Thoracic Society of Australia and New Zealand (TSANZ) position statement on chronic suppurative lung disease and bronchiectasis in children, adolescents and adults in Australia and New Zealand

Abstract

This position statement, updated from the 2015 guidelines for managing Australian and New Zealand children/adolescents and adults with chronic suppurative lung disease (CSLD) and bronchiectasis, resulted from systematic literature searches by a multi‐disciplinary team that included consumers. The main statements are: Diagnose CSLD and bronchiectasis early; this requires awareness of bronchiectasis symptoms and its co‐existence with other respiratory diseases (e.g., asthma, chronic obstructive pulmonary disease). Confirm bronchiectasis with a chest computed‐tomography scan, using age‐appropriate protocols and criteria in children. Undertake a baseline panel of investigations. Assess baseline severity, and health impact, and develop individualized management plans that include a multi‐disciplinary approach and coordinated care between healthcare providers. Employ intensive treatment to improve symptom control, reduce exacerbation frequency, preserve lung function, optimize quality‐of‐life and enhance survival. In children, treatment also aims to optimize lung growth and, when possible, reverse bronchiectasis. Individualize airway clearance techniques (ACTs) taught by respiratory physiotherapists, encourage regular exercise, optimize nutrition, avoid air pollutants and administer vaccines following national schedules. Treat exacerbations with 14‐day antibiotic courses based upon lower airway culture results, local antibiotic susceptibility patterns, clinical severity and patient tolerance. Patients with severe exacerbations and/or not responding to outpatient therapy are hospitalized for further treatments, including intravenous antibiotics and intensive ACTs. Eradicate Pseudomonas aeruginosa when newly detected in lower airway cultures. Individualize therapy for long‐term antibiotics, inhaled corticosteroids, bronchodilators and mucoactive agents. Ensure ongoing care with 6‐monthly monitoring for complications and co‐morbidities. Undertake optimal care of under‐served peoples, and despite its challenges, delivering best‐practice treatment remains the overriding aim.

Chronic suppurative lung disease and bronchiectasis in children, adolescents and adults in Australia and New Zealand: TSANZ position statement summary

“…In bronchiectasis, P. aeruginosa is associated with worse clinical outcomes, 1,7 and, consistent with other international guidelines, 9,10,13 the 2023 Statement 12 now states that eradication therapy for newly detected P. aeruginosa in respiratory secretions should be offered, rather than considered, and provides advice in the figure on how this might be achieved. This was based upon four before and after (two prospective) studies in adults reporting improved quality of life and reduced exacerbations and hospitalisations following eradication, and two systematic reviews of randomised controlled trials of inhaled antibiotics in adults with bronchiectasis and chronic P. aeruginosa infection, where eradication was associated with reduced exacerbations but was a secondary outcome 12 …”

“…The 2023 Position Statement has an overarching technical report available in appendix 1 of the online supplement. 12 The possibility of mild bronchiectasis being reversible in children if identified early and treated optimally reinforces the importance of recognising the clinical features of bronchiectasis and using paediatric radiographic diagnostic criteria when interpreting chest CT scans. However, making the diagnosis is the beginning, and not the end, of the diagnostic journey.…”

“…This was based upon four before and after (two prospective) studies in adults reporting improved quality of life and reduced exacerbations and hospitalisations following eradication, and two systematic reviews of randomised controlled trials of inhaled antibiotics in adults with bronchiectasis and chronic P. aeruginosa infection, where eradication was associated with reduced exacerbations but was a secondary outcome. 12 Although the optimal duration of antibiotic treatment of exacerbations is unknown, a single, doubleblind randomised controlled trial in children and adolescents with non-severe (non-hospitalised) exacerbations found that oral amoxycillin-clavulanate was superior to placebo at achieving symptom resolution and shortening symptom duration after a 14-day treatment. 14 Accordingly, the 2023 Statement 12 has recommended antibiotics be continued for at least 14 days, rather than the ten days stated in the 2015 Guidelines.…”

“…Overall, of the 33 individual statements, one is new, 28 are modified, and four unchanged from the 2015 Guideline 11 . The new and modified statements are often fuller and more detailed than presented in the 2015 Guideline, 11 and are accompanied by three boxes, a table and a figure 12 . There is a box outlining the clinical features of bronchiectasis, including trigger points for referring children and adolescents to paediatric respiratory specialist services.…”

“…Meanwhile, the figure is adapted from the European Respiratory Society guidelines 10 and suggests a series of pathways for attempting to eradicate newly detected Pseudomonas aeruginosa in respiratory secretions. The 2023 Position Statement has an overarching technical report available in appendix 1 of the online supplement 12 …”