Bronchiectasis, Airway and Lung Infection, Chronic Cough CE/CME ACCREDITED Watch Time: 32 mins

touchPANEL DISCUSSION Current and future best practice for the management of non-cystic fibrosis bronchiectasis

Experts discuss best practice management options for patients with non-cystic fibrosis bronchiectasis.

Dr Charles Daley

National Jewish Health, Denver, CO, USA

CHAIR

Panelists:
Prof. Stefano Aliberti, Dr Anne O’Donnell
 
Video Chapters
Introduction

Chair, Dr Charles Daley, introduces the expert panel and agenda for this discussion on best practice management of non-cystic fibrosis bronchiectasis.

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Disease prevalence and risk factors for acute exacerbations

The panel discuss the prevalence of non-cystic fibrosis bronchiectasis and the burden of disease, including key signs and symptoms, and the impact of acute exacerbations on the quality of life of patients with non-cystic fibrosis bronchiectasis.

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2/4 Next Chapter
 
Management of chronic infection

The panel consider treatment options for chronic infections in patients with non-cystic fibrosis bronchiectasis and discuss the role of eradication protocols in managing chronic infections.

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3/4 Next Chapter
 
Available and emerging pharmacotherapeutic strategies

The panel share their insights on how to select the optimum treatment for patients with non-cystic fibrosis bronchiectasis and consider potential future treatments.

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Learning Objectives & Overview
Overview

In this activity, the expert panel discuss three clinical themes covering the disease prevalence and risk factors for acute exacerbations, the management of chronic infection, and available and emerging pharmacotherapeutic strategies to optimize the management of patients with non-cystic fibrosis bronchiectasis.

This activity is jointly provided by USF Health and touchIME. read more

Target Audience

This activity has been designed to meet the educational needs of respiratory care specialists and respiratory paediatricians involved in the management of patients with non-cystic fibrosis bronchiectasis.

Disclosures

USF Health adheres to the Standards for Integrity and Independence in Accredited Continuing Education.
All individuals in a position to influence content have disclosed to USF Health any financial relationship with an ineligible organization. USF Health has reviewed and mitigated all relevant financial relationships related to the content of the activity. The relevant relationships are listed below. All individuals not listed have no relevant financial relationships.

Faculty

Dr Charles Daley discloses: Advisory board or panel fees from AN2 Therapeutics, AstraZeneca, Insmed, Matinas, Paratek, Pfizer, Renovion and Spero. Consultancy fees from AN2 Therapeutics, Genentech, Paratek and Renovion. Grants/research support from AN2 Therapeutics, Bugworks, Insmed, Paratek and Renovion.

Prof. Stefano Aliberti discloses: Advisory board or panel fees from AstraZeneca UK Ltd (relationship terminated), Insmed, and Insmed Italy Srl (relationship terminated). Consultancy fees from Grifols Shared Services North America Inc., Fondazione Internazionale Menarini, Insmed Ireland Ltd, Insmed Italy Srl and Zambon Spa (relationships terminated with all companies). Grants/research support from Fisher & Paykel and Insmed. Speaker’s bureau fees from CSL Behring GmbH, GlaxoSmithKline SpA and Insmed Italy Srl (relationships terminated with all companies).

Dr Anne O’Donnell discloses: Advisory board or panel fees from AstraZeneca, Boehringer Ingelheim, Electromed, Insmed, Paratek, Xellia (relationship terminated) and Zambon. Grants/research support from AstraZeneca, Insmed, Paratek, Redhill Biopharma and Zambon.

Content reviewer

Dr Debabrata Bandyopadhya, MBBS, MD, FRCP, FACP, FCCP has no financial interests/relationships or affiliations in relation to this activity.

Touch Medical Director

Katrina Lester and Hannah Fisher have no financial interests/relationships or affiliations in relation to this activity.

USF Health Office of Continuing Professional Development and touchIME staff have no financial interests/relationships or affiliations in relation to this activity.

Requirements for Successful Completion

In order to receive credit for this activity, participants must review the content and complete the post-test and evaluation form. Statements of credit are awarded upon successful completion of the post-test and evaluation form.

If you have questions regarding credit please contact cpdsupport@usf.edu.

Accreditations

Physicians

This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through a joint providership of USF Health and touchIME. USF Health is accredited by the ACCME to provide continuing medical education for physicians.

USF Health designates this enduring material for a maximum of 0.75 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

The European Union of Medical Specialists (UEMS) – European Accreditation Council for Continuing Medical Education (EACCME) has an agreement of mutual recognition of continuing medical education (CME) credit with the American Medical Association (AMA). European physicians interested in converting AMA PRA Category 1 Credit™ into European CME credit (ECMEC) should contact the UEMS (www.uems.eu).

Advanced Practice Providers

Physician Assistants may claim a maximum of 0.75 Category 1 credit for completing this activity. NCCPA accepts AMA PRA Category 1 Credit™ from organizations accredited by ACCME or a recognized state medical society.

The AANPCP accepts certificates of participation for educational activities approved for AMA PRA Category 1 Credit™ by ACCME-accredited providers. APRNs who participate will receive a certificate of completion commensurate with the extent of their participation.

Date of original release: 24 May 2022. Date credits expire: 24 May 2023.

If you have any questions regarding credit please contact cpdsupport@usf.edu.

Learning Objectives

After watching this activity, participants should be better able to:

  • Review the incidence, causes and risk factors for non-cystic fibrosis bronchiectasis
  • Discuss eradication protocols for infection in patients with non-cystic fibrosis bronchiectasis
  • Evaluate available and emerging pharmacotherapeutic treatments for non-cystic fibrosis bronchiectasis
Faculty & Disclosures
Dr Charles Daley

National Jewish Health and University of Colorado, Denver, CO, USA
Icahn School of Medicine at Mount Sinai, New York, NY, USA

Charles Daley is chief of the Division of Mycobacterial and Respiratory Infections at National Jewish Health (NJH) and professor of medicine at NJH, the University of Colorado, and Icahn School of Medicine at Mount Sinai. read more

Dr Daley has served on and chaired expert panels for the World Health Organization, Centers for Disease Control and Prevention, Infectious Diseases Society of America and American Thoracic Society. He has participated in multiple guideline panels for these organizations. He recently chaired the revision of the multi-society sponsored Non-tuberculous Mycobacterial Pulmonary Disease Treatment Guideline.

Dr Daley was awarded the World Lung Health Award by the American Thoracic Society for his work in multidrug-resistant tuberculosis. Dr Daley served as the inaugural chair of the Bronchiectasis Research Registry. He was previously associate editor of the American Journal of Respiratory and Critical Care Medicine and is currently associate editor of the European Respiratory Journal. His academic interests include tuberculosis global health policy and clinical and translational research related to tuberculosis, non-tuberculous mycobacterial infections and bronchiectasis.

Dr Charles Daley discloses: Advisory board or panel fees from AN2 Therapeutics, AstraZeneca, Insmed, Matinas, Paratek, Pfizer, Renovion and Spero. Consultancy fees from AN2 Therapeutics, Genentech, Paratek and Renovion. Grants/research support from AN2 Therapeutics, Bugworks, Insmed, Paratek and Renovion.

Prof. Stefano Aliberti

Humanitas University and Humanitas Research Hospital, Milan, Italy

Stefano Aliberti is professor of respiratory medicine at Humanitas University and director of the Respiratory Department at the Humanitas Research Hospital in Milan, Italy. He is also leading the bronchiectasis and non-tuberculous mycobacteria programmes at the Humanitas Research Hospital. read more

Prof. Aliberti has extensive experience in epidemiological and clinical research in pneumonia since the early 2000s when he was working for the Community-Acquired Pneumonia Organization at the Division of Infectious Diseases at the University of Louisville, KY, USA. 

Over the past 15 years, Prof. Aliberti has been heavily involved in chronic respiratory infection research, including bronchiectasis and non-tuberculous mycobacteria, and received the Young Researcher Award in Respiratory Infections from the European Respiratory Society (ERS) for his contribution to community-acquired pneumonia. He founded the European Bronchiectasis Registry and is the chair of both the Italian Bronchiectasis Registry and the Italian Registry of Pulmonary Non-Tuberculous Mycobacteria. He is also chair of the ERS END-COVID clinical research collaboration. Prof. Aliberti has been an active member in different international societies over the past decade, including ERS, American College of Chest Physicians and the European Cystic Fibrosis Society. Prof. Aliberti has been involved in the development of guidelines on bronchiectasis, COVID-19 and severe pneumonia, as well as statements on tuberculosis. He is also associate editor (chest infections) for CHEST

Prof. Aliberti’s major clinical and research interests are in both acute and chronic respiratory infections.

Prof. Stefano Aliberti discloses: Advisory board or panel fees from AstraZeneca UK Ltd (relationship terminated), Insmed, and Insmed Italy Srl (relationship terminated). Consultancy fees from Grifols Shared Services North America Inc., Fondazione Internazionale Menarini, Insmed Ireland Ltd, Insmed Italy Srl and Zambon Spa (relationships terminated with all companies). Grants/research support from Fisher & Paykel and Insmed. Speaker’s bureau fees from CSL Behring GmbH, GlaxoSmithKline SpA and Insmed Italy Srl (relationships terminated with all companies).

Dr Anne O’Donnell

Georgetown University, Washington, DC, USA

Anne O’Donnell is professor of medicine and the Nehemiah and Naomi Cohen chair in pulmonary disease research at Georgetown University Medical Center, Washington DC, USA. She is also the chief, Division of Pulmonary, Critical Care and Sleep Medicine. read more

Dr O’Donnell is board certified in pulmonary medicine, critical care, sleep medicine and internal medicine. Her clinical and research activities focus on the care of patients with non-cystic fibrosis bronchiectasis and related infections. She has a long track record of publications and leadership in clinical trials for bronchiectasis and associated infections.

Dr Anne O’Donnell discloses: Advisory board or panel fees from AstraZeneca, Boehringer Ingelheim, Electromed, Insmed, Paratek, Xellia (relationship terminated) and Zambon. Grants/research support from AstraZeneca, Insmed, Paratek, Redhill Biopharma and Zambon.

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Question 1/5
Considering the EMBARC/BRR definitions working group consensus definition of non-CF bronchiectasis, how would you define a pulmonary exacerbation in your adult patient with non-CF bronchiectasis?

BRR, Bronchiectasis Research Registry; CF, cystic fibrosis; EMBARC, European Multicentre Bronchiectasis Research Collaboration.
Correct

Following a systematic review of exacerbation definitions used in clinical trials of adults with non-CF bronchiectasis from January 2000 to December 2015, and a Delphi process, the EMBARC/BRR definitions working group unanimously approved the definition of a pulmonary exacerbation in adults with clinically significant non-CF bronchiectasis as deterioration of at least three symptoms for ≥48 hours. These symptoms include cough, sputum volume and/or consistency, sputum purulence, breathlessness and/or exercise tolerance, fatigue and/or malaise, and haemoptysis.1  

Abbreviations

BRR, Bronchiectasis Research Registry; CF, cystic fibrosis; EMBARC, European Multicentre Bronchiectasis Research Collaboration.

Reference

  1. Hill AT, et al. Eur Respir J. 2017;49:1700051.
Question 2/5
According to the ERS guidelines for the management of adult patients with non-CF bronchiectasis, eradication treatment should be offered following infection with a new isolate of which potentially pathogenic microorganism?

CF, cystic fibrosis; ERS, European Respiratory Society.
Correct

The ERS guidelines for the management of adult patients with non-CF bronchiectasis suggest eradication antibiotic treatment should be offered for patients with bronchiectasis and a new isolation of Pseudomonas aeruginosa (conditional recommendation, very low quality of evidence).1

There are no therapies licensed for use in this condition, and agents for eradication are used off-label.2 The ERS does not suggest offering eradication treatment for any other pathogen (conditional recommendation, very low quality of evidence).1 

Abbreviations

CF, cystic fibrosis; ERS, European Respiratory Society.

References

  1. Polverino E, et al. Eur Respir J. 2017;50:1700629.
  2. European Respiratory Society. European Lung White Book. Available at: www.erswhitebook.org/chapters/bronchiectasis/ (accessed 13 April 2022).
Question 3/5
When treating your patient with non-CF bronchiectasis, how would you define chronic infection with a pathogenic microorganism?

CF, cystic fibrosis.
Correct

SEPAR and the euroCareCF Working Group provide a general definition of chronic infection with a pathogenic organism in patients with non-CF bronchiectasis as two or more consecutive positive cultures or >50% of cultures positive for the same pathogen within 6–12 months, in samples taken at least 1 month apart.1–3

Abbreviations

CF, cystic fibrosis; SEPAR, Spanish Society of Pneumology and Thoracic Surgery.

References

  1. Di Pasquale M, et al. Expert Opin Pharmacother. 2020;21:1975–90.
  2. Martínez-García MÁ, et al. Arch Bronconeumol (Enlg Ed). 2018;54:88–98.
  3. Pressler T, et al. J Cyst Fibros. 2011;10(Suppl. 2):S75–8.
Question 4/5
Your adult patient has been diagnosed with non-CF bronchiectasis. Subsequent sputum analysis of this patient conducted every 2 months over the course of 6 months found three consecutive cultures positive for Pseudomonas aeruginosa. Which of the following treatment options would you consider for this patient?

CF, cystic fibrosis; rhDNase, recombinant human deoxyribonuclease.
Correct

Nebulized saline solution is a tolerable and effective mucolytic agent for the treatment of chronic infection with Pseudomonas aeruginosa in patients with non-CF bronchiectasis.1 A meta-analysis of seven studies reported that there is insufficient evidence to support the routine use of inhaled corticosteroids in adults with non-CF bronchiectasis.2 There are currently no trials that support the use of acetylcysteine in patients with non-CF bronchiectasis.3 While rhDNase demonstrated improvements in lung function and decreased frequency of exacerbations in patients with CF in clinical trials, in patients with non-CF bronchiectasis, inhaled rhDNase treatment resulted in more frequent exacerbations and hospitalizations and is, therefore, not recommended.4

Abbreviations

CF, cystic fibrosis; rhDNase, recombinant human deoxyribonuclease.

References

  1. Nicolson CH, et al. Respir Med. 2012;106:661–7. 
  2. Kapur N, et al. Cochrane Database Syst Rev. 2018;5:CD000996.
  3. Tarrant BJ, et al. Respirology. 2017;22:1084–92.
  4. O’Donnell AE, et al. Chest. 1998;113:1329–34.
Question 5/5
Your adult patient was diagnosed with non-CF bronchiectasis and started on a self-management plan, airway clearance and prompt antibiotic treatment for exacerbations. Despite the regimen they still suffered three exacerbations per year and progressed to receive regular chest physiotherapy. They have suffered four exacerbations in the past 12 months and were recently found to have Haemophilus influenzae colonisation. According to the BTS guidelines, how would you further manage this patient?

BTS, British Thoracic Society; CF, cystic fibrosis.
Correct

The BTS guidelines recommend that patients with non-CF bronchiectasis who are only receiving chest physiotherapy and who suffer three or more exacerbations per year should receive long-term azithromycin or erythromycin as a first-line antimicrobial therapy. Other treatment options include long-term oral or inhaled targeted antibiotics.1

Abbreviations

BTS, British Thoracic Society; CF, cystic fibrosis.

Reference

  1. Hill AT, et al. Thorax. 2019;74:1–69.
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