Beyond inhaled antibiotics: Next-generation anti-inflammatories in bronchiectasis

Background: Bronchiectasis is a chronic airway disease defined by permanent bronchial dilation and complicated by impaired mucociliary clearance, which can result in retention of phlegm in the airways. The model of pathophysiology encompasses a vortex of persistent infection and exaggerated neutrophil-dominant inflammation with obstruction of the airways. Available therapeutic options have targeted the obstruction and infection, but clinicians lacked an effective method of quieting the inflammation. Recent research offers a greater understanding of the inflammatory cells and their association with untoward clinical outcomes, with great interest in the neutrophil and its serine proteases. Methods: A narrative literature review of published peer-reviewed literature from the last ten years was performed. Results: This review describes our understanding of the pathophysiology of bronchiectasis, the clinical consequences of excess serine proteases (especially neutrophil elastase), and the evidence of recent clinical trials of novel agents that target the neutrophil. Conclusion: The future of bronchiectasis care is expanding, beyond bronchodilators, inhaled steroids, and inhaled antibiotics, toward targeted modulation of the inflammatory cascade that drives disease progression.