Egészségügy | Betegségek » Lin-Xu-Qu - Bronchiectasis in China

PERSPECTIVES Bronchiectasis in China Jie-Lu Lin1, Jin-Fu Xu1*, and Jie-Ming Qu2 1 Department of Respiratory Medicine, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China; and 2Department of Respiratory Medicine, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China ORCID ID: 0000-0002-8039-8973 (J.-FX) Abstract Bronchiectasis is a common but long-neglected disease in China, causing a substantial disease burden both to patients and to society. The overall prevalence of physician-diagnosed bronchiectasis in people aged 40 years or older is estimated at 1.2% and is trending upward with aging of the population. The etiology of bronchiectasis has not been identified heretofore in more than 70% of patients in China, although pneumonia and tuberculosis still appear to be the most common causes of acquired bronchiectasis. Etiologies, comorbidities, and infecting organisms vary greatly across previously published epidemiological

studies, resulting in considerable uncertainty. Little is known about the spectrum of severity of bronchiectasis in China. Presently, engagement of pulmonologists is largely limited to acute treatment of exacerbations of severe bronchiectasis. Based on limited available data and expert consensus, the first comprehensive guidelines for the diagnosis and treatment of bronchiectasis in China were published in 2012. Research to advance medical care for patients with this disease in China should focus on several priorities, including: standardization of diagnostic criteria with appropriate application of computed tomographic imaging; use of validated multidimensional grading systems to assess the severity of bronchiectasis; and epidemiological studies that are designed to measure mild to moderate as well as severe disease, and to represent the population beyond large urban centers. Better estimates of the true burden of bronchiectasis are needed to guide allocation of national medical

resources and to implement public health strategies for prevention of the disease. Treatment should be expanded to include expert maintenance care of ambulatory patients in addition to treatment of exacerbations. Keywords: bronchiectasis; China; prevalence; burden; challenge (Received in original form November 7, 2015; accepted in final form February 16, 2016 ) *These authors contributed equally to this work. Supported by National Science Foundation of China grant 81,370,109, programs from Science and Technology Commission of Shanghai Municipality grants 134119a6400 and 12JC1402300, and Innovation Program of Shanghai Municipal Education Commission grant 13SG21. Correspondence and requests for reprints should be addressed to Jie-Ming Qu, M.D, PhD, Department of Pulmonary Medicine, Ruijin Hospital, 197 Rui Jin Er Road, Shanghai 200025, China. E-mail: jmqu0906@163com; or Jin-Fu Xu, MD, PhD, Department of Respiratory Medicine, Shanghai Pulmonary Hospital, Tongji University School of

Medicine, Shanghai, China. E-mail: jfxucn@gmailcom Ann Am Thorac Soc Vol 13, No 5, pp 609–616, May 2016 Copyright 2016 by the American Thoracic Society DOI: 10.1513/AnnalsATS201511-740PS Internet address: www.atsjournalsorg Non–cystic fibrosis (CF) bronchiectasis (hereafter simply referred to as bronchiectasis) is pathologically defined as permanent, abnormal dilatation of one or more bronchi. Patients with bronchiectasis often suffer from chronic cough and copious production of purulent sputum, recurrent chest infections, and occasional hemoptysis (1). The basic characteristics of bronchiectasis are a long duration and progressive damage to lung function, which negatively influence its patients’ quality of life and cause them enormous social and economic burdens. Perspectives Although regarded as an “orphan” disease in developed countries (2), bronchiectasis has never been perceived as an uncommon disease in China (3). This is likely due to the higher prevalent risk

factors for infection, poor understanding of pathogenesis, and lack of uniform guidelines for the diagnosis and management of this disease in China. In this review, we analyze available studies on bronchiectasis in China, including data on prevalence, causes and related diseases, diagnosis, and clinical management. Prevalence The prevalence of bronchiectasis worldwide remains largely unknown given the lack of specific symptoms or simple, accurate, and noninvasive screening tests for largescale population investigations. No comprehensive study of the prevalence of bronchiectasis is available for China, and published data are limited. An urban population–based, crosssectional survey of bronchiectasis conducted in China between 2002 and 2004 showed that the overall prevalence 609 PERSPECTIVES A 2.5% 2.1% Prevalence 2.0% 1.5% 1.5% 1.1% 1.0% 0.5% 0.5% 0.0% 40~ 50~ 70 60~ Age B 3.0% Male Female Total 2.5% Prevalence 2.0% 1.5% 1.0% 0.5% 0.0% Beijing Shanghai

Guangdong Liaoning Tianjin City/Province Chongqing Shaanxi Average Figure 1. Prevalence of bronchiectasis among seven urban cities in China (A) Prevalence of bronchiectasis increasing with age (B) Comparison of male and female prevalence of bronchiectasis in different regions in China. of physician-diagnosed bronchiectasis in people aged 40 years or older was 1.2% and trended upwards with increasing age (see Figure 1A) (4). However, the reported percentage included only those individuals diagnosed with bronchiectasis. The number of patients with undiagnosed bronchiectasis remains largely unknown. The actual prevalence of bronchiectasis in China is expected to be far greater than 1.2% Contrary to the situation in China, bronchiectasis is considered uncommon in the Western world. Weyker and colleagues (5) reported the prevalence of bronchiectasis in the United States as 4.2 per 100,000 persons aged 18–34 years, 610 and 271.8 per 100,000 persons aged over 75 years. Across Western

countries, bronchiectasis is thought to be more common in women (6). In contrast, the proportions reported in China (1.5% in males, 1.1% in females) are less skewed (see Figure 1B) (4). This may reflect a difference in the causes of bronchiectasis in China compared with the West. In Western countries, many common, related diseases with a predisposition to bronchiectasis, such as rheumatoid arthritis, sarcoidosis, and Sjögren’s syndrome, have female predominance (7, 8). In contrast, pulmonary tuberculosis, which is rare in the West, but one of the more common causes of bronchiectasis in China, occurs more frequently in males (9, 10). However, these are difficult to compare because of differences in the methods and targeted populations in the studies involved. There are no available longitudinal data on the prevalence of bronchiectasis in China. A decline in recent years might be expected for countries that have implemented widespread vaccination against measles and pertussis and

offer routine access to antimicrobial therapy for pneumonia and tuberculosis. However, the prevalence reportedly increased in the United States 8.7% per year between 2000 and 2007. This increase could be due to a true increase in instances of the condition, AnnalsATS Volume 13 Number 5 | May 2016 PERSPECTIVES or increased ability to recognize previously undiagnosed cases after the advent of high-resolution computed tomographic (HRCT) imaging (11). On a related note, the U.S researchers have reported that Asians have 2.5- and 39fold higher prevalence for bronchiectasis compared with white and black populations among people aged 65 years and older with one CT scan (11), implying a predisposition to bronchiectasis in Asian populations. Data from a Korean health screening program also showed a high (9.1%) prevalence of bronchiectasis in adults (12), which may indicate a similar situation to that of China. Because estimates for the prevalence of bronchiectasis in China are based

primarily on physician diagnosis by medical history in urban cities, many patients may remain undiagnosed or misdiagnosed with other chronic respiratory diseases. The true prevalence of bronchiectasis in China is likely to be grossly underestimated. Common Etiologies for Bronchiectasis in China Bronchiectasis is a final common structural endpoint for many diseases with diverse primary causes (1, 13). Traditionally, epidemic diseases, such as pertussis, measles, and tuberculosis, have been major causes of bronchiectasis, but effective vaccination programs and antituberculosis therapy have significantly reduced the impact of these diseases in relatively affluent regions of China, especially with regard to pediatric bronchiectasis. Etiological analysis from several studies in China reveals that the main causes have shifted from pertussis, measles, and tuberculosis to bacterial, mycoplasmal, and viral pneumonia during the past 5 decades (see Figure 2) (14–17). For example, Liu and

Jiang (18) showed a relationship between bronchiectasis and recurrent and chronic pulmonary infections. Among 91 children with bronchiectasis, 33 were attributed to a discrete episode of pneumonia, 77 had a history of recurrent pneumonia, and 88 occurrences were thought to be infection related. The study also concluded that there were differences in etiology between patients with diffuse as opposed to local bronchiectasis. Several groups of investigators have reported that pneumonia and tuberculosis are still the most commonly identified causes of acquired bronchiectasis in China; however, the exact etiology cannot be identified in more than 70% of patients (19–21). The authors of a retrospective study performed at Peking Union Medical College Hospital found that one or more potential risk factors could be found in 55.2% of the unidentified cases after further research (19). Qi Q and colleagues (22) from Shangdong studied 476 adult patients with bronchiectasis by analysis of

clinical history and auxiliary examinations. “Idiopathic” (66.0%) was the most commonly listed cause in their report, followed by posttuberculosis (16.0%) Other causes included post-pneumonia (3.8%), immunodeficiency (38%), allergic bronchopulmonary aspergillosis (4.0%), rheumatic diseases (4.4%), and primary ciliary dyskinesia (0.9%) Investigators in Guangzhou showed that idiopathic (46.0%), postinfection (270%), and immunodeficiency (8.8%) were the most common etiologies among the 148 patients they sampled (23). These results are consistent with the study from Pasteur and colleagues (24), which suggested that intensive evaluation of patients with bronchiectasis led to identification of one or more causative factors in 47% of cases, with 15% presenting etiological factors amenable to specific treatment or in making a prognosis. A study from Italy showed that, among the 1,258 patients enrolled, an etiology of bronchiectasis was determined in 60%. Etiologies led management

changes were identified in 13% of the cases (25). before the 1970’s 10.00% 4.00% 21.88% 30.30% 45.31% the 1970’s to 1990’s 3.03% 23.44% 33.33% Tuberculosis Other viral infection Bronchial foreign body 48.00% Measles Mycoplasmal pneumonia Others after the 1990’s Pertusis Chronic parochial sinusitis Bacterial infection Immunodefect Figure 2. The changes of etiologies in pediatric bronchiectasis in China Data collected from literature covered by the Chinese core journals Perspectives 611 PERSPECTIVES Comorbidities Bronchiectasis is receiving attention for an increasing frequency of detection in patients with chronic obstructive pulmonary disease (COPD). Recent studies report that 29–69% of patients with COPD show bronchiectasis on CT imaging. On average, those patients had poorer lung function and suffered more often from dyspnea compared with patients with COPD who did not have bronchiectasis. COPD-related bronchiectasis is therefore an important diagnosis

with potential implications for treatment (26–29). In 2013, Martı́nez-Garcı́a and colleagues (30) demonstrated that patients with COPD with concomitant bronchiectasis have a higher mortality rate compared with those without bronchiectasis. Accordingly, the 2014 Global Initiative for Chronic Obstructive Lung Disease listed bronchiectasis as the seventh leading comorbidity for COPD (29). In a cohort of Chinese patients, we found similarly that the mortality rate over 5 years for patients with COPD and bronchiectasis was higher than for patients with COPD without bronchiectasis (31). In addition, recent research has shown an inextricable pathophysiological link between bronchiectasis and nontuberculous mycobacterial (NTM) lung disease (32). A study by Mirsaeidi and colleagues (33) found that almost 30% of patients with bronchiectasis had NTM infection. In our retrospective study, we identified 3,857 patients with bronchiectasis in Shanghai, and found 431 patients who had at least

one positive NTM culture, with a separation of 11.2% Among these patients, 192 cases were ultimately diagnosed as having NTM lung disease, accounting for 5% of the sample (34). There is mounting evidence showing that patients with NTMrelated bronchiectasis have a distinct immunologic phenotype that results in a cytokine imbalance and the inability of the host to resist mycobacterial infection (35, 36). As these findings become better defined mechanistically, perhaps by genetic studies, the role of NTM in the genesis of bronchiectasis will likely be clarified. Infecting Organisms Several studies in China have shown that the most common pathogen cultured from the sputum is Pseudomonas aeruginosa in 612 patients with bronchiectasis during exacerbations, accounting for 21.5–735% (20, 37–39) of cases. Recently, Guan and colleagues (40) also reported that P. aeruginosa is the most common organism causing heightened airway inflammation and poor function. Compared with other types of

bronchiectasis, cystic bronchiectasis is likely to present with more bacterial colonization and infection (41). Yang and colleagues (42) used a 16S ribosomal DNA pyrosequencing technique to detect the predominant pathogenic organism during exacerbation of bronchiectasis, and found that it was more effective at detecting the complex bacterial composition of a sputum sample, with results obtained 2 days earlier than regular cultures, allowing for earlier institution of the correct antibiotic. Gao and colleagues (43) published the first prospective study evaluating the incidence and clinical impact of viral triggers of bronchiectasis exacerbation in adults. They reported that respiratory viruses were found in nearly 50% of exacerbations, compared with 20% in the stable state. The most common viruses were coronavirus (39%), rhinovirus (25%), and influenza A/B (25%). Recommendations to Improve Diagnosis and Management Diagnosis Early diagnosis and treatment is thought to be beneficial

in chronic inflammatory airway diseases, such as asthma and COPD. Presently, however, most patients with bronchiectasis are already at a severe stage or having exacerbations when first diagnosed. This is likely due to the very low follow-up rate of these patients in China, as well as a lack of awareness on the part of clinicians on differentiating bronchiectasis from other chronic respiratory diseases. By contrast, patients with tuberculosis tend to detect bronchiectasis in its initial stages, owing to the more routine follow-up visits of patients with tuberculosis. Bronchiectasis should be suspected in any patient with chronic respiratory symptoms, such as daily cough and purulent sputum. In addition, patients often complain of hemoptysis, chest pain, weight loss, and dyspnea according to some research in China (19–21). Investigation of a patient with suspected bronchiectasis should initially aim to establish the diagnosis of bronchiectasis by collecting comprehensive medical

history and chest radiography findings, then to determine the underlying etiology by additional laboratory testing, and finally to evaluate disease severity (13, 44). Sputum analysis may further strengthen a clinical diagnosis. CT imaging, especially HRCT scanning of the chest, has replaced bronchography as the gold standard for detection of bronchiectasis. HRCT imaging is not only capable of demonstrating or ruling out bronchiectasis, but also helps clinicians to evaluate the surrounding lung tissue and exclude other lesions, such as neoplasms (45). Although diagnosing bronchiectasis has become significantly easier with the advent of HRCT imaging, the allocation of CT scanners in China remains imbalanced, insufficiency in some regions coexisting with surplus in others (46). Patients in rural areas or far-western China often cannot be diagnosed promptly and accurately, leading to delayed intervention. Assessing Severity Recently, two scoring systems specific for bronchiectasis

severity have been developed and are gaining attention. The bronchiectasis severity index was derived from and validated by a large, international, multicenter study of 1,310 patients with bronchiectasis, and can identify patients at risk of future mortality, hospitalization, and exacerbations across healthcare systems. It is described as a simple, web-based calculator, which is accessible at www.bronchiectasisseveritycom (47) Martı́nez-Garcı́a and colleagues (48) developed another easy-to-use, multidimensional grading system. Their FEV1, Age, Colonization, Extension of Bronchiectasis and Dyspnea score has proven capable of accurately classifying the severity of bronchiectasis based on prognosis. In China, the appearance of sputum, 24-hour sputum volume, frequency of acute exacerbations, lung function testing, and other clinical variables can be recorded to comprehensively evaluate the patients with bronchiectasis. However, some of these indexes are hard to quantify, and which

matter more in the changes of disease status relies on subjective judgment. Moreover, we should note that, although bronchiectasis AnnalsATS Volume 13 Number 5 | May 2016 PERSPECTIVES severity index and FEV1, Age, Colonization, Extension of Bronchiectasis and Dyspnea score have been developed to assess the severity of bronchiectasis in developed countries, independent validation is still required for Chinese patients. Clinical Management The aims of management of bronchiectasis are to identify and treat the underlying causes, prevent disease progression, maintain or improve pulmonary function, and improve quality of life by reducing daily symptoms and exacerbations. Antibiotics and chest physiotherapy are the mainstay therapies. Other modalities (beyond those for specific associated conditions) may include bronchodilators, corticosteroid therapy, dietary supplementation, and oxygen or surgical therapies (44, 49). A statement on treatment of adult bronchiectasis in China was

first established in 2012 (44). The statement is generally in accord with British Thoracic Society guideline on bronchiectasis, which play an important role in promoting standardized treatment for bronchiectasis in China. Nonetheless, many knowledge gaps and management challenges remain in clinical practice, and there is still a long way to proper implementation of guidelines for both clinicians and patients. Treatment of Exacerbations Treatment of bronchiectasis is vital in preventing declines in patient lung function and quality of life. Presently, the majority of clinical work for respiratory physicians in China is treating patients who have severe exacerbations, with the use of antibiotics, bronchodilators, and expectorants. In general, the duration of antibiotic therapy for mild and moderate illness is 7–10 days. In a follow-up study of 32 patients with exacerbations, intravenous antibiotic therapy for 14 days was also found to be beneficial (50). Although the consensus of

Chinese experts suggests 14-day therapy as well (44), the optimal duration of treatment remains unclear. Broad-spectrum antibacterial agents are preferred for these patients while awaiting sputum microbiology results (51). A multicenter trial from China showed that intravenous levofloxacin with a dose of 500 mg once per day is effective and safe in treating bacterial infections in bronchiectasis, with an effective rate of 87.2% (157/180) (52) In several studies Perspectives from China, bronchoalveolar lavage and local administration by flexible bronchoscopy have also been reported as having safe and therapeutic effects in patients with bronchiectasis with infection (53–57), but there are currently no randomized, double-blind, placebocontrolled clinical trials with long-term follow-up. Ciprofloxacin can be used in patients colonized with P. aeruginosa, with cautious use in the elderly. Our study has shown that remarkable efficacy can also be achieved by using biapenem in the

treatment of bronchiectasis complicated by Pseudomonas infection (58). Combination antibiotics are not recommended except for infections due to strains of Pseudomonas that are resistant to one or more antiPseudomonas antibiotics (including ciprofloxacin) or if the clinician suspects the patient will require many subsequent antibiotic courses to reduce the likelihood of developing drug resistance (49). Maintenance Management Management of clinically stable bronchiectasis has been emphasized in recent reviews and guidelines published by clinicians working in Western countries. Recommendations feature long-term antibiotic therapy, anti-inflammatory therapy, and mucoactive therapy. Balancing clinical benefits against the risk of developing antibiotic resistance, clinicians must tailor therapies to individual patients based on their best clinical judgment and information from the data and guidelines currently available in published literature (59). Recent British Thoracic Society

guidelines suggest that long-term antibiotics should be considered for patients with three or more exacerbations per year as part of a comprehensive management plan (49). However, this approach is currently not recommended in China (44), despite the advent of treatments such as macrolide therapy (60–62), which combines antimicrobial activity with antiinflammatory and immunomodulatory properties (63–66). Internationally, three large randomized clinical trials have investigated the effects of macrolides on bronchiectasis, showing its benefits in reducing exacerbation frequency and sputum volume (67, 68), and increasing the length of time before the first exacerbation requiring antibiotics (69). Several small studies from China have shown consistency in these outcomes. For example, Tsang and colleagues (70) from Hong Kong found that 8-week administration of low-dose erythromycin (500 mg twice a day) improves lung function and sputum volume in patients with bronchiectasis. Gu and

colleagues (71) showed that low-dose azithromycin (250 mg twice weekly) administered over 6 months improved clinical symptoms, sputum microbiology, and lung functions across a sample of 35 patients with bronchiectasis. Another study from China showed similar results for 4 months of clarithromycin treatment (250 mg once a day) (72). Another potential therapy that also merits attention is inhaled antibiotics. A recent meta-analysis of 12 trials suggested that inhaled antibiotics may provide an effective suppressive antibiotic therapy with an acceptable safety profile in adult patients with stable non-CF bronchiectasis and chronic bronchial infection (73). Unfortunately, these therapies cannot be recommended as routine practice before further research is performed in China, highlighting the necessity of increasing attention to the field. Inhaled corticosteroids are being considered for daily use in patients with significant obstructive physiology and evidence of reversibility

suggesting airway hyperreactivity. Benefits have been described in several small studies, including a trend toward improved lung function and reduced exacerbations and sputum, especially in patients with P. aeruginosa infection (74, 75). A recently published trial showed that medium-dose formoterol– budesonide treatment combined in a single inhaler is safer and more effective compared with high-dose treatment with budesonide alone (76). Our own study also suggested similar outcomes for the combined inhalation of salmeterol and fluticasone for patients with bronchiectasis with different degrees of airflow limitation. This treatment has shown to be effective in clinical symptom relief, decreasing the frequency of acute attack, as well as slowing pulmonary function recession in patients with grade III pulmonary function or Pseudomonas colonization (data not shown). However, a review by Kapur and colleagues (77) reported that the evidence supporting the use of inhaled steroids in 613

PERSPECTIVES adults with stable bronchiectasis is insufficient. Although a therapeutic trial may be justified in adults with difficult-to-control symptoms and in certain subgroups, this must be balanced with the risk of adverse events, especially if high doses are used. When prescribing the medication, physicians should also consider the potential complications of inhaler use for hemoptysis. Traditional Chinese medicine is also commonly used in China for the treatment of patients with stable bronchiectasis. As there is no standardized traditional Chinese herbal decoction for stable bronchiectasis, treatment is generally individualized and based on empirical syndrome differentiation. However, a recent pilot study suggested no significant difference between individualized herbal decoction and a control decoction on either symptom score or 24-hour sputum volume in patients with bronchiectasis (78). There is interest in combining traditional medicine with the application of modern

medical technology. For example, Huang and colleagues (79) proposed that combining traditional recipes for bronchiectasis with segmental bronchial lavage may enhance long-term clinical effects of the treatment without compromising safety. Mucoactive therapy is also an important aspect in the management of clinical stable bronchiectasis. Good bronchial hygiene is paramount in bronchiectasis treatment, as it can promote clearance of tenacious sputum and potentially break the “vicious cycle” of the disease. Postural drainage with percussion and vibration is used to loosen and mobilize secretions, and the inhalation of nebulized hypertonic saline and mannitol inhaled as a dry powder improves mucus clearance by reducing its osmolality (80–81). However, correlative studies reported in the Chinese population are rare and should be performed as soon as possible. Surgical Therapy Unilateral and localized bronchiectasis may be amenable to surgical resection in selected instances. A large

retrospective study performed in China showed that resection of bronchiectasis improved symptoms and is a safe procedure with acceptable operative morbidities, mortality, and outcomes (82). Further analysis from the same group reported that key factors for successful surgical treatment include daily sputum volume lower than 30 ml, absence of gramnegative bacteria, and bronchial stump coverage using intercostal muscles or pedicle pleura embedding (83). Lung transplantation can also be a useful intervention in cases of very advanced bronchiectasis. Other types of treatment, including self-management, suitable airway clearance techniques, and general supportive treatment, are also important for patients with bronchiectasis. Although treatments are diverse, many have not been well validated in Chinese patients, and considerable work is needed to improve prognosis for patients with bronchiectasis in China. Recommendations for Future Research Physicians aiming to improve the diagnosis and

treatment of bronchiectasis in China face many challenges, chiefly the lack of a concerted effort to perform national studies on the disease. The prevalence and geographic distribution of bronchiectasis in China is largely unknown and almost certainly underestimated. The etiological diagnosis of bronchiectasis and the treatment of stable bronchiectasis are both commonly overlooked. To improve patient care and prognosis, more attention must be paid to this long-neglected disease. Well conducted, nationwide epidemiological studies are urgently needed to estimate the true burden of the bronchiectasis, region by region, to identify potentially effective preventive interventions and to improve the allocation of China’s public health resources for pediatric and adult patients who suffer from this disease. References 1 Barker AF. Bronchiectasis N Engl J Med 2002;346:1383–1393 2 Keistinen T, Säynäjäkangas O, Tuuponen T, Kivelä SL. Bronchiectasis: an orphan disease with a

poorly-understood prognosis. Eur Respir J 1997;10:2784–2787. 614 As the main causes of bronchiectasis in China (e.g, tuberculosis) differ from those in Western countries, large studies of etiology focusing specifically on Chinese populations are necessary. Clearly, more intensive investigation of the underlying causes of bronchiectasis in China, rather than simply labeling unidentified cases as “idiopathic bronchiectasis,” is needed to improve diagnostic accuracy and therapeutic specificity. The high proportion of patients labeled with an idiopathic etiology also reflects our poor understanding of the disease. More studies are needed to customize treatment recommendations for China. These studies should recognize the etiologies that are most prevalent in the country as well as variations in the availability of health care resources across the country. More research is needed in particular on the role of traditional medicine therapies alone or in combination with modern

medical therapies. Comprehensive guidelines on diagnosis of management of bronchiectasis in children as well as adults should be developed or expanded and updated regularly. Public health authorities should consider the distribution of HRCT scanners and microbiology laboratories in China in accordance with the prevalence and geographic distribution of patients who suffer from bronchiectasis. Educational programs are also needed to raise awareness of the public regarding bronchiectasis and the importance of continuous monitoring and maintenance therapy for patients with moderate or severe disease. n Author disclosures are available with the text of this article at www.atsjournalsorg Acknowledgment: The authors thank Mr. Arthur Zhang (volunteer from Canada) for his language editing work. 3 Xu JF. Bronchiectasis: an common disease going unheeded [article in Chinese]. Int J Respir 2013;33:1601–1604 4 Zhou YM, Wang C, Yao WZ, Chen P, Kang J, Huang SG, Chen BY, Wang CZ, Ni DT, Liu SM, et

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