Bronchiectasis Flashcards
Clinical features
Chronic cough worse on waking
Profuse purulent offensive yellow-green sputum (advanced cases)
Investigations
Blood tests:
. Immunoglobulins – IgG, IgA, IgM
. Total IgE
. Aspergillus serology – IgE (RAST) and IgG (precipitins)
Chest X-ray:
. Normal or bronchial changes
. Often abnormal, but not usually diagnostic.
. A normal chest x‑ray does not exclude the diagnosis
. It is important to exclude other causes of chronic cough, e.g.
malignancy, tuberculosis.
Sputum examination;
–for resistant pathogens
–to exclude TB
Sputum sampling:
. Sample when clinically stable to provide baseline soon after
diagnosis.
. Arrange routine bacterial culture and 3 samples for
mycobacterial cultures to assess for non-tuberculous
mycobacteria as baseline.
Spirometry testing:
. FEV1 < 50% is a marker of severe disease and poor outcomes.
. Spirometry may be normal, obstructive, or restrictive
High resolution CT Chest:
. the gold standard to establish diagnosis.
. can show bronchial wall thickening
. Request must be made on the recommendation of a hospital
respiratory physician or a radiologist report advising chest CT.
. Ideally perform when the patient is clinically stable, and not in
the setting of an acute exacerbation.
Bronchograms: very unpleasant and used only if diagnosis in doubt or possible localised disease amenable to surgery (rare)
About bronchiectasis
Bronchiectasis is an abnormal dilatation and distortion of bronchi and bronchioles.
It is characterised by chronic productive cough, chronic bacterial infection, neutrophilic inflammation, and recurrent pulmonary exacerbations.
A vicious cycle of infection, inflammation, and airway damage results in airway destruction and distortion.
It is underdiagnosed in adults and children. Delays in diagnosis are common.
It is associated with reduced quality of life, increased risk of hospital admission and re-admission, and increased mortality.
It can be misdiagnosed or missed because
the clinical features overlap with asthma, COPD, sinusitis, gastro-oesophageal reflux, and common upper and lower airway infections.
Consider a diagnosis of bronchiectasis if:
- Chronic cough;
Bronchiectasis is more likely if chronic cough is associated with:
1. daily sputum production with recurrent infection and isolation of respiratory pathogens in sputum.
These include Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, Staphylococcus aureus or Pseudomonas aeruginosa.
Pseudomonas infection is an important predictor of increased exacerbations, admission to hospital, and reduced quality of life.
2. history of symptoms over many years.
3. no history of smoking. - Frequent courses of antibiotics for recurrent lower respiratory tract infections.
- COPD (or suspected COPD) with frequent or prolonged exacerbations.
- unexplained haemoptysis, usually recurrent blood-streaked sputum. Consider other causes of haemoptysis, e.g. lung cancer, pulmonary tuberculosis.
- Māori and Pasifika patients with persistent cough and sputum.
- finger clubbing.
Check for specific secondary causes or associations
In up to 50% of cases of bronchiectasis, no underlying cause is identified (idiopathic bronchiectasis).
In about 40%, the cause is post-infective (especially childhood infections):
. bacterial and viral pneumonia
. pertussis
. tuberculosis
. adenovirus
. measles
Bronchiectasis may be associated with:
. allergic bronchopulmonary aspergillosis (ABPA) and asthma
. congenital syndromes and abnormalities, e.g. Kartagener’s syndrome
. cystic fibrosis
. COPD
. gastroenterological reflux and aspiration
. sinusitis
. inflammatory bowel disease
. rheumatoid arthritis and other connective tissue disorders
. mucociliary dysfunction
. immune deficiency, especially immunoglobulin deficiency
. post-obstruction, e.g. with unrecognised foreign body
Management
Explanation and preventive advice
Postural drainage e.g:
- lie over side of bed with head and thorax down for 10–20 mins 3 times/d
Antibiotics according to organism
- —it is important to eradicate infection to halt progress of the disease.
- Initially use amoxycillin 500 mg (o) tds or roxithromycin for 2–3 wks
Bronchodilators if evidence of bronchospasm
Management depends on underlying cause of bronchiectasis.
1) Make the diagnosis with high resolution CT Chest.
2) Consider requesting either:
a. pulmonary rehabilitation, improves quality of life and exercise capacity, and reduces cough and sputum volumes
or
b. Physiotherapy
3) Vaccinations;
a. Influenza vaccination is recommended.
b. Pneumococcal vaccination is recommended but not funded for adults with bronchiectasis:
. If the patient is vaccination naïve, give 13‑valent conjugate vaccine first, then 23‑valent polysaccaride vaccine ≥ 8 weeks later.
. If the patient has previously been given 23‑valent vaccine, give 13‑valent vaccine 1 year after.
. Give 13-valent vaccine once only. If the patient has previously been given 13-valent vaccine, do not give again.
. Give 23-valent vaccine at minimum 5 year intervals, with maximum 3 vaccinations in the patient’s lifetime.
. See also Ministry of Health – Immunisation Handbook 2017: Pneumococcal disease [2nd ed., Mar 2018, Ch 15]
4) Consider homes and heating – consider housing and financial support.
5) Smoking cessation
6) Respond to acute exacerbations:
a. Treat with antibiotics.
b. Encourage sputum clearance. If struggling with sputum retention, consider physiotherapy, stating that referral is for a respiratory physiotherapist.
7) If the patient has ≥ 3 exacerbations per year, request non-acute respiratory assessment for consideration of long-term antibiotics (oral macrolides).
8) If evidence of airflow obstruction, consider inhaled medications
Acute exacerbations
. Defined as > 48 hours deterioration in ≥ 3 key symptoms (increased cough, increased sputum volume or purulence, breathlessness, fatigue, or haemoptysis) with or without systemic disturbance.
. When well, patients often have daily cough with sputum production, and positive sputum cultures. These are not indicators for antibiotic treatment.
Request acute respiratory assessment if any of the following:
Large or persistent haemoptysis, as the patient may need bronchial artery embolisation or surgery.
Acute exacerbation that is not responding to oral antibiotics and requires intravenous antibiotics (including for P. aeruginosa).
Request non-acute respiratory assessment if any of the following:
. Persistent symptoms.
. Spirometry shows moderate to severe airflow obstruction.
. Significantly impaired quality of life.
. Recurrent exacerbations (≥ 3 a year) in spite of appropriate community treatment.
. P. aeruginosa cultured in sputum.
. Considering long-term antibiotics.
. Bronchiectasis associated with rheumatoid arthritis, immune deficiency, or inflammatory bowel disease.
. Bronchiectasis associated with significant upper airway symptoms e.g., recurrent sinusitis and polyps. Consider a dual request for non-acute respiratory assessment and non-acute ORL assessment.
. Clinically significant bronchiectasis, and resides in Counties Manukau or Waitemata.
. Seek respiratory advice if sputum culture grows non-tuberculosis mycobacteria.
