The 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

Research output: Contribution to journalArticle


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

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

Methods: An observational cohort of 333 patients from the East of Scotland(2012-2016). Symptoms were either modelled as a continuous variable or patients were classified as high, moderate and low symptom burden(>70, 40-70 and <40 using the SGRQ symptom score). We hypothesised that exacerbation would be reduced in highly symptomatic patients. This was tested in a post-hoc analysis of a randomized trial of inhaled mannitol (N=461 patients) Measurement 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 high symptom scores had higher exacerbation rates (RR 1.74, 95% CI 1.12-2.72,P=0.01) over 12 months follow-up compared to those with lower symptoms. Inhaled mannitol treatment improved the time to first exacerbation (hazard ratio [HR] 0.56; 95% CI 0.40-0.77; P<0.001) and the proportion of patients remaining exacerbation free for 12 months treatment was higher in the mannitol group (32.7% vs. 14.6%; RR 2.84, 95% CI 1.40-5.76; P=0.003) only in highly symptomatic patients. In contrast no benefit was evident in patients with lower symptom burden.

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

Original languageEnglish
JournalAmerican Journal of Respiratory and Critical Care Medicine
Early online date25 Feb 2020
Publication statusE-pub ahead of print - 25 Feb 2020



  • bronchiectasis
  • Cough
  • Exacerbations
  • Mucoactive
  • Macrolides

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