The Saudi Thoracic Society guidelines for diagnosis and management of noncystic fibrosis bronchiectasis

Bronchiectasis management in adults: state of the art and future directions

Formerly regarded as a rare disease, bronchiectasis is increasingly recognised. A renewed interest in this disease has led to significant progress in bronchiectasis research. Randomised clinical trials (RCTs) have demonstrated the benefits of airway clearance techniques, inhaled antibiotics and long-term macrolide therapy in bronchiectasis patients. However, the heterogeneity of bronchiectasis remains one of the most challenging aspects of management. Phenotypes and endotypes of bronchiectasis have been identified to help find "treatable traits" and partially overcome disease complexity. The goals of therapy for bronchiectasis are to reduce the symptom burden, improve quality of life, reduce exacerbations and prevent disease progression. We review the pharmacological and non-pharmacological treatments that can improve mucociliary clearance, reduce airway inflammation and tackle airway infection, the key pathophysiological features of bronchiectasis. There are also promising treatments in development for the management of bronchiectasis, including novel anti-inflammatory therapies. This review provides a critical update on the management of bronchiectasis focusing on treatable traits and recent RCTs.

Investigation and Management of Bronchiectasis in Nontuberculous Mycobacterial Pulmonary Disease

Patients with nontuberculous mycobacterial (NTM) lung infection require life-long attention to their bronchiectasis, whether or not their NTM infection has been cured. The identification of the cause of bronchiectasis and/or coexisting diseases is important because it may affect therapeutic strategies. Airway clearance is the mainstay of bronchiectasis management. It can include multiple breathing techniques, devices, and mucoactive agents. The exact airway clearance regimen should be customized to each individual patient. Chronic pathogenic airway bacteria, such as Pseudomonas aeruginosa, may warrant consideration of eradication therapy and/or chronic use of maintenance inhaled antibiotics.

Pediatric pulmonology 2021 year in review: Rare and diffuse lung disease

The field of rare and diffuse pediatric lung disease is experiencing rapid progress as diagnostic and therapeutic options continue to expand. In this annual review, we discuss manuscripts published in Pediatric Pulmonology in 2021 in (1) children's interstitial and diffuse lung disease, (2) congenital airway and lung malformations, and (3) noncystic fibrosis bronchiectasis including primary ciliary dyskinesia. These include case reports, descriptive cohorts, trials of therapies, animal model studies, and review articles. The results are put into the context of other literature in the field. Each furthers the field in important ways, while also highlighting the continued need for further studies.

Clinical outcomes of bronchiectasis in India: data from the EMBARC/Respiratory Research Network of India registry

BACKGROUND

Identifying risk factors for poor outcomes can help with risk stratification and targeting of treatment. Risk factors for mortality and exacerbations have been identified in bronchiectasis but have been almost exclusively studied in European and North American populations. This study investigated the risk factors for poor outcome in a large population of bronchiectasis patients enrolled in India.

METHODS

The European Multicentre Bronchiectasis Audit and Research Collaboration (EMBARC) and Respiratory Research Network of India (EMBARC-India) registry is a prospective observational study of adults with computed tomography-confirmed bronchiectasis enrolled at 31 sites across India. Baseline characteristics of patients were used to investigate associations with key clinical outcomes: mortality, severe exacerbations requiring hospital admission, overall exacerbation frequency and decline in forced expiratory volume in 1 s.

RESULTS

1018 patients with at least 12-month follow-up data were enrolled in the follow-up study. Frequent exacerbations (≥3 per year) at baseline were associated with an increased risk of mortality (hazard ratio (HR) 3.23, 95% CI 1.39-7.50), severe exacerbations (HR 2.71, 95% CI 1.92-3.83), future exacerbations (incidence rate ratio (IRR) 3.08, 95% CI 2.36-4.01) and lung function decline. Coexisting COPD, dyspnoea and current cigarette smoking were similarly associated with a worse outcome across all end-points studied. Additional predictors of mortality and severe exacerbations were increasing age and cardiovascular comorbidity. Infection with Gram-negative pathogens (predominantly Klebsiella pneumoniae) was independently associated with increased mortality (HR 3.13, 95% CI 1.62-6.06), while Pseudomonas aeruginosa infection was associated with severe exacerbations (HR 1.41, 95% CI 1.01-1.97) and overall exacerbation rate (IRR 1.47, 95% CI 1.13-1.91).

CONCLUSIONS

This study identifies risk factors for morbidity and mortality among bronchiectasis patients in India. Identification of these risk factors may support treatment approaches optimised to an Asian setting.

Inhaled Colistimethate Sodium in the Management of Patients with Bronchiectasis Infected by Pseudomonas aeruginosa: A Narrative Review of Current Evidence

International guidelines on the treatment of bronchiectasis indicate that the use of inhaled antibiotics is effective, especially in symptomatic chronic bronchial infection (CBI) due to Pseudomonas aeruginosa (PA). To date, however, no such treatment has been approved by regulatory agencies. Of the inhaled antibiotics on the market, colistimethate sodium (colistin) is one of the most used in many countries, either in its nebulized presentation or as dry powder. Among the characteristics of this antibiotic, it is worth noting that its main target is the lipopolysaccharide in the outer membrane of the cell wall of gram-negative bacteria and that it has a low rate of resistance to PA (<1%). Most observational studies have shown that the use of colistin in patients with bronchiectasis and CBI due to PA results in a decrease in both the number and severity of exacerbations, an improvement in quality of life, a decrease in sputum volume and purulence, and a high rate of PA eradication, although there are no clear differences with respect to other inhaled antibiotics. However, the lack of randomized clinical trials (RCT) with positive results for its main variable (exacerbations) in an intention-to-treat analysis has prevented its approval by regulatory agencies as a formal indication for use in bronchiectasis. The PROMIS program, made up of two RCT with identical methodology, is currently underway. The first of these RCT (already concluded) has demonstrated a clearly positive effect on the group randomized to colistin in its main variable (number of annual exacerbations), while the results of the second are still pending. This review presents exhaustive information on the pharmacological and microbiological characteristics of colistin, the results of the studies carried out to date, and the future challenges associated with this treatment.

Inhaled Corticosteroids in Adults with Non-cystic Fibrosis Bronchiectasis: From Bench to Bedside. A Narrative Review

Due to their potent anti-inflammatory capacity (particularly in predominantly eosinophilic inflammation) and immunosuppressive properties, inhaled corticosteroids (ICSs) are widely used in asthmatic patients and also in individuals with chronic obstructive pulmonary disease (COPD) who suffer multiple exacerbations or have peripheral eosinophilia. However, there is little evidence for their use in non-cystic fibrosis bronchiectasis (hereafter, bronchiectasis). According to data extracted from large databases of bronchiectasis in adults, ICSs are used in more than 50% of patients without any scientific evidence to justify their efficacy and contrary to the recommendations of international guidelines on bronchiectasis that generally advise against their use. Indeed, bronchiectasis is a disease with predominantly neutrophilic inflammation and a high likelihood of chronic bacterial bronchial infection. Furthermore, it is known that due to their immunosuppressive properties, ICSs can induce an increase in bacterial infections. This manuscript aims to review the basic properties of ICSs, how they impact bronchiectasis in adults, the current position of international guidelines on this treatment, and the current indications and future challenges related to ICS use in bronchiectasis.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Bronchiectasis: Retrospective Analysis of Clinical and Pathological Findings in a Tertiary-Care Hospital

BACKGROUND

Bronchiectasis is still a challenging chronic lung disease in developing countries. Patients with bronchiectasis can also have pulmonary hypertension. There are sparse data on the prevalence of pulmonary hypertension in patients with bronchiectasis. Materials and methods. Archived H&E-stained slides of 141 patients histopathologically diagnosed with bronchiectasis were reevaluated. Cases were categorized into 4 subgroups based on histology: tubular, varicose, follicular, and cystic. In addition, concomitant histopathological changes were also reevaluated. For patients with available CT sections, main, right, and left pulmonary artery (PA) diameters and PA/aorta ratio were measured with regard to pulmonary hypertension.

RESULTS

Of the cases, 70% (n = 89) were female and 30% (n = 52) were male, with a mean age of 36.58 in females and 33.84 in males. Histopathologically, 43% (n = 68) of the cases showed follicular, 37% (n = 59) showed varicose, 35% (n = 56) showed tubular, and 28% (n = 45) showed cystic bronchiectasis morphology. All cases showed chronic inflammation, fibrosis, muscle destruction, and cartilage destruction. Aspergillus were present in 11% of the cases showing cystic morphology. Approximately 17% of the cases (n = 24) were found to have neuroendocrine cell proliferations. In cases with medial hypertrophy, a statistically significant increase in the left pulmonary artery diameter was radiologically determined.

CONCLUSIONS

Medial hypertrophy was found to be significant with regard to indicating a radiological increase in left pulmonary artery diameter. Vascular changes observed in bronchiectasis cases and the presence of neuroendocrine cell proliferations should be specified in pathology reports, and aspergilloma should be carefully investigated in cases with predominant cystic morphology.

Rationale and Clinical Use of Bronchodilators in Adults with Bronchiectasis

Currently, there is much controversy surrounding the therapeutic approach to pulmonary function abnormalities in patients with bronchiectasis and, consequently, whether and when to use bronchodilators in these patients. National and international guidelines on the treatment of bronchiectasis in adults do not recommend the routine use of bronchodilators because there is no evidence that a significant response to a bronchodilator or the presence or hyperresponsiveness of the airway are good predictors of future effective clinical response. However, some guidelines recommend them in the presence of airway obstruction and/or special conditions, which vary according to the guideline in question, although there are no recommendations on optimal dosing and bronchodilator treatment combined with or without inhaled corticosteroids. Nonetheless, in contrast with guideline recommendations, bronchodilators are overused in real-world patients with bronchiectasis even in the absence of airway obstruction, as demonstrated by analysis of national and international registries. This overuse can be explained by the awareness of the existence of a solid pharmacological rationale that supports the use of bronchodilators in the presence of chronic airway obstruction independent of its aetiology. We performed a systematic review of the literature and were able to verify that there are no randomised controlled trials (apart from a small study with methodological limitations and a very recent trial involving a not-very-large number of patients), or any long-term observational studies on the short- or long-term effect of bronchodilators in patients with bronchiectasis. Therefore, we believe that it is essential and even urgent to evaluate the effects of bronchodilators in these patients with appropriately designed studies.

Survey of the management of patients with bronchiectasis: a pilot investigation in Asian populations

BACKGROUND/AIMS

Although international guidelines for bronchiectasis management have been published in Western countries, there is a lack of data about their application in Asian populations including patients with different phenotypes. We aimed to investigate the current status of bronchiectasis management in Asian populations.

METHODS

A nationwide questionnaire survey was performed of Asian respiratory specialists from South Korea, Japan, Taiwan, Singapore, Vietnam, and Sri Lanka. Participants were invited by e-mail to answer a questionnaire comprising 25 questions based on international guidelines for the management of bronchiectasis.

RESULTS

A total of 221 physicians participated in the survey. About half of them were Korean (50.2%), with the next most common nationalities being Japanese (23.1%), Taiwanese (13.6%), and Singaporean (7.7%). Only 18 (8.1%) responders had local guidelines for bronchiectasis. While 85 (38.5%) responders checked sputum acid-fast bacillus smear/culture about 1 to 3 times per year, only a small proportion of responders routinely performed a serum immunoglobulin test (36/221, 16.3%) or evaluated for allergic bronchopulmonary aspergillosis (41/221, 18.6%). Less than half (43.4%) of responders performed eradication treatment in patients with drug-sensitive Pseudomonas aeruginosa infection, mainly due to the limited availability of inhaled antibiotics (34.8%). In addition, 58.6% of responders considered physiotherapy such as airway clearance and pulmonary rehabilitation.

CONCLUSION

Discrepancies might exist between guideline recommendations and practice for bronchiectasis management in Asian populations, partly due to the limited availability of treatment in each country. The development of local guidelines that consider the phenotypes and situation will help to standardize and improve the management of bronchiectasis.

Diagnosis and Initial Investigation of Bronchiectasis

Bronchiectasis refers to both the name of a disease and a single radiological appearance that may, or may not, be associated with disease. As chronic respiratory disease, bronchiectasis is characterized by a variable range of signs and symptoms that may overlap with other chronic respiratory conditions. The proper identification of bronchiectasis as a disease in both primary and secondary care is of paramount importance. However, a standardized definition of radiologically and clinically significant bronchiectasis is still missing. Disease heterogeneity is a hallmark of bronchiectasis and applies not only to radiological features and clinical manifestations but also to other aspects of the disease, including the etiological and microbiological diagnosis as well as the evaluation of pulmonary function. Although the guidelines suggest a "minimum bundle" of tests, the diagnostic approach to bronchiectasis is challenging and may be driven by the "treatable traits" approach based on endotypes and biological characteristics. A broad spectrum of diagnostic tests could be used to investigate the etiology of bronchiectasis as well as other pulmonary, extrapulmonary, and environmental traits. Individualizing bronchiectasis workup according to the site of care (e.g., primary, secondary, and tertiary care) could help optimize patients' management and reduce healthcare costs.

Prognostic utility of various multidimensional grading scales among Saudi patients with bronchiectasis

INTRODUCTION

A number of multidimensional scoring systems, including the Bronchiectasis Severity Index (BSI), the FACED score, and the Exacerbation-FACED (Exa-FACED, a derivative of FACED), have been proposed and validated to assess the severity and prognosis in patients with bronchiectasis. Although these metrics have been validated through large multicenter efforts in Europe and Latin America, there have been no attempts at external validation in other populations.

OJECTIVES

The aim of this study was to validate specific multidimensional grading scales (BSI, FACED, and Exa-FACED) in predicting mortality, future exacerbations, and hospitalizations among Saudi patients with bronchiectasis.

METHODS

A prospective observational cohort study was conducted at a tertiary care centre. The three multidimensional grading scales (BSI, FACED, and Exa-FACED) were calculated for each patient. Future frequent acute exacerbations (≥2/year) and severe acute exacerbations leading to hospitalization were recorded for 1 year, and all-cause mortality was monitored for up to 5 years.

RESULTS

A total of 301 patients with bronchiectasis (mean age of 60±17 years and 66% female) were include. All Grading scales performed well in predicting 5-year survival. Area under the curve (AUC) values for BSI (0.86, 95% CI: 0.82-0.90), FACED (0.81, 95% CI: 0.76-0.85), and Ex-FACED (0.83, 95% CI: 0.78-0.87). The BSI (AUC=0.98, 95% CI: 0.96-0.99) performed better than FACED scoring (AUC=0.77, 95% CI: 0.71-0.81; P<0.0001) in predicting hospitalization. Exa-FACED scoring (AUC=0.84, 95% CI: 0.80-0.88) improved upon FACED scores in predicting hospitalization. The BSI (AUC=0.95, 95% CI: 0.91-0.97) fared significantly better than FACED scoring (AUC=0.76, 95% CI: 0.70-0.80; p<0.0001) in predicting frequent acute exacerbations (≥2/year). Again, Exa-FACED scoring (AUC=0.85, 95% CI: 0.81-0.89) improved upon FACED scores in predicting frequent acute exacerbations (≥2/year).

CONCLUSIONS

All scoring systems performed adequately in 5-year mortality projections. Although Exa-FACED scoring improved upon FACED scores in predicting forthcoming frequent acute exacerbations and hospitalization, the BSI outperformed both in this regard.

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.

Assessing the Quality of Clinical Practice Guidelines in the Middle East and North Africa (MENA) Region: A Systematic Review

Aim

Clinical practice guidelines (CPGs) have progressively become a popular tool for making optimal clinical decisions. The literature shows that the poor quality of CPGs can form a barrier against adhering to them, resulting in a suboptimal level of healthcare. The objective of this systematic review is to evaluate the quality of CPGs in the Middle East and North Africa (MENA) region using the Appraisal of Guidelines for Research & Evaluation II (AGREE II) Instrument.

Methods

The authors searched in the MEDLINE and EMBASE databases through the Ovid interface on May 25, 2019. Keywords relating to CPGs and MENA countries were combined using Boolean search operators. The search was not limited to specific diseases. The quality of guidelines was appraised by two reviewers independently using the AGREE II Instrument. Discrepancies within a group were resolved through the involvement of a principle investigator.

Results

A total of 61 CPGs were appraised. These guidelines were mainly from Saudi Arabia, and the most covered disease topic was cancer. Among the six domains of the AGREE II Instrument, CPGs scored the highest on clarity of presentation (mean 82%), while the lowest score was granted to the rigor of development domain (mean 28%). This indicates substantial deficiencies in reporting the developmental processes of CPGs and the resources used for the synthesis of evidence.

Conclusion

From this review, it was found that the number of retrieved guidelines published in the MENA region is limited considering the large geographical area of the MENA region. The main domains that have higher quality scores were clarity of presentation and scope and purpose, whereas domains with the lowest scores were rigor of development and applicability. The authors’ findings will help policymakers identify areas for improvement in CPGs, which can lead them to implement strategies such as the training of individuals and recruitment of international experts to ultimately develop high-quality CPGs.

Effectiveness of hypertonic saline nebulization in airway clearance in children with non-cystic fibrosis bronchiectasis: A randomized control trial

INTRODUCTION

Failure to expectorate mucus resulting in progressive airway damage is the hallmark of bronchiectasis. Therefore effective airway clearance techniques (ACT) is the key step in its management. The aim of this study was to evaluate the efficacy of 3% hypertonic saline (HS) pre-medication in ACT in children with non cystic fibrosis (non-CF) bronchiectasis.

METHODS

In this randomized crossover control trial five to 15 year old children, diagnosed with non-CF bronchiectasis were randomized either to receive 200 µg of inhaled salbutamol followed by HS nebulization (test) or only 200 µg of inhaled salbutamol, before chest physiotherapy which is the conventional ACT (controls) for 8 weeks. Inhaled salbutamol was administered via a pressurized metered dosed inhaler with a valved holding chamber. After completion of first phase both groups went through one month washout period, before being crossed over to the opposite arms in the second phase. Spirometric parameters and number of exacerbations were recorded at the end of phase I, washout period and phase II.

RESULTS

Fifty two out of 63 enrolled completed the study. Baseline characteristics of the two groups were similar. A significantly higher mean improvement was seen in predicted forced expiratory volume in 1 s in the HS arm during phase 1 (HS = 14.15 ± 5.50 vs. conventional = 5.04 ± 5.55, p = .001) and phase II (HS = 10.81 ± 5.51 vs. conventional = 3.54 ± 5.13, p = .001) compared to conventional ACT arm. HS group showed a significantly higher mean improvement in predicted forced vital capacity in phase I (HS = 13.77 ± 5.73 vs. conventional = 7.54 ± 4.90, p = .001) and phase II, (HS = 9.42 ± 7.00 vs. conventional = 4.42 ± 4.00, p = .003). Mean number of exacerbations experienced by a single child during phase I (2 months) were significantly less (p = .001) in HS arm (0.42 ± 0.64) compared to that of conventional arm (1.30 ± 1.05) butthis difference was not significant in phase II (HS = 0.65 ± 0.74 and conventional = 1.03 ± 0.77, p = .074).

CONCLUSION

Incorporating HS nebulization into ACT is an effective strategy to improve dynamic lung volumes and morbidity in children with non-CF bronchiectasis.

Performance of Multidimensional Severity Scoring Systems in Patients with Post-Tuberculosis Bronchiectasis

Objective

The aim of this study was to assess the clinical characteristics and outcomes of patients with post-tuberculosis (post-TB) bronchiectasis. We also evaluated the performance of various multidimensional severity score systems to predict mortality, future exacerbation, and hospitalization.

Methods

We conducted a prospective observational cohort study to evaluate the etiology of bronchiectasis in 301 patients. Patients fell into three groups: post-TB (129 [43%]), idiopathic (76 [25%]), and other (96 [32%]) etiologies of bronchiectasis. Four multidimensional grading scales, including the Bronchiectasis Severity Index (BSI), the FACED score, and two derivative versions of the FACED score, Exacerbation (Exa-FACED and E-FACED), were calculated and compared for each patient.

Results

Patients with post-TB bronchiectasis were predominantly female (61%) with a mean age of 68±11 years. Moreover, 26% of post-TB bronchiectasis patients were colonized with Pseudomonas aeruginosa. At baseline, patients with post-TB bronchiectasis were older, had higher severity scores, and were more likely to have experienced severe exacerbations that required hospitalization compared to patients with idiopathic bronchiectasis or bronchiectasis arising from other causes. During follow-up, 52% of patients required hospitalization, 58% had frequent (≥2 per year) acute exacerbations, and the overall 5-year mortality rate was 30%. Five-year survival was efficiently predicted by each of the grading scales. Although the modified variations of the FACED outperformed the original FACED scale in predicting forthcoming frequent acute exacerbations and hospitalization, the BSI outperformed all three systems in this regard.

Conclusion

Patients with post-TB bronchiectasis had higher severity scores than patients with idiopathic bronchiectasis or bronchiectasis arising from other causes. In addition, all scoring systems performed adequately in 5-year mortality projections. BSI and the modified versions of the FACED outperformed the FACED in predicting forthcoming exacerbations and hospitalizations.

Update on pharmacotherapy for adult bronchiectasis

Bronchiectasis refers to abnormal dilatation of the bronchi, which leads to the failure of mucus clearance and increased risk of infection. Pharmacotherapy for stable bronchiectasis includes oral or inhaled mucoactive agents, anti-inflammatory therapy, inhaled bronchodilators, long-term antibiotics, and long-term macrolide treatment. Among them, mucoactive agents are the most common adjunctive agents to airway clearance techniques. When patients with impaired lung function suffer from dyspnea, inhaled bronchodilators may be prescribed to relieve the symptom. Long-term macrolide treatment has been proven to prevent exacerbation in patients with frequent bronchiectasis exacerbation. If exacerbation occurs despite the above mentioned treatments, one or two weeks of antibiotics should be prescribed to cover respiratory bacteria that include <i>Pseudomonas aeruginosa</i>. Because evidence supporting the use of pharmacotherapy for bronchiectasis is weak, further research is warranted.

Non-cystic fibrosis bronchiectasis in children and adolescents: Neglected and emerging issues

Pediatric non-cystic fibrosis (CF) bronchiectasis is characterized by endobronchial suppuration, airway neutrophilic inflammation and poor mucus clearance and is associated with persistent productive cough due to recurrent airway infections. Most recommendations are based on expert opinion or extrapolated from CF practice. The present narrative review aims to address some issues on the management of children or adolescents with non CF-bronchiectasis that still require attention, and analyze what available literature offers to reply to open questions. We focused on the potential offered by technological advances on lung disease assessment through novel chest imaging techniques and new or old pulmonary function tests. We also summarized the main novelties in the disease prevention and treatment. Finally, a novel diagnostic algorithm is proposed, that might help physicians in the daily clinical decision-making process. Future directions for research on pediatric non-CF bronchiectasis should include larger study populations and longer prospective clinical trials, as well as new clinical and laboratory endpoints to determine the underlying mechanisms of lung disease progression and support the role of new and existing treatments.

Nebulized hypertonic saline in noncystic fibrosis bronchiectasis: a comprehensive review

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The Saudi Initiative for Asthma - 2019 Update: Guidelines for the diagnosis and management of asthma in adults and children

This is the fourth version of the updated guidelines for the diagnosis and management of asthma, developed by the Saudi Initiative for Asthma (SINA) group, a subsidiary of the Saudi Thoracic Society. The main objective of the SINA is to have guidelines that are up to date, simple to understand, and easy to use by healthcare workers dealing with asthma patients. To facilitate achieving the goals of asthma management, the SINA panel approach is mainly based on the assessment of symptom control and risk for both adults and children. The approach to asthma management is now more aligned for different age groups. The guidelines have focused more on personalized approaches reflecting better understanding of disease heterogeneity with integration of recommendations related to biologic agents, evidence-based updates on treatment, and role of immunotherapy in management. The medication appendix has also been updated with the addition of recent evidence, new indications for existing medication, and new medications. The guidelines are constructed based on the available evidence, local literature, and current situation at national and regional levels. There is also an emphasis on patient–doctor partnership in the management that also includes a self-management plan.

Bronchiectasis: Treatment decisions for pulmonary exacerbations and their prevention

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

Nurse-led versus doctor-led care for bronchiectasis

BACKGROUND

Specialist nursing roles to manage stable disease populations are being used to meet the needs of both patients and health services. With increasing cost pressures on health departments, alternative models such as nurse-led care are gaining momentum as a substitute for traditional doctor-led care. This review evaluates the safety, effectiveness, and health outcomes of nurses practising in autonomous roles while using advanced practice skills, within the context of bronchiectasis management in subacute, ambulatory, and/or community care.

OBJECTIVES

To compare the effectiveness of nurse-led care versus doctor-led care in the management of stable bronchiectasis.

SEARCH METHODS

We searched the Cochrane Airways Group Specialised Register and bibliographies of selected papers in addition to grey literature such as electronic clinical trials registries. Searches were current as of March 2018.

SELECTION CRITERIA

Randomised controlled trials were eligible for inclusion in the review.

DATA COLLECTION AND ANALYSIS

Two reviewers extracted and entered data from included studies. Primary outcomes were numbers of exacerbations requiring treatment with antibiotics, hospital admissions, and emergency department attendances.

MAIN RESULTS

We included one United Kingdom (UK) study in the review. In this randomised controlled trial, a total of 80 participants, with a mean age of 58 years, were treated for 12 months by a specialist nurse or doctor, then were crossed over to the other clinician for the next 12 months. Two participants died during the study period. Six participants failed to cross over to nurse-led care because of unstable bronchiectasis. Overall, the level of study completion was high.Data show no difference in the numbers of exacerbations requiring treatment with antibiotics (rate ratio 1.09, 95% confidence interval (CI) 0.91 to 1.30, 80 participants, moderate-certainty evidence). Investigators reported more hospital admissions in the nurse-led care group (rate ratio 1.52, 95% CI 1.04 to 2.23, 80 participants, moderate-certainty evidence) and did not report emergency department attendance.For secondary outcomes, participants in the nurse-led care group used more healthcare resources during the first year of the trial. Increased admissions and greater use of resources made treatment costs for nurse-led groups' higher. Total costs for both years of the study were £8,464 and £5,228 for nurse-led care compared with doctor-led care. However, by the second year, treatment costs were almost equitable between the two groups, which may reflect the nurses' learning of how to better treat people with bronchiectasis. No statistically significant changes were observed in quality of life, exercise capacity, mortality, or lung function. Wide confidence intervals led to uncertainty regarding these results. Adverse events were not an outcome for this review.

AUTHORS' CONCLUSIONS

This update of the review shows that only one trial met review criteria. Review authors were unable to demonstrate effectiveness of nurse-led care compared with doctor-led care on the basis of findings of a single study. The included study reported no significant differences, but limited evidence means that differences in clinical outcomes between nurse-led care and usual care within the setting of a specialist clinic remain unclear. Further research is required to determine whether nurse-led care is cost-effective, if guidelines and protocols for bronchiectasis management are followed does this increases costs and how effective nurse-led management of bronchiectasis is in other clinical settings such as inpatient and outreach.