Professor Yuanlin Song
Head of Department of Pulmonary and Critical Care Medicine, Zhongshan Hospital, Fudan University
Distinguished Professor appointed by Shanghai Municipal Education Commission and PhD Supervisor, Fudan University
Deputy Head of Shanghai Research Institute of Respiratory Diseases
Executive Member of the Chinese Thoracic Society, Chinese Medical Association
President-elect,  Shanghai Thoracic Society
Head of the Respiratory Infectious Disease Assembly, Asian Pacific Society of Respirology

Bronchiectasis is a common disease in China. The first Expert Consensus on Adult Bronchiectasis was written by Professor He Quanying’s team in 2012 – since then, there has been more emphasis on the diagnosis and management of this disease. More researches and literatures with clinical significance have been published over the past nine years. Professor Yuanlin Song from Zhongshan Hospital, Fudan University shared the latest updates on the Expert Consensus, as well as the clinical use of sitafloxacin – a new generation fluoroquinolone.

Q1. As one of the members of the updated Expert Consensus on Diagnosis and Treatment of Adult Bronchiectasis, could you provide us with a brief background on the updated edition, and the key differences between this and the previous edition?

The first edition of the Expert Consensus on Diagnosis and Treatment of Adult Bronchiectasis was published in 2012. Bronchiectasis has gained greater attention with the four consecutive annual national bronchiectasis conference held. Professor Qu Jieming has taken the lead to set up the China Bronchiectasis Alliance, and we have obtained numerous evidence-based medical research and data – contributed by various experts in the field. As such, we thought that it was appropriate to review these data in the updated edition of the Expert Consensus. We also intend to provide supplementary data to refine specific guidelines. Briefly, the updated Expert Consensus has expanded upon its content and format – providing more comprehensive and systematic information on the epidemiology, pathogenesis, aetiology, clinical and differential diagnosis, treatment, management, and patient education of bronchiectasis in China.

1) More researches and literatures have been published on the epidemiology and risk factors of bronchiectasis in China over the past few years. Epidemiological surveys have been conducted in Shandong, Guangdong, Shanghai, and other provinces. Supplementary aetiological data has also  provided reliable insights into the epidemiology of the condition; and helped in the better understanding of infection, tuberculosis, and other key risk factors of bronchiectasis in China.

2) In terms of diagnosis, we rely on radiology to diagnose bronchiectasis. To date, the most common diagnosis tool is a high-resolution computed tomography (HRCT) of the chest. More specifically, a thin-section CT scan with a slice thickness ≤1mm has a great significance in the diagnosis of bronchiectasis. The imaging also helps the identification of any underlying causes of bronchiectasis, such as airway blockages.

3) In terms of treatment evaluation, we have introduced relevant scoring systems for bronchiectasis (Reiff score, BSI, E-FACED, etc) from the European Respiratory Society guidelines. Besides regular laboratory tests, we have also included molecular diagnostics. These diagnostic tools have provided better accuracy compared to previous methods. Besides regular treatment options, we have also added clear recommendations for each treatment plan (including comorbidities and complications) that are rooted in evidence-based medicine. This includes supplementary information on the standardisation of treatment for comorbidities like Pseudomonas aeruginosa infections and nontuberculous mycobacterial (NTM) lung diseases, as well as in antibotics selection. These revisions have improved the overall treatment efficacy.

The updated Expert Consensus now covers the management of bronchiectasis, which is significant for the patients. Bronchiectasis is a chronic respiratory disease which requires long-term management. Clinicians should monitor their patients’ condition and evaluate the efficacy of treatment regularly, making appropriate adjustments based on the severity index guidelines so that patients can maintain their control over the condition.

Q2. Frequent acute exacerbations lead to poor quality of life. The consequences of exacerbated symptoms on a daily basis are decreased lung function and increased mortality. Therefore, it is imperative and necessary to determine the periods of acute exacerbation accurately. What are some of the key considerations when treating patients with acute exacerbated bronchiectasis?

When treating bronchiectasis, it is pertinent to treat the underlying causes to slow development and reduce the chances of acute exacerbation. We would also want to reduce the severity of symptoms while maintaining or improving lung function, which will help to improve the patient’s quality of life. There are two key considerations to acute exacerbation of bronchiectasis. Firstly, early detection and diagnosis so that appropriate antibiotics can be prescribed in a timely manner to treat the infection. It is crucial to identify typical early signs of acute exacerbation, such as increase in yellow sputum, breathing difficulties, hypoxaemia, and fever, so that timely treatment can be provided. A comprehensive treatment plan is crucial to keep the infection in control. Poor infection control may result in recurrent acute exacerbations that will trigger deterioration of the lung function and respiratory failure, increasing the probability of a serious infection. Furthermore, long-term antibiotic use may lead to drug resistance. Early identification of the causative pathogen and use of appropriate antibiotics is crucial for patients suffering from acute exacerbated bronchiectasis. Secondly, it is necessary to treat comorbidities and complications. Bronchiectasis patients are at a higher risk of requiring critical care compared with other respiratory diseases. Prompt treatment is required when the patient experience coughing up of blood, respiratory failure, pulmonary hypertension and other comorbidities or complications.

Q3. The updated Expert Consensus also discusses the effects of the fluoroquinolone sitafloxacin against P. aeruginosa. Whatyou’re your suggestions pertaining to the clinical use of this new drug?

Around 20% of non-CF bronchiectasis patients experience P. aeruginosa colonisation and infection. The bacterium has a significant impact on the severity and prognosis of bronchiectasis. The guidelines for acute exacerbation suggest using ciprofloxacin to eradicate the presence of P. aeruginosa. Sitafloxacin is effective against P. aeruginosa activity. Furthermore, sitofloxacin has a lower minimum inhibitory concentration (MIC) which makes it a safer choice. It can be considered for use in treating acute exacerbation of bronchiectasis, or de-escalation therapy and combination therapy.

References:

1. Authorial team of Expert Consensus on diagnosis and treatment of adult bronchiectasis. Chinese Journal of Tuberculosis and Respiratory Diseases. 2021; 44(4):311-319
2. Authorial team of Expert Consensus on diagnosis and treatment of adult bronchiectasis. Chinese Journal of Tuberculosis and Respiratory Diseases. 2012; 35(7):485-492.
3. Gao Yonghua, et al. Chinese Journal of Tuberculosis and Respiratory Diseases. 2019; 42(4):254-261.
4. Ikeda K, et al. BMC Ear Nose Throat Disord. 2015; 15:5.