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.
