Bronchiectasis is a chronic pulmonary condition that is clinically characterised by a vicious cycle of recurrent lower respiratory tract infections and airway inflammation (1, 2). Globally, there is emerging evidence to suggest that presence of bronchiectasis is associated with overall higher mortality rates (3–9). In the Australian context, approximately 3.3% of the population self-identify as of Aboriginal and/or Torres Strait Islander descent (from here on “Indigenous” is used to refer to global First nations populations, while “Aboriginal Australian/ population/patients/people” is used to specifically refer to Australians First Nations population) and the Northern Territory (NT) of Australia has the highest proportion of Australian Aboriginal people in comparison to all other Australian states and territories (10). Chronic respiratory disorders are reported to be highly prevalent among the adult Aboriginal Australian population (11, 12), and more so among those residing in the NT of Australia. In particular, prevalence of bronchiectasis is noted to be substantially higher among Aboriginal Australians compared to non-Aboriginal Australians (13, 14). Furthermore, hospital admission rates and overall mortality secondary to chronic respiratory disorders, including for bronchiectasis, are significantly higher among adult Aboriginal Australians in comparison to their non-Aboriginal counterparts (15–20).

In other diverse non-Indigenous ethnic populations, studies have demonstrated several factors which influence survival and mortality amongst patients with bronchiectasis such as, but not limited to lung function parameters, sputum microbiology, body mass index (BMI) and therapeutic interventions such as respiratory airway clearance (21–23). However, despite the high prevalence of bronchiectasis among Aboriginal Australians, there is scant evidence in the literature determining if these same factors are associated with survival or mortality in this population. The high prevalence of comorbidities, reduced lung function parameters (11–20, 24, 25), and unique environmental context of Aboriginal Australians which may predispose them to colonisation by other micro-organisms may indicate that other factors should be considered when predicting mortality risk. Hence, it is reasonable to explore those potential clinical parameters that may be influential for survival or mortality among adult Aboriginal Australians with bronchiectasis. This may lead on to identifying relevant clinical data for future interventions which would aid in reducing on-going adverse health consequences amongst adult Aboriginal patients suffering from bronchiectasis. Therefore, the aim of this study is to investigate and identify relevant clinical parameters that may indicate or influence survival and mortality in an adult Aboriginal Australian cohort diagnosed to have bronchiectasis over a 10-year study period (2011–2020) in the Top End Health Service (TEHS) region of the NT of Australia.

To the best of the authors knowledge, this is the first study to demonstrate potential clinical parameters that may influence survival or future mortality amongst an adult Aboriginal Australian population, particularly among those residing in the Top End, NT of Australia. This study has illustrated that increasing age, prior need for ICU admissions, and prior positive sputum microbiology demonstrating Pseudomonas may increase the risk of mortality. On the other hand, a higher BMI, better lung function on spirometry and prior positive sputum microbiology demonstrating Haemophilus may be associated with a favourable outcome.

Across various ethnically diverse non-Indigenous populations, hospitalisation and mortality data have been well documented in the literature (3–9, 21–23, 28–31). Although the available reports suggest that the burden of chronic respiratory disorders is much higher among global First Nations Indigenous people (including higher heath care utilisation and hospital admission rates), there is scant evidence pertaining to factors that may predict mortality or survival among First Nations Indigenous people (20, 32–38).

In comparison to international bronchiectasis cohorts, the current study cohort showed some unique clinical features. Most notably, the median age of death was 59.2 years, whereas in international data most deaths are among those aged >70 years (3). However, similar to as has been reported previously (3, 22, 39), we also noted a lower BMI in the deceased group at a median 22 kg/m². The reason for a lower BMI being associated with mortality is unclear. It is reasonable to speculate that the resting energy expenditure and higher basal metabolic rate due to chronic respiratory tract infection, alongside chronic airway inflammation may be contributing to a lower BMI among patients with bronchiectasis as observed among patients with COPD (40, 41).

Among patients with bronchiectasis, multimorbidity, and especially respiratory comorbidities have been associated with significantly greater morbidity and mortality (4–6). Coexisting COPD in particular is shown to have a much worse prognosis (42). Among our cohort there was a significant prevalence of COPD, particularly among the deceased cohort at 91%, however, 79% of surviving patients were also noted to have COPD. This significant presence of disease amongst both surviving and deceased cohorts limits its ability to be used as a prognostic marker as it is in other populations.

In relation to laboratory parameters, lower lung function values, presence of pseudomonas on sputum microbiology and CT evidence of multi-lobar involvement are shown to be associated with poorer long-term prognosis among patients with bronchiectasis (3–9, 21). Among the deceased cohort in our study, lung function values were reduced (medians for FVC 45 vs. 53%, FEV₁ 29 vs. 40%, FEV₁/FVC ratio 57 vs. 66 deceased vs. surviving, respectively) though this did not reach statistical significance. Although, this may not be statistically significant, it may have clinical relevance. Similar to what is observed in previous reports (6, 43), Pseudomonas was cultured more commonly among deceased patients than those surviving (45.8 vs. 27.6%). However, in our study in addition to pseudomonas, presence of non-Aspergillus fungi on sputum microbiology was significantly more common among deceased patients (64.8 vs. 46.3%). Further prospective studies may be useful to explore microbiology data in this population. The effects of therapeutic interventions, such as inhaled antibiotics (44) on survival and mortality has not been widely explored in the adult Aboriginal Australian patients with bronchiectasis. Further studies may be useful to investigate the beneficial effects of therapeutic modalities such as inhaled antibiotics, including N- Acetylcysteine in Indigenous patients (45). Use of ICS among patients with bronchiectasis is controversial (46, 47). Nonetheless, in our study more than half of the patients recorded an ICS prescription. ICS did not show any positive or negative association with mortality in our study. LABA and LAMA prescription however, was associated with reduced odds of mortality, and LABA prescription with an older age at death in multivariate regressions, though statistical significance of both was attenuated on multiple hypotheses adjustment. Nevertheless, in view of previous studies demonstrating positive impact on the use of LAMA among patients with bronchiectasis (48, 49), it is reasonable to assume that use of LAMA may have some favourable impact on survival in our study patients.

Among Aboriginal Australian patients, hospital admission rates secondary to respiratory conditions are reported to be higher than among non-Aboriginal Australian patients (50). In our study we noted that among the deceased cohort there was a significantly longer median time spent in hospital (34 compared to 12 days). Furthermore, a greater proportion among the deceased cohort required ICU care at some point (42 vs. 22%). ICU visits were one of the few parameters to retain a statistically significant association with increased mortality following multiple hypothesis correction, indicating that this factor should be considered as a marker for poor long-term prognosis among Aboriginal patients with bronchiectasis.

This study has demonstrated that several classic clinical parameters used for predicting survival, exacerbations/hospital admissions or mortality amongst adults with bronchiectasis may not be as applicable to Aboriginal Australians as in other non-Indigenous population (51–53). This is due to a significant background presence of comorbidities, high smoking rates, reduced lung function parameters, significantly younger age and generally lower BMI within this cohort. Given the disparity noted in some of the clinical parameters in comparison to other ethnic non-Indigenous patients as noted in this study and in general (54–69), moving forwards, it may be time to invest in establishing Indigenous specific bronchiectasis assessment and severity classification tool. This will be very valuable to identify high risk adult Aboriginal patients with bronchiectasis in order to guide clinical decision making and early interventions to reduce overall morbidity and mortality.

This study’s outcomes pertain to Aboriginal Australian people residing in the TEHS region of the NT of Australia and the results represented in this study cannot be generalised to the wider Aboriginal populations in Australia or for Indigenous people globally. Spirometry data and BMI values were not available for all patients, hence would have introduced a bias in the outcome observed. We also did not have data to represent therapeutic interventions other than inhaled pharmacotherapy use and moreover, we did not have dates of prescription of inhaled pharmacotherapy, nor to assess dosages or adherence to medication which would be significant confounders. Furthermore, with a high presence of COPD, CAD, and CKD in this population, which was observed among both deceased and surviving cohorts, it is uncertain if bronchiectasis is a primary or a secondary cause contributing to mortality. Nonetheless, this is the first study to assess factors predicting survival and mortality in an Aboriginal population, which could be useful to compare for any future similar studies in other Indigenous global populations.

Among adult Aboriginal Australian patients diagnosed to have bronchiectasis, advancing age, cultured Pseudomonas and prior ICU visits are strongly associated with mortality. Higher BMI, better lung function parameters, prior positive sputum microbiology for Haemophilus and use of LABA and LAMA may have a favourable effect. However, further studies are warranted in larger cohorts to determine if these findings are replicable. Furthermore, it is clear that efforts must be made to establish bronchiectasis severity assessment tools specific to Indigenous people to stratify high risk patients, so that interventions can be implemented to prevent mortality.

The original contributions presented in the study are included in the article/Supplementary material, further inquiries can be directed to the corresponding author.

The studies involving humans were approved by the Human Research Ethics Governance/Committee of the TEHS, NT and Menzies School of Health Research (Reference: HREC; 2019-3547). The studies were conducted in accordance with the local legislation and institutional requirements. The Ethics Committee/Institutional Review Board waived the requirement of written informed consent for participation from the participants or the participants’ legal guardians/next of kin because Due to this research being a retrospective study–informed consent was waived by the Ethics Committee.

SH: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review and editing. CG: Conceptualization, Data curation, Investigation, Methodology, Resources, Software, Validation, Visualization, Writing – original draft, Writing – review and editing. SR: Conceptualization, Data curation, Investigation, Resources, Visualization, Writing – review and editing. DE: Conceptualization, Data curation, Investigation, Resources, Validation, Visualization, Writing – review and editing. AA: Conceptualization, Data curation, Investigation, Methodology, Resources, Software, Validation, Visualization, Writing – original draft, Writing – review and editing. TH: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review and editing.