Treatment of bronchiectasis should aim to maximise quality of life, reduce symptoms, prevent exacerbations and prevent any further lung damage. With good treatment, it is possible for individuals with bronchiectasis to remain stable for many years and to have good control of their symptoms.

The condition progresses through what is called a ‘vicious cycle’ of infection, inflammation and lung damage. Infections cause the lungs to become inflamed and the inflammation damages the lung. More lung damage makes you more open to infection. Treatment tackles all three aspects as shown in the diagram:

• Inflammation can be treated by

  • Anti-inflammatory inhalers: some inhalers contain medicine that, as well as opening up the airways to reduce breathlessness, can dampen down the inflammation in the lungs. These are discussed in more detail below.
  • Anti-inflammatory tablets: some medications can also reduce inflammation. This includes a type of antibiotic called 'macrolides' that includes azithromycin, erythromycin, roxithromycin and clarithromycin which as well as treating infection have effects that dampen inflammation.

  
  

• Infection can be treated by

  • Taking an annual flu vaccine and a pneumonia vaccine.
  • Treating chest infections promptly with antibiotics.
  • Taking preventative antibiotics in some cases.
  • Clearance of bacteria like Pseudomonas.

  
  

• Lung damage can be treated by

  • Physiotherapy to clear sputum.
  • Medications that help to clear the sputum.
  • Bronchodilator inhalers that relax the muscles in the airway.
  • Exercise, which helps to clear the sputum and helps the lungs to work better.

  Other important considerations are to avoid smoking and to treat the underlying cause of bronchiectasis if this has been identified.

  
  

• Advice about smoking

  Bronchiectasis is not caused by smoking, but symptoms can be made much worse by smoking and the condition will progress more rapidly unless you are able to stop.

  There is help available to help you stop smoking and alternatives to make quitting easier. Talk to your family doctor, practice nurse or pharmacist about the services available.

What is an inhaler?

Inhalers allow drugs to be delivered directly to your lungs. There are different types including dry powder inhalers (DPI's) and aerosol metered dose inhalers (MDI's).

Inhalers can be divided into those that are designed to give quick relief for symptoms (relievers) and those designed to give a longer lasting relief or prevention of symptoms.

Reliever inhalers open up the lungs to allow more air in and out by relaxing muscles in the lungs. They are best for helping with breathlessness.

• Types of inhalers

  There are different types of reliever inhalers which are shown below:

  Type of inhaler:	Examples (drug name):
  Quick acting bronchodilators: usually prescribed on an "as required" basis. Can also be used regularly.	Salbutamol® Terbutaline®
  Anticholinergic bronchodilator: works in a different way. Takes longer to have an effect. It is taken regularly.	Ipratropium bromide (Atrivebt R®)
  Reliever combinations: allow you to take two different bronchodilators at the same time. Usually prescribed on a regular basis.	Salbutamol + Ipatroprium: known as Combivent R®) Fenoterol + Ipatroprium: known as Duovent R®

  
  

  Long acting preventative inhalers are taken regularly. They do not relieve symptoms, but by taking them once or twice a day, symptoms can be prevented or reduced. There are different types and they can be divided into those that open up the lungs, as a long acting version of the relievers, and medications that contain steroids, which are used to treat asthma and some other inflammatory conditions.

  
  Non-steroid containing long acting inhalers

  Type of inhaler:	Examples (drug name):
  Long-acting bronchodilators: taken once or twice a day. They take about 30 minutes to work but effects last for 12-24 hours.	Salmeterol® Formoterol® Indacaterol® Oladaterol®
  Long acting anticholinergic:needs to be taken once or twice every 24 hours depending on which medicine is used. Cannot be taken with another anticholinergic inhaler (e.g. Atrovent R or Combinent R,	Tiotropium® Glycopyronium® Umeclidinium® Aclidinium®
  Combination bronchodilator inhalers: these contain two of the drugs listed above in a single inhaler. They are taken once or twice a day depending on which one is prescribed.	Spiolto® Anoro® Duaklir® Ultibro®

  
  

  Steroid inhalers

  Inhalers containing steroids are used for people with asthma and for some other inflammatory conditions. They are used to reduce the inflammation of your airways, but they only work against certain types of inflammation. You will not feel better immediately after starting one of these inhalers, and it can take up to 6 weeks to feel a benefit.

  Steroids can have quite serious side effects but, because inhalers deliver the drug directly to the lungs, the side effects of steroid inhalers are less than the side effects of taking steroid tablets. Steroid inhalers can be given as combinations with bronchodilators (above) or as steroids by themselves.

  
  

  Type of inhaler:	Examples (drug name):
  Steroid inhalers taken once or twice a day	Beclomethasoe® Budesonide® Ciclesonide® Fluticasone®
  Steroid and bronchodilator combinations	Seretide® Symbicort® Fostair® Flutiform® Relvar® Duoresp®

  
  

  Thrush is a common side effect of inhalers, especially those containing steroids and so it is recommended that you rinse your mouth out with water after taking your inhalers.

What are antibiotics?

Antibiotics are a group of drugs that fight bacterial infection. They can be given by mouth (oral) as tablets or liquid, or by injection (intravenous, which means directly into the vein). Some antibiotics can be put into a nebuliser (see image) to be taken regularly (inhaled). Different antibiotics work against different bacteria, but many work against multiple bacteria.

Common oral antibiotics that are used in treating bronchiectasis include:

• Penicillins: these include penicillin, amoxicillin and coamoxiclav
• Macrolide antibiotics: these include clarithromycin, erythromycin and azithromycin
• Doxycycline: this is another type of antibiotic taken once a day
• Quinolones: these include ciprofloxacin, levofloxacin and moxifloxacin

• How soon will they work?

  Antibiotics will not work immediately because it can take several days for them to kill the bacteria caused by an infection. Even after the bacteria have been killed, your body's inflammatory response to the bacteria can continue making you feel unwell. This is why it can take several days before you start to feel better.

  
  

• Potential side effects

  All antibiotics have potential side effects, but most people will have no problems taking them. If you develop a side effect or allergy with a particular antibiotic, it is important to tell your doctor so that they can avoid that antibiotic in future.
  

• About antibiotics and resistance

  Many people are rightly concerned that taking antibiotics can make bacteria become resistant to them. Some bacteria are naturally resistant to some antibiotics, and others can become resistant to antibiotics they have “seen before”.

  Bacteria will not always become resistant, and so it is possible in many cases to use the same antibiotic successfully for many years. If the bacteria in your sputum become resistant to an antibiotic, your doctor will advise you if you need to take a different antibiotic.

  Taking frequent courses of antibiotics can have side effects, including upsetting the bacteria in the gut causing diarrhoea or other symptoms.

  So, it is important to only use antibiotics when they are really needed, such as when you have an exacerbation or your symptoms are severe. Avoid using antibiotics if you do not have an infection or if your symptoms are under good control.

• Long term oral antibiotic treatment

  Long term antibiotic treatment is given to individuals who have a lot of exacerbations or very severe symptoms. Taking an antibiotic regularly helps to suppress the bacteria that live in the lungs and prevent chest infections.

  The most commonly used antibiotics of this kind are macrolides like azithromycin, clarithromycin, erythromycin and roxithromycin. They can be taken everyday, or sometimes three times per week. The doses are lower than those given to treat a full blown infection, which helps to reduce the side effects.

  Nevertheless, up to 1 in 5 people with bronchiectasis will get some side effects; most often diarrhoea or abdominal pain. Tinnitus (ringing in the ears) is a rare side effect but you should stop taking the medicine if this happens and speak to your doctor. These medications can interact with other tablets and so it is important to always tell other doctors that you are taking regular antibiotics before they prescribe you other drugs.

  Antibiotics are often given for at least 1 year and sometimes longer. They will not work straight away and so need to be taken regularly to have their full effect.

• Inhaled antibiotics

  These are given when chest infections occur frequently and when symptoms are hard to control. Usually, inhaling an antibiotic involves putting a liquid into a nebuliser and then inhaling the vapour.

• Intravenous antibiotics

  Occasionally treatment will be given by injection instead of as tablets. This is usually because oral antibiotics have not worked, or because the bacteria causing the infection is resistant to all of the antibiotics that are available orally. Injection antibiotics are also used for severe infections requiring admission to hospitals.

  In some hospitals, there are services that allow intravenous antibiotics to be given at home. This involves placing a small tube into the vein which stays in place when you are at home. You can be trained to give the injections yourself, or they can be given by a family member or by a nurse/healthcare professional.

  
  

  
  

Things that help with this

Bronchiectasis leads to a build up of mucus which can make infections more likely and also causes worsening symptoms of cough and breathlessness. It is therefore essential that you learn to clear mucus from the airways effectively. This is done by:

• Performing airway clearance exercises: see What you can do for advice about airway clearance exercises including video demonstrations.

• Taking medication to help clear the lungs (mucoactive drugs): Some medications are given by a nebuliser or might be given by an inhaler or tablet and are designed to help the mucus come up more easily. For example, inhaling salt water (saline) helps to hydrate mucus making it less thick and therefore easier to cough up. Other drugs which try to do similar things include mannitol (given via an inhaler) and carbocisteine (which is taken as tablets).

These medications should be combined with regular physiotherapy exercises for the best effect.

• Vaccinations

  People with bronchiectasis should have an annual flu vaccination and should be vaccinated once in their lifetime against Streptococcus pneumoniae (this vaccine is sometimes called the pneumonia vaccine as it protects against the most common bacteria causing pneumonia).

  The reason for this is that people with bronchiectasis are at higher risk of developing chest infections like flu and pneumonia, and they can be more severe when they develop.

• Oxygen therapy

  Oxygen is given to people with bronchiectasis when their oxygen levels are low. This might happen when you are in hospital with a chest infection and in this case oxygen will be stopped when the oxygen levels return to normal.

  In some people with bronchiectasis, oxygen levels drop when the lung is damaged and no longer taking in enough oxygen. In this case, oxygen can be provided to take at home through a machine. This should be used at least 15 hours a day to have the best effect.

• Surgery

  In most cases bronchiectasis can be well controlled and cared for without needing surgery. Surgery is now rarely used, but can sometimes be helpful if the bronchiectasis affects only a small part of the lung and so might be cured by removing it. Surgery can also be used where a section of the lung is very badly damaged and causing a lot of infections.

What to expect and how to access

Treatment of bronchiectasis is best provided by a team of doctors and other healthcare professionals that are experienced in caring for bronchiectasis.

In many countries there are now specialised clinics which are dedicated to people with bronchiectasis. These clinics will all be slightly different but will include:

• A doctor, or team of doctors, with a specialist interest and experience in bronchiectasis
• A physiotherapist, or team of physiotherapists, that can teach chest clearance exercises
• Nurses or other healthcare professionals that can provide education and support
• Services to provide inhaled/nebulised antibiotics, other specialised medications and intravenous antibiotics at home.
• Specialised tests of the immune system or body functions to diagnose the cause of bronchiectasis

Some people with bronchiectasis will regularly attend specialist clinics, while some might be seen in the specialist clinic once, or on a few occasions, and then be transferred back to the care of their regular doctor.

If you think you need to see a specialist, please discuss this with your doctor. There is no directory of bronchiectasis specialists across Europe, but if you have difficulty finding an appropriate specialist please contact European Lung Foundation.

Bronchiectasis Patient Checklist

The Bronchiectasis Patient Checklist is based on the European Bronchiectasis Guidelines 2017 and reflect what most patients with bronchiectasis should expect from their care according to these guidelines. Ask your specialist, doctor or nurse to go through the checklist. You can keep track of each recommendation by ticking it off the passport. Find your language below (more languages coming soon):

• Bronchiectasis Patient Checklist (EN) (PDF (273 KB))
• Die Bronchiektasie- Patientencheckliste (DE) (PDF, 169KB)
• H Λίστα ελέγχου Ασθενούς με Βρογχεκτασίες (EL) (PDF (273 KB))
• La check-list du patient souffrant de bronchectasie (FR) (PDF (185 KB))
• Rozstrzenie oskrzeli Lista kontrolna dla pacjenta (PL) (PDF, 175 KB)
• Lista de verificare a bolnavului cu bronșiectazie (RO) (PDF, 601 KB)