Reviews Evidence-Based Approach to Treatment and Prevention of Bronchiectasis

Research in bronchiectasis has undergone a resurgence with rapid advances in understanding of the disease and its treatment.

RESPIRE-1&2, ORBIT-3&4 and AIR-BX1&2 showed variable effects of inhaled antibiotics on exacerbation frequencies and time to exacerbation endpoints. Brensocatib, a serine protease inhibitor has shown promise in reducing inflammation and exacerbations in a phase 2 trial.

EMBARC and EMBARC-India have highlighted substantial differences across continents. Microbial interaction networks aggravate airway inflammation and are integral to the “vicious vortex” of bronchiectasis. Cardiovascular events drive mortality, especially around exacerbations. A substantial minority (30%) have eosinophilic inflammation. Airway clearance therapies remain cornerstone of management; oral macrolides or inhaled aminoglycosides are useful in “frequent exacerbators”. Anti-inflammatory therapy is gaining center-stage with dipeptidyl peptidase-1 inhibitors and IL-5 inhibitors showing early promise in neutrophilic and eosinophilic phenotypes. Trials enrolling patients with “treatable traits” (ASPEN, MAHALE) should elucidate clinically relevant phenotypes.