Respiratory: bronchiectasis Flashcards
What is the most frequent pathogen in bronchiectasis?
- Haemophilus influenzae
- pseudomonas aeruginosa
what causes bronchiectasis?
- inflammatory damage to the airways
*most common cause is previous severe lower respiratory tract infection e.g. pneumonia, pertussis, pulmonary tuberculosis, mycoplasma, influenza, or other viral infection.
when should bronchiectasis be suspected?
- persistent purulent sputum
- risk factors for bronchiectasis
- cough >8 weeks, especially with sputum production/Hx of trigger
- RA with chronic productive cough
- COPD with frequent exacerbations (>=2 a year) or with psuedomonas positive culture
- Severe asthma / poor control
- IBD and chronic productive cough
What are other causes of bronchiectasis (severe LRTI is most common)?
- Aspiration injury.
- Chronic obstructive pulmonary disease, asthma.
- Disorders of mucociliary clearance.
- Immunodeficiency.
- Endobronchial tumours.
- Allergic bronchopulmonary aspergillosis (ABPA).
- Connective tissue disorders — rheumatoid arthritis.
- Inflammatory bowel disease — for ulcerative colitis or Crohn’s disease (UC more common).
What investigations should be done in suspected bronchiectasis?
- sputum culture
- CXR (exclude other pathology, can confirm if severe)
- spirometry - assess airflow obstruction, identify co-existent COPD/asthma
- oxygen sats
- FBC incl differential WCC
- BMI
- Refer all to respiratory to confirm the diagnosis in 2ry care (HRCT), and find underlying cause, and treatment
Which investigation is done in 2ry care to diagnose bronchiectasis?
High-resolution computed tomography (HRCT) (thin section scanning)
which investigations are done in 2ry care to determine underlying cause of bronchiectasis?
- CF - (sweat chloride or gene) all children, adults <40, or older if featured of CF
- screening for gross antibody deficiency -IgG, IgA, IgM - all people
- IgE, and skin prick to aspergillus (exclude ABPA)
- test for primary ciliary diskinesia
Which patients with bronchiectasis should be followed up in 2ry care?
- three or more exacerbations in a year.
- Chronic Pseudomonas aeruginosa, methicillin-resistant Staphylococcus aureus, or non-tuberculous mycobacteria colonization.
- Deteriorating bronchiectasis with declining lung function or advanced disease.
- Allergic pulmonary aspergillosis.
- Long-term antibiotic therapy.
- Associated rheumatoid arthritis, immune deficiency, inflammatory bowel disease, or primary ciliary dyskinesia.
- considering lung transplantation.
What are the clinical features of bronchiectasis?
- Daily expectoration of large volumes of purulent sputum (75% of people).
- Dyspnoea (60% of people).
- Fever.
- Fatigue, reduced exercise tolerance.
- Haemoptysis that can be frank (up to 10 mL) or massive (more than 235 mL) (26–51.2%).
- Rhinosinusitis.
- Weight loss.
- Chest pain that is present between exacerbations and is usually non-pleuritic (19–46.3% of people).
- Sputum colonization with P. aeruginosa.
- Young age at presentation.
- History of symptoms over many years.
- Absence of smoking history.
How should patients with bronchiectasis be followed up in 1ry care?
all children should be reviewed in 2ry care
- annual review:
- symptoms & impact
- BMI (if <20 - get nutritionist advice)
- exacerbation frequency - if 3 or more exacerbations a year- refer back to resp (may get prophylactic abx)
- sputum sample
- MRC scale
- spirometry
- O2 sats
- compliance with sputum clearance (refer physio if not been taught)
- Imms - strep pneumoniae and flu
When should those with infective exacerbation of bronchiectasis be admitted to hospital?
- significant comorbidities
- psychosocial issues
- Need IV ABX - sepsis/resp failure:
- cyanosis
- confuction
- severe SOB
- peripheral oedema
- temp >=38
How should infective exacerbation of bronchiectasis be treated in 1ry care?
- consider pneumonia
- send sputum before starting ABX
- then start abx without delay for 7-14 days
- airway clearance techniques
- review culture results and amend ABX
- trial LABA if significant breathlessness
Consider home rescue ABX
If on long term abx - amend these once recovered - based on sputum culture and inform resp
Which ABX should be used for acute exacerbation of bronchiectasis?
- previous cultures should guide
- if no culture results available - amoxicillin 500mg TDS for 7-14 days
- if pen all: clarithromycin 500mg BD for 7-14 days or doxycyline 200 then 100mg OD 7-14 days
- If at higher risk of Rx failure: co-amoxiclav 625mg 7-14 days. or in pen all - levofloxacin 500mg once or BD for 7-14 days.
what antibiotics should be given for a new pseudomonas aeruginosa positive sputum culture in acute infection ?
Ciprofloxacin 500 mg twice daily (or 750 mg twice daily in more severe infections) for 2 weeks
second line: IV ABX (antipseudomonal beta-lactam ± aminoglycoside) for 2 weeks then 3 months nebulised colistin/gentamicin/tobramycin
What are the first line treatments for bronchiectasis abx prophylaxis?
Azithromycin 500 mg three times a week, or
Azithromycin 250 mg daily, or
Erythromycin ethyl succinate 400 mg twice a day.
In people with concurrent Pseudomonas aeruginosa infection, first-line therapy is inhaled colistin.
What tests should be done before commencing prophylactic oral macrolides?
- ecg to assess QTC
- baseline LFTs
- sputum culture, including Non tuberculous mycobacteria (NTM) do not use macrolide if NTM identified
- explain adverse effects: GI upset, hearing and balance disturbance, QTprolongation, micro resistance
What examination findings can be seen in bronchiectasis?
- coarse crackles, especially in the lower lung zones
- wheeze
- large airway rhonchi (low pitched snore-like sounds)
- finger clubbing.
Eradiation therapy with ABX for 3 months is recommended for which bronchiectasis patients?
Eradication therapy is only recommended for patients who have a new infection with Pseudomonas aeruginosa (if they remain infected after 14 days oral ciprofloxacin)
How many exacerbations in a year would trigger consideration of long term ABX for bronchiectasis?
guidance recommends offering long-term antibiotics for adults with bronchiectasis who have three or more acute exacerbations per year.
What is the most frequent pathogen causing pulmonary infection in cystic fibrosis?
In childhood
In late teenage years and adult life
- childhood: staph.aureus. H.influenzae is next most common
- Late teenage and adult: pseudomonas aeruginosa
Secondary colonisation by fungi is also common: aspergillus fumigatus. Causes allergic bronchopulmonary aspergillosis. (ABPA)
