Managing Bronchiectasis: Acute Exacerbations vs Chronic Therapy

This episode, "Managing Bronchiectasis: Acute Exacerbations vs Chronic Therapy," features Dr. Metersky walking through how chronic and acute bronchiectasis treatment strategies differ.

Dr. Basavaraj asks Dr. Metersky to walk through the evolving treatment landscape, distinguishing acute exacerbation management from long-term suppressive therapy. Dr. Metersky reiterates that airway clearance remains the foundational chronic therapy, since removing impacted mucus and infected secretions also removes the inflammatory mediators that drive ongoing airway damage. Many patients respond adequately to airway clearance alone and require no additional therapy, he notes.

For patients with persistent symptoms, Dr. Metersky explains that chronic macrolide therapy is often added next, since it reduces exacerbation frequency and appears to improve quality of life. He stresses that non-tuberculous mycobacterial infection must be definitively ruled out first, since macrolide monotherapy in an undiagnosed MAC infection risks creating drug-resistant Mycobacterium avium complex. For patients with chronic pseudomonas and severe symptoms, inhaled antibiotics have been the traditional next step, with meta-analyses showing modest reductions in exacerbations and modest quality-of-life improvement, though not dramatic gains. Dr. Metersky describes this as a large unmet need that brensocatib is now positioned to address, given its demonstrated reductions in exacerbation rate, quality-of-life improvement, and, at the higher dose, mitigation of FEV1 decline.

Turning to acute management, Dr. Metersky explains that exacerbations are typically treated with a course of antibiotics, even though clinicians often cannot determine whether an episode is bacterial, viral, or otherwise triggered. He notes that the new CHEST guidelines acknowledge that historical practice favored long courses of fourteen to twenty-one days, but the supporting evidence for that duration is weak. Whether a shorter course of about seven days performs as well as fourteen days remains uncertain, he says, so clinicians often adjust duration based on the suspected organism and their judgment about bacterial versus viral triggers, without definitive data to guide the choice either way.

Our next episode, "Airway Clearance Strategies for Bronchiectasis Patients," turns to the practical realities of prescribing and sustaining airway clearance therapy.