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The primary care management
of Bronchiectasis
Andrew White
Consultant Respiratory Physician
Gloucestershire Royal Hospital
Respiratory Lead GHNHSFT
COPD Lead GHNHSFT
Sally King
Respiratory Specialist Physiotherapist
Gloucestershire Care Services
When to consider the diagnosis
How to make the diagnosis
What is the role of secondary care
How to manage patients in the
community
What is Bronchiectasis?
Bronchiectasis is a condition in which symptoms of
persistent or recurrent bronchial sepsis related to
irreversibly damaged and dilated bronchi
Usually separated into cystic fibrosis (CF) associated
bronchiectasis and Non-CF bronchiectasis
Epidemiology
 True prevalence is unknown
 Symptoms often overlap with other respiratory diagnoses
 Increasing use of CT can show evidence of bronchiectasis
when no symptoms are present
 Often a secondary phenomenon to more serious pulmonary
pathology
 Prevalence increases with age
 In USA 4.2 per 100,000 18-34
 increasing to 271.8 per 100,000 in >75
 Little reliable epidemiological data in UK
 How many patients in Gloucestershire?
Causes of bronchiectasis?
 Structural lung syndromes
 Toxic injury (inhalation, chronic aspiration, Reflux)
 Obstruction to a single bronchus (tumour/foreign body)
 Airways disease (Asthma/COPD/AATD)
 Mucociliary dysfunction (ciliary dyskinesia, Channelopathies)
 Allergic Bronchopulmonary Aspergillosis
 Immunodeficiencies
 Post infectious
 Non-tuberculous mycobacterial infection
 Associated with systemic disease
 Inflammatory bowel disease
 Connective tissue disease
 Idiopathic
COPD and Bronchiectasis
 In 2 studies 29% and 50% of patients diagnosed with
chronic bronchitis and COPD had evidence of
Bronchiectasis
 Patients with COPD and bronchiectasis had more severe
exacerbations and increased sputum inflammation than
those with COPD alone, matched for severity
 Does COPD cause bronchiectasis or does bronchiectasis
cause fixed airflow obstruction?
 Probably both
 Is it COPD or is it bronchiectasis?
 Is it Asthma?
Symptoms of bronchiectasis
 Chronic cough with sputum
 Recurrent “chest infections”
 Recurrent “pleurisy”
 Breathlessness and wheeze
 Green or yellow sputum in stable clinical state
 Fatigue
When to consider bronchiectasis
in adults
 Productive cough with:
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Young age at presentation
Symptoms over many years
Especially if never smoker
Daily sputum production
Haemoptysis
Sputum positive for pseudomonas
 Unexplained haemoptysis or cough without sputum
 Patients with particularly troublesome COPD or asthma
with frequent exacerbations
How to diagnose bronchiectasis
 Computed Tomography (CT scan)
 Must be with a high resolution protocol (HRCT)
 Contrast not necessary
 Bronchi > accompanying bronchial artery
 Bronchial wall thickening (harder to define)
 May help to define aetiology
 ABPA (proximal), CF, Tracheobronchomegaly
Initial assessment to establish
cause and severity
 Routine tests
 Serum immunoglobulins and protein electrophoresis
 Sputum examination (state bronchiectasis on form)
 Spirometry
 Other tests to consider
 Total IgE and RAST to Aspergillus
 If joint problems or systemic symptoms consider Rheumatoid Factor/ANA
 Sputum for AFB
Who should be referred to secondary
care
 Patients with chronic Pseudomonas or Staphylococcus in
sputum
 Deteriorating patients with declining lung function
 Recurrent exacerbations >3yr
 Patients requiring prophylactic antibiotics (oral or nebulised)
 Patients with ABPA, rheumatoid associated bronchiectasis,
immunodeficiency, inflammatory bowel disease and primary
ciliary dyskinesia
 Patients with severe advanced disease and those considering
lung transplantation
Management principles
 Indentify and treat underlying causes to prevent
progression
 Maintain or improve lung function
 Improve quality of life by reducing daily symptoms and
exacerbations
Airway clearance
 Patients should see a specialist respiratory
physiotherapist to be taught airway clearance
techniques
 Active cycle of breathing technique
 Postural drainage
 Oscillating positive expiratory devices
 Forces expiration technique
 Autogenic drainage
 Manual techniques during exacerbations
Other aids for airway clearance
 Nebulised normal saline
 Nebulised hypertonic saline
 Nebulised bronchodilators
 Exercise and pulmonary rehabilitation
 ?mucolytics/inhaled manitol
Other drugs
 Bronchodilators if airflow obstruction present
 No evidence to support inhaled corticosteroids unless
there is concomitant asthma
 Use lowest dose that controls symptoms
 Possible link between high dose steroids and nontuberculous mycobacteria
 No evidence for leukotreine receptor antagonists
Antibiotics
 Sputum samples should always be sent before commencing
antibiotics
 Empirical antibiotics should be started while waiting for
results of sputum culture
 Amoxycillin 500mg tds
 Clarithromycin 500mg bd
 Amoxycillin 1g tds or 3g bd if severe bronchiectasis associated
with Haemophilus influenzae (Doxycycline 100mg bd for pen
allergic)
 Ciprofloxacin 750mg bd for Pseudomonas
 Failure to respond should prompt repeat sputum tests
 IVs should be considered when patients particularly unwell,
have resistant organisms or fail to respond to oral therapy
Duration of antibiotics
14 days
Antibiotics in special situations
 Combinations of IV antibiotics in those with
pseudomonas not responding to oral Ciprofloxacin
 MRSA treat with 2 oral antibiotics or 1 IV agent
 If >= 3 exacerbations/yr consider long term antibiotics
 Macrolides in low dose probably best if tolerated
 Nebulised antibiotics in pseudomonas and can be used in
selected cases due to other pathogens
Simple steps in primary care
 Suspect Bronchiectasis and consider CT scan
 If positive
Check sputum
Refer for chest physiotherapy for sputum clearance
Review patient with patient management plan
Give 14 day course of rescue antibiotics based on last
sputum result
 Consider secondary care referral if
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 Complicated comorbidities or severe disease
 If pseudomonas or Staphylococcus in sputum
 Very frequent exacerbations despite adequate antibiotic
shoices and duration based on microbiology
Organisation of care – the vision
 Developing a Non CF specialist bronchiectasis service
 Cross county multidisciplinary service
 Supported by integrated respiratory nursing team to
reinforce self management and rapid access to specialists
 Easy access to pulmonary rehabilitation and physiotherapy
 Links to community IV service and ambulatory day unit
 Supported by regular MDT meetings
 Pathways developed with clinical immunology and
microbiology
 Supporting a more responsive patient centred approach
Case Study
 Mrs B is a 56 year old with a new diagnosis of
bronchiectasis.
 Diagnosis made by GP following GP organised HRCT
 Referred to the Bronchiectasis MDT
 Mrs B was seen by a respiratory specialist
physiotherapist who taught airway clearance
techniques, gave Mrs B disease education and gave a
self management plan
 Exacerbations managed effectively with patient
instigating antibiotic therapy
 1 year after diagnosis; exacerbation not responding to
treatment
 Self referral to the Bronchiectasis MDT
 Sputum specimen sent
 Antibiotic therapy rationalised accordingly
 Admission required for IV therapy; arranged as a
planned admission through the MDT
 Completion of IV therapy in the community
 Ongoing support in the community by MDT nurses and
physiotherapists