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Bronchiectasis

 

The gold standard investigation for bronchiectasis is a High Resolution CT scan (HRCT). As the great majority of patients referred to the respiratory physicians querying the diagnosis of bronchiectasis have an HRCT scan, the radiology department have agreed GPs can refer straight to test if they are confident that Bronchiectasis is the likely differential diagnosis and are >25 years.

 

 

When to consider referral for HRCT* (refer to resp. clinic at same time)

(*Note patients <25 years should be referred without HRCT due to risk of radiation)

1. Persistently productive cough (min. 6 weeks) plus 2 or more of:

  • Young age at presentation;
  • Absence of smoking history;
  • Daily expectoration of large volumes of very purulent sputum;
  • Haemoptysis;
  • Sputum colonisation with Pseudomonas aeruginosa.

In the absence of 2 or more of these features, then please consider referral to a respiratory clinic without HRCT.

 

2. COPD (Patients may have bronchiectasis alone or in addition): Referral for HRCT is appropriate if:

  • Management is not straightforward;
  • There is slow recovery from lower respiratory tract infections
  • Recurrent exacerbations;
  • There is no history of smoking

 

Primary care management prior to referral:

  • Consideration and trial of treatment of alternative explanation to the productive cough, such as chronic rhinosinusitis, postnasal drip etc.
  • CXR (within the past 6 months)
  • Spirometry
  • Sputum sample

 

Clinic options:

  • If the primary concern is to include or exclude a diagnosis of bronchiectasis, with bronchiectasis a likely differential diagnosis, then refer for an HRCT scan via ICE at the same time as a referral to general respiratory clinic.
  • If there is uncertainty if bronchiectasis is part of the differential, then please consider referral to a general respiratory clinic.
  • Newly diagnosed bronchiectasis on HRCT scanning should be referred to the Respiratory Physicians for assessment
  • Any patient's fitting criteria for a 2WW pathway should be referred via the 2WW pathway.

 

Known bronchiectasis management: 

  • Exacerbation (combination of feeling unwell PLUS increased breathlessness PLUS change in cough – colour alone, or positive culture is not an indication alone for treatment, equally negative sputum cultures do not mean no infection if other criteria met) – send sputum sample and antibiotics should be for 2 weeks, usually higher doses e.g. doxycycline 100mg twice a day; amoxicillin 1000mg three times a day; ciprofloxacin (if pseudomonas) 750mg twice a day – warn to watch for tendonitis
  • If not improving or further infection within 6 weeks may need IV antibiotics via ACAH
  • Follow individualized management plan if provided
  • Refer if 3 or more exacerbations a year and ensure recent sputum sample sent. 

 

 

References

1. https://www.brit-thoracic.org.uk/quality-improvement/guidelines/bronchiectasis-in-adults/   

2. https://bmjopenrespres.bmj.com/content/5/1/e000348

3. https://www.nice.org.uk/guidance/ng117/resources/visual-summary-pdf-6606081325

 

 

Date reviewed                     19/11/2021

Next review due                  19/11/2022

Sifter name                          Dr Madeleine Attridge