Bronchiectasis involves four main physiological factors that are part of a “vicious vortex,” according to a presentation at the CHEST Annual Meeting in Boston, Massachusetts. The four factors are interconnected and contribute to each other, often creating a cycle that leads to exacerbations.
In a presentation titled “Clinical and Patient-Centered Discussions on the Role of Inflammation In Bronchiectasis,” speaker Brian Morrissey, MD, of the University of California, Berkeley, highlighted the four factors:
- Chronic airway infection
- Chronic airway inflammation
- Impaired mucociliary clearance
- Lung destruction
A bronchiectasis exacerbation is defined as worsening of three or more symptoms for at least 48 hours that requires a change in treatment. The symptoms of interest include cough; sputum volume, consistency, or purulence; breathlessness or exercise intolerance; hemoptysis; and fatigue or malaise. “Once they have one exacerbation, two-thirds are going to have another within a year and three-quarters will have another in two years,” Dr. Morrissey said. “And exacerbations are associated with poor outcomes, rapid decline in lung function, increased anxiety, worse symptoms scores, and a 55% increase in all-cause hospitalization.”
Dr. Morrissey emphasized that exacerbations have traditionally been attributed to bacterial and viral infections, but inflammation is increasingly being recognized as important. Inflammation in bronchiectasis can be eosinophilic but is usually neutrophilic. Neutrophils are essential to immune surveillance and protection, but patients with bronchiectasis often have elevated airway neutrophils. Neutrophils release neutrophil elastase (NE), which can contribute to exacerbations and the progression of bronchiectasis. Sputum NE is a marker of neutrophilic airway inflammation in bronchiectasis, and it has been correlated with the time to the next exacerbation and time to the next hospitalization for a severe exacerbation.
There are strategies to manage four of the factors in the “vicious vortex,” such as surgery and pulmonary rehabilitation for lung destruction, antimicrobials for infections, and airway clearance therapies for impaired clearance. However, there are limited treatment options to address inflammation. Dr. Morrissey concluded by encouraging clinicians to monitor patients with bronchiectasis with the four factors in mind.
Reference
Morrissey B. Clinical and patient-centered discussions on the role of inflammation in bronchiectasis (Learning Theater presentation). Presented at the CHEST Annual Meeting; October 6-9, 2024; Boston, Massachusetts.
