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Preliminary Guidelines for Adult Bronchiectasis
For the first time, we have preliminary North American guidelines for adult bronchiectasis!
But they might not be quite what you expect.
Until a few years ago, I thought guidelines were written by experts sitting around a table, sharing opinions about what they believed worked best. It turns out that is not how it happens at all.
A team of experts is indeed formed, but they must follow a clear, evidence-based process to decide which questions to answer.
This is because they can only make recommendations when there is research to support them, meaning there must be clinical trials to evaluate what is being proposed as a guideline question.
For these new U.S. guidelines, the team focused on eight specific clinical questions. Needless to say, these eight questions do not address everything people with bronchiectasis face in daily life.
Broader topics will likely appear in the upcoming Standards of Care, which are being developed for the Bronchiectasis Care Center Network, a growing collaboration of more than 150 centers across the United States.
Each question in the guidelines is built around the PICO framework, a structured tool that helps researchers ask focused questions and find the best available evidence to guide care.
PICO stands for:
P – Population
I – Intervention
C – Comparison
O – Outcome
Example:
In adults with non-cystic fibrosis bronchiectasis (P), does long-term preventive antibiotic therapy (I), compared with standard symptomatic treatment (C), reduce flare-ups and improve quality of life (O)?
After reviewing all available research, the experts rate the strength of the evidence and prepare their recommendations.
The final version may be released in time for the Second North American Bronchiectasis and NTM Conference at NYU Langone in December.
This is an exciting start. Over time, more questions will be explored, more evidence will be gathered, and the guidelines will continue to evolve. Each update brings us closer to better, more consistent care for everyone living with bronchiectasis.
Warm regards,
Linda Esposito
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@becleartoday Thanks for sharing. I was surprised with the recommendation that patients on brensocatib not be on atorvastatin long term. I've read atorvastatin is thought to have anti-inflammatory properties and small studies showed benefits of atorvastatin in bronchiectasis for that reason. Do you have insight on this issue? Are some patients taking it for just bronchiectasis and panel wants to discourage that? It doesn't sound like it works thru same pathway, therefore it doesn't seem it would increase toxicity. Are they recommending patients on it for cardiac issues stop? It's ok if we just need to wait for release of recs. I'm just curious.
@kathyjjb I have read other articles that suggest people who take 250 or 500 mg of Azithro or another macrolide three times a week, could take a ‘drug holiday’ over the summer months when there are fewer infections from RSV, flu, Covid..
My lung function is normal but I have Bronchiectasis in many areas and I produce lots of mucus that I must clear. My BE was likely due to untreated respiratory infections despite bringing all of this to my physician’s attention. (I encourage people to get second opinions!)
I’m taking 250 mg / 3 times a week right now to lessen inflammation and keep infections at bay. It also decreases the mucus production. I will take a break for at least four months in the late spring.
It’s so positive to see that Bronchiectasis is getting more attention. Perhaps more physicians will become more aware. A quick AI search and deeper dive into AI now provides some decent information!
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5 Reactions@jnmy Thank you for your reply. That's really good to know-the 3 times/week dose. My exasperations always occur in Spring/Fall. My only concern is that if we get infected with NTM during those 4 months, we are running the risk of a macrolide mutation. That's the Catch-22.
@kathyjjb I would request a monthly sputum culture within an AFB.
@kathyjjb You’re welcome. I think it is a risk / benefit analysis. If you take the ‘drug holiday’ from the antibiotic that can be beneficial and the risk of a macrolide mutation with NTM isn’t as problematic, compared to the outcomes / risk of increased inflammation and exacerbations over time.
I also read an article or study recently that concluded that the outcomes of NTM Bronchiectasis patients isn’t that different from non NTM BE patients. The article stated that it could have an impact on the treatment discussions with BE patients with NTM. I’ll look for it to post.
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1 Reaction@kathyjjb
Here is the journal article I mentioned above.
The data is based on the US registry of Bronchiectasis patients and I think some researchers believe that people in the registry may have more severe symptoms.
Could that impact the results / conclusions?
@kathyjjb
Here is the journal article-
https://www.atsjournals.org/doi/full/10.1164/rccm.202307-1165OC
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1 Reaction@becleartoday I was thinking the same thing, I will definitely request that.
@jnmy I'm not really surprised. I understand the risk/benefit. After being diagnosed with macrolide resistant M. Abscessus and told the cure rate is only 45% (25% with cavity disease), the risk to benefit quickly becomes meaningless. Not to mention the drugs needed from day 1-are much more toxic than azithromycin (though there are exceptions). I would like to see a study of BE participants without an NTM and taking the prophylactic macrolides and following the participants for 5 years. I think the solution, like "beclear" suggested would be monthly sputum cultures (if possible). Particularly for MABC that has a fast growth rate-so culture turn around can be very fast-depending on the lab. I would want to send to NJH lab and definitely discuss with my ID doctor. Thank you for bringing it up, I can see the benefit-particularly since I will not be using Brinsupri anytime soon.
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3 Reactions@jnmy why are you taking azithro? How did you know you had inflammation? I have constant inflammation and I have BE and MAC so they don’t want to give me azithro. Instead I take i puff of pulmozyme twice a day because without it I coughed nonstop.