The Bronchiectasis Severity Index and FACED score for assessment of the severity of bronchiectasis

Bronchiectasis Severity Index and FACED scores in patients with allergic bronchopulmonary aspergillosis complicating asthma: do they correlate with immunological severity or high-attenuation mucus?

Background: The utility of two disease-severity indices, namely bronchiectasis severity index (BSI) and FACED score in allergic bronchopulmonary aspergillosis (ABPA) remains unknown.Objective: To correlate the BSI and FACED scores with immunological parameters (serum IgE [total and A. fumigatus-specific], A. fumigatus-specific IgG, blood eosinophil count), and high-attenuation mucus on chest computed tomography in ABPA. The secondary objectives were to evaluate the correlation between BSI and FACED scores and correlate the BSI/FACED scores with the bronchiectasis health questionnaire (BHQ) and Saint George's Respiratory Questionnaire (SGRQ).Methods: We included treatment-naïve ABPA subjects with bronchiectasis in a prospective observational study. We computed the BSI and FACED scores for each subject before initiating treatment. The subjects also completed two quality-of-life questionnaires (BHQ and SGRQ).Results: We included 91 subjects. The mean (standard deviation) BSI and FACED scores were 3.43 (3.39) and 1.43 (1.27). We found no correlation between BSI or FACED with any immunological parameter or high-attenuation mucus. There was a strong correlation between BSI and FACED scores (r = 0.76, p < 0.001). We found a weak correlation between BSI and BHQ/SGRQ and FACED and SGRQ.Conclusion: We found no correlation between BSI and FACED with immunological parameters in ABPA. However, we found a significant correlation between BSI and FACED and a weak correlation between SGRQ and BHQ. ABPA likely requires a separate disease-severity scoring system.

Clinical outcomes of long-term inhaled combination therapies in patients with bronchiectasis and airflow obstruction

BACKGROUND AND OBJECTIVES

Few studies have reported which inhaled combination therapy, either bronchodilators and/or inhaled corticosteroids (ICSs), is beneficial in patients with bronchiectasis and airflow obstruction. Our study compared the efficacy and safety among different inhaled combination therapies in patients with bronchiectasis and airflow obstruction.

METHODS

Our retrospective study analyzed the patients with forced expiratory volume in 1 s (FEV1)/forced vital capacity < 0.7 and radiologically confirmed bronchiectasis in chest computed tomography between January 2005 and December 2021. The eligible patients underwent baseline and follow-up spirometric assessments. The primary endpoint was the development of a moderate-to-severe exacerbation. The secondary endpoints were the change in the annual FEV1 and the adverse events. Subgroup analyses were performed according to the blood eosinophil count (BEC).

RESULTS

Among 179 patients, the ICS/long-acting beta-agonist (LABA)/long-acting muscarinic antagonist (LAMA), ICS/LABA, and LABA/LAMA groups were comprised of 58 (32.4%), 52 (29.1%), and 69 (38.5%) patients, respectively. ICS/LABA/LAMA group had a higher severity of bronchiectasis and airflow obstruction, than other groups. In the subgroup with BEC ≥ 300/uL, the risk of moderate-to-severe exacerbation was lower in the ICS/LABA/LAMA group (adjusted HR = 0.137 [95% CI = 0.034-0.553]) and the ICS/LABA group (adjusted HR = 0.196 [95% CI = 0.045-0.861]) compared with the LABA/LAMA group. The annual FEV1 decline rate was significantly worsened in the ICS/LABA group compared to the LABA/LAMA group (adjusted β-coefficient=-197 [95% CI=-307--87]) in the subgroup with BEC < 200/uL.

CONCLUSION

In patients with bronchiectasis and airflow obstruction, the use of ICS/LABA/LAMA and ICS/LABA demonstrated a reduced risk of exacerbation compared to LABA/LAMA therapy in those with BEC ≥ 300/uL. Conversely, for those with BEC < 200/uL, the use of ICS/LABA was associated with an accelerated decline in FEV1 in comparison to LABA/LAMA therapy. Further assessment of BEC is necessary as a potential biomarker for the use of ICS in patients with bronchiectasis and airflow obstruction.

Bronchiectasis

Bronchiectasis is a final common pathway of a wide variety of underlying conditions including infectious, autoimmune, allergic, genetic and inflammatory conditions. Patients experience a chronic disease with variable clinical symptoms and course, but most experience cough, sputum production and recurrent exacerbations. Symptoms of bronchiectasis lead to poor quality of life and exacerbations are the major driver of morbidity and mortality. Patients are often chronically infected with bacteria with the most common being Pseudomonas aeruginosa and Haemophilus influenzae. Treatment of bronchiectasis includes standardised testing to identify the underlying cause with targeted treatment if immune deficiency, allergic bronchopulmonary aspergillosis or non-tuberculous mycobacterial infection, for example, are identified. Airway clearance is the mainstay of therapy for patients with symptoms of cough and sputum production. Frequently exacerbating patients may benefit from long term antibiotic or mucoactive therapies. Bronchiectasis is a heterogeneous disease and increasingly precision medicine approaches are advocated to target treatments most appropriately and to limit the emergence of antimicrobial resistance.

The effect of N-acetylcysteine in patients with non-cystic fibrosis bronchiectasis (NINCFB): study protocol for a multicentre, double-blind, randomised, placebo-controlled trial

Background

N-acetylcysteine (NAC), which is specifically involved in airway mucus clearance and antioxidation, is recommended by the treatment guideline for non-cystic fibrosis bronchiectasis (NCFB). However, there is little clinical evidence of its long-term efficacy concerning quality of life (QoL) and exacerbation in patients with NCFB. In addition, the influences of NAC on airway bacterial colonization, chronic inflammation and oxidative stress in NCFB are also unclear.

Methods

NINCFB is a prospective, multicentre, double-blind, randomised, placebo-controlled trial that will recruit 119 patients with NCFB and randomly divide them into an NAC group (n = 79) and a control group (n = 40). Participants in the NAC group will receive 600 mg oral NAC twice daily for 52 weeks, while patients in the control group will receive 600 mg placebo twice daily for 52 weeks. The information at baseline will be collected once participants are enrolled. The primary endpoints are the changes in St George’s Respiratory Questionnaire scores and the number of exacerbations in 52 weeks. The secondary endpoints are the 16S rRNA of sputum and the levels of inflammatory factors and oxidative stressors in sputum and serum. Other data related to radiography, lung function tests, number of oral and/or intravenous antibiotic therapies and adverse events (AEs) will also be analysed. Further subgroup analysis distinguished by the severity of disease, severity of lung function, airway bacterial colonization and exacerbation frequency will be performed.

Discussion

The objective of this study is to determine the long-term efficacy of NAC on QoL and exacerbation of NCFB and to explore the effectiveness of NAC for antibiosis, anti-inflammation and antioxidation in NCFB. The study results will provide high-quality clinical proof for the revision and optimization of treatment guidelines and for expert consensus on NCFB treatment.

Trial registration

The trial was registered on the Chinese Clinical Trial Register at April 11, 2020 (chictr.org.cn, ChiCTR2000031817).

Prevalence of Bronchiectasis in Patients with Chronic Rhinosinusitis in a Tertiary Care Center

BACKGROUND

Whereas chronic rhinosinusitis (CRS) is associated with asthma, and vice versa, the association between CRS and other lower respiratory conditions is not well-established. Bronchiectasis is characterized by permanent damage of the airways, and as many as 45% of bronchiectasis patients have CRS, but the prevalence of bronchiectasis among CRS patients is not known.

OBJECTIVE

To determine the prevalence of bronchiectasis among CRS patients and to characterize demographic and clinical features of patients with bronchiectasis and CRS.

METHODS

Electronic medical records of patients with rhinosinusitis were searched by computer algorithm supplemented with manual chart review to identify patients with CRS, asthma, and/or bronchiectasis. Demographic and clinical features and antibiotic courses for sinopulmonary infections 2 years before and after sinus surgery were obtained by manual chart review.

RESULTS

The prevalence of bronchiectasis as determined by International Classification of Diseases, Ninth Revision code was significantly higher in CRS patients than in asthmatic patients (2.3% vs 1.7%; P < .003). Similarly, based on a text word search of "bronchiectasis" in the chest computed tomography (CT) scan reports, patients with CRS who had chest CT scans had a higher prevalence of bronchiectasis than did asthmatic patients with chest CT scans (24.3% vs 19.5%; P = .005). Patients with CRS and concurrent bronchiectasis did not have a reduction in the frequency of sinopulmonary infections after sinus surgery compared with patients with CRS without bronchiectasis (P < .05).

CONCLUSIONS

Bronchiectasis is an important comorbidity in patients with CRS and may identify a severe phenotype of chronic sinonasal disease.

Prognostic performance of the FACED score and bronchiectasis severity index in bronchiectasis: a systematic review and meta-analysis

Background: Bronchiectasis is a multidimensional lung disease characterized by bronchial dilation, chronic inflammation, and infection. The FACED (Forced expiratory volume in 1 s (FEV1), Age, Chronic colonization, Extension, and Dyspnea) score and Bronchiectasis Severity Index (BSI) are used to stratify disease risk and guide clinical practice. This meta-analysis aimed to quantify the accuracy of these two systems for predicting bronchiectasis outcomes.

Methods: PubMed, Embase, and the Cochrane Database of Systematic Reviews were searched for relevant studies. Quality of included studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) criteria. Pooled summary estimates, including sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), and diagnostic odds ratio (DOR) were calculated. Summary receiver operating characteristic curves were constructed, and the area under the curve (AUC) was used to evaluate prognostic performance.

Results: We analyzed 17 unique cohorts (6525 participants) from ten studies. FACED scores with a cut-off value ≥ 5 predicted all-cause mortality better than BSI with a cut-off value ≥ 9, based on pooled sensitivity (0.34 vs 0.7), specificity (0.94 vs 0.66), PLR (4.76 vs 2.05), NLR (0.74 vs 0.48), DOR (6.67 vs 5.01), and AUC (0.87 vs 0.75). Both FACED scores with a cut-off value ≥ 5 (AUC = 0.82) and BSI scores with a cut-off value ≥ 5 or 9 (both AUC = 0.80) help to predict hospitalization.

Conclusions: At a cut-off value ≥ 5, FACED scores can reliably predict all-cause mortality and hospitalization, while BSI scores can reliably predict hospitalization with a cut-off of ≥5 or ≥9. Further studies are essential to validate the prognostic performance of these two scores.

Pseudomonas aeruginosa associated with severity of non-cystic fibrosis bronchiectasis measured by the modified bronchiectasis severity score (BSI) and the FACED: The US bronchiectasis and NTM Research Registry (BRR) study

RATIONALE

Non-cystic fibrosis bronchiectasis (NCFB) is characterized by dilated bronchi, poor mucus clearance and susceptibility to bacterial infection. Pseudomonas aeruginosa (PA) is one of the most frequently isolated pathogens in patients with NCFB. The purpose of this study was to evaluate the association between presence of PA and disease severity in patients within the US Bronchiectasis and Nontuberculous mycobacteria (NTM) Research Registry (BRR).

METHODS

Baseline US BRR data from adult patients with NCFB collected between 2008 and 2018 was used for this study. The presence of PA was defined as one or more positive PA cultures within two years prior to enrollment. Modified Bronchiectasis Severity Index (m-BSI) and modified FACED (m-FACED) were computed to evaluate severity of bronchiectasis. Unadjusted and multivariable multinomial regression models were used to assess the association between presence of PA and severity of bronchiectasis.

RESULTS

Average age of the study participants (n = 1831) was 63.7 years (SD = 14.1), 91.5% white, and 78.8% female. Presence of PA was identified in 25.4% of the patients. Patients with presence of PA had significantly lower mean pre-bronchodilator FEV1% predicted compared to those without PA (62.8% vs. 73.7%, p < .0001). In multivariate analyses, patients with presence of PA had significantly greater odds for having high (ORadj = 6.15 (95%CI:3.98-9.50) and intermediate (ORadj = 2.06 (95%CI:1.37-3.09) severity vs. low severity on m-BSI.

CONCLUSION

The presence of PA is common in patients with NCFB within the Bronchiectasis and NTM Research Registry. Severity of bronchiectasis is significantly greater in patients with PA which emphasizes high burden of the disease.

Effectiveness of hypertonic saline nebulization in airway clearance in children with non-cystic fibrosis bronchiectasis: A randomized control trial

INTRODUCTION

Failure to expectorate mucus resulting in progressive airway damage is the hallmark of bronchiectasis. Therefore effective airway clearance techniques (ACT) is the key step in its management. The aim of this study was to evaluate the efficacy of 3% hypertonic saline (HS) pre-medication in ACT in children with non cystic fibrosis (non-CF) bronchiectasis.

METHODS

In this randomized crossover control trial five to 15 year old children, diagnosed with non-CF bronchiectasis were randomized either to receive 200 µg of inhaled salbutamol followed by HS nebulization (test) or only 200 µg of inhaled salbutamol, before chest physiotherapy which is the conventional ACT (controls) for 8 weeks. Inhaled salbutamol was administered via a pressurized metered dosed inhaler with a valved holding chamber. After completion of first phase both groups went through one month washout period, before being crossed over to the opposite arms in the second phase. Spirometric parameters and number of exacerbations were recorded at the end of phase I, washout period and phase II.

RESULTS

Fifty two out of 63 enrolled completed the study. Baseline characteristics of the two groups were similar. A significantly higher mean improvement was seen in predicted forced expiratory volume in 1 s in the HS arm during phase 1 (HS = 14.15 ± 5.50 vs. conventional = 5.04 ± 5.55, p = .001) and phase II (HS = 10.81 ± 5.51 vs. conventional = 3.54 ± 5.13, p = .001) compared to conventional ACT arm. HS group showed a significantly higher mean improvement in predicted forced vital capacity in phase I (HS = 13.77 ± 5.73 vs. conventional = 7.54 ± 4.90, p = .001) and phase II, (HS = 9.42 ± 7.00 vs. conventional = 4.42 ± 4.00, p = .003). Mean number of exacerbations experienced by a single child during phase I (2 months) were significantly less (p = .001) in HS arm (0.42 ± 0.64) compared to that of conventional arm (1.30 ± 1.05) butthis difference was not significant in phase II (HS = 0.65 ± 0.74 and conventional = 1.03 ± 0.77, p = .074).

CONCLUSION

Incorporating HS nebulization into ACT is an effective strategy to improve dynamic lung volumes and morbidity in children with non-CF bronchiectasis.

Correlation between clinical-functional parameters and number of lobes involved in non-cystic fibrosis bronchiectasis

Background

Currently, the prognosis of bronchiectasis is based on different prognostic indicators, like BSI and FACED score, founded on clinical-demographic, functional and radiological criteria. Both scoring systems include the number of lobes involved in bronchiectasis, which represents an adverse prognostic index. Our study aimed to investigate the prognostic role of the clinical-functional parameters and the number of involved lobes ratio in adult bronchiectasis.

Methods

The study was conducted on 52 patients diagnosed with non-cystic fibrosis bronchiectasis (NCFB) between 2015 and 2017 who attended the Pneumology Unit of Monaldi Hospital in Naples, Italy. Correlations between clinical- functional parameters (BMI, smoking history, number of exacerbations in the previous year, spirometry, DL_CO, ABG test, and 6MWT) and number of involved lobes were investigated.

Results

At baseline, the number of exacerbations in the previous year had a statistically significant association with the number of involved lobes. Furthermore, at baseline, the radiological criterion was also negatively associated with some functional parameters (FEV₁/FVC ratio e FEF_25-75%). Statistical significance was lost during the follow up, demonstrating the effectiveness of the therapy.

Conclusions

Imaging extension represents a promising biomarker of disease severity as well as a helpful follow up tool for non-Cystic Fibrosis bronchiectasis (NCFB).

Primary Immun Deficiency in Patients with Non-Cystic Fibrosis Bronchiectasis and Its Relationship with Clinical Parameters

OBJECTIVE

Bronchiectasis is characterized by chronic respiratory infection. The role of immunodeficiency in this disease is poorly studied in relation to clinical indices. The primary aim of this study was to determine the frequency of these neglected altered immune status by evaluating immunoglobulins, lymphocyte subsets, complement levels, and neutrophil function, and to assess its relationship with clinical parameters in adult patients with non-cystic fibrosis bronchiectasis (NCFB).

MATERIAL AND METHODS

A total of 74 (30 men and 44 women with a mean age of 47±17 years) adult patients with stable NCFB were enrolled in this study. The bronchiectasis severity index (BSI) and FACED (F:FEV1, A: Age, C: Chronic colonization, E: Extension, D: Dyspnea) scores were assessed. Peripheral blood samples were collected for the detection of total IgG, IgA, IgM, IgE, and IgG subclasses and C3 and C4 levels. The counts of CD3, CD4, CD8, CD19, CD16/56 expressing peripheral blood lymphocytes and neutrophil oxidative function were evaluated.

RESULTS

In the study population, BSI and FACED severity index scores increased with longer duration of the disease (p=0.01 and p=0.040, respectively). Of the 74 patients, 27 (37%) showed humoral aberrations. The number of male patients were higher in this group (p=0.03). High serum total IgE levels were associated with high scores in BSI (moderate-severe group versus mild group, p=0.030). Patients with bronchiectasis demonstrated lower CD3+ T cell count, lower CD4+ T helper cell percentage, and lower CD4+ T cell count (p=0.031, p=0.030, p=0.029, respectively) than healthy subjects. A significant negative correlation was found between the percentage and count of CD16/56+ natural killer (NK) cells and the number of exacerbations within the past year (r=-0.230, p=0.049 and r=-0.264, p=0.023, respectively).

CONCLUSION

Humoral aberrations in adult patients with NCFB were found to be frequent. IgE levels were related to high scores for disease severity indices. Furthermore, patients with low percentage and counts of NK cells had higher rates of exacerbations. These results emphasize the importance of immune function assessment in adult patients with NCFB.

Effectiveness of two high frequency chest wall oscillation techniques in patients with bronchiectasis: a randomized controlled preliminary study

BACKGROUND

Chest physiotherapy is an important tool in the treatment of bronchiectasis. High frequency chest wall oscillation (HFCWO) is a technique designed to create a global percussion of the lung which moves secretions and probably clears the peripheral bronchial tree. We propose the comparison between an existing device (SmartVest) and a new device (RespIn 11).

METHODS

Sixty patients were randomized into three groups: a group was treated with SmartVest, a group with RespIn 11, and a group with pharmacological therapy alone. Primary outcome measures included exacerbations at 3, 6 and 12 months after the end of treatment. Secondary outcome measures were pulmonary function testing, arterial blood gas analysis (ABG), and hematological examinations, cough, dyspnea, health and quality of life scores (Bronchiectasis Health Questionnaire [BHQ], Breathlessness, Cough, and Sputum Scale [BCSS], COPD Assessment Test [CAT], Leicester Cough Questionnaire [LCT]). A 5-point Likert scale was used to evaluate patient's preference.

RESULTS

Both patients in the HFCWO groups showed a significant improvement in the tests of dyspnea, cough and health and quality of life score evaluations (BHQ, BCSS, CAT, LCT) compared to the control group, but not in pulmonary function tests and ABG. Only RespIn 11 significantly reduced exacerbations in comparison with the control group. RespIn 11 also had a higher score regarding patients' preference.

CONCLUSIONS

The two machines have improved health and quality of life scores in patients with bronchiectasis. RespIn 11 also demonstrated a significant lowering of exacerbations and a better patient acceptance.

Prevalence and characterization of chronic rhinosinusitis in patients with non-cystic fibrosis bronchiectasis at a tertiary care center in the United States

BACKGROUND

Chronic rhinosinusitis (CRS) is associated with bronchiectasis; however, this relationship has not been well studied in the United States (US) population. In this work we aimed to determine the prevalence of CRS among patients with bronchiectasis affiliated with a US tertiary medical center and identify which comorbid diseases are associated with the presence of CRS in patients with bronchiectasis.

METHODS

This was a retrospective cohort study in which data were obtained from a large database warehouse at a tertiary care center. Patients with bronchiectasis were identified from 2007 to 2017 using diagnosis codes from the the ninth and tenth revisions of the International Classification of Diseases (ICD-9/10) and confirmed by radiographic evidence of bronchiectasis on chest computed tomography (CT) scans. Patients were divided into cohorts based on presence or absence of concomitant CRS. Characteristics analyzed included demographics, comorbidities, peripheral eosinophil counts, and pulmonary function testing.

RESULTS

CRS was present in 45% (408 of 900) of patients with bronchiectasis. Females represented a majority of bronchiectasis patients, both with and without CRS (69% and 64%, respectively, p = 0.09). After controlling for demographic factors, asthma (p < 0.01), allergic rhinitis (p < 0.01), gastroesophageal reflux disease (p < 0.01), and antibody deficiency (p < 0.01) were associated with the presence of CRS in patients with bronchiectasis.

CONCLUSION

CRS had a high prevalence and was associated with numerous comorbid conditions in patients with bronchiectasis. These findings have clinical implications for the treatment of patients with bronchiectasis and future research.

Outpatient Parenteral Antimicrobial Treatment for Non-Cystic Fibrosis Bronchiectasis Exacerbations: A Prospective Multicentre Observational Cohort Study

BACKGROUND

The recently published guidelines of the Spanish Society of Pulmonology and Thoracic Surgery encourage physicians to use outpatient antimicrobial therapy to treat exacerbations in patients with non-cystic fibrosis bronchiectasis (NCFB). The published literature on this topic, however, is scarce.

METHODS

We report a prospective observational cohort study of patients with NCFB who received treatment at home for at least one exacerbation episode between September 2012 and September 2017 as part of an outpatient parenteral antimicrobial therapy (OPAT) program. Patients were included in the analysis if they fulfilled all of the following criteria: established diagnosis of bronchiectasis according to current guidelines criteria, clinical exacerbation, requiring intravenous antibiotics because of failure to respond to oral antibiotics, or isolation of a microorganism resistant to oral options.

OBJECTIVES

To evaluate the effectiveness and safety of the treatment of patients with NCFB exacerbations in an OPAT program under "real-world" conditions.

RESULTS

Sixty-seven patients were treated in the OPAT program due to bacterial exacerbations of NCFB. Forty-five (67.2%) patients were admitted to hospital for a median of 7 days before starting OPAT. Sixty-three (94%) patients achieved resolution of the exacerbation at the end of therapy. Four patients needed hospital readmission, and one died. The OPAT program saved 11,586 days of hospital admission, equivalent to EUR 7,866,904.

CONCLUSIONS

OPAT appears to be a safe, effective, and efficient strategy for treating patients with exacerbations of NCFB.

The Effects of Modified Pursed Lips Breathing on Oxygenation Status in Children

Respiratory disease in children can contribute to damaged alveoli, frailty of respiratory muscles, reduced lung function, impaired gas exchange, and gas retention in the airway. Such condition may lead to disruption of oxygen status. This study aimed to examine the effects of modified pursed lips breathing (PLB) by blowing into a water-filled bottle through a straw and a party whistle on the oxygenation status in children with oxygenation problems. This study used a quasi-experiment method with a pretest-posttest without a control group design approach. The sample consisted of 32 school-aged children and adolescents who were divided into two intervention groups. Group 1 underwent modified PLB by blowing into a water-filled bottle through a straw and Group 2 was provided with modified PLB by blowing a party whistle. The intervention was conducted one time in a day, in a rest time, for 10 min. The results showed that modified PLB by blowing into a water-filled bottle through a straw was more effective in reducing respiratory rate (RR) and improving oxygen saturation (SpO₂) than modified PLB by blowing a party whistle. Modified PLB intervention by blowing into a water-filled bottle through a straw improved the oxygenation status of children affected by oxygenation problems. This intervention can be implemented as an independent nursing intervention to improve children's oxygenation status.