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Spanish Guidelines on Treatment of Bronchiectasis in AdultsNormativa sobre el tratamiento de las bronquiectasias en el adulto,☆☆

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Abstract

In 2008, the Spanish Society of Pulmonology (SEPAR) published the first guidelines in the world on the diagnosis and treatment of bronchiectasis. Almost 10 years later, considerable scientific advances have been made in both the treatment and the evaluation and diagnosis of this disease, and the original guidelines have been updated to include the latest therapies available for bronchiectasis. These new recommendations have been drafted following a strict methodological process designed to ensure quality of content, and are linked to a large amount of online information that includes a wealth of references. The guidelines are focused on the treatment of bronchiectasis from both a multidisciplinary perspective, including specialty areas and the different healthcare levels involved, and a multidimensional perspective, including a comprehensive overview of the specific aspects of the disease. A series of recommendations have been drawn up, based on an in-depth review of the evidence for treatment of the underlying etiology, the bronchial infection in its different forms of presentation using existing therapies, bronchial inflammation, and airflow obstruction. Nutritional aspects, management of secretions, muscle training, management of complications and comorbidities, infection prophylaxis, patient education, home care, surgery, exacerbations, and patient follow-up are addressed.

Resumen

En 2008, la Sociedad Española de Neumología y Cirugía Torácica (SEPAR) publicó las primeras normativas del mundo sobre el diagnóstico y tratamiento de las bronquiectasias. Tras casi una década, muchos han sido los avances científicos en esta enfermedad, tanto en sus aspectos terapéuticos como en su valoración y diagnóstico. Por ello estas nuevas normativas sobre el tratamiento de las bronquiectasias en el adulto tratan de ofrecer al lector una actualización del conocimiento científico sobre las posibilidades terapéuticas en bronquiectasias, basándose en un estricto procedimiento metodológico que asegura la calidad del contenido de la misma, y en una amplia cantidad de información online que incluye abundante bibliografía. En estas normativas se ha enfocado el tratamiento de las bronquiectasias desde un punto de vista tanto multidisciplinar, que implica las especialidades y escalones asistenciales involucrados, como multidimensional que incluye todos y cada uno de los aspectos que definen a la enfermedad. Así, se establecen recomendaciones basadas en una exhaustiva revisión de la evidencia sobre los tratamientos de la etiología, de la infección bronquial en sus diferentes formas de presentación y con las diferentes terapias existentes, de la inflamación bronquial y de la obstrucción al flujo aéreo. Se revisan los aspectos nutricionales, el manejo de las secreciones, el entrenamiento muscular, el manejo de las complicaciones y comorbilidades, la profilaxis de la infección, los aspectos educacionales, el manejo del paciente en el domicilio, el tratamiento quirúrgico, las agudizaciones y el seguimiento de los pacientes.

Introduction

Non-cystic fibrosis (CF) bronchiectasis (hereinafter, bronchiectasis [BE]) is the third most common chronic inflammatory disease of the airways after asthma and chronic obstructive pulmonary disease (COPD), and is closely related to both. In 2008, the Spanish Society of Pulmonology and Thoracic Surgery (SEPAR) became the first scientific society to establish guidelines on the diagnosis and treatment of BE, including CF.1 More than 8 years later, the scientific evidence on BE has become clearer on a number of major issues, and the findings of recent studies have compelled us to publish these new guidelines, which, in order to provide the reader with more specific information, will focus solely on BE in adults. This section concerns the treatment of BE. The guidelines have been prepared with the advice of an expert in methodology. A Delphi system was used to create the list of topics, prioritizing the clinical questions (Annex 1); key clinical questions were structured according to the PICO (Patient-Intervention-Comparison-Outcome) system, and appear as an annex at the end of the manuscript (Annex 3). Finally, the certainty of the evidence and the strength of the recommendations were established following the Grades of Recommendation Assessment, Development and Evaluation (GRADE) system (Annexes 1 and 2).

Section snippets

Treatment of the Etiology

It is important to identify BE etiologies that have specific treatment, in order to start therapy as soon as possible to control symptoms and prevent progression of lung damage (Table 1). Treatment of the underlying disease should be reviewed at each clinical assessment.1

Antibiotic Treatment of the Initial Bronchial Infection

An association has been shown between chronic bronchial Pseudomonas aeruginosa (P. aeruginosa) infection and poorer prognosis in patients with BE.2, 3, 4, 5 Based mainly on the benefit of P. aeruginosa eradication in CF,

Definition

Exacerbation is defined as an acute sustained clinical deterioration characterized by an increase in the usual cough and changes in the sputum characteristics consisting of increased purulence, volume or viscosity, which may be accompanied by an increase in dyspnea, fever, asthenia, poor general condition, anorexia, pleuritic chest pain, hemoptysis, changes in the respiratory examination, changes in the patient's usual treatment or a significant decline in lung function.

The frequency and

Care Levels

BE is a disease that requires multidisciplinary management, so all care levels should be involved.

Primary care: clinical suspicion, differential diagnosis with other airway diseases, referral to specialists for diagnosis and etiological study, prioritization of referral, monitoring of the non-severe, stable patient, and monitoring of mild–moderate exacerbations as well as mild treatment side effects.

Nursing: control of treatment adherence, assessment of tolerance, education in the use of

Follow-Up

The frequency and intensity of follow-up of patients with BE depends on their initial severity, disease progression, their follow-up center, and the healthcare resources available. Table 9 shows the recommended timing of visits and tests. In general, patients who are monitored in specialized BE clinics or units should been seen at least once every 6–12 months. More severe or unstable patients are advised to attend once every 1–3 months, with clinical and microbiological study performed at all

Conflict of Interests

Miguel Ángel Martínez has participated in training sessions sponsored by Gilead, Novartis, Glaxo, Praxis, Teva and Zambon. He has also been the principal investigator in projects funded by Praxis and Zambon, and has participated in meetings analyzing clinical trial outcomes organized by Bayer and Grifols.

Luis Máiz has participated in training sessions sponsored by Gilead, Novartis, Zambon and Praxis.

Casilda Olveira has participated in training activities or expert committees sponsored by

Acknowledgements

David Rigau. Iberoamerican Cochrane Center. Barcelona. Spain. [email protected].

Gabriel Olveira. Endocrinology and Nutrition Service, Nutrition Unit, Regional University Málaga Hospital, CIBERDEM, CIBER of Diabetes and Associated Metabolic Diseases (Instituto de Salud Carlos III), Madrid, Spain. e-mail: [email protected].

Radiology: M.a Isabel Marco Galve. Department of Radiology. Hospital de Alta Resolución de Benalmádena (E.P. Hospital Costa del Sol). Málaga. [email protected]

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  • Cited by (0)

    Please cite this article as: Martínez-García MÁ, Máiz L, Olveira C, Girón RM, de la Rosa D, Blanco M, et al. Normativa sobre el tratamiento de las bronquiectasias en el adulto. Arch Bronconeumol. 2018;54:88–98.

    ☆☆

    Annex 4 online contains an extensive set of literature references for each of the points discussed in these guidelines.

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