Chronic suppurative lung disease and bronchiectasis in children and adults in Australia and New Zealand. A position statement from the Thoracic Society of Australia and New Zealand and the Australian Lung Foundation

Abstract

Consensus recommendations for managing chronic suppurative lung disease (CSLD) and bronchiectasis, based on systematic reviews, were developed for Australian and New Zealand children and adults during a multidisciplinary workshop. The diagnosis of bronchiectasis requires a high‐resolution computed tomography scan of the chest. People with symptoms of bronchiectasis, but non‐diagnostic scans, have CSLD, which may progress to radiological bronchiectasis. CSLD/bronchiectasis is suspected when chronic wet cough persists beyond 8 weeks. Initial assessment requires specialist expertise. Specialist referral is also required for children who have either two or more episodes of chronic (> 4 weeks) wet cough per year that respond to antibiotics, or chest radiographic abnormalities persisting for at least 6 weeks after appropriate therapy. Intensive treatment seeks to improve symptom control, reduce frequency of acute pulmonary exacerbations, preserve lung function, and maintain a good quality of life. Antibiotic selection for acute infective episodes is based on results of lower airway culture, local antibiotic susceptibility patterns, clinical severity and patient tolerance. Patients whose condition does not respond promptly or adequately to oral antibiotics are hospitalised for more intensive treatments, including intravenous antibiotics. Ongoing treatment requires regular and coordinated primary health care and specialist review, including monitoring for complications and comorbidities. Chest physiotherapy and regular exercise should be encouraged, nutrition optimised, environmental pollutants (including tobacco smoke) avoided, and vaccines administered according to national immunisation schedules. Individualised long‐term use of oral or nebulised antibiotics, corticosteroids, bronchodilators and mucoactive agents may provide a benefit, but are not recommended routinely.

Antibiotics for bronchiectasis exacerbations in children: rationale and study protocol for a randomised placebo-controlled trial

“…The marked paucity of RCTs [21,55] is reflected in the existence of only a single (small) published placebo-controlled RCT in children with bronchiectasis [21,56]. That study described a reduction in sputum purulence and airway hyper-responsiveness in children receiving roxithromycin (n = 13) [57].…”

“…There are no RCTs on the management of bronchiectasis exacerbations in children [58]. Almost all current recommendations are based on CF management [21,28]. Such extrapolation can, on occasions, be detrimental for those with non-CF bronchiectasis.…”

“…There is increasing evidence that intensive treatment of children who either have bronchiectasis or are at risk of developing severe bronchiectasis prevents poor lung function in adulthood [17-20]. Cohort data have shown that approximately 80% of newly diagnosed adults (non-smokers) with bronchiectasis reported symptoms dating back to childhood and that the duration of chronic cough (the most common symptom of bronchiectasis [21]) was related (r = −0.51, P  < 0.001) to lung function at diagnosis [22]. Arguably, appropriate overall management and treatment of exacerbations (leading to reduction of persistent symptoms) potentially prevents or reduces deterioration of chronic respiratory disease [23].…”

“…Antibiotics are one of the key interventions used to treat acute respiratory exacerbations of bronchiectasis [21,28]. However, it is biologically plausible that antibiotics are not useful for treating some respiratory exacerbations triggered by viral infections.…”

Bronchiectasis exacerbation study on azithromycin and amoxycillin-clavulanate for respiratory exacerbations in children (BEST-2): study protocol for a randomized controlled trial

“…Cohort data have shown that about 80% of newly diagnosed adults (non-smokers) with bronchiectasis reported symptoms dating back to childhood, and that the duration of chronic cough (the most common symptom of bronchiectasis [24]) was related (r = −0.51, P <0.001 in non-smokers) to lung function at diagnosis [25]. Arguably, appropriate overall management and treatment of exacerbations (leading to a reduction in persistent symptoms) potentially prevents or reduces deterioration of chronic respiratory disease [26].…”