Note from the National Guideline Clearinghouse (NGC): For full context of the major recommendations stated below, please see the National Guideline Clearinghouse (NGC) summary of the American College of Chest Physician's guideline An Empiric Integrative Approach to the Management of Cough: ACCP Evidence-based Clinical Practice Guidelines, which utilizes a comprehensive approach, including algorithms for the clinician to follow in evaluating and treating the patient with acute, subacute, and chronic cough.
Definitions for the level of evidence, strength of recommendation, and net benefit follow the "Major Recommendations."
Disorders That Predispose the Patient to the Development of Bronchiectasis
Disorders |
Description |
Focal distribution |
|
Bronchial obstruction |
Foreign body |
|
Tumor |
|
Broncholithiasis |
|
Compression by peribronchial lymph nodes |
Previous pneumonia |
|
Diffuse distribution |
|
Cystic fibrosis (CF) |
|
Reduced host immunity |
Congenital and acquired hypogammaglobulinemia (especially Immunoglobulin G (IgG) and/or IgG subclasses)
Human immunodeficiency virus (HIV) infection |
Primary ciliary dyskinesia |
|
Allergic bronchopulmonary mycoses |
|
Chronic Mycobacterium avium complex (MAC) infection |
|
Aspiration or toxic inhalation |
|
Rheumatoid arthritis |
|
Inflammatory bowel disease |
|
Other congenital disorders |
Alpha-1-antitrypsin deficiency |
|
Tracheobronchomegaly (Mounier-Kuhn syndrome) |
|
Cartilage deficiency (Williams-Campbell syndrome) |
|
Young syndrome |
|
Pulmonary sequestration |
|
Marfan syndrome |
Yellow nail syndrome |
|
- In patients with suspected bronchiectasis without a characteristic chest radiograph finding, a high resolution computed tomography (HRCT) scan should be ordered because it is the diagnostic procedure of choice to confirm the diagnosis. Level of evidence, low; benefit, substantial; grade of recommendation, B
- In patients for whom there is no obvious cause, a diagnostic evaluation for an underlying disorder causing bronchiectasis should be performed, because the results may lead to treatment that may slow or halt the progression of disease. Level of evidence, low; benefit, substantial; grade of recommendation, B
- In patients with bronchiectasis with airflow obstruction and/or bronchial hyperreactivity, therapy with bronchodilators may be of benefit. Level of evidence, expert opinion; benefit, small; grade of recommendation, E/C
- In patients with bronchiectasis caused by cystic fibrosis (CF), recombinant human DNase (rhDNase) should be used to improve spirometry. Level of evidence, low; benefit, small; grade of recommendation, C
- In patients with CF, prolonged treatment with systemic corticosteroids should not be offered to most patients because of significant side effects. Level of evidence, low; benefit, conflicting; grade of recommendation, I
- In patients with CF, prolonged courses of ibuprofen should not be used. Level of evidence, low; benefit, conflicting; grade of recommendation, I
- In patients with idiopathic bronchiectasis, the prolonged systemic administration of antibiotics may produce small benefits in reducing sputum volume and purulence, but may also be associated with intolerable side effects. Level of evidence, low; benefit, conflicting, grade of recommendation, I
- In patients with CF, therapy with aerosolized antipseudomonal antibiotics are recommended. Level of evidence, low; benefit, intermediate; grade of recommendation, C
- In patients with idiopathic bronchiectasis, aerosolized antibiotics should not be used. Level of evidence, low; benefit, negative; recommendation, D
- In patients with conditions associated with the hypersecretion of mucus and the inability to expectorate effectively, chest physiotherapy should be used and patients should be monitored for symptom improvement. Level of evidence, expert opinion; benefit, small/weak; grade of recommendation, E/C
- In selected patients with localized bronchiectasis that causes intolerable symptoms despite maximal medical therapy, surgery should be offered. Level of evidence, low; benefit, substantial; grade of recommendation, B
- In patients with exacerbations of bronchiectasis, antibiotics should be used, with the selection of agents depending on the likely pathogens. Level of evidence, low; benefit, substantial; grade of recommendation, B
Definitions:
Quality of the Evidence
Good = evidence is based on good randomized controlled trials (RCTs) or meta-analyses
Fair = evidence is based on other controlled trials or RCTs with minor flaws
Low = evidence is based on nonrandomized, case-control, or other observational studies
Expert opinion = evidence is based on the consensus of the carefully selected panel of experts in the topic field. There are no studies that meet the criteria for inclusion in the literature review.
Strength of Recommendations
A = strong recommendation
B = moderate recommendation
C = weak recommendation
D = negative recommendation
I = no recommendation possible (inconclusive)
E/A = strong recommendation based on expert opinion only
E/B = moderate recommendation based on expert opinion only
E/C = weak recommendation based on expert opinion only
E/D = negative recommendation based on expert opinion only
Net Benefit
Substantial = There is evidence of benefit that clearly exceeds the minimum clinically significant benefit and evidence of little harm
Intermediate = Clear evidence of benefit but with some evidence of harms, with a net benefit between that defined for "substantial" and "small/weak"
Small/weak = There is evidence of a benefit that may not clearly exceed the minimum clinically significant benefit, or there is evidence of harms that substantially reduce (but do not eliminate) the benefit such that it may not clearly exceed the minimum clinically significant benefit
None = Evidence shows that either there is no benefit or the benefits equal the harms
Conflicting = Evidence is inconsistent with regard to benefits and/or harms such that the net benefit is uncertain
Negative = Expected harms exceed the expected benefits to the population
Table: Relationship of Strength of the Recommendations Scale to Quality of Evidence and Net Benefits
|
Net Benefit |
Quality of Evidence |
Substantial |
Intermediate |
Small/Weak |
None |
Conflicting |
Negative |
Good |
A |
A |
B |
D |
I |
D |
Fair |
A |
B |
C |
D |
I |
D |
Low |
B |
B |
C |
I |
I |
D |
Expert Opinion |
E/A |
E/B |
E/C |
I |
I |
E/D |