Relationship between Symptoms, Exacerbations, and Treatment Response in Bronchiectasis

Yong-Hua Gao, Hani Abo Leyah, Simon Finch, Mike Lonergan, Stefano Aliberti, Anthony De Soyza, Thomas C. Fardon, Gregory Tino, James D. Chalmers (Lead / Corresponding author)

Research output: Contribution to journalArticlepeer-review

2 Citations (Scopus)


Rationale: Bronchiectasis guidelines regard treatment to prevent exacerbation and treatment of daily symptoms as separate objectives.

Objectives: We hypothesized that patients with greater symptoms would be at higher risk of exacerbations and therefore that a treatment aimed at reducing daily symptoms would also reduce exacerbations in highly symptomatic patients.

Methods: Our study comprised an observational cohort of 333 patients from the East of Scotland (2012-2016). Either symptoms were modeled as a continuous variable or patients were classified as having high, moderate, or low symptom burden (>70, 40-70, and <40 using the St. George's Respiratory Questionnaire symptom score). The hypothesis that exacerbation reductions would only be evident in highly symptomatic patients was tested in a post hoc analysis of a randomized trial of inhaled dry powder mannitol (N = 461 patients).

Measurements and Main Results: In the observational cohort, daily symptoms were a significant predictor of future exacerbations (rate ratio [RR], 1.10; 95% confidence interval [CI], 1.03-1.17; P = 0.005). Patients with higher symptom scores had higher exacerbation rates (RR, 1.74; 95% CI, 1.12-2.72; P = 0.01) over 12-month follow-up than those with lower symptoms. Inhaled mannitol treatment improved the time to first exacerbation (hazard ratio, 0.56; 95% CI, 0.40-0.77; P < 0.001), and the proportion of patients remaining exacerbation free for 12 months of treatment was higher in the mannitol group (32.7% vs. 14.6%; RR, 2.84; 95% CI, 1.40-5.76; P = 0.003), but only in highly symptomatic patients. In contrast, no benefit was evident in patients with lower symptom burden.

Conclusions: Highly symptomatic patients have increased risk of exacerbations, and exacerbation benefit with inhaled mannitol was only evident in patients with high symptom burden.

Original languageEnglish
Pages (from-to)1499-1507
Number of pages9
JournalAmerican Journal of Respiratory and Critical Care Medicine
Issue number12
Early online date25 Feb 2020
Publication statusPublished - 15 Jun 2020


  • bronchiectasis
  • cough
  • exacerbations
  • macrolides
  • mucoactive

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