Bronchiectasis Is Underrecognized: Obada Shamaa, MD, PhD

Bronchiectasis is increasingly diagnosed but remains underrecognized in the community, which leads to undermanagement, according to Obada Shamaa, MD, PhD, a clinical instructor of medicine at the University of Chicago Medicine.

In an interview with The American Journal of Managed Care®, Shamaa discussed when clinicians should suspect bronchiectasis, why brensocatib is replacing chronic azithromycin in the practice, and how airway clearance and antibiotic plans can be individualized.

When to Suspect Bronchiectasis

“Bronchiectasis is becoming a more commonly diagnosed disease, but it’s underrecognized in the community, and that leads to undermanagement,” Shamaa said. Clinicians should consider the condition in patients with a persistent productive cough that lasts longer than would be expected for a viral or other infectious cause, as well as in those who are not responding to other treatment approaches. Shamaa said these patients should get a CT scan to rule out or evaluate bronchiectasis.

Once bronchiectasis is suspected, the workup is largely routine. Shamaa said testing for autoimmune disease, immunodeficiency, and alpha-1 antitrypsin deficiency is standard, and adult cystic fibrosis testing is discussed with every patient, with next steps based on the patient’s interest in pursuing a diagnosis. Determining cause can be difficult, Shamaa noted, because it is often “a chicken or the egg kind of scenario” in which it is unclear whether an infection led to bronchiectasis or bronchiectasis led to the infection.

Why Brensocatib Is Replacing Azithromycin

Shamaa said brensocatib has a more favorable safety profile than long-term azithromycin, and that has changed prescribing. “I’m switching all of my patients who are on chronic azithromycin to brensocatib just because of the risks of azithromycin,” Shamaa said.

Among the risks Shamaa cited are cardiac risk factors and hearing loss. Patients with bronchiectasis are also prone to nontuberculous mycobacteria (NTM), and Shamaa pointed out that a patient who develops NTM while on chronic azithromycin could be at very high risk if the organism has become resistant to the antibiotic.

Why Airway Clearance Must Be Individualized

Shamaa described an approach to airway clearance that starts gently. “Oftentimes, what I start off with is gentle airway clearance techniques to see if they respond,” Shamaa said, adjusting the plan if there is no improvement. The goal is to build an airway clearance plan and an antibiotic plan together and learn what works and what does not for each patient.

That requires weighing disease severity against what a patient can tolerate and keep up with. For patients in their 70s to 90s in particular, Shamaa said, treatment decisions are a risk-benefit tradeoff. Some patients cannot tolerate antibiotics that would be effective against their disease or cannot manage the duration of therapy, and more aggressive airway clearance schedules may not be feasible either. “Everything is about personalized care,” Shamaa said.

Shamaa said airway clearance is also undermanaged because many clinicians are familiar with only a narrow range of techniques and recommend standard regimens that may not suit a particular patient. Techniques such as percussion therapy, postural drainage, and huff cough are often left out, possibly because of time limits in community practice. Positive expiratory pressure therapy and other options should be individualized as well, Shamaa said, and a “cookie cutter” approach is not the way to go.

Looking ahead, Shamaa raised the idea of a combined infectious disease and pulmonary clinic for these patients. The main obstacle is logistics, such as coordinating a time and place and building the patient population from scratch. If both specialists cannot be in the same location, Shamaa said, having one join by televisit could improve access.