Bronchiectasis-associated hospitalizations in Germany, 2005-2011: a population-based study of disease burden and trends

Bronchiectasis Exacerbation Increases the Risk of Adverse Renal Outcomes-Results From a Large Territory-Wide Cohort Study

INTRODUCTION

Bronchiectasis exacerbation (BE) is associated with unfavorable sequelae in other organs such as the cardiovascular system; data regarding its impact on adverse term renal outcomes, however, is lacking.

METHODS

A territory-wide retrospective cohort study was conducted in Hong Kong between 1/1/1993 and 31/12/2017. All patients with bronchiectasis followed in the public healthcare system in 2017 were classified as "Exacerbators" or "Non-Exacerbators," and their adverse renal outcomes (renal progression [decrease in eGFR by 30 mL/min lasted for more than 12 months during follow up], acute kidney injury [AKI], and annual rate of eGFR decline) in the ensuing 7 years were compared. Results were also analyzed in the 1:1 propensity score matched (PSM) cohort.

RESULTS

A total of 7929 patients (1074 "Exacerbators" group and 6855 "Non-exacerbators") were followed for 6.2 ± 1.6 years. A total of 1570 patients (19.8%) had renal progression, and 935 (11.8%) patients developed AKI. "Exacerbators" showed significantly increased risk of renal progression (adjusted odds ratio [aOR] 1. 27 [95% CI 1.08-1.50, p = 0.003]), more rapid eGFR decline (-3.67 [-1.74 to -6.54] vs. -3.03 [-1.56 to -5.12] mL/min/1.73 m2/year, p = 0.004) and AKI (aOR 1.99; 95% CI 1.44-2.73, p < 0.001) than the "Non-exacerbators." Annual number of BE was associated with renal progression (aOR 1.45; 95% CI 1.22-1.72, p < 0.001) and AKI (aOR 2.00; 95% CI 1.38-2.91, p < 0.001). Results were consistent in the analysis with the PSM cohort.

CONCLUSIONS

Renal progression and AKI are common among patients with bronchiectasis, and BE is an independent risk factor for adverse renal outcomes.

[Management of adult bronchiectasis - Consensus-based Guidelines for the German Respiratory Society (DGP) e. V. (AWMF registration number 020-030)]

Bronchiectasis is an etiologically heterogeneous, chronic, and often progressive respiratory disease characterized by irreversible bronchial dilation. It is frequently associated with significant symptom burden, multiple complications, and reduced quality of life. For several years, there has been a marked global increase in the prevalence of bronchiectasis, which is linked to a substantial economic burden on healthcare systems. This consensus-based guideline is the first German-language guideline addressing the management of bronchiectasis in adults. The guideline emphasizes the importance of thoracic imaging using CT for diagnosis and differentiation of bronchiectasis and highlights the significance of etiology in determining treatment approaches. Both non-drug and drug treatments are comprehensively covered. Non-pharmacological measures include smoking cessation, physiotherapy, physical training, rehabilitation, non-invasive ventilation, thoracic surgery, and lung transplantation. Pharmacological treatments focus on the long-term use of mucolytics, bronchodilators, anti-inflammatory medications, and antibiotics. Additionally, the guideline covers the challenges and strategies for managing upper airway involvement, comorbidities, and exacerbations, as well as socio-medical aspects and disability rights. The importance of patient education and self-management is also emphasized. Finally, the guideline addresses special life stages such as transition, family planning, pregnancy and parenthood, and palliative care. The aim is to ensure comprehensive, consensus-based, and patient-centered care, taking into account individual risks and needs.

Baseline neutrophil-to-lymphocyte ratio as a predictor of response to hospitalized bronchiectasis exacerbation risks

Background

Bronchiectasis is a disease with predominantly neutrophilic inflammation. As a readily available biomarker, there is little evidence to support the use of blood neutrophil-to-lymphocyte ratio (NLR) to predict bronchiectasis exacerbation severe enough to warrant hospitalization.

Methods

A registry-based retrospective cohort study was conducted at a in Hong Kong. Chinese patients with non-cystic fibrosis (CF) bronchiectasis were retrospectively reviewed and subsequently followed up to investigate the association of NLR and the need for hospitalization for bronchiectasis exacerbation. Data on the NLR for patients in a clinically stable state in 2018 were collected and patients followed up from 1 January 2019 to 31 December 2022. The primary outcome was the need for hospitalization due to bronchiectasis exacerbation over the next 4 years.

Results

We reviewed 473 Chinese patients with non-CF bronchiectasis, of whom 94 required hospitalization for bronchiectasis exacerbation during the 4-year follow-up period. Multi-variable logistic regression adjusted for E-FACED score (Exacerbation, Forced expiratory volume in 1 s (FEV1), Age, Chronic colonization, Extension, and Dyspnea score), gender, age, smoking status, and presence of co-existing chronic obstructive pulmonary disease (COPD) was conducted to compare patients with highest and lowest quartile NLR. Results revealed that those with NLR at the highest quartile were at increased risk of hospitalization for bronchiectasis exacerbation with an adjusted odds ratio (aOR) of 2.02 (95% confidence interval = 1.00-4.12, p = 0.05).

Conclusion

Blood NLR may serve as a marker to predict the need for hospitalization due to bronchiectasis exacerbation.

Medical Causes of Hospitalisation among Patients with Bronchiectasis: A Nationwide Study in Japan

PURPOSE

Although the international guidelines for managing bronchiectasis are centred on preventing the exacerbation of bronchiectasis, the medical causes of admissions to hospital among patients with bronchiectasis have not been fully investigated.

METHODS

This study targeted patients with bronchiectasis who were admitted to hospitals between April 2018 and March 2020 using the national inpatient database in Japan. The causes of hospitalisation and types of antibiotics used for hospitalised patients were recorded.

RESULTS

In total, 21,300 hospitalisations of 16,723 patients with bronchiectasis were analysed. The most common cause was respiratory diseases in 15,145 (71.1%) admissions, including bacterial pneumonia and the exacerbation of bronchiectasis in 6238 (41.2%) and 3151 (20.8%), respectively. Antipseudomonal antibiotics were used in approximately 60% of patients with bacterial pneumonia who were administered antibiotic treatments and in approximately 50% of patients with the exacerbation of bronchiectasis.

CONCLUSIONS

Bacterial pneumonia was the most frequent cause of hospitalisation, followed by the exacerbation of bronchiectasis, among patients with bronchiectasis. Physicians need to focus on the prevention of bacterial pneumonia in addition to the exacerbation of bronchiectasis in patients with bronchiectasis.

Systemic immune-inflammation index in predicting hospitalized bronchiectasis exacerbation risks and disease severity

Background

Bronchiectasis is a common respiratory disease with neutrophilic inflammation being the predominant pathophysiology. Systemic immune-inflammation index (SII) is a simple and readily available biomarker being studied in various conditions including asthma, chronic obstructive pulmonary disease, and interstitial lung disease, but not in bronchiectasis. We aim to investigate the prognostic role of SII in bronchiectasis with this study.

Methods

A retrospective cohort study in Chinese patients with non-cystic fibrosis (CF) bronchiectasis was conducted in Hong Kong, to investigate the association between baseline SII and of hospitalized bronchiectasis exacerbation risk over 4.5 years of follow-up, as well as correlating with disease severity in bronchiectasis. The baseline SII in 2018 was calculated based on stable-state complete blood count.

Results

Among 473 Chinese patients with non-CF bronchiectasis were recruited, 94 of the patients had hospitalized bronchiectasis exacerbation during the follow-up period. Higher SII was associated with increased hospitalized bronchiectasis exacerbation risks with adjusted odds ratio (aOR) of 1.001 [95% confidence interval (CI): 1.000-1.001, P=0.003] for 1 unit (cells/µL) increase in SII count and aOR of 1.403 (95% CI: 1.126-1.748, P=0.003) for 1 standard deviation (SD) increase in SII. SII was found to have significant negative association with baseline forced expiratory volume in the first second (FEV1) (in litre and percentage predicted), forced vital capacity (FVC) in percentage; and significant positive correlation with the extent of bronchiectasis and baseline neutrophil to lymphocyte ratio (NLR).

Conclusions

SII could serve as biomarker to predict the risks of hospitalized exacerbation in bronchiectasis patients, as well as correlating with the disease severity.

Phenotype and Clinicoradiological Differences in Multifocal and Focal Bronchiectasis

Introduction: Bronchiectasis is a chronic progressive respiratory disease characterized by permanent dilatation of the bronchi. It is a complex condition with numerous different etiologies, co-morbidities, and a heterogeneous presentation. As we know, there is a lack of studies that describe the differences and compare the characteristics between focal and multifocal bronchiectasis. The aim of this study is to identify differences in clinical characteristics presentation, severity or distribution in focal and multifocal bronchiectasis, and prognostic implications. Methods: 126 patients with computed tomography (CT)-verified bronchiectasis were enrolled. Baseline characteristics that included age, sex, smoking history, and respiratory symptoms were recorded, with special attention paid to hemoptysis appearance, body mass index, and comorbidities. The type of bronchiectasis determined by CT scan and the modified Reiff scores indicating radiological severity were recorded. Patients were divided in two groups (I is focal and II is multifocal). Results: There were no statistically significant differences in age, smoking status, comorbidity, and BMI between the two groups. Multifocality was associated with a significantly higher proportion of females (p = 0.014), the rate of hemoptysis (p = 0.023), and the number of hospitalizations, but not of exacerbations and prevalence of immunodeficiency (p = 0.049). Significantly, a high number of subjects with multifocality had bronchiectasis of moderate severity, and post-infective and asthma-associated phenotypes were the dominant in this group. Unexpectedly, the cystic and varicose radiological phenotype (which need more time to develop) were more dominant in the focal group. The cylindrical phenotype was equally observed in the multifocal and focal groups. Conclusions: Our study suggests that multifocality is not related to age, number of exacerbations, or radiological phenotype, but it seems to be associated with the clinical post-infective phenotype, immunodeficiency, frequent hospitalizations, and severity. Thus, the presence of multifocal bronchiectasis may act as a biomarker of severity and poor outcomes in these patients.

Factors influencing survival and mortality among adult Aboriginal Australians with bronchiectasis-A 10-year retrospective study

Background

The prevalence of bronchiectasis among adult Aboriginal Australians is higher than that of non-Aboriginal Australians. However, despite evidence to suggest higher prevalence of bronchiectasis among Aboriginal people in Australia, there is sparce evidence in the literature assessing clinical parameters that may predict survival or mortality in this population.

Methods

Aboriginal Australians residing in the Top End Health Service region of the Northern Territory of Australia aged >18 years with chest computed tomography (CT) confirmed bronchiectasis between 2011 and 2020 were included. Demographics, body mass index (BMI), medical co-morbidities, lung function data, sputum microbiology, chest CT scan results, hospital admissions restricted to respiratory conditions and all-cause mortality were assessed.

Results

A total of 459 patients were included, of whom 146 were recorded deceased (median age at death 59 years). Among the deceased cohort, patients were older (median age 52 vs. 45 years, p = 0.023), had a higher prevalence of chronic obstructive pulmonary disease (91 vs. 79%, p = 0.126), lower lung function parameters (median percentage predicted forced expiratory volume in 1 s 29 vs. 40%, p = 0.149), a significantly greater proportion cultured non-Aspergillus fungi (65 vs. 46%, p = 0.007) and pseudomonas (46 vs. 28%, p = 0.007) on sputum microbiology and demonstrated bilateral involvement on radiology. In multivariate models advancing age, prior pseudomonas culture and Intensive care unit (ICU) visits were associated with increased odds of mortality. Higher BMI, better lung function on spirometry, prior positive sputum microbiology for Haemophilus and use of inhaled long-acting beta antagonist/muscarinic agents may have a favourable effect.

Conclusion

The results of this study may be of use to stratify high risk adult Aboriginal patients with bronchiectasis and to develop strategies to prevent future mortality.

Increased exacerbations of bronchiectasis following recovery from mild COVID-19 in patients with non-cystic fibrosis bronchiectasis

BACKGROUND AND OBJECTIVE

Respiratory viral infection is a common trigger of bronchiectasis exacerbation. Knowledge of the intermediate to long-term effect of COVID-19 on bronchiectasis is poor.

METHODS

A retrospective cohort study of patient records was conducted to assess the frequency of bronchiectasis exacerbation following recovery from mild-to-moderate COVID-19. The exacerbation frequency at baseline, using 2019 and 2019-2021 data, was compared with that during the 1 year following recovery.

RESULTS

A total of 234 adult patient records who had a confirmed diagnosis of bronchiectasis were identified, of whom 52 (22.2%) were classified as the COVID-19 group. Patients with COVID-19 had significantly more frequent annual exacerbations of bronchiectasis (total exacerbations and hospitalizations). Compared with 2019-2021 data, the total exacerbation frequency decreased by 0.1 ± 0.51 per year among non-COVID-19 patients but increased by 0.68 ± 1.09 per year among the COVID-19 group (p < 0.001). Compared with 2019 only data, exacerbation frequency decreased by 0.14 ± 0.79 per year among non-COVID-19 patients but increased by 0.76 ± 1.17 per year in the COVID-19 group, p < 0.001. The annual frequency of hospitalization for bronchiectasis increased by 0.01 ± 0.32 per year among non-COVID-19 patients and increased by 0.39 ± 1.06 per year in the COVID-19 group (p < 0.001) compared with 2019 to 2021 data. When compared with only 2019 data, it remained unchanged at 0 ± 0.43 per year among non-COVID-19 patients but increased to 0.38 ± 1.12 per year among COVID-19 patients (p < 0.001).

CONCLUSION

Mild-to-moderate COVID-19 was associated with an increase in frequency of bronchiectasis exacerbation and frequency of hospitalizations following recovery.

High-sensitivity C-reactive protein level in stable-state bronchiectasis predicts exacerbation risk

BACKGROUND

Elevation of systemic inflammatory markers were found to correlate with increased disease extent, reduced lung function and higher risk of future severe exacerbations in patients with bronchiectasis. Although a significant correlation of circulating hs-CRP levels with HRCT scores and resting oxygen saturation in patients with stable-state non-cystic fibrosis (CF) bronchiectasis was suggested, there is little data on the relationship between hs-CRP and the prognosis of bronchiectasis and a lack of data on the role of hs-CRP in predicting bronchiectasis exacerbation.

METHODS

A prospective study was conducted on Chinese patients with non- CF bronchiectasis from 1st October to 31st December 2021. Baseline serum hs-CRP were obtained at stable-state. The follow-up period lasted for one year. Co-primary endpoints were the development of any bronchiectasis exacerbation and hospitalized bronchiectasis exacerbation.

RESULTS

Totally 123 patients were included. Higher hs-CRP was associated with increased risk to develop any bronchiectasis exacerbation, adjusted odds ratio (aOR) of 2.254 (95% CI = 1.040-4.885, p = 0.039), and borderline significantly increased hospitalized bronchiectasis exacerbation with aOR of 1.985 (95% CI = 0.922-4.277, p = 0.080).

CONCLUSION

Baseline serum hs-CRP level at stable-state can predict risk of bronchiectasis exacerbation, which is reflecting chronic low-grade inflammation in bronchiectasis.

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.

Validation of diagnostic coding for bronchiectasis in an electronic health record system in Hong Kong

BACKGROUND AND OBJECTIVE

Electronic medical record (EMR) databases can facilitate epidemiology research in various diseases including bronchiectasis. Given the diagnostic challenges of bronchiectasis, the validity of the coding in EMR requires clarification. We aimed to assess the validity of International Classification of Diseases, 9th Revision (ICD-9) code algorithms for identifying bronchiectasis in the territory-wide electronic medical health record system of Clinical Data Analysis and Reporting System (CDARS) in Hong Kong.

MATERIALS AND METHODS

Adult patients who had the diagnosis of bronchiectasis input from Queen Mary Hospital in 2011-2020 were identified using the ICD-9 code of 494 by CDARS. All patients who had high resolution computed tomography (HRCT) were reviewed by respiratory specialists to confirm the presence of bronchiectasis on HRCT.

RESULTS

A total of 19 617 patients who had the diagnostic code of bronchiectasis among all public hospitals in Hong Kong and 1866 in Queen Mary Hospital in the same period. Six hundred and forty-eight cases were randomly selected and validated using medical record and HRCT review by a respiratory specialist. The overall positive predictive value (PPV) was 92.7% (95% CI 90.7-94.7).

CONCLUSIONS

This was the first ICD-9 coding validation for bronchiectasis in Hong Kong CDARS. Our study demonstrated that using ICD-9 code of 494 was reliable to support utility of CDARS database for further clinical research on bronchiectasis.

Trends in hospital admissions for chronic obstructive pulmonary disease over 16 years in Canada

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is an ambulatory care-sensitive condition, and the rate of hospital admissions for COPD is an indicator of the quality of outpatient care. We sought to determine long-term trends in hospital admissions for COPD in Canada.

METHODS

Using a comprehensive national database of hospital admissions in Canada, we identified those with a main discharge diagnosis of COPD for patients aged 40 years and older between 2002 and 2017. We calculated sex-specific, age-standardized trends in annual rates of hospital admissions for COPD separately for younger (40-64 yr) and older adults (≥ 65 yr). We used spline regression to examine changes in the admissions trends for each sex and age group.

RESULTS

Over 16 years, 1 134 359 hospital admissions were for COPD. Between 2002 and 2017, the total number of admissions increased by 68.8%, from 52 937 to 89 384. The overall crude admission rate increased by 30.0%, from 368 to 479 per 100 000 population, and the sex-and age-standardized admission rate increased by 9.6%, from 437 to 479 per 100 000 population. Age-standardized rates increased by 12.2% among younger females, by 24.4% among younger males and by 29.8% among older females, but decreased by 9.0% among older males. Over the same period, the all-cause sex-and age-standardized admission rate declined by 23.0%.

INTERPRETATION

Hospital admissions for COPD have increased since 2010, even after adjusting for population growth and aging, and despite declining rates of all-cause hospital admissions. The secular increase in COPD admissions indicates that the burden of COPD on Canadian health care systems is increasing.

Hemoptysis as the presenting manifestation of bronchiectasis-associated hospitalization in Korea

BACKGROUND

Patients with bronchiectasis commonly experience disease exacerbations, which cause significant morbidity and mortality. However, data regarding the clinical features of bronchiectasis patients hospitalized with hemoptysis are scarce.

METHODS

We retrospectively collected the data of patients with bronchiectasis-associated hospitalization at a tertiary referral center in Korea, and classified them into the hemoptysis and infective exacerbation (IE) groups. The presence of hemoptysis was defined as a volume of expectorated blood larger than 10 mL per 24 hours. The clinical, radiological, and laboratory parameters were compared between the two groups.

RESULTS

Patients were classified into the hemoptysis [267 (54.5%)] and IE [223 (45.5%)] groups. Among the 44 patients of the hemoptysis group, 37 (84.1%) presented with hemoptysis than with IE at the recurrent episode. The hemoptysis group had a significantly lower 30-day mortality than that of the IE group. Previous pulmonary tuberculosis (TB), mycetoma, and bronchial artery hypertrophy were independently associated with the hemoptysis group. In contrast, male sex, poor performance status, colonization of Pseudomonas aeruginosa, ≥3 involved lobes, cystic bronchiectasis, and emphysema were inversely associated with the hemoptysis group. The absence of hemoptysis was one of the independent predictors of 30-day mortality in patients with bronchiectasis-associated hospitalization.

CONCLUSIONS

In Korea, bronchiectasis patients hospitalized with hemoptysis exhibit a distinct phenotype, and are more likely to have previous pulmonary TB, mycetoma, and bronchial artery hypertrophy. Hemoptysis is associated with a lower risk of short-term mortality compared to IE in bronchiectasis-associated hospitalization.

The relation between inspiratory muscle strength and bacterial colonization and other clinical factors in patients with non-cystic fibrosis bronchiectasis

Introduction

This study aimed to investigate whether inspiratory muscle strength was associated with bacterial colonization and other clinical outcomes and whether bacterial colonization was associated with clinical outcomes in patients with non-cystic fibrosis bronchiectasis (NCFB).

Materials and Methods

Eighty-six patients were enrolled in a cross-sectional study. Patients were divided into two groups according to the presence of inspiratory muscle weakness and bacterial colonization. Parameters were compared between groups.

Result

Bronchiectasis etiologies were post-infectious, Kartagener's syndrome, and primary ciliary dyskinesia. The median value of MIP was -68, and MEP was 89 cm H2O in all patients. Although the ratio of bacterial colonization was similar to patients without inspiratory muscle weakness, the inspiratory muscle weakness group had a higher number of females, lower FEV1, FVC, ISWT, CRQ, higher MRC, E-FACED, SGRQ, number of hospitalization (p<0.05). When colonized and non-colonized patients were compared, MIP, and MEP were similar in spite of adjusted BMI, age, and sex. FEV1, FVC, ISWT, and ESWT were lower, and E-FACED scores (p<0.05) were higher in colonized patients.

Conclusions

Although inspiratory muscle strength was not associated with bacterial colonization in NCFB patients, it is an important factor that could be linked to disease severity, pulmonary functions, quality of life, and exercise capacity. Bacterial colonization was also associated with severe disease, deteriorated pulmonary functions, and exercise capacity.

COPD Exacerbation: Why It Is Important to Avoid ICU Admission

Chronic obstructive pulmonary disease (COPD) is one of the major causes of morbidity and mortality worldwide. Hospitalization due to acute exacerbations of COPD (AECOPD) is a relevant health problem both for its impact on disease outcomes and on health system resources. Severe AECOPD causing acute respiratory failure (ARF) often requires admission to an intensive care unit (ICU) with endotracheal intubation and invasive mechanical ventilation. AECOPD also acts as comorbidity in critically ill patients; this condition is associated with poorer prognoses. The prevalence reported in the literature on ICU admission rates ranges from 2 to 19% for AECOPD requiring hospitalization, with an in-hospital mortality rate of 20-40% and a re-hospitalization rate for a new severe event being 18% of the AECOPD cases admitted to ICUs. The prevalence of AECOPD in ICUs is not properly known due to an underestimation of COPD diagnoses and COPD misclassifications in administrative data. Non-invasive ventilation in acute and chronic respiratory failure may prevent AECOPD, reducing ICU admissions and disease mortality, especially when associated with a life-threating episode of hypercapnic ARF. In this review, we report on up to date evidence from the literature, showing how improving the knowledge and management of AECOPD is still a current research issue and clinical need.

Clinical relevance of bronchiectasis in patients with community-acquired pneumonia

BACKGROUND

Data regarding the clinical characteristics and treatment outcomes of patients with community-acquired pneumonia (CAP) and bronchiectasis (BE) are rare. This study aims to elucidate the clinical relevance of BE in patients with CAP.

METHODS

Patients hospitalized with CAP in a single center were retrospectively analyzed and divided into significant BE (BE with ≥ 3 lobes or cystic BE on computed tomography) and control groups. Clinical and microbiological characteristics were compared between the two groups.

RESULTS

In the final analysis, 2112 patients were included, and 104 (4.9%) had significant BE. The significant BE group exhibited a higher prevalence of sputum production, dyspnea, and complicated parapneumonic effusion or empyema than the control group. Pseudomonas aeruginosa was more frequently isolated in the significant BE group than in the control group, whereas Mycoplasma pneumoniae was less commonly identified. Length of hospital stay (LOS) was significantly longer in the significant BE group than the control group (12 [8-17] days vs. 9 [6-13] days, p < 0.001). In contrast, 30-day and in-hospital mortality rates did not significantly differ between the two groups. Furthermore, significant BE was an independent predictor of prolonged hospitalization in two models based on CURB-65 and pneumonia severity index.

CONCLUSIONS

Significant BE occurred in approximately 5% of patients with CAP and was more likely to be associated with sputum, dyspnea, complicated parapneumonic effusion or empyema, and isolation of P. aeruginosa. Significant BE was an independent predictor of LOS in patients with CAP.

Risk Factors for Influenza-Induced Exacerbations and Mortality in Non-Cystic Fibrosis Bronchiectasis

Influenza infection is a cause of exacerbations in patients with chronic pulmonary diseases. The aim of this study was to investigate the clinical outcomes and identify risk factors associated with hospitalization and mortality following influenza infection in adult patients with bronchiectasis. Using the Chang Gung Research Database, we identified patients with bronchiectasis and influenza-related infection (ICD-9-CM 487 and anti-viral medicine) between 2008 and 2017. The main outcomes were influenza-related hospitalization and in-hospital mortality rate. Eight hundred sixty-five patients with bronchiectasis and influenza infection were identified. Five hundred thirty-six (62%) patients with bronchiectasis were hospitalized for influenza-related infection and 118 (22%) patients had respiratory failure. Compared to the group only seen in clinic, the hospitalization group was older, with more male patients, a lower FEV1, higher bronchiectasis aetiology comorbidity index (BACI), and more acute exacerbations in the previous year. Co-infections were evident in 55.6% of hospitalized patients, mainly caused by Pseudomonas aeruginosa (15%), fungus (7%), and Klebsiella pneumoniae (6%). The respiratory failure group developed acute kidney injury (36% vs. 16%; p < 0.001), and shock (47% vs. 6%; p < 0.001) more often than influenza patients without respiratory failure. The overall mortality rate was 10.8% and the respiratory failure group exhibited significantly higher in-hospital mortality rates (27.1% vs. 6.2%; p < 0.001). Age, BACI, and previous exacerbations were independently associated with influenza-related hospitalization. Age, presence of shock, and low platelet counts were associated with increased hospital mortality. Influenza virus caused severe exacerbation in bronchiectasis, especially in those who were older and who had high BACI scores and previous exacerbations. A high risk of respiratory failure and mortality were observed in influenza-related hospitalization in bronchiectasis. We highlight the importance of preventing or treating influenza infection in bronchiectasis.

Clinical, Radiological, and Lung Function Characteristics of Post-tuberculosis Bronchiectasis: An Experience From a Tertiary Care Center in India

Introduction Among chronic respiratory diseases, bronchiectasis is one of the important causes of mortality and morbidity in developing countries. Objective This study aimed to assess the clinical, radiological, microbiological, and pulmonary function profiles of adult patients with post-tubercular bronchiectasis. Methods We enrolled 138 patients with bronchiectasis confirmed by high-resolution CT scans from July 2017 to August 2018. Results A total of 138 patients with bronchiectasis were enrolled. The data from 132 patients were analyzed; six patients were excluded from the study. The mean age of post-TB bronchiectasis (post-tuberculosis bronchiectasis) patients was 36.08±13.08, which was lower than the non-tuberculosis bronchiectasis group. The proportion of the male population was more in the post-TB bronchiectasis group (54.55% vs. 37.88%, p=0.48). Smoking prevalence was high in post-TB bronchiectasis (27.27% vs. 12.12%, p=0.04). The predominant symptom was cough in the post-tubercular bronchiectasis group (48.5% vs. 41.7%, p=0.019). The history of the recurrent common cold was seen most frequently in non-post-tubercular bronchiectasis (40.9% vs. 12.9%, p=0.001). The most common radiological variant of bronchiectasis found in all patients was a cystic type (75%). The most common site of involvement was the left lower lobe, followed by the lingula in all patients and post-tuberculosis bronchiectasis patients. Pulmonary function on spirometry revealed obstructive, restrictive, and mixed patterns in 55%, 25%, and 15%, respectively. Patients with post-tuberculosis bronchiectasis had lower lung function post-FEV1/FVC (forced expiratory volume in one second/forced vital capacity) ratio (70.31±15.56 vs. 76.85±11.82, p=0.015). Binary multivariate logistic regression analysis showed that only recurrent cough cold was a significant independent risk factor for post-TB bronchiectasis. Conclusion Post-tuberculosis, and bronchiectasis followed by post-infectious causes, were the most common causes of bronchiectasis and poor lung function.

Cardiovascular and cerebrovascular-associated mortality in patients with preceding bronchiectasis exacerbation

BACKGROUND

Bronchiectasis is associated with an increased incidence of atherosclerotic cardiovascular disease (ASCaVD) and atherosclerotic cerebrovascular disease (ASCeVD). Its effect on associated mortality is unclear.

OBJECTIVES

This study investigated the effects of bronchiectasis exacerbation prior to ASCaVD or ASCeVD events on mortality in patients with bronchiectasis using a large population-based database.

METHODS

A retrospective cohort of patients with bronchiectasis who experienced ASCaVD (n = 1066) or ASCeVD (n = 825) was studied for the first time using a nationwide population-based database (National Health Insurance Service-National Sample Cohort, Korea, 2002-2015). We classified each cohort according to the presence of moderate bronchiectasis exacerbation within 1 year before the ASCaVD or ASCeVD event. We evaluated 90-day, 1-year, and all-cause mortalities risk.

RESULTS

Within 1 year before the index ASCaVD or ASCeVD event, 149 (13.9%) and 112 (13.6%) patients with bronchiectasis experienced moderate exacerbation(s), respectively. Mild exacerbations did not different in frequency between the survivors and nonsurvivors. In both cohorts, more nonsurvivors experienced moderate exacerbations than survivors. The odds ratios of 90-day and 1-year mortalities and hazard ratios of all-cause mortalities on experiencing moderate exacerbations were 2.27 [95% confidence interval (CI) = 1.26-4.10], 3.30 (95% CI = 2.03-5.38), and 1.78 (95% CI = 1.35-2.34) in the bronchiectasis-ASCaVD cohort and 1.73 (95% CI = 0.94-3.19), 1.79 (95% CI = 1.07-3.00), and 1.47 (95% CI = 1.10-1.95), in the bronchiectasis-ASCeVD cohort.

CONCLUSION

Hospitalization or emergency room visit for bronchiectasis exacerbation within 1 year before ASCaVD or ASCeVD is associated with an increased ASCaVD- or ASCeVD-associated mortality.

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.

Follow-up of a cohort of patients with noncystic fibrosis bronchiectasis for 1 year

OBJECTIVE

The objective of this study was to evaluate the quality of life of patients with noncystic fibrosis bronchiectasis during a 1-year follow-up by using the EuroQol - 5 Dimensions - 3 Levels (EQ-5D-3L) questionnaire.

METHODS

A cohort study was conducted with 100 patients with noncystic fibrosis bronchiectasis and followed up with face-to-face visits or by telephone contact every 3 months for 1 year. All patients were recruited from a single referral center for bronchiectasis. At the time of recruiting and at the end of 1 year, the EQ-5D-3L questionnaire was applied to evaluate the patients' quality of life. Variables, such as exacerbation, emergency care, comorbidities, hemoptysis, colonization, and hospitalization, were assessed.

RESULTS

Of the 100 patients, 99 completed the study and 72% were women. There were no marked limitations in the mobility and self-care domains during the follow-up. At the end of the follow-up, 32 patients were extremely anxious or depressed. The quality of life assessed by using EQ-5D-3L had an initial mean score of 0.545 and of 0.589 after 1 year, which was statistically significant (p=0.011).

CONCLUSION

Patients with noncystic fibrosis bronchiectasis have a poor quality of life, and the EQ-5D-3L questionnaire may be a tool for monitoring patients with bronchiectasis.

Profile of Clinical and Analytical Parameters in Bronchiectasis Patients during the COVID-19 Pandemic: A One-Year Follow-Up Pilot Study

Whether the COVID-19 pandemic may have modified the clinical planning and course in bronchiectasis patients remains to be fully elucidated. We hypothesized that the COVID-19 pandemic may have influenced the management and clinical outcomes of bronchiectasis patients who were followed up for 12 months. In bronchiectasis patients (n = 30, 23 females, 66 years), lung function testing, disease severity [FEV₁, age, colonization, radiological extension, dyspnea (FACED), exacerbation (EFACED)] and dyspnea scores, exacerbation numbers and hospitalizations, body composition, sputum microbiology, and blood analytical biomarkers were determined at baseline and after a one-year follow-up. Compared to baseline (n = 27, three patients dropped out), in bronchiectasis patients, a significant increase in FACED and EFACED scores, number of exacerbations, and erythrocyte sedimentation rate (ESR) was observed, while FEV₁, ceruloplasmin, IgE, IgG, IgG aspergillus, IgM, and IgA significantly decreased. Patients presenting colonization by Pseudomonas aeruginosa (PA) remained unchanged (27%) during follow-up. In bronchiectasis patients, FEV₁ declined only after a one-year follow-up along with increased exacerbation numbers and disease severity scores, but not hospitalizations. However, a significant decrease in acute phase-reactants and immunoglobulins was observed at the one-year follow-up compared to baseline. Despite the relatively small cohort, the reported findings suggest that lung function impairment may not rely entirely on the patients’ inflammatory status.

Chest wall muscle mass depletion is related to certain pulmonary functions and diseases in patients with bronchiectasis

Background and objective

Many bronchiectasis patients suffer dyspnea, decreased exercise tolerance, and low body mass index. Chest wall muscles play a special role in respiratory movement and make up parts of skeletal muscles. This study aimed to examine the chest wall muscle thickness and their relationship with disease severity in bronchiectasis.

Methods

We retrospectively included 166 patients with bronchiectasis and 62 patients with pneumonia as comparators. The thickness of chest wall muscle as determined in chest CT, pulmonary function, and Bronchiectasis Severity Index (BSI) score were recorded. We compared the thickness of the chest wall muscle in two groups and assessed the relationships among chest wall muscle thickness, pulmonary function, and BSI score.

Results

Chest wall muscle thickness of the anterior midclavicular line and posterior exterior scapula were thinner in bronchiectasis patients than comparators both above the aortic arch level and at the aortic arch window level. Muscle thickness of the posterior interior scapula above the aortic arch level was significantly thinner in bronchiectasis patients. Chest wall muscle thickness at the anterior midclavicular line both the above aortic arch level and at the level of the aortic arch window were related to diffuse capacity in bronchiectasis patients. Anterior chest wall muscle thickness above the aortic arch was found to be a risk factor of disease severity.

Conclusion

Anterior chest wall muscles in the upper and middle chest were thinner in bronchiectasis patients than in comparators, and had relationship with spirometry and diffuse compacity factors. We provide another method to conveniently assess bronchiectasis severity.

Developing a diagnostic bundle for bronchiectasis in South Korea: A modified Delphi Consensus Study

Background

A diagnostic bundle for bronchiectasis in South Korea is necessary because the etiologies of bronchiectasis and related diseases vary significantly among different regions and ethnicities.

Methods

A modified Delphi method was used to develop expert consensus statements on a diagnostic bundle for bronchiectasis in South Korea. Initial statements proposed by a core panel, based on international bronchiectasis guidelines, were discussed over one online meeting and two email surveys by a panel of experts (≥70% agreement).

Results

Twenty-one experts participated in the study, and 30 statements on a diagnostic bundle for bronchiectasis were classified as recommended, conditional, or not recommended. The expert panel agreed that 1) a standardized diagnostic bundle is useful in clinical practice, 2) diagnostic tests for specific diseases, including immunodeficiency and allergic bronchopulmonary aspergillosis, are necessary when clinically suspected, 3) initial diagnostic tests, including sputum microbiology and spirometry, are essential in all bronchiectasis patients, and 4) patients should be referred to specialized centers when rare causes such as primary ciliary dyskinesia are suspected.

Conclusion

In this Delphi survey, expert consensus statements were generated on which specific diagnostic, laboratory, microbiologic, and pulmonary function tests to obtain when managing patients with bronchiectasis in South Korea.

Telemedicine and Remote Monitoring as an Adjunct to Medical Management of Bronchiectasis

The limited resources and the practice of social distancing during the COVID pandemic create a paradigm shift in the utilization of telemedicine in healthcare. However, the implementation of best practices is hampered in part by a lack of literature devoted to telehealth in bronchiectasis. In this commentary, we examine multiple approaches to structuring of telemedicine care for patients with bronchiectasis, highlight current evidence-based interventions that can be incorporated into the management of bronchiectasis, and describe our experience with telemedicine at the University of Connecticut Center for Bronchiectasis Care during the COVID-19 pandemic. The structural model must be adapted to different local dynamics and available technologies with careful attention to patient characteristics and access to technology to avoid the potential paradoxical effects of increasing patients’ burden and healthcare disparities in underserved populations.

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

Bronchiectasis: moving from an orphan disease to an unpleasant socioeconomic burden

Bronchiectasis has received increasing attention in recent years. At the same time, studies have shown a high incidence of this disease, especially in older populations, associated with high health-related costs and economic burden. https://bit.ly/2WPfVZ7.

Imaging in non-cystic fibrosis bronchiectasis and current limitations

Non-cystic fibrosis bronchiectasis represents a heterogenous spectrum of disorders characterised by an abnormal and permanent dilatation of the bronchial tree associated with respiratory symptoms. To date, diagnosis relies on computed tomography (CT) evidence of dilated airways. Nevertheless, definite radiological criteria and standardised CT protocols are still to be defined. Although largely used, current radiological scoring systems have shown substantial drawbacks, mostly failing to correlate morphological abnormalities with clinical and prognostic data. In limited cases, bronchiectasis morphology and distribution, along with associated CT features, enable radiologists to confidently suggest an underlying cause. Quantitative imaging analyses have shown a potential to overcome the limitations of the current radiological criteria, but their application is still limited to a research setting.

In the present review, we discuss the role of imaging and its current limitations in non-cystic fibrosis bronchiectasis. The potential of automatic quantitative approaches and artificial intelligence in such a context will be also mentioned.

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.

Phenotypic and Genomic Variability of Serial Peri-Lung Transplantation Pseudomonas aeruginosa Isolates From Cystic Fibrosis Patients

Cystic fibrosis (CF) represents one of the major genetic and chronic lung diseases affecting Caucasians of European descent. Patients with CF suffer from recurring infections that lead to further damage of the lungs. Pulmonary infection due to Pseudomonas aeruginosa is most prevalent, further increasing CF-related mortality. The present study describes the phenotypic and genotypic variations among 36 P. aeruginosa isolates obtained serially from a non-CF and five CF patients before, during and after lung transplantation (LTx). The classical and genomic investigation of these isolates revealed a common mucoid phenotype and only subtle differences in the genomes. Isolates originating from an individual patient shared ≥98.7% average nucleotide identity (ANI). However, when considering isolates from different patients, substantial variations in terms of sequence type (ST), virulence factors and antimicrobial resistance (AMR) genes were observed. Whole genome multi-locus sequence typing (MLST) confirmed the presence of unique STs per patient regardless of the time from LTx. It was supported by the monophyletic clustering found in the genome-wide phylogeny. The antibiogram shows that ≥91.6% of the isolates were susceptible to amikacin, colistin and tobramycin. For other antibiotics from the panel, isolates frequently showed resistance. Alternatively, a comparative analysis of the 36 P. aeruginosa isolates with 672 strains isolated from diverse ecologies demonstrated clustering of the CF isolates according to the LTx patients from whom they were isolated. We observed that despite LTx and associated measures, all patients remained persistently colonized with similar isolates. The present study shows how whole genome sequencing (WGS) along with phenotypic analysis can help us understand the evolution of P. aeruginosa over time especially its antibiotic resistance.

Exercise training for bronchiectasis

BACKGROUND

Bronchiectasis is characterised by excessive sputum production, chronic cough, and acute exacerbations and is associated with symptoms of dyspnoea and fatigue, which reduce exercise tolerance and impair quality of life. Exercise training in isolation or in conjunction with other interventions is beneficial for people with other respiratory diseases, but its effects in bronchiectasis have not been well established.

OBJECTIVES

To determine effects of exercise training compared to usual care on exercise tolerance (primary outcome), quality of life (primary outcome), incidence of acute exacerbation and hospitalisation, respiratory and mental health symptoms, physical function, mortality, and adverse events in people with stable or acute exacerbation of bronchiectasis.

SEARCH METHODS

We identified trials from the Cochrane Airways Specialised Register, ClinicalTrials.gov, and the World Health Organization trials portal, from their inception to October 2020. We reviewed respiratory conference abstracts and reference lists of all primary studies and review articles for additional references.

SELECTION CRITERIA

We included randomised controlled trials in which exercise training of at least four weeks' duration (or eight sessions) was compared to usual care for people with stable bronchiectasis or experiencing an acute exacerbation. Co-interventions with exercise training including education, respiratory muscle training, and airway clearance therapy were permitted if also applied as part of usual care.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened and selected trials for inclusion, extracted outcome data, and assessed risk of bias. We contacted study authors for missing data. We calculated mean differences (MDs) using a random-effects model. We used the GRADE approach to assess the certainty of evidence.

MAIN RESULTS

We included six studies, two of which were published as abstracts, with a total of 275 participants. Five studies were undertaken with people with clinically stable bronchiectasis, and one pilot study was undertaken post acute exacerbation. All studies included co-interventions such as instructions for airway clearance therapy and/or breathing strategies, provision of an educational booklet, and delivery of educational sessions. The duration of training ranged from six to eight weeks, with a mix of supervised and unsupervised sessions conducted in the outpatient or home setting. No studies of children were included in the review; however we identified two studies as currently ongoing. No data were available regarding physical activity levels or adverse events. For people with stable bronchiectasis, evidence suggests that exercise training compared to usual care improves functional exercise tolerance as measured by the incremental shuttle walk distance, with a mean difference (MD) between groups of 87 metres (95% confidence interval (CI) 43 to 132 metres; 4 studies, 161 participants; low-certainty evidence). Evidence also suggests that exercise training improves six-minute walk distance (6MWD) (MD between groups of 42 metres, 95% CI 22 to 62; 1 study, 76 participants; low-certainty evidence). The magnitude of these observed mean changes appears clinically relevant as they exceed minimal clinically important difference (MCID) thresholds for people with chronic lung disease. Evidence suggests that quality of life improves following exercise training according to St George's Respiratory Questionnaire (SGRQ) total score (MD -9.62 points, 95% CI -15.67 to -3.56 points; 3 studies, 160 participants; low-certainty evidence), which exceeds the MCID of 4 points for this outcome. A reduction in dyspnoea (MD 1.0 points, 95% CI 0.47 to 1.53; 1 study, 76 participants) and fatigue (MD 1.51 points, 95% CI 0.80 to 2.22 points; 1 study, 76 participants) was observed following exercise training according to these domains of the Chronic Respiratory Disease Questionnaire. However, there was no change in cough-related quality of life as measured by the Leicester Cough Questionnaire (LCQ) (MD -0.09 points, 95% CI -0.98 to 0.80 points; 2 studies, 103 participants; moderate-certainty evidence), nor in anxiety or depression. Two studies reported longer-term outcomes up to 12 months after intervention completion; however exercise training did not appear to improve exercise capacity or quality of life more than usual care. Exercise training reduced the number of acute exacerbations of bronchiectasis over 12 months in people with stable bronchiectasis (odds ratio 0.26, 95% CI 0.08 to 0.81; 1 study, 55 participants). After an acute exacerbation of bronchiectasis, data from a single study (N = 27) suggest that exercise training compared to usual care confers little to no effect on exercise capacity (MD 11 metres, 95% CI -27 to 49 metres; low-certainty evidence), SGRQ total score (MD 6.34 points, 95%CI -17.08 to 29.76 points), or LCQ score (MD -0.08 points, 95% CI -0.94 to 0.78 points; low-certainty evidence) and does not reduce the time to first exacerbation (hazard ratio 0.83, 95% CI 0.31 to 2.22).

AUTHORS' CONCLUSIONS

This review provides low-certainty evidence suggesting improvement in functional exercise capacity and quality of life immediately following exercise training in people with stable bronchiectasis; however the effects of exercise training on cough-related quality of life and psychological symptoms appear to be minimal. Due to inadequate reporting of methods, small study numbers, and variation between study findings, evidence is of very low to moderate certainty. Limited evidence is available to show longer-term effects of exercise training on these outcomes.

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.

Outcomes Of Non-Cystic Fibrosis Related Bronchiectasis Post Lung Transplantation

BACKGROUND

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Impact of asthma on bronchiectasis severity and risk of exacerbations

OBJECTIVE

Asthma is a frequent comorbidity of bronchiectasis, with possible implications for exacerbation and severity. We investigated the clinical impact of asthma on bronchiectasis in terms of disease severity and exacerbation risk.

METHODS

We collected demographic, clinical, and functional characteristics of patients with a confirmed diagnosis of bronchiectasis. All patients were investigated for concomitant diagnosis of asthma. The Bhalla score was used to assess radiological severity of bronchiectasis, and the Bronchiectasis Severity Index (BSI) was used to assess the clinical severity. Blood and sputum samples were collected to assess blood cell count, erythrocyte sedimentation rate, c-reactive protein, immunological status (IgA, IgE, IgM, IgG, and IgG subclasses), and microbiological analysis.

RESULTS

A total of 106 patients were enrolled in the study; 30.2% had concomitant asthma and were characterized by higher frequency of bronchiectasis exacerbation, despite higher Bhalla score and lower BSI compared to patients without asthma. Pseudomonas aeruginosa was more frequently isolated from the sputum of bronchiectasis patients without asthma. Total serum IgG, IgG1, and IgG3 were lower in patients with asthma. Blood eosinophils and exhaled nitric oxide were higher in patients with associated asthma. The presence of asthma and presence of Pseudomonas in sputum were the only significant determinants of frequent exacerbations in a binary logistic regression analysis.

CONCLUSION

The coexistence of asthma and bronchiectasis is associated with an independent increase in the risk of bronchiectasis exacerbation despite lower radiological and clinical severity indexes. Asthmatic airway inflammation could promote an enhanced "Cole's Cycle" that is responsible for a higher frequency of exacerbations.

Factors associated with bronchiectasis in Korea: a national database study

Background

Many important clinical features of bronchiectasis have been reported. However, the factors were evaluated using a specific disease cohort. Thus, clinical factors associated with bronchiectasis have not been well assessed in comparison to the general population. The aim of this study was to evaluate the factors associated with bronchiectasis using a national representative database.

Methods

We conducted a cross-sectional study using data from the Korean National Health and Nutrition Examination Survey 2007–2009. To evaluate factors associated with bronchiectasis, a multivariable logistic analysis was used with adjustment for demographic and socioeconomic factors.

Results

In the present study, the prevalence of bronchiectasis was 0.4%. Compared with subjects without bronchiectasis, subjects with bronchiectasis were older (55.1 vs. 44.4 years, P<0.001) and had lower body mass index (BMI) (23.2 vs. 24.2 kg/m², P<0.001). The proportions of low family income (70.5% vs. 40.2%, P<0.001) and low educational level (less than high school) (85.3% vs. 70.6%, P=0.041) were higher in subjects with bronchiectasis than in subjects without bronchiectasis. Regarding comorbidities, subjects with bronchiectasis were more likely to have asthma (17.8% vs. 2.9%, P<0.001), previous history of pulmonary tuberculosis (TB) (43.5% vs. 5.0%, P<0.001), osteoporosis (19.1% vs. 7.8%, P=0.002), and depression (9.3% vs. 3.0%, P=0.015) compared with subjects without bronchiectasis. In addition, subjects with bronchiectasis had more respiratory symptoms and poorer quality of life measured using the EuroQoL five dimensions questionnaire (EQ-5D) index (0.87 vs. 0.93, P<0.001) than subjects without bronchiectasis. In multivariable logistic regression analysis, low family income (adjusted odds ratio, OR =3.83, 95% confidence interval, CI: 1.46–10.03), asthma (adjusted OR =3.73, 95% CI: 1.29–10.79), pulmonary TB (adjusted OR =7.88, 95% CI: 2.65–23.39), and the presence of airflow limitation (adjusted OR =2.98, 95% CI: 1.01–8.98) were independently associated with bronchiectasis.

Conclusions

Subjects with bronchiectasis suffered from more respiratory symptoms with limited physical activity and poorer quality of life than the general population. Factors independently associated with bronchiectasis were lower family income and comorbid pulmonary conditions, such as previous pulmonary TB, asthma, and airflow limitation.

Surgical treatment of bronchiectasis: Our 23 years of experience

Background

In this study, we aimed to evaluate the success of surgery and a complete resection for bronchiectasis treatment and to present our 23 years of surgical experience.

Methods

Between January 1991 and December 2013, a total of 1,357 patients (667 males, 690 females; mean age 30.5±14.3 years; range, 3 to 73 years) with the diagnosis of bronchiectasis who underwent pulmonary resection in our clinic were retrospectively analyzed. Demographic and clinical characteristics of the patients, etiologies, symptoms, localizations, surgical procedures, and long-term follow-up results were evaluated.

Results

There were 1,394 surgeries, as 37 (2.7%) patients had bilateral disease. The surgical procedures included lobectomy (n=702, 50.3%), pneumonectomy (n=183, 13.1%), segmental resections (n=114, 8.2%), bilobectomy (n=83, 6.0%), and lobectomy + segmentectomy (n=312, 22.4%). During the postoperative period, 1,269 (93.5%) patients were followed at a mean duration of 51.6 (range, 1 to 120) months. After surgery, 774 (61%) patients were asymptomatic, 456 (35.9%) showed an improvement, and 39 (3.1%) had no response or deterioration.

Conclusion

The surgical treatment plays an important role in the clinical and symptomatic improvement of patients with bronchiectasis. Surgery reduces the morbidity and mortality rates with careful preoperative preparation and appropriately selected cases.

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.

Prevalence, causes, and chest sonographic findings of bronchiectasis among admitted patients in tertiary care hospital: 10 years’ experience

Background

Bronchiectasis may be associated and/or co-exist with respiratory diseases as bronchial asthma and chronic obstructive pulmonary disease (COPD) or non-respiratory diseases. However, data about this association and/or co-existence is little. The objectives of the study were to determine the prevalence of bronchiectasis among admitted patients in the Chest Department in 10 years’ period (2008–2018) and to detect associated and/or co-existent respiratory diseases. In a retrospective cohort study, the diagnosis of bronchiectasis was based on chest HRCT. Data included the total number of hospitalized patients during this period, their final diagnosis, co-existing diagnosis associated with bronchiectasis, and sonographic and spirometric findings.

Results

The total number of patients admitted in 2008–2018 was 17,531 patients. The prevalence of bronchiectasis during this period was 9.04%. COPD was the commonest suspected cause (54.1%) followed by post-tuberculosis bronchiectasis (17.1%). On admission, 63.7% had acute type 2 respiratory failure, 21.1% had decompensated cor pulmonale, 3.8% required mechanical ventilation (MV), and 1.3% required non-invasive MV. On discharge, 9.9% required long-term oxygen therapy. The presence of B lines in chest ultrasonography was recorded in 68.2% and air bronchogram in 29.1%.

Conclusions

The prevalence of bronchiectasis among admitted patients was still increasing. COPD with bronchiectasis accounted for more than half of cases. More researches are needed to identify the impact of the COPD-bronchiectasis phenotype.

Trial registration

ClinicalTrials.gov, NCT04101448

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.

Is bronchiectasis really a disease?

The definition of a disease requires that distinguishing signs and symptoms are present that are common, and that the constellation of signs and symptoms differentiate the condition from other causes. In bronchiectasis, anatomical changes, airways inflammation and airway infection are the distinguishing features that are common to this disease. However, bronchiectasis is a heterogenous disease: signs and symptoms are shared with other airway diseases, there are multiple aetiologies and certain phenotypes of bronchiectasis have distinct clinical and laboratory features that are not common to all people with bronchiectasis. Furthermore, response to therapeutic interventions in clinical trials is not uniform. The concept of bronchiectasis as a treatable trait has been suggested, but this may be too restrictive in view of the heterogeneity of bronchiectasis. It is our opinion that bronchiectasis should be defined as a disease in its own right, but one that shares several pathophysiological features and "treatable traits" with other airway diseases. These traits define the large heterogeneity in the pathogenesis and clinical features and suggest a more targeted approach to therapy.

Association between physical activity and risk of hospitalisation in bronchiectasis

Background

Patients with bronchiectasis have a less active lifestyle than healthy peers, but the association with hospital admission has not been explored. The aim of this study was to investigate the association between 1) any physical activity variable; and 2) sedentary time, with hospitalisation due to exacerbation in adults with bronchiectasis.

Methods

In this prospective observational study, baseline lung function, quality of life, exercise tolerance, severity of bronchiectasis and physical activity were recorded. Physical activity was objectively assessed over a week using a SenseWear armband and the results were expressed in steps·day–1 and sedentary time. Number of hospitalisations due to a bronchiectasis exacerbation and time to first event were recorded after 1-year follow-up.

Results

Sixty-four patients with bronchiectasis were analysed, of whom 15 (23%) were hospitalised during the follow-up. Hospitalised patients showed poor baseline clinical and severity outcomes, fewer steps walked per day and more sedentary behaviour than the non-hospitalised group. Patients who walked ≤6290 steps·day–1 or spent ≥7.8 h·day–1 in sedentary behaviour had an increased risk of hospital admission due to bronchiectasis exacerbation at 1-year follow-up. Specifically, ≥7.8 h·day–1 of sedentary behaviour was associated with a 5.9-fold higher risk of hospital admission in the following year.

Conclusions

Low levels of physical activity and high sedentary time at baseline were associated with a higher risk of hospitalisation due to bronchiectasis exacerbation. If these findings are validated in future studies, it might be appropriate to include physical activity and sedentary behaviour as an item in severity scores.

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.

Mortality risk and causes of death in patients with non-cystic fibrosis bronchiectasis

BACKGROUND

All-cause mortality risk and causes of death in bronchiectasis patients have not been fully investigated. The aim of this study was to compare the mortality risk and causes of death between individuals with bronchiectasis and those without bronchiectasis.

METHODS

Patients with or without bronchiectasis determined based on chest computed tomography (CT) at one centre between 2005 and 2016 were enrolled. Among the patients without bronchiectasis, a control group was selected after applying additional exclusion criteria. We compared the mortality risk and causes of death between the bronchiectasis and control groups without lung disease. Subgroup analyses were also performed according to identification of Pseudomonas or non-tuberculous mycobacteria, airflow limitation, and smoking status.

RESULTS

Of the total 217,702 patients who underwent chest CT, 18,134 bronchiectasis patients and 90,313 non-bronchiectasis patients were included. The all-cause mortality rate in the bronchiectasis group was 1608.8 per 100,000 person-years (95% confidence interval (CI), 1531.5-1690.0), which was higher than that in the control group (133.5 per 100,000 person-years; 95% CI, 124.1-143.8; P < 0.001). The bronchiectasis group had higher all-cause (adjusted hazard ratio (aHR), 1.26; 95% CI, 1.09-1.47), respiratory (aHR, 3.49; 95% CI, 2.21-5.51), and lung cancer-related (aHR, 3.48; 95% CI, 2.33-5.22) mortality risks than the control group. In subgroup analysis, patients with airflow limitation and ever smokers showed higher all-cause mortality risk among bronchiectasis patients. Therefore, we observed significant interrelation between bronchiectasis and smoking, concerning the risks of all-cause mortality (P for multiplicative interaction, 0.030, RERI, 0.432; 95% CI, 0.097-0.769) and lung cancer-related mortality (RERI, 8.68; 95% CI, 1.631-15.736).

CONCLUSION

Individuals with bronchiectasis had a higher risk of all-cause, respiratory, and lung cancer-related mortality compared to control group. The risk of all-cause mortality was more prominent in those with airflow limitation and in ever smokers.

Management of Australian Adults with Bronchiectasis in Tertiary Care: Evidence-Based or Access-Driven?

PURPOSE

Australian data regarding the management of patients with bronchiectasis is scarce. We sought to compare the management of adults with bronchiectasis attending tertiary Australian centres with recent national and international guidelines.

METHODS

The Australian Bronchiectasis Registry is a centralised database of patients with radiologically confirmed bronchiectasis unrelated to cystic fibrosis recruited from 14 tertiary Australian hospitals. We excluded children (<18 years) and those with incomplete data, leaving 589 adults for cross-sectional analyses. We compared the proportion of patients receiving certain therapies, as compared to the proportion eligible for those treatments according to the current guidelines and baseline clinical information available from the registry.

RESULTS

Pulmonary rehabilitation was attended by 22%, although it was indicated in 67% of the cohort. Airway clearance was undertaken in 52% of patients, although 71% reported chronic productive cough. Sputum bacterial culture results were available for 59%, and mycobacterial culture results were available for 29% of the cohort. Inhaled antibiotics were used in half of potentially eligible patients. Despite guideline recommendations against routine use, inhaled corticosteroids were used in 48% of patients. Long-term macrolides were used in 28% of participants.

CONCLUSIONS

Discrepancies exist between guideline recommendations and real-world treatment of bronchiectasis in Australia, even in tertiary centres. These findings suggest the need for increased patient referral to pulmonary rehabilitation, increased attention to airway clearance, increased collection of sputum samples (especially for mycobacterial culture) and rationalisation of inhaled corticosteroid use. These findings encourage a review of treatment access and will inform ongoing education to promote evidence-based care for people living with bronchiectasis.

Australian adults with bronchiectasis: The first report from the Australian Bronchiectasis Registry

BACKGROUND

/objective: There are no large, multi-centre studies of Australians with bronchiectasis. The Australian Bronchiectasis Registry (ABR) was established in 2015 to create a longitudinal research platform. We aimed to describe the baseline characteristics of adult ABR participants and assess the impact of disease severity and exacerbation phenotype on quality of life (QoL).

METHODS

The ABR is a centralised database of patients with radiologically confirmed bronchiectasis unrelated to cystic fibrosis. We analysed the baseline data of adult patients (≥18 years).

RESULTS

From March 2016-August 2018, 799 adults were enrolled from 14 Australian sites. Baseline data were available for 589 adults predominantly from six tertiary centres (420 female, median age 71 years (interquartile range 64-77), 14% with chronic Pseudomonas aeruginosa infection). Most patients had moderate or severe disease based on the Bronchiectasis Severity Index (BSI) (84%) and FACED (59%) composite scores. Using Global Lung function Initiative-2012 reference equations, the majority of patients (48%) had normal spirometry; only 34% had airflow obstruction (FEV₁/FVC < LLN). Disease severity scores (BSI and FACED) were negatively correlated with QoL-Bronchiectasis domain scores (r_s between -0.09 and -0.58). The frequent exacerbator phenotype (≥3 in the preceding year) was identified in 23%; this group had lower scores in all QoL-B domains (p ≤ 0.001) and more hospitalisations (p < 0.001) than those with <3 exacerbations.

CONCLUSIONS

The largest cohort of Australian adults with bronchiectasis has been described. Using contemporary criteria, most patients with bronchiectasis did not have airflow obstruction. The frequent exacerbation trait connotes poorer QoL and greater health-care utilisation.

Management of bronchiectasis in adults

Once neglected in research and underappreciated in practice, there is renewed interest in bronchiectasis unrelated to cystic fibrosis. Bronchiectasis is a chronic lung disease characterised by chronic cough, sputum production and recurrent pulmonary exacerbations. It is diagnosed radiologically on high resolution computed tomography chest scan by bronchial dilatation (wider than the accompanying artery). The causes of bronchiectasis are diverse and include previous respiratory tract infections, chronic obstructive pulmonary disease, asthma, immunodeficiency and connective tissue diseases. A large proportion of cases are idiopathic, reflecting our incomplete understanding of disease pathogenesis. Progress in the evidence base is reflected in the 2017 European management guidelines and the 2015 update to the Australian guidelines. Effective airway clearance remains the cornerstone of bronchiectasis management. This should be personalised and reviewed regularly by a respiratory physiotherapist. There is now robust evidence for the long term use of oral macrolide antibiotics in selected patients to reduce exacerbation frequency. The routine use of long term inhaled corticosteroids and/or long-acting bronchodilators should be avoided, unless concomitant chronic obstructive pulmonary disease or asthma exists. The evidence for nebulised agents including hypertonic saline, mannitol and antibiotics is evolving; however, access is challenging outside tertiary clinics, and nebulising equipment is required. Smokers should be supported to quit. All patients should receive influenza and pneumococcal vaccination. Patients with impaired exercise capacity should attend pulmonary rehabilitation. There is an important minority of patients for whom aetiology-specific treatment exists. The prevalence of bronchiectasis is increasing worldwide; however, the burden of disease within Australia is not well defined. To this end, the Australian Bronchiectasis Registry began recruitment in 2016 and is interoperable with the European and United States bronchiectasis registries to enable collaborative research. The recent addition of a bronchiectasis diagnosis-related group to the Australian Refined Diagnostic Related Group classification system will allow definition of the disease burden within the Australian hospital system.