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REMEDY : BNSSG referral pathways & Joint Formulary

Bronchiectasis (Adult) - DRAFT

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Overview

Bronchiectasis is a chronic respiratory disease characterised by abnormal dilatation of the bronchi with chronic airway inflammation, and is associated with significant sputum production, recurrent chest infections, colonisation with unusual organisms and airflow obstruction.

Clinical features

The following features may raise suspicion of a diagnosis in adults:

  • Persistent productive cough - copious daily production of purulent sputum
  • Productive cough in patient with rheumatoid arthritis or inflammatory bowel disease
  • Frequent exacerbations
  • Haemoptysis
  • Persistent lung crackles on auscultation
  • Finger clubbing
  • Frequent bacterial colonisation of sputum (particularly P. aeruginosa)

 

Who to Refer

Refer patient to respiratory outpatients if:

  • Idiopathic bronchiectasis in young (<50 years old) patient
  • Suspicion of Allergic Broncho-Pulmonary Aspergillosis (ABPA)
  • Multilobar or extensive disease on CT chest
  • Recurrent non-respiratory infections suggesting immunodeficiency
  • Associated rheumatoid arthritis or inflammatory bowel disease
  • Chronic pseudomonas, mycobacteria, multi-resistant organisms or MRSA isolation in sputum
  • 3 or more exacerbations per year
  • Deteriorating bronchiectasis with decline in lung function

Consider referral to HOT clinic if

  • Inadequate response to appropriate oral therapy
  • Infection/deterioration for which there are unlikely to be oral treatment options

 

If referral is not necessarily required, then a specialist opinion can be obtained via advice and guidance which can be provided much more rapidly than an outpatient appointment.

 

 

Red Flags

What to do before referral

History

Take full history including childhood infections, systemic inflammatory conditions, immunodeficiency, TB risk and smoking history. Ask about features of CF and primary ciliary dyskinesia including infertility, malabsorption, sinusitis and pancreatitis.

Investigations

  • Sputum MC+S
  • CXR – to rule out other diagnoses. Features of severe bronchiectasis may be seen on CXR
  • HRCT (High Resolution CT scan of chest)  – the gold standard in diagnosis of bronchiectasis. Can be ordered in primary care.
  • Spirometry – may be normal or show an obstructive pattern usually without reversibility
  • Bloods - consider in confirmed bronchiectasis to find an underlying cause – FBC, Immunoglobulins (IgG, IgA, IgM), HIV, total IgE, specific IgE to aspergillus and vitamin D. If connective tissue disease or vasculitis is suspected then consider Rh factor, Anti-CCP, ANA, ANCA