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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/advagg_css\/css__ce2QY63WIanKyr8eSq7eavr1XQRRmFD6ZSmwpyJi8lM__zXwFqpqmxrZOXXcd_TpBQpjuELbmIP9wBR5UuTDWAO4__YJWWMMdfCJuAFm5cUEp88OsodhO3ZA-2lzRfoBsSlk4.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n            \u003Cp id=\u0022p-1\u0022\u003ERecommended diagnostic protocols of bronchiectasis assume that patients are alike, which can be questioned, especially when many tests are recommended for diagnosis. Evaluation is influenced by factors including age, disease severity and character, and the resources available to perform the diagnostic tests. This article discusses the systematic evaluation of these patients and treatment strategies for non-CF bronchiectasis.\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003ELower Respiratory Infections\u003C\/li\u003E\u003C\/ul\u003E\u003Cul class=\u0022kwd-group clinical-trial\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003EPulmonary \u0026amp; Respiratory Medicine\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ELower Respiratory Infections\u003C\/li\u003E\u003C\/ul\u003E\u003Cp id=\u0022p-2\u0022\u003EMark Metersky, MD, University of Connecticut School of Medicine, Farmington, Connecticut, USA, discussed the systematic evaluation of patients with bronchiectasis. Recommended diagnostic protocols assume that patients are alike, which can be questioned, especially when many tests are recommended for diagnosis. Evaluation is influenced by factors including age, disease severity and character, and the resources available to perform the diagnostic tests.\u003C\/p\u003E\u003Cp id=\u0022p-3\u0022\u003EThe list of reported etiologies of bronchiectasis is long, and the cause is unknown in about 50% of patients. Infections are a relatively frequently identified cause [Quast TM et al. \u003Cem\u003EDis Mon.\u003C\/em\u003E 2008] and include allergic bronchopulmonary aspergillosis and \u003Cem\u003EMycobacterium avium\u003C\/em\u003E complex. Idiopathic causes may include an unrecalled previous infection, or deficiencies in heterozygote \u03b1-1 antitrypsin or immunoglobulin G subclass; other causes are listed in \u003Ca id=\u0022xref-table-wrap-1-1\u0022 class=\u0022xref-table\u0022 href=\u0022#T1\u0022\u003ETable 1\u003C\/a\u003E.\u003C\/p\u003E\u003Cdiv id=\u0022T1\u0022 class=\u0022table pos-float\u0022\u003E\u003Cdiv class=\u0022table-inline\u0022\u003E\u003Cdiv class=\u0022callout\u0022\u003E\u003Cspan\u003EView this table:\u003C\/span\u003E\u003Cul class=\u0022callout-links\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022\/\u0022 class=\u0022table-expand-inline\u0022 data-table-url=\u0022\/highwire\/markup\/15515\/expansion?postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0026amp;table-expand-inline=1\u0022 html=\u00221\u0022 fragment=\u0022#\u0022 external=\u00221\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView inline\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022\/highwire\/markup\/15515\/expansion?width=1000\u0026amp;height=500\u0026amp;iframe=true\u0026amp;postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media\u0022 class=\u0022colorbox colorbox-load table-expand-popup\u0022 rel=\u0022gallery-fragment-tables\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView popup\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/15515\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cdiv class=\u0022table-caption\u0022\u003E\u003Cspan class=\u0022table-label\u0022\u003ETable 1.\u003C\/span\u003E \n            \u003Cp id=\u0022p-4\u0022 class=\u0022first-child\u0022\u003ECauses of Idiopathic Bronchiectasis\u003C\/p\u003E\n         \u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-6\u0022\u003EDetermining the etiology, however challenging, can help patients understand their condition, which can be valuable in genetic counseling. A definitive diagnosis can also guide therapy [Pasteur MC et al. \u003Cem\u003EAm J Respir Crit Care Med.\u003C\/em\u003E 2000; Shoemark A et al. \u003Cem\u003ERespir Med.\u003C\/em\u003E 2007]. Imaging can be useful in diagnosis.\u003C\/p\u003E\u003Cp id=\u0022p-7\u0022\u003EPatient characteristics of note include age, with younger patients being more likely to have a congenital cause; previous severe infection; autoimmune disease; paranasal sinus diseases; and fertility issues.\u003C\/p\u003E\u003Cp id=\u0022p-8\u0022\u003ERecommended tests for all patients include high-resolution computed tomography; pulmonary function; examination of sputum for bacteria, acid-fast bacilli, and fungus; blood count; and quantification of immunoglobulin classes [Metersky ML. \u003Cem\u003EClin Chest Med.\u003C\/em\u003E 2012]. In the absence of an etiology, determination of \u03b1-1 antitrypsin and screening for CF are prudent courses. The relationship of \u03b1-1 antitrypsin deficiency with bronchiectasis is contentious. Whereas some studies have not reported increased prevalence of \u03b1-1 antitrypsin deficiency in patients with bronchiectasis, a study of 74 patients with the deficiency reported bronchiectasis in 70 [Parr DG et al. \u003Cem\u003EAm J Respir Crit Care Med.\u003C\/em\u003E 2007]. Newly identified patients with bronchiectasis should be evaluated using a selection of tests.\u003C\/p\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-1\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003ECURRENT TREATMENT OPTIONS FOR NON-CYSTIC FIBROSIS BRONCHIECTASIS\u003C\/h2\u003E\n         \u003Cp id=\u0022p-9\u0022\u003EAshwin Basavaraj, MD, New York University Langone Medical Center, New York, New York, USA, discussed treatment strategies for non-CF bronchiectasis, starting with the vicious cycle hypothesis (\u003Ca id=\u0022xref-fig-1-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F1\u0022\u003EFigure 1\u003C\/a\u003E).\u003C\/p\u003E\n         \u003Cdiv id=\u0022F1\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/45\/21\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022The Vicious Cycle of Bronchiectasis\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-1483283710\u0022 data-figure-caption=\u0022The Vicious Cycle of Bronchiectasis\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 1.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/45\/21\/F1.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/45\/21\/F1.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 1.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/45\/21\/F1.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/15514\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 1.\u003C\/span\u003E \n               \u003Cp id=\u0022p-10\u0022 class=\u0022first-child\u0022\u003EThe Vicious Cycle of Bronchiectasis\u003C\/p\u003E\n            \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-1\u0022\u003EReprinted with permission of the American Thoracic Society. Copyright \u00a9 2014 American Thoracic Society. McShane PJ et al. Non-Cystic Fibrosis Bronchiectasis. \u003Cem\u003EAm J Respir Crit Care Med.\u003C\/em\u003E 2013;188:647\u2013656. Official Journal of the American Thoracic Society.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n         \u003Cp id=\u0022p-11\u0022\u003EAirway clearance options include physiotherapy (high-frequency chest wall oscillation, positive expiratory pressure, posture-related drainage, and manual manipulation of the chest) and use of inhaled hypertonic saline or mannitol. These approaches appear safe in those with stable bronchiectasis, although their roles in cases of acute exacerbations are unclear, and the relative merits of each airway clearance option need to be explored [Lee AL et al. \u003Cem\u003ECochrane Database Syst Rev.\u003C\/em\u003E 2013].\u003C\/p\u003E\n         \u003Cp id=\u0022p-12\u0022\u003EThe use of inhaled mannitol to hydrate the mucus and promote its clearance has been explored in several randomized trials. One reported reduced plugging of small airways by mucus in mannitol-treated patients, although there were no differences in quality of life (QOL), exercise capacity, spirometry, inflammatory markers, or bacterial load between the treated and placebo arms [Bilton D et al. \u003Cem\u003EChest\u003C\/em\u003E. 2013]. In another study, no difference in annual rate of exacerbations was evident in patients who inhaled 400 mg (n = 233) or 50 mg (n = 228) of mannitol twice daily for 52 weeks, although the higher dose was associated with significant improvements in time to first exacerbation and QOL [Bilton D et al. \u003Cem\u003EThorax\u003C\/em\u003E. 2014].\u003C\/p\u003E\n         \u003Cp id=\u0022p-13\u0022\u003EPulmonary rehabilitation can aid in airway clearance, providing short-term improvement in exercise capacity and QOL; whether the benefits persist is unclear [Lee AL et al. \u003Cem\u003ERespir Res.\u003C\/em\u003E 2014]. Drug therapies of potential benefit include atorvastatin [Mandal P et al. \u003Cem\u003ELancet Respir Med.\u003C\/em\u003E 2014] and formoterol-budesonide [Martinez-Garcia MA et al. \u003Cem\u003EChest\u003C\/em\u003E. 2012].\u003C\/p\u003E\n         \u003Cp id=\u0022p-14\u0022\u003EThe use of macrolide antibiotics suppresses inflammatory mediators, modifies the production of mucus, and may reduce biofilm formation. The EMBRACE trial [Wong C et al. \u003Cem\u003ELancet\u003C\/em\u003E. 2012] that evaluated the macrolide antibiotic azithromycin reported a benefit in terms of time to first exacerbation, decreased C-reactive protein at 6 months, and increased forced vital capacity at 6 and 12 months. The BLESS trial [Serisier DJ et al. \u003Cem\u003EJAMA\u003C\/em\u003E. 2013] evaluated low-dose erythromycin twice daily for 12 months versus placebo. While the rate of pulmonary exacerbations was decreased, increased macrolide resistance tempered the significance of the findings.\u003C\/p\u003E\n         \u003Cp id=\u0022p-15\u0022\u003EAntibiotics are another option in bronchiectasis treatment. Inhalation is a potentially effective route of delivery [Brodt AM et al. \u003Cem\u003EEur Respir J.\u003C\/em\u003E 2014; Haworth CS et al. \u003Cem\u003EAm J Respir Crit Care Med.\u003C\/em\u003E 2014; Serisier DJ et al. \u003Cem\u003EThorax\u003C\/em\u003E. 2013]. However, in 2 double-blind, randomized, placebo-controlled trials, the delivery of aztreonam via inhalation was not effective [Barker AF et al. \u003Cem\u003ELancet Respir Med.\u003C\/em\u003E 2014].\u003C\/p\u003E\n         \u003Cp id=\u0022p-16\u0022\u003ESurgery, such as lobectomy, pneumonectomy, and segmentectomy, is an option for patients who are nonre-sponsive or intolerant to the aforementioned therapies, and can help resolve complications including recurrent infection, empyema, or hemoptysis [Balci AE et al. \u003Cem\u003EAnn Thorac Surg\u003C\/em\u003E. 2014; Mitchell JD et al. \u003Cem\u003EAnn Thorac Surg\u003C\/em\u003E. 2012]. The results can be improvement of symptoms and QOL.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-2\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003ETREATMENTS ON THE HORIZON FOR NON-CF BRONCHIECTASIS\u003C\/h2\u003E\n         \u003Cp id=\u0022p-17\u0022\u003EAnne O\u0027Donnell, MD, Georgetown University, Washington, DC, USA, provided a look ahead at treatments for non-CF bronchiectasis. Treatment is governed by 4 treatment tenets: Educate patients, understand the disease\u0027s impact, understand the extent of the disease, and target organisms. Goals are to reduce exacerbations, control symptoms, improve QOL, preserve lung function, and reduce mortality.\u003C\/p\u003E\n         \u003Cp id=\u0022p-18\u0022\u003EEssentially, all therapies for non-CF bronchiectasis are new, because none have been approved by the Food and Drug Administration. Treatments target the underlying disease if possible, with the goals of clearing airways, controlling inflammation, and treating exacerbations. Avenues being explored in treating the underlying disease include using CF-targeted drugs like ivacaftor, replacement of \u03b1-1 antitrypsin or immunoglobulin, and addressing vitamin D deficiency. The latter has been linked to bronchiectasis [Chalmers JD et al. \u003Cem\u003EThorax\u003C\/em\u003E. 2013], but Dr O\u0027Donnell noted that no clinical trials were underway.\u003C\/p\u003E\n         \u003Cp id=\u0022p-19\u0022\u003EConcerning anti-inflammatory therapies, the use of macrolides has yielded promising results, although development of resistance is a problem. Inhaled steroids, phosphodiesterase 4 inhibitors, and statins are all potentially beneficial. The neutrophil elastase inhibitor AZD9668 was well tolerated and showed promise in a small phase 2 study in terms of improved lung function and prognostic biomarkers [Stockley R et al. \u003Cem\u003ERespir Med.\u003C\/em\u003E 2013].\u003C\/p\u003E\n         \u003Cp id=\u0022p-20\u0022\u003EAntibiotics delivered intravenously or via inhalation have shown potential in numerous studies, but further, larger studies need to be done. The use of inhaled aztreonam was not found to confer benefit [Barker A et al. \u003Cem\u003EEur Respir J.\u003C\/em\u003E 2013]. Antibiotic therapy targeting \u003Cem\u003EPseudomonas\u003C\/em\u003E [White L et al. \u003Cem\u003ERespir Med.\u003C\/em\u003E 2012] and an intensive course of intravenous antibiotics [Mandal P et al. \u003Cem\u003EQJM\u003C\/em\u003E. 2013] have also shown promise.\u003C\/p\u003E\n         \u003Cp id=\u0022p-21\u0022\u003EThe take-home message of the future of non-CF bronchiectasis therapy is potential, with further studies necessary to proceed toward clinical use.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2014 MD Conference Express\u00ae\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/14\/45\/21.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_figures.js?nzoibq\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzoibq\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_tables.js?nzoibq\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}