Key learning points

  • Bronchiectasis should be considered in patients with an ongoing productive cough and/or recurrent respiratory infection
  • Bronchiectasis is often associated with conditions such as COPD, asthma, rheumatoid arthritis and immunosuppression
  • Patients with bronchiectasis have often experienced pulmonary infection in childhood
  • If bronchiectasis is suspected imaging should be requested, initially chest X-ray, then high-resolution CT scan if diagnosis uncertain
  • Patients with confirmed bronchiectasis should be referred to respiratory medicine for assessment of underlying causes
  • A multidisciplinary team approach is required to manage bronchiectasis which should include education about airway clearance and expert microbiological support if repeated clinical infection with complex pathogens

Introduction

Non-cystic fibrosis bronchiectasis is a rare condition in general practice; however, as the population ages, prevalence is likely to increase.1 The prevalence in the UK is 4.86/1,000 men and 5.66/1,000 women.1 Bronchiectasis can be associated with other airway conditions such as COPD and asthma; systemic inflammatory conditions, such as rheumatoid arthritis; previous pulmonary infection in childhood; and immunosuppression such as myeloma and hypogammaglobulinaemia.2 Patient education and shared management between primary and secondary care is key to successful treatment. 

Case study

Mrs Shaw, a 79-year-old who has a background of well-controlled hypertension, saw her GP for the fourth time in five months with a cough productive of about a tablespoon a day of yellow/white sputum that turned green when she became unwell. Auscultation revealed bibasal crackles. She had had two courses of amoxicillin and one course of doxycycline and steroids with transient improvement only. She reported a longstanding productive cough for years. She remembers suffering from many bouts of bronchitis as a child following severe whooping cough. She had never smoked.

Her GP requested a chest X-ray, some baseline bloods and a sputum sample for microscopy, culture and sensitivity. Her chest X-ray showed mild bilateral non-specific changes consistent with infection. A high resolution CT scan was suggested and this confirmed bronchiectasis. Her sputum grew Haemophilus influenzae, resistant to amoxicillin but sensitive to co-amoxiclav. As she had ongoing cough with purulent sputum a course of co-amoxiclav was prescribed and an urgent referral was made to the respiratory team.

Mrs Shaw’s outcome

Mrs Shaw was seen in a sub-specialty bronchiectasis clinic that included medical, nurse specialist and respiratory physiotherapy input. Specific additional investigations were organised to identify a possible underlying cause (see Box). The physiotherapist taught Mrs Shaw the active cycle of breathing technique and gave her an ‘adjunct’ device to enhance airway clearance. Azithromycin prophylaxis was to be considered if recurrent chest infections persisted (three exacerbations in one year). However, a two-week course of targeted antibiotics successfully cleared the infection and a three-month review showed that further antibiotics had not been needed and sputum production was reduced.

Box: Relevant investigations for new diagnosis of bronchiectasis

Bloods
Full blood count (FBC)
Creatinine and electrolytes
Liver function tests (LFT)
Calcium profile
C-reactive protein (CRP)
Total IgE
Aspergillus IgE
Aspergillus IgG
Alpha-1-antitrypsin (A1AT)
HIV
Antinuclear antibodies (ANA)
Anti-cyclic citrullinated peptide (CCP)
Immunoglobulins (IgG, IgA and IgM)
Serum protein electrophoresis (SPE)
Sputum
MC&S (bronchiectasis)
Acid-fast bacillus (AFB)

Ig, immunoglobulin.

Discussion

Bronchiectasis is relatively rare in primary care and may be overlooked. It is an important diagnosis to consider in those with an ongoing productive cough and/or recurrent respiratory infection, especially in those with COPD, rheumatoid arthritis or immunosuppression. Patients with suspected or radiologically confirmed bronchiectasis should be referred to respiratory medicine for assessment of underlying causes. A multidisciplinary team (MDT) approach should include respiratory physiotherapy to teach airway clearance, an experienced respiratory physician and expert microbiological support to rule out more complex pathogens such as Pseudomonas, non-tuberculous mycobacteria and Aspergillus disease.2

Once patients are diagnosed, subsequent lower respiratory tract infections (increased sputum production, change in colour, increased breathlessness) require prompt sputum culture and empirical antimicrobial therapy if no culture results available. Antibiotics can then be modified if subsequent culture reveals a resistant organism and there has been no clinical improvement. If patients are not responding, the respiratory team may suggest alternative, intravenous and/or nebulised antibiotics, particularly if Pseudomonas is identified. Frequent exacerbations may benefit from prophylactic use of oral antibiotics such as azithromycin and/or long-term nebulised anti-Pseudomonas antibiotics such as colistin or gentamicin.2

Summary

Non-cystic fibrosis bronchiectasis is a long-term condition that will become more prevalent in general practice with an aging population. The mainstay of treatment is good multidisciplinary management, including patient education. When managed with good airway clearance techniques and prompt treatment of infections, long-term outcomes are positive. Although relatively rare in general practice, this is an important condition to identify. In patients with known bronchiectasis, prompt identification of infection, facilitating sputum clearance and use of sputum culture to identify specific pathogens, is key to achieving good outcomes.2 Those with uncontrolled symptoms and frequent exacerbations (three or more per year) may benefit from referral to specialist care for MDT management.

Dr Helen Casey, specialist registrar in infectious diseases and microbiology; Dr Adam Malin, consultant respiratory physician, Royal United Hospitals Bath NHS Foundation Trust

This project was initiated and funded by Teva Respiratory. Teva have had no influence over content. Topics and content have been selected and written by independent experts.

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