Document type

Clinical pathways

Place

Hertfordshire and West Essex ICB

Output type

Clinical Pathways

Pathway

Bronchiectasis in Adults | SuspectedBronchiectasis in Adults |Management in Primary Care

Bronchiectasis in Adults

Next review date: July 2025. 

Bronchiectasis in adults – Suspected

Take full respiratory history including presenting symptoms, past medical & family history as per pathway.

Factors favouring further investigation: young age at presentation, history of symptoms over many years, absence of smoking history, daily expectoration of large volumes of very purulent sputum.

Exclusion of differential diagnoses is essential in chronic cough:

• Upper airway cough syndrome, e.g. post nasal drip syndrome
• Gastroesophageal reflux disease (GORD)
• Lung malignancy
• Allergic bronchopulmonary aspergillosis (ABPA)
• Pulmonary fibrosis
• Pneumonia
• Tuberculosis

Foreign body

(If potential lung malignancy, refer for urgent CXR or refer via 2ww.  See Lung Cancer pathway.)

Further investigations (see pathway for further details)

• Radiological investigations
• Sputum microbiology
• Spirometry
• Blood testing

If Bronchiectasis still suspected refer for CT Chest – NB: if bronchiectasis confirmed and patient is under 40 you should organise genetic testing for Cystic fibrosis.

See Below for management of bronchiectasis in primary care.

Management of Bronchiectasis in Primary Care

Exclude red flags requiring admission – see pathway.

Referral criteria for secondary care respiratory consultant – see pathway.

If patient has history of cystic fibrosis or primary/ secondary immune deficiency, refer to appropriate specialist.

Develop an individualised written self-management plan with the patient - The British Thoracic Society produce a template: https://www.brit-thoracic.org.uk/

Annual review - All patients should be offered an annual review, which includes:

• Smoking cessation advice
• Review of the number of exacerbations in the last year
• Assessment of breathlessness associated with activities of daily living
• Review of sputum volume, character and undertake sputum culture and sensitivity test to assess for chronic bacterial colonization
• If patient is regularly productive of sputum, consider referral to pulmonary rehabilitation service to teach individualised chest clearance techniques
• If patient is short of breath on exertion MRC 2 or above consider referral to pulmonary rehab service for group exercise sessions (See pathway)
• Spirometry is not recommended for people who are stable, with minimal exercise limitation, and who have few exacerbations.
• Do not routinely repeat CXRs.

Immunisation, treatment & review self-management plan

• Immunisations -  annual influenza vaccination
  • offer immunization against Streptococcus pneumoniae and seasonal influenza
• Treat co-morbid respiratory conditions, e.g. COPD
• If patient is regularly productive of sputum refer to pulmonary rehabilitation service to teach individualised chest clearance techniques
• If patient is short of breath on exertion MRC 2 or above pulmonary rehabilitation group exercise sessions
• Ensure people who are able to self-manage medication have been advised to start antibiotics themselves on exacerbation.  They should understand when it is appropriate to start treatment and the importance of collecting sputum before starting treatment
• Review and update self-management plan including how to recognise exacerbations and understand the condition.  A patient information leaflet on bronchiectasis is available from the British Lung Foundation: http://www.blf.org.uk/Conditions/Detail/Bronchiectasis

Infective exacerbations

• Optimal management of infective exacerbation can only be achieved if there is knowledge of the microbiological cause
• Sputum cultures are useful in the stable phase as they may inform treatment for a subsequent exacerbation
• Sputum sample should be sent for culture whenever possible at the start of an exacerbation and prior to starting antibiotic treatment
• Empirical therapy should be initiated whilst awaiting culture results
  • See pathway for further guidance on management and follow-up.

Bronchopulmonary Hygiene

• Patients with hypersecretion of mucus should be referred to specialist pulmonary rehab team to encourage expectoration and enhance clearance:
• It is essential for all patients with daily production of purulent sputum to be taught airway clearance by a suitably qualified physiotherapist
• Patients with a non-productive cough should be taught an appropriate technique to use during exacerbations

Manage Complications

• Haemoptysis is a common complication in patients with bronchiectasis due to proliferation, dilatation, and malformation of the bronchial arteries surrounding the damaged airways
• Episodes are typically related to an infective exacerbation

Small volume haemoptysis is usually managed with antibiotic therapy if due to an infective exacerbation (procoagulant agent, e.g. tranexamic acid, initiation would be on the advice of a specialist only).

Associated extra-pulmonary manifestations

• Rhinosinusitis
• Fatigue

Rheumatoid arthritis

These complications should be treated in their own right.

Management of underlying causes - additional specialist input

• Immunodeficiency should be jointly managed by an immunologist and a respiratory physician
• Connective tissue disease should be jointly managed by a rheumatologist and a respiratory physician
• Inflammatory bowel disease should be jointly managed by a gastroenterologist and a respiratory physician

Cystic fibrosis should be managed under the care of a specialist cystic fibrosis centre

Contact secondary care respiratory physician if considering adjuvant pharmacological therapy

• Bronchodilators should only be prescribed after a trial of therapy has demonstrated improvement of symptoms of lung function
• Long-term antibiotic therapy
• Nebulised saline - may be considered to increase sputum yield, reduce sputum viscosity and improve ease of expectoration
• Corticosteroids (inhaled or oral), not recommended for use unless there is coexistent asthma

For the HOOF forms please go directly to the BOC portal - they are the people who supply the oxygen.  Their number is 088456 094345