Asthma and Bronchiectasis;

A New Kid on The Block

Prof. Magdy Zedan

Professor of Allergy,
Respiratory Medicine and Clinical Immunology
Faculty of Medicine, Mansoura University
Egypt 2022
 Asthma and Bronchiectasis;
a New Kid on The Block

Key Points
• Asthma and bronchiectasis share common symptoms,
several comorbidities and pathogenesis.
• This overlap results in a more severe disease with
frequent exacerbations.
• HRCT chest should be considered in patients with severe
asthma to rule out the co-presence of bronchiectasis.
• Tailored treatment of both diseases is crucial for
symptoms control and halt disease progression and
structural lung injury.
 Asthma and Bronchiectasis;
a New Kid on The Block

• However, asthma and bronchiectasis share

similar functional and clinical features which
in practice, can lead to;
Misdiagnosis in favor with asthma and
Under estimation of bronchiectasis.
 Asthma and Bronchiectasis; a New Kid on The Block

• Considering the diagnosis of both diseases:

 The gold standard tool for the diagnosis of
bronchiectasis is HRCT chest, which is not routinely
indicated for asthmatic patients.
 On the contrary, the diagnosis of asthma is mainly
based on functional criteria such as:
•Reversibility of airway obstruction
•Hyper-sensitivity tests
 However these tests have high susceptibility, but low
specificity. How?
Asthma and Bronchiectasis; a New Kid on The Block

• Reversibility of airway obstruction can be

observed in 25% of patients with
bronchiectasis that is related to presence of
chronic eosinophilic inflammation.

• This leads to misdiagnosis of bronchiectasis

and treatment delay.
 Bronchiectasis
What We are Talking About?

• B:A Ratio
• Cough • Bronchiola <2cm
Clinical Symptoms Radiological • Mucous plugging
• Sputum
and Signs Alteration • Lack of bronchial
• Recurrent Infections
tapering in the
peripheral areas

B:A ratio= broncho-arterial ratio

 Bronchiectasis
What We are Talking About?

• B:A Ratio
• Cough
Clinical Symptoms Radiological • Bronchiola <2cm
• Sputum
and Signs Alteration • Mucous plugging
• Recurrent Infections
• Lack of tapering
 Bronchiectasis
A Pool of Different Conditions
• Bronchiectasis: irreversible dilatation of the bronchial tree, is
caused by recurrent inflammation or infection of the airway

Different Causes: Complex and Expensive Diagnosis:

• Cystic fibrosis • HRCT
• Post-infectious • Blood analysis: hemogram,
• Immunity disorders complement, response to
• Defects of airway clearance vaccines (S pneumonie and H
(ciliary dyskinesia) infleunza, Alfa1 AT, autoimmunity,
• Rheumatologic disorders IgE, IgA, IgG subclasses,
• Inflammatory bowel diseases aspergillus precipitins
• COPD, asthma, ABPA • Lung function tests
• Broncho-aspiration sequale • Exhaled NO, electron microscopy,
• Mechanical bronchial obstruction Sweat and genetic tests for CF
• Miscellaneous • Microbiology (NTM, etc..)
• Idiopathic (35-50%)
 ERS Bronchiectasis Guidelines
Recommendations
• All Patients Should Have:
Immunodeficiencies
– Circulating white blood cell count
– Immunoglobulins
– Screening for ABPA for total and specific IgE to
ABPA/allergy
aspergillus or skin test
• In Selected Patients: Antimicrobials
– Sputum for NTM
CF/PCD Management
– CF/ PCD testing
Augmentation therapy
– Alpha 1 antitrypsin
 Bronchiectasis
A Heterogeneous Disease
 Prevalence of
Bronchiectasis in Asthma
Author Year N= Severity of Prevalence of
asthma BX
Zhang 2021 839 Not described 36.6%
Kim 2018 91 severe 35.2%
Weatherburn 2017 84 505 Not described 0.8%
Henkle 2017 511/1247 Not described 19/28
Dimakou 2017 40 severe 67.5%
kang 2017 2270 Not described 2.2%
lujan 2014 100 Not described 12.0%
Menzies 2013 133 severe 35.3%
Bisaccioni 2011 245 Not described 26.8%
Gupta 2009 463 severe 40.0%
Oguzulgen 2007 1680 All/non specified 3.0%
Paganin 1996 126 All/non specified 80.0%
 Asthma and Bronchiectasis
Airway Inflammation

Asthma Bronchiectasis

Mostly Chronic Mostly

Eosinophilic Inflammation Neutrophilic

Neutrophil
TGF-b Eastase
MM Airway Matrix
Metalloproteinase
IL-13 Damage
IL-8
 Asthma and Bronchiectasis
Airway Inflammation

Asthma Bronchiectasis

MUC5A Mucous Bacterial

Goblet Cell Hypersecretion Colonozation
Hyperplasia

Simplified
Excess of Dysfunctional
Microbiota
pathogenic Microbiota
Bronchiectasis in Asthma Patients
Bronchiectasis in Asthma Patients
How can you suspect?
 Bronchiectasis in Asthma Patients
How can you suspect?

Fe NOPES
AUC-ROC 75% Pneumonia
Expectoration
Severity
Specificity 95% asthma

• NOPES score was developed on the basis of these variables: FeNO (cut
off point:20.5 ppb), Pneumonia, Expectoration and asthma Severity.
 Bronchiectasis in Asthma Patients
How can you suspect?

Non allergic asthma

Fe NOPES
AUC-ROC 75% Pneumonia
Lower FeNO Expectoration
(<20.5 ppb) Severity
Specificity 95% asthma

NOPES from 0 to 4 points where

Neutrophilic inflammation 0 = no risk
4= high risk
 Bronchiectasis in Asthma Patients
Clinical Features (warning signs)
Older Patient

Non Reversible Obstruction

Chronic Expectoration

More Frequent Exacerbation

Increased severity of asthma

 Bronchiectasis in Asthma Patients:
Associated Factors
• Asthma and Bronchiectasis not only share
similar clinical symptoms (cough, sputum and
dyspnea), but also underlying cause and
extrapulmonary comorbidities as both are
associated with;
ABPA, Rhinosinusitis,
Immune deficiency, GERD,
Infections with more exacerbations,
Good clinical response to macrolide.
 Bronchiectasis in Asthma Patients:
Associated Factors

• In severe asthma is associated with:

– Neutrophilic inflammation A. Fumigatus sensitization
 Allergic Broncho Pulmonary
Aspergillosis
• ABPA is a common risk factor for severe
bronchial asthma (5-25%) and bronchiectasis
(nearly 11%).
• ABPA is defined as a hypersensitivity reaction
(T2 mediated) against aspergillus fumigates.
 Allergic Broncho Pulmonary
Aspergillosis
• Amazing feature of asthmatic patients with
ABPA is absence of atopic diseases such as
allergic rhinitis, urticaria and eczema.

• Bronchiectasis, especially central ones, are

pathognomic element for ABPA. For this
reason, HRCT chest is essential for evaluating
patients with severe asthma.
Bronchiectasis in Asthma Patients:
Associated Factors

Bronchiectasis Prevalence
Bronchiectasis in Asthma Patients:
Associated Factors

Bronchiectasis Prevalence

20/50 (40%) • In steroid dependent asthma group

6/50 (12%) • In non SDA group had bronchiectasis

Asthma in Bronchiectasis Patients
Asthma in Bronchiectasis Patients

Only Few Studies

Clinical, Functional and Biological

No Established Clinical Management

 Asthma and Bronchiectasis

20/99 0.832 >22.5ppb

• Bx patients with • AUC-ROC for FeNO • Cut-off value of
asthma to distinguish FeNO for
asthma differentiating
bronchiectasis asthma - Bx
Asthma and Bronchiectasis
Two Sides… The Same Coin
 Asthma and Bronchiectasis:
Two Sides, Same Coin

Asthma with Bx: Bx with asthma:

• Older patient • Younger patients

• Worse lung function • Better lung function
• Lower Ig level • Lower Ig
• Lower FeNO • Higher FeNO
• Less P. aurginosa
• More exacerbations
Asthma and Bronchiectasis:
Two Sides, Same Coin

Could it be simply a
matter of time ?
 Asthma and Bronchiectasis:
What is The Problem (Challenges in Diagnosis)

• Overlap of symptoms
Clinical without functional criteria

• Hyperreactivity in Bx even in
Functional absence of asthma features

Biological • Neutrophilic asthma

 Asthma and Bronchiectasis:
What to treat and how?
Asthma Bronchiectasis

Bronchodilators
• Established treatment • Recommended in presence of
breathlessness
• Recommended when asthma or COPD is
associated
• Pre-medication for physiotherapy or
inhaled treatment
• No contraindications • Risk of hemoptysis ??
Inhaled Corticosteroids
• First line treatment in asthma

• Poor response in neutrophilic asthma • Not recommended

• High dose-> risk of bacterial airway
infection
 Asthma and Bronchiectasis:
What to treat and how?
Asthma Bronchiectasis

Macrolides
• Improved QoL • Improved QoL
• Reduced symptoms and exacerbation • Reduced symptoms and exacerbation
rate rate
• Macrolide resistant NTM strains • Macrolide resistant NTM strains
• Cardiovascular and auditive side effects • Cardiovascular and auditive side effects
Inhaled Antibiotics
• No indication • Reduced exacerbation rate
• Potential bronchospasm • No contra-indication
Physiotherapy
• Improve muco-ciliary function • Improve muco-ciliary function
• Reduced infection
• No contraindication • No contraindication
 Bronchiectasis in Asthma
Take Home Message
1. CATCH IT

Chronic
Severe Asthma
Expectoration

Recurrent Bronchial Poor Response to

Infections Treatment
CT Scan
 Bronchiectasis in Asthma
Take Home Message
2. CHASE IT

Perform regular sputum culture

 Bronchiectasis in Asthma
Take Home Message
2. CHASE IT

Perform regular sputum culture

Role out NTM infection before starting macrolide

 Bronchiectasis in Asthma
Take Home Message
3. TREAT IT

Bronchial
Obstruction

BD
ICS
 Bronchiectasis in Asthma
Take Home Message
3. TREAT IT

Bronchial Chronic
Obstruction Inflammation

BD Macrolides
Immuno-modulatory
role directed at
neutrophilic
inflammation
(no specific trial in
ICS asthma)
 Bronchiectasis in Asthma
Take Home Message
3. TREAT IT

Bronchial Obstruction Chronic Inflammation Mucous Hypersecretion

BD Macrolides
Immuno-modulatory
role directed at
Physiotherapy
neutrophilic With maneuvers
inflammation adapted to
(no specific trial in obstructive pattern
ICS asthma)
 Bronchiectasis in Asthma
Unresolved Issue
Prognosis
No longitudinal or comparative study

Use of Oral Steroid

Risk of infection

Biomarkers
Which and how?

Inhaled Antibiotics
No studies in asthmatic patients, risk of bronchospasm

Respiratory Physiotherapy
No consensus on best technique
Thank You