Bronchiectasis

Question 1

What are the bronchiectasis symptoms?

Answer 1

-Chronic cough
-Chronic sputum production (frankly purulent)
-Recurrent chest infections
-Fatigue/ malaise/ chest pain/ poor QOL

Question 2

Prevalence of bronchiectasis

Answer 2

-Rising 2004 to 2013
-Increased to 16 above
-10 per thousand

Question 3

Underlying causes of bronchiectasis

Answer 3

-Past infection: most common aetiology after no cause (TB, pneumonia, whooping cough, measles)
-Immune defects (immunoglobulin deficiency)
-Connective tissue disease (RA, lupus)
-Fungus= asperges fumagatus/ asthma
-Ciliary defects
-IBD
-Aspiration
-Congenital

Question 4

What do people with bronchiectasis need to be investigated for?

Answer 4

-Allergic bronchopulmonary aspergillosis
-Common variable immunodeficiency
-Cystic fibrosis if indicated

=Specific and treatable

Question 5

Microbiology of sputum

Answer 5

Organism found 75%
Mycobacteria 2-30%
1. H. influenzas (38.6%)
2. P. aeruginosa (21%)
3. S. aureus (12.4%)
4. M. catarrhalis (11.4%)
5. S. pneumoniae (9.7%)
6. Others (9.3)

Question 6

Bronchiectasis with p. aeruginosa

Answer 6

-Poor QOL
-More exacerbations
-More hospital admissions
-Higher mortality

Question 7

When should patients with bronchiectasis have sputum culture?

Answer 7

-When clinically stable at least once a year
-Start of an exacerbation before starting antibiotics
-Empirical antibiotic treatment ASAP (not await the results)

Question 8

Diagnosis of bronchiectasis

Answer 8

-Confirmed by chest CT scan (1mm slices)- signet ring sign
-CXR

Question 9

What demonstrates severity of bronchiectasis?

Answer 9

-Degree of bronchial dilatation
-Number of bronchopulmonary segments with emphysema
-BRICS (1 mild, 2-3 moderate, 4-5 severe)
-Free elastase increased (neutrophils)

Question 10

Clinical assessment of bronchiectasis

Answer 10

-Sputum purulence
=Mucoid
=Mucopurulent
=Purulent

Question 11

Bronchiectasis Severity Index Scoring

Answer 11

-Score range 0-26
=Mild 0-4
=Moderate 5-8
=Severe 9+

RISK FACTORS
-Age
-BMI<18.5
->3 lobes involved or cystic bronchiectasis
-FEV1% predicted
-Hospital admission before study
-Exacerbations before study >3
-Dyspnoea MRC score
-Pseudomonas colonization
-Colonisation with other organisms

Question 12

Comorbid diseases with bronchiectasis

Answer 12

-Asthma
-COPD

-HIV
-RA
-Connective tissues disease
-IBD
-Bone marrow transplant

Question 13

What is bronchiectasis an idependant risk factor for?

Answer 13

-Vascular disease
=CHD
=Stroke

-Usually after exacerbation

Question 14

BTS Guidelines 2010 for Bronchiectasis treatment of exacerbation

Answer 14

-Antibiotics recommended when:
=Acute deterioration (usually over several days)
=Worsening local symptoms (cough, increased sputum volume or change of viscosity, increased sputum purulence with or without increasing wheeze, breathlessness, haemoptysis)
=Systemic upset

Question 15

Indications for IV antibiotics

Answer 15

-IV antibiotics for 14 days
=Hospital admission as severe exacerbation
=Failure of an appropriate oral antibiotic
=Has a pathogen only responsive o IV antibiotic therapy (P. aeruginosa)

Question 16

Bronchiectasis treatment at home

Answer 16

-Home IV antibiotic treatment for exacerbations (midline catheter/ porta catheters)
-Respiratory nurse specialists
=Assessment of safety to deliver self-administered therapy and baseline assessment day 7 and 14

Question 17

Physiotherapy in bronchiectasis

Answer 17

-Postural drainage
=Active cycle of breathing
=Positive expiratory pressure
=Oscillatory positive expiratory pressure devices (PEP)- acapella and flutter valves
-Chest wall percussion

Question 18

Adjuncts to physiotherapy

Answer 18

-SABA/ 0.9% saline nebulised= more sputum yield

Question 19

Long term bronchiectasis treatment strategy

Answer 19

-If airways obstructed:
=Salbutamol/ SABA
=Anticholinergic (Atrovent)

-Short acting first, long acting if significant breathlessness and response to SA agents

-Anti-infectives= macrolides long-term reduces exacerbations, improve QOL, maintains FEV1 but more GI side effects

Question 20

What needs to be considered when deciding on long-term macrolides?

Answer 20

-Tolerability
=Hearing impairment (middle ear)
=GI side effects
=Potential CV effects

-Ecological
=Resistance to S. pneumoniae
=Impact on environmental mycobacterial infection
=Influence on lung microbiome

-Other
=Optimal drug/dose selection and duration of therapy
=Drug interactions (statins)

Question 21

Use of inhaled/nebulised antibiotics and reduced bacterial load

Answer 21

1. Tobramycin/ Gentamycin?
2. Ciprofloxacin
3. Aztreonam
4. Colistin
5. Amikacin

Bronchospasm?

Question 22

Target group for LT inhaled antibiotics

Answer 22

-Chronic P. aeruginosa or resistance
-Intolerance or lack of effect with macrolides
-Gentamicin/ colomycin