery embolization, length of stay, and hospitalization costs.

Methods

The authors queried the Nationwide Inpatient Sample (NIS) claims database for hospitalizations between 2016 and 2017 using the ICD-10-CM codes for hemoptysis and bronchiectasis in the United States. Multivariable regression was used to evaluate predictors of in-hospital mortality, embolization, length of stay, and hospital costs.

Results

There were 8240 hospitalizations (weighted) for hemoptysis in the United States from 2016 to 2017. The overall in-hospital mortality was 4.5%, but higher in males compared to females. Predictors of in-hospital mortality included undergoing three or more procedures, age, and congestive heart failure. Bronchial artery embolization (BAE) was utilized during 2.1% of hospitalizations and was more frequently used in those with nontuberculous mycobacteria and aspergillus infections, but not pseudomonal infections. The mean length of stay was 6 days and the median hospitalization cost per patient was USD $9,610. Having comorbidities and procedures was significantly associated with increased length of stay and costs.

Conclusion

Hemoptysis is a frequent indication for hospitalization among the bronchiectasis population. In-hospital death occurred in approximately 4.5% of hospitalizations. The effectiveness of BAE in treating and preventing recurrent hemoptysis from bronchiectasis needs to be explored.

Epidemiology and economic burden of bronchiectasis requiring hospitalisation in Singapore

Background and objective

Little is known about the epidemiology and cost of bronchiectasis in Asia. This study describes the disease burden of bronchiectasis in Singapore.

Methods

A nationwide administrative dataset was used to identify hospitalisations with bronchiectasis as a diagnosis. Population statistics and medical encounter data were used to estimate the incidence, mortality, prevalence and direct medical costs associated with bronchiectasis requiring hospitalisation.

Results

There were 420 incident hospitalised bronchiectasis patients in 2017, giving an incidence rate of 10.6 per 100 000. Age-standardised incidence declined on average by 2.7% per year between 2007 and 2017. Incidence rates increased strongly with age in both men and women. Tuberculosis was a secondary diagnosis in 37.5% of incident hospitalisations in 2007, but has declined sharply since then. Patient survival was considerably lower in both men (5-year relative survival ratios (RSR) 0.63, 95% CI 0.59–0.66) and women (5-year RSR 0.75, 95% CI 0.72–0.78). The point prevalence of bronchiectasis was 147.1 per 100 000 in 2017, and increased sharply with age, with >1% of people aged ≥75 years having bronchiectasis. Total first-year costs among incident bronchiectasis patients in 2016 varied widely, with a mean±sd USD 7331±8863. Approximately 10% of the patients admitted in 2016 had total first-year costs of more than USD 14 380.

Conclusion

Bronchiectasis is common and imposes a substantial burden on healthcare costs and survival rates of patients in Singapore.

Bronchiectasis is common, with a prevalence >1% in older persons, and imposes a substantial burden on healthcare costs and survival rates of patients living with bronchiectasis in Singaporehttps://bit.ly/3iErV79

ROSE: radiology, obstruction, symptoms and exposure - a Delphi consensus definition of the association of COPD and bronchiectasis by the EMBARC Airways Working Group

INTRODUCTION

The coexistence of COPD and bronchiectasis seems to be common and associated with a worse prognosis than for either disease individually. However, no definition of this association exists to guide researchers and clinicians.

METHODS

We conducted a Delphi survey involving expert pulmonologists and radiologists from Europe, Turkey and Israel in order to define the "COPD- [bronchiectasis] BE association".A panel of 16 experts from EMBARC selected 35 statements for the survey after reviewing scientific literature. Invited participants, selected on the basis of expertise, geographical and sex distribution, were asked to express agreement on the statements. Consensus was defined as a score of ≥6 points (scale 0 to 9) in ≥70% of answers across two scoring rounds.

RESULTS

102 (72.3%) out of 141 invited experts participated in the first round. Their response rate in the second round was 81%. The final consensus definition of "COPD-BE association" was: "The coexistence of (1) specific radiological findings (abnormal bronchial dilatation, airways visible within 1 cm of pleura and/or lack of tapering sign in ≥1 pulmonary segment and in >1 lobe) with (2) an obstructive pattern on spirometry ([forced expiratory volume in 1 s] FEV1/[forced vital capacity] FVC <0.7), (3) at least two characteristic symptoms (cough, expectoration, dyspnoea, fatigue, frequent infections) and (4) current or past exposure to smoke (≥10 pack-years) or other toxic agents (biomass, etc.)". These criteria form the acronym "ROSE" (Radiology, Obstruction, Symptoms, Exposure).

CONCLUSIONS

The Delphi process formulated a European consensus definition of "COPD-BE association". We hope this definition will have broad applicability across clinical practice and research in the future.

Evaluating the Prevalence and Incidence of Bronchiectasis and Nontuberculous Mycobacteria in South Korea Using the Nationwide Population Data

Although the prevalence and incidence of bronchiectasis are rising worldwide, basic epidemiologic data have not been reported in Korea. Therefore, this study was conducted to investigate epidemiological characteristics of bronchiectasis and NTM (nontuberculous mycobacteria) pulmonary diseases in Korea using the National Health Insurance Service-National Sample Cohort (NHIS-NSC) data. The relative risks of prevalence and incidence after adjusting for demographic characteristics were evaluated by multivariate Poisson regression. The result of this study showed the prevalence and incidence rates of bronchiectasis and NTM to be epidemiologically similar to each other with a few slight differences, while the prevalence rate of bronchiectasis was not significantly different by gender, and its incidence rate was significantly lower in women than in men. Both the prevalence and incidence of NTM were significantly higher in women than in men. Both the prevalence and incidence rates of bronchiectasis and NTM were significantly lower in the age group below 40–49 years, and significantly higher in the age groups thereafter. As there were gender differences of bronchiectasis and NTM, gender-sensitive risk management should be available. In addition, since both bronchiectasis and NTM increase in prevalence and incidence after the age of 40–49, early detection and intervention strategies targeting the appropriate age group are needed.

Chronic wet cough in Australian children: Societal costs and quality of life

INTRODUCTION

Children with chronic wet cough regularly use the health system, experience considerable variability in care, have reduced quality of life (QoL), and, left untreated, poorer health outcomes. Despite this, little is known about the associated economic burden. This study aimed to quantify the cost of chronic wet cough among Australian children from the perspectives of families and the health system.

METHODS

A cost of illness study was conducted at the Queensland Children's Hospital, Brisbane, using data on 91 children newly referred to a respiratory specialist between July 2015 and January 2017 with a history of chronic wet cough (>4 weeks) of unknown etiology. Administrative and parent-reported data were used to estimate costs (reported in 2019 Australian Dollars [AUD]) for up to 12 months before and following initial pulmonology consultation. QoL was assessed for the same periods.

RESULTS

Mean cost per child-month during the average 9.8 months of observation preceding pulmonology consultation was AUD689 (95% confidence interval [CI] 534-844) increasing to AUD1339 (95% CI 1051-1628) during the average 11.9 months following pulmonology consultation. This translated to a total of AUD1.9 million across the study period, with families bearing 26.4% of costs. Aspiration and bronchiectasis were associated with higher total costs. For all etiologies, cough-specific QoL improved following pulmonology consultation, while direct medical costs declined.

CONCLUSION

Childhood chronic wet cough is associated with substantial societal costs. The observed cost decrease after specialist diagnosis suggests that early referral to a respiratory specialist may have economic benefits, in addition to the known health benefits.

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.

Small Airway Disease and Emphysema Are Associated with Future Exacerbations in Smokers with CT-derived Bronchiectasis and COPD: Results from the COPDGene Cohort

Background Chronic obstructive pulmonary disease (COPD) and bronchiectasis can overlap and share pathologic features, such as small airway disease (SAD). Whether the presence of SAD and emphysema in smokers with CT-derived bronchiectasis is associated with exacerbations is unknown. Purpose To assess whether SAD and emphysema in smokers with CT-derived bronchiectasis are associated with future exacerbations. Materials and Methods SAD and emphysema were quantified using the parametric response map method in former and current heavy smokers with and without bronchiectasis at CT from the COPDGene Study (from July 2009 to July 2018). Exacerbations were prospectively assessed through biannual follow-up. An exacerbation was defined as an increase in or new onset of respiratory symptoms treated with antibiotics and/or corticosteroids. Severe exacerbations were defined as those that required hospitalization. The association of a high burden of SAD (≥15.6%) and high burden of emphysema (≥5%) at CT with exacerbations was assessed with generalized linear mixed models. Results Of 737 participants, 387 (median age, 64 years [interquartile range, 58-71 years]; 223 women) had CT-derived bronchiectasis. During a 9-year follow-up, after adjustment for age, sex, race, body mass index, current smoking status, pack-years, exacerbations before study entry, forced expiratory volume in 1 second, or FEV₁, and bronchiectasis severity CT score, high burden of SAD and high burden of emphysema were associated with a higher number of exacerbations per year (relative risk [RR], 1.89 [95% CI: 1.54, 2.33] and 1.37 [95% CI: 1.13, 1.66], respectively; P ≤ .001 for both). Results were comparable among participants with bronchiectasis meeting criteria for COPD (n = 197) (RR, 1.67 [95% CI: 1.23, 2.27] for high burden of SAD and 1.51 [95% CI: 1.20, 1.91] for high burden of emphysema; P ≤ .001 for both). Conclusion In smokers with CT-derived bronchiectasis and chronic obstructive pulmonary disease, structural damage to lung parenchyma and small airways was associated with a higher number of exacerbations per year. Clinical trial registration no. NCT00608764 © RSNA, 2021.

Home-based pulmonary rehabilitation in people with bronchiectasis: a randomised controlled trial

Aim

To investigate the short- and long-term effects of home-based pulmonary rehabilitation (HBPR) on functional capacity, quality of life, peripheral muscle strength, dyspnoea and daily physical activity in people with bronchiectasis.

Methods

Randomised controlled trial with 63 participants with bronchiectasis. The HBPR group performed three sessions per week for 8 weeks (aerobic exercise: step training for 20 min; resistance training: exercises for quadriceps, hamstrings, deltoids and biceps brachii using elastic bands). The control group received a recommendation to walk at moderate intensity, three times per week. A weekly phone call was conducted for all participants, and the HBPR group received a home visit every 15 days. The primary outcome was distance in the incremental shuttle walk test (ISWT). Secondary outcomes were time in the endurance shuttle walk test (ESWT), number of steps in the incremental step test, quality of life, quadriceps muscle strength and daily physical activity. Measures were taken before and after intervention and 6 months later.

Results

After the intervention, the HBPR group had increased ISWT distance compared with the control group with between-group difference 87.9 m (95% CI 32.4–143.5 m). In addition, between-group differences were found in the ESWT, incremental step test, quality of life and quadriceps muscle strength, favouring the HBPR group. After 6 months, no differences were observed between the groups.

Conclusion

HBPR is an effective alternative offering of pulmonary rehabilitation for people with bronchiectasis. However, the programme was not effective in maintaining the benefits after 6 months of follow-up.

Home-based pulmonary rehabilitation (HBPR) delivers improvements in functional capacity, peripheral muscle strength and QoL in people with bronchiectasis. HBPR is safe, well tolerated and can be considered an alternative rehabilitation programme.https://bit.ly/2Q2Bout

Clinical features related to hospital expenses for non-cystic fibrosis bronchiectasis in China

Objective

Bronchiectasis is a common chronic airway disease. We investigated the economic burden and associated factors of bronchiectasis in China.

Methods

In this multicenter retrospective cohort study, we reviewed medical records of patients admitted to 18 tertiary hospitals during 2010 to 2014 with a bronchiectasis-related diagnosis.

Results

A total 5469 patients with bronchiectasis were admitted, accounting for 3.13% ± 1.80% of all discharged patients with any diagnosis during the same period; 13 patients died upon discharge. The median hospitalization cost was RMB 8421.52 (RMB 5849.88–12,294.47). Risk factors associated with hospitalization costs included age at admission (>70 vs. <40 years, odds ratio (OR) = 1.221, 95% confidence interval (CI) = 1.082–1.379; >80 vs. <40 years, OR = 1.251, 95% CI = 1.089–1.438), smoking (≤15 packs/year vs. non-smokers, OR = 1.125, 95% CI = 1.006–1.271; >15 packs/year vs. non-smokers, OR = 1.127, 95% CI = 1.062–1.228), length of hospitalization (OR = 1.05, 95% CI = 1.046–1.054), combination antibiotic treatment (OR = 1.089, 95% CI = 1.033–1.148), cough (OR = 0.851, 95% CI = 0.751–0.965), dyspnea (OR = 0.93, 95% CI = 0.878–0.984), chronic obstructive pulmonary disease (OR = 0.935, 95% CI = 0.878–0.996), respiratory failure (OR = 0.923, 95% CI = 0.862–0.989), cor pulmonale (OR = 0.919, 95% CI = 0.859–0.982), and death (OR = 1.816, 95% CI = 1.113–2.838).

Conclusions

Age, smoking status, symptoms, and respiratory comorbidities were associated with hospitalization costs of bronchiectasis.

Increased mortality in patients with non cystic fibrosis bronchiectasis with respiratory comorbidities

There are limited data regarding whether mortality is higher in patients with non cystic fibrosis bronchiectasis (bronchiectasis) than in those without bronchiectasis. Using 2005–2015 data from the Korean National Health Insurance Service, we evaluated hazard ratio (HR) for all-cause mortality in the bronchiectasis cohort relative to the matched cohort. The effect of comorbidities over the study period on the relative mortality was also assessed. All-cause mortality was significantly higher in the bronchiectasis cohort than in the matched cohort (2505/100,000 vs 2142/100,000 person-years, respectively; P < 0.001). Mortality risk was 1.15-fold greater in the bronchiectasis cohort than in the matched cohort (95% confidence interval [CI] 1.09–1.22); mortality was greatest among elderly patients (HR = 1.17, 95% CI 1.10–1.25) and men (HR = 1.19, 95% CI 1.10–1.29). Comorbidities over the study period significantly increased the risk of death in the bronchiectasis cohort relative to the matched cohort: asthma (adjusted HR = 1.20, 95% CI 1.11–1.30), chronic obstructive pulmonary disease (adjusted HR = 1.24, 95% CI 1.15–1.34), pneumonia (adjusted HR = 1.50, 95% CI 1.39–1.63), lung cancer (adjusted HR = 1.85, 95% CI 1.61–2.12), and cardiovascular disease (adjusted HR = 1.34, 95% CI 1.23–1.45). In contrast, there were no significant differences in the risk of death in patients without bronchiectasis-related comorbidities and the matched cohort, except in the case of non-tuberculous mycobacterial infection. In conclusion, all-cause mortality was higher in patients with bronchiectasis cohort than those without bronchiectasis, especially in elderly patients and men. Comorbidities over the study period played a major role in increasing mortality in patients with bronchiectasis relative to those without bronchiectasis.

Evolution and Comparative Analysis of Hospitalizations in Spain Due to COPD and Bronchiectasis between 2004 and 2015

Chronic obstructive pulmonary disease (COPD) is the leading cause of hospitalization for chronic respiratory illness in Spain. In recent years hospital admissions due to bronchiectasis have been increasing, although it is not known whether this is in proportion to COPD hospitalizations. Our main objective was to analyze the temporal evolution of discharges due to COPD, bronchiectasis, and their combination, and secondly, to assess their impact on in-hospital mortality and healthcare costs. We performed a retrospective study, based on the analysis of the Minimum Basic Data Set (MBDS) of hospital discharges using data from Spanish Ministry of Health with diagnostic codes of COPD or bronchiectasis between 2004 and 2015. We found 3 356 186 discharges with a diagnosis of COPD or bronchiectasis. After exclusions, 1 386 430 episodes were analyzed: 85.2% with COPD, 8.4% bronchiectasis, and 6.4% with both pathologies. Mean age of patients was 74.8 (10.9) years and with a male predominance of 80.1%. The increase in the annual number of discharges was greater in the two groups with bronchiectasis: 48.8% in the bronchiectasis group and 55.4% in the mixed group, compared to 6.6% in the COPD group. The mean length of stay was greater in both groups with bronchiectasis (p < 0.001), while in-hospital mortality was higher in the COPD group (p < 0.001). Similarly, the annual increase of costs was more evident in the two groups with bronchiectasis. Conclusions: Hospitalizations and health costs for bronchiectasis have increased in recent years significantly more than for COPD.Supplemental data for this aricle can be accessed here.

The Effect of a High-Intensity PrO2Fit Inspiratory Muscle Training Intervention on Physiological and Psychological Health in Adults with Bronchiectasis: A Mixed-Methods Study

Bronchiectasis is characterised by airflow obstruction and hyperinflation resulting in respiratory muscle weakness, and decreased exercise capacity. Inspiratory muscle training (IMT) is potentially an alternative treatment strategy to enhance respiratory muscle strength and endurance. Therefore, the aim was to investigate the effects of IMT on those with bronchiectasis. Eighteen participants (10 bronchiectasis) took part in an eight-week, three times a week IMT programme at 80% sustained maximal inspiratory pressure (SMIP). Lung function, respiratory muscle strength and endurance, exercise capacity, physical activity and self-determination theory measures were taken. Participants also took part in a semi-structured interview to assess their perceptions and experience of an IMT intervention. After eight weeks of IMT, bronchiectasis and healthy participants exhibited significant increases in MIP (27% vs. 32%, respectively), SMIP (16% vs. 17%, respectively) and inspiratory duration (36% vs. 30%, respectively). Healthy participants exhibited further improvements in peak expiratory flow and maximal oxygen consumption. Bronchiectasis participants reported high levels of perceived competence and motivation, reporting higher adherence and improved physical ability. Eight weeks of IMT increased inspiratory muscle strength and endurance in those with bronchiectasis. IMT also had a positive effect on perceived competency and autonomy, with bronchiectasis participants reporting improved physical ability and motivation, and high adherence.

'It's not one size fits all': a qualitative study of patients' and healthcare professionals' views of self-management for bronchiectasis

Background

Bronchiectasis is a chronic respiratory condition that impacts significantly on individuals and healthcare services. Self-management is recommended in clinical guidelines for bronchiectasis as an intervention to enable patients to manage their condition, yet there is little evidence to support it.

Methods

Three face to face focus groups (17 adults with bronchiectasis) were conducted at three National Health Service (NHS) sites in North West England. Additionally, semi-structured telephone interviews were undertaken with 11 healthcare professionals (HCPs), including doctors, nurses and physiotherapists. Thematic analysis identified common themes and occurrences verified by independent audit.

Findings

Four common overarching themes were identified: the meaning of self-management; benefits; barriers and influencers to self-management; subthemes varied. Both groups recognised component interventions. Patients highlighted that self-management enabled them to learn what works and moderate behaviour. Aspects of delivery and structure were important to HCPs but a ‘make do’ culture was evident. Benefits for both groups included empowering patients. Common barriers for patients were time, mood and lack of access to support which could mitigate engagement with self-management. HCPs identified barriers including patient characteristics and lack of resources. Influencers for patients were peer, carer and psychosocial support, for HCPs influencers were individual patient attributes, including ability and motivation, and HCP characteristics such as knowledge and understanding about bronchiectasis.

Summary

This is the first study to explore patients’ and HCPs’ views of self-management for bronchiectasis. The need for an individual, flexible and responsive self-management programme specific to bronchiectasis was evident. Personal characteristics of patients and HCPs could affect the uptake and engagement with self-management and HCPs knowledge of the disease is a recognised precursor to effective self-management. The study identified key aspects for consideration during development, delivery and sustainability of self-management programmes and findings suggest that patients’ psychosocial and socioeconomic circumstances may affect adoption and activation of self-management behaviours.

Relationship between Symptoms, Exacerbations, and Treatment Response in Bronchiectasis

Rationale: Bronchiectasis guidelines regard treatment to prevent exacerbation and treatment of daily symptoms as separate objectives.Objectives: We hypothesized that patients with greater symptoms would be at higher risk of exacerbations and therefore that a treatment aimed at reducing daily symptoms would also reduce exacerbations in highly symptomatic patients.Methods: Our study comprised an observational cohort of 333 patients from the East of Scotland (2012-2016). Either symptoms were modeled as a continuous variable or patients were classified as having high, moderate, or low symptom burden (>70, 40-70, and <40 using the St. George's Respiratory Questionnaire symptom score). The hypothesis that exacerbation reductions would only be evident in highly symptomatic patients was tested in a post hoc analysis of a randomized trial of inhaled dry powder mannitol (N = 461 patients).Measurements and Main Results: In the observational cohort, daily symptoms were a significant predictor of future exacerbations (rate ratio [RR], 1.10; 95% confidence interval [CI], 1.03-1.17; P = 0.005). Patients with higher symptom scores had higher exacerbation rates (RR, 1.74; 95% CI, 1.12-2.72; P = 0.01) over 12-month follow-up than those with lower symptoms. Inhaled mannitol treatment improved the time to first exacerbation (hazard ratio, 0.56; 95% CI, 0.40-0.77; P < 0.001), and the proportion of patients remaining exacerbation free for 12 months of treatment was higher in the mannitol group (32.7% vs. 14.6%; RR, 2.84; 95% CI, 1.40-5.76; P = 0.003), but only in highly symptomatic patients. In contrast, no benefit was evident in patients with lower symptom burden.Conclusions: Highly symptomatic patients have increased risk of exacerbations, and exacerbation benefit with inhaled mannitol was only evident in patients with high symptom burden.

Validation of the Korean Version of the Bronchiectasis Health Questionnaire

BACKGROUND

The Bronchiectasis Health Questionnaire (BHQ) is a simple and repeatable, self-reporting health status questionnaire for bronchiectasis. We have translated the original version of the BHQ into Korean using a standardized methodology. The purpose of this study was to assess the validity of the Korean version of the BHQ (K-BHQ) with Korean patients.

METHODS

Stable state patients with bronchiectasis from two academic hospitals were enrolled in this study. The validity was assessed by investigating the relationship between the K-BHQ scores and the Korean version of the Chronic Obstructive Pulmonary Disease Assessment Test (K-CAT) scores. We also investigated the relationship between the K-BHQ scores and other variables of the modified Medical Research Council's (mMRC) dyspnea scale, lung function, and exacerbations.

RESULTS

A total of 126 patients with bronchiectasis were enrolled. The mean age was 64.3 (standard deviation [SD], 9.7). Women comprised 53.2% of the patients. The mean forced expiratory volume in one second (FEV1) was 60% of the predicted value (SD, 18.9%); the mean K-CAT score was 17.6 (SD, 9.1). The K-BHQ scores correlated strongly with the K-CAT scores (r=-0.656, p<0.001). There was significant correlation between the K-BHQ scores and the mMRC dyspnea scale (ρ=-0.409, p<0.001), FEV1 (r=0.406, p<0.001), and number of exacerbations requiring hospitalization (ρ=-0.303, p=0.001).

CONCLUSION

The K-BHQ is valid for assessing the health-related quality of life or health status of Korean bronchiectasis patients.

Measuring airway clearance outcomes in bronchiectasis: a review

While airway clearance techniques (ACTs) are recommended for individuals with bronchiectasis, many trials have demonstrated inconsistent benefits or failed to reach their primary outcome. This review determined the most common clinical and patient-reported outcome measures used to evaluate the efficacy of ACTs in bronchiectasis. A literature search of five databases using relevant keywords and filtering for studies published in English, up until the end of August 2019, was completed. Studies included randomised controlled trials, using crossover or any other trial design, and abstracts. Studies were included where the control was placebo, no intervention, standard care, usual care or an active comparator. Adults with bronchiectasis not related to cystic fibrosis were included. Extracted data comprised study authors, design, duration, intervention, outcome measures and results. The search identified 27 published studies and one abstract. The most common clinical outcome measures were sputum volume (n=23), lung function (n=17) and pulse oximetry (n=9). The most common patient-reported outcomes were health-related quality of life (measured with St George's Respiratory Questionnaire, n=4), cough-related quality of life (measured with Leicester Cough Questionnaire, n=4) and dyspnoea (measured with Borg/modified Borg scale, n=8). Sputum volume, lung function, dyspnoea and health- and cough-related quality of life appear to be the most common clinical and patient-reported measures of airway clearance treatment efficacy.

Cost of hospitalization for bronchiectasis exacerbation in children

BACKGROUND AND OBJECTIVE

Despite paediatric bronchiectasis being recognized increasingly worldwide, prior reports of hospitalization costs for bronchiectasis in children are lacking. This study aimed to (i) identify health service costs of hospitalizations and (ii) factors associated with these costs in children admitted to an Australian paediatric hospital following an acute exacerbation of their bronchiectasis.

METHODS

Demographic and hospital resource use data were prospectively recorded for 100 hospitalizations in 80 children aged <18 years admitted consecutively to the QCH, Brisbane, Australia. Costs (2016 AUD) were obtained from the hospital's Finance Department. Linear regressions, with bootstrap resampling to quantify uncertainty, were used to estimate factors affecting cost of hospitalization.

RESULTS

The 100 hospitalizations (48 males) had a median (IQR) age of 6.04 (4.04-9.85) years. Their mean (SD) LOS was 12.30 (4.60) days. The mean (SD) direct health service cost was AUD 30 182 (13 998) per hospitalization. The greatest contributor to costs was health professional wages, accounting for 70% of the cost per episode. LOS, younger age at admission and number of bronchiectatic lobes affected were associated with higher costs, whilst HITH service was associated with lower cost. The cost to families on average was AUD 2669.50 (SD: 991.50) per hospitalization when accounting for lost wages and opportunity cost.

CONCLUSION

The per episode healthcare cost burden of hospitalizations for paediatric bronchiectasis exacerbations is substantial. Interventions that prevent hospitalized exacerbations and reduce severity of childhood bronchiectasis with even moderate effectiveness are likely to result in substantial hospital costs savings.

Etiology and characteristics of patients with bronchiectasis in Taiwan: a cohort study from 2002 to 2016

Background

Bronchiectasis is a chronic infectious respiratory disease with diverse causes and ethnic or geographic differences. However, few large-scale studies of its etiology have been conducted in Asia. This study aimed to determine the etiology and clinical features of bronchiectasis in Taiwan.

Methods

This longitudinal cohort study investigated the etiology and clinical features of newly diagnosed non-cystic fibrosis bronchiectasis patients from January 2002 to December 2016. The clinical, functional and microbiological data of patients were retrieved from the Chang Gung Research Database, which includes seven medical facilities throughout Taiwan. The index date was the date of the first bronchiectasis diagnosis. Known diseases that were diagnosed before the index date were regarded as etiologies of bronchiectasis.

Results

The cohort comprised 15,729 adult patients with bronchiectasis. Idiopathic (32%) was the most common cause, followed by post-pneumonia (24%). Other causes included post-tuberculosis (12%), chronic obstructive pulmonary disease (14%), asthma (10%), gastroesophageal reflux disease (2%) and rheumatic diseases (2%). At diagnosis, 8487 patients had sputum culture. Pseudomonas aeruginosa (5.3%) was the most common bacteria, followed by non-tuberculosis mycobacteria (3.6%), Haemophilus influenzae (3.4%) and Klebsiella pneumoniae (3.1%), but 6155 (72.1%) had negative sputum cultures. Patients with post-tuberculosis had a higher sputum isolation rate of non-tuberculosis mycobacteria than P. aeruginosa. Patients with post-tuberculosis and post-pneumonia bronchiectasis had a higher frequency of chronic lung infection than other groups (p < 0.05). Clinical characteristics, such as gender, lung function, comorbidities and microbiology, were significantly different between idiopathic and known etiologies.

Conclusions

Idiopathic, post-infection and tuberculosis constitute major bronchiectasis etiologies in Taiwan. Clinical characteristics and sputum microbiology were distinct among separate etiology phenotypes.

KMBARC registry: protocol for a multicentre observational cohort study on non-cystic fibrosis bronchiectasis in Korea

INTRODUCTION

Despite the significant disease burden of bronchiectasis in Korea, no large-scale, representative prospective cohort studies have been conducted to evaluate the clinical characteristics of Korean patients with bronchiectasis, indicating an urgent need for cohort studies on bronchiectasis.

METHODS AND ANALYSIS

The Korean Multicenter Bronchiectasis Audit and Research Collaboration (KMBARC) is a prospective, non-interventional observational cohort study on bronchiectasis in Korea. The inclusion criteria of this registry are as follows: (1) adult patients (aged ≥18 years) with or without respiratory symptoms (cough, chronic sputum and/or recurrent respiratory infection) and chest computed tomography revealing bronchiectasis affecting one or more lobes and (2) stable status at the time of registration: patients with bronchiectasis who were admitted for a respiratory aetiology can be enrolled at least 4 weeks after hospital discharge. The exclusion criteria are as follows: (1) bronchiectasis due to cystic fibrosis; (2) traction bronchiectasis associated with interstitial lung disease; (3) patients actively being treated for pneumonia, pulmonary tuberculosis or non-tuberculous mycobacterial infection; (4) patients who are unable or unwilling to provide informed consent; and (5) pregnant patients. Although the KMBARC questionnaires for baseline and annual follow-up data are similar to the European Multicentre Bronchiectasis Audit and Research Collaboration questionnaires, KMBARC has distinctive features such as use of Bronchiectasis Health Questionnaires, measurement with fatigue and depression scales, blood tests, use of consensus definition of exacerbations and information on emergency room or hospitalisation.We aim to recruit at least 1200 patients over the study period from more than 26 hospitals in South Korea. Patients will undergo a detailed baseline and yearly assessment for up to 5 years. The study objectives of the KMBARC registry are as follows: (1) uncovering the natural course of bronchiectasis; (2) aiding in establishing evidence-based bronchiectasis guidelines in Korea; and (3) encouraging and facilitating studies on bronchiectasis in Korea.

ETHICS AND DISSEMINATION

This study received necessary approval from the Institutional Review Boards of all participating institutions. The Asan Medical Center Institutional Review Board gave overall approval for the study. Results will be disseminated via peer-reviewed publications and conference presentations.

TRIAL REGISTRATION NUMBER

KCT0003088.