Role of inhaled corticosteroids in management of non CF bronchiectasis

People with bronchiectasis have significant morbidity (e.g. cough, wheeze, sputum production) and have more rapid lung function decline. As asthma like symptoms are common in people with bronchiectasis, the routine use of inhaled corticosteroids is potentially beneficial in reducing exacerbations, symptoms and pulmonary decline. The review found that there is insufficient evidence for the routine use of inhaled corticosteroids in people with bronchiectasis. While inhaled corticosteroids may be beneficial in a subgroup of people with bronchiectasis, its use has to be balanced with adverse effects that include potential increase in commensal bacterial density in the sputum.

Authors' conclusions: 

The present review indicates that there is insufficient evidence to recommend the routine use of inhaled steroids in adults with stable state bronchiectasis. While a therapeutic trial may be justified in adults with difficult to control symptoms and in certain subgroups, this has to be balanced with adverse events especially if high doses are used. No recommendation can be made for the use of ICS in adults during an acute exacerbation or in children (for any state) as there were no studies.

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Background: 

Bronchiectasis is increasingly recognized as a major cause of respiratory morbidity especially in developing countries and in some ethnic populations of affluent countries. It is characterized by irreversible dilatation of airways, generally associated with chronic bacterial infection. Medical management largely aims to reduce morbidity by controlling the symptoms and by preventing the progression of bronchiectasis.

Objectives: 

To evaluate the efficacy of inhaled corticosteroids (ICS) in children and adults with bronchiectasis (a) during stable bronchiectasis; and for reducing; (b) the severity and frequency of acute respiratory exacerbations and (c) long term pulmonary decline.

Search strategy: 

The Cochrane Register of Controlled Trials (CENTRAL), the Cochrane Airways Group Specialized Register of trials, MEDLINE and EMBASE databases were searched by the Cochrane Airways Group. The latest searches were performed in October 2010.

Selection criteria: 

All randomised controlled trials comparing ICS with a placebo or no medication. Children and adults with clinical or radiographic evidence of bronchiectasis were included, but patients with cystic fibrosis (CF) were excluded.

Data collection and analysis: 

Results of searches were reviewed against pre-determined criteria for inclusion.

Main results: 

There were no paediatric studies. Six adult studies fulfilled the inclusion criteria. Of the 303 randomised, 278 subjects completed the trials. In the short term group (ICS for less then 6 months duration), adults on huge doses of ICS (2g per day of budesonide equivalent) had significantly improved forced expiratory volume in the first second (FEV1), forced vital capacity (FVC), Quality of life (QOL) score and sputum volume but no significant difference in peak flow, exacerbations, cough or wheeze, when compared to adults in the control arm (no ICS). When only placebo-controlled studies were included, there were no significant difference between groups in all outcomes examined (spirometry, clinical outcomes of exacerbation or sputum volume etc). The single study on long term outcomes showed no significant effect of inhaled steroids in any of the outcomes.

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