1. Consider bronchiectasis in persistent productive cough.
Think of bronchiectasis in patients who have a persistent productive cough for many years with increased sputum production or recurrent chest infections, especially younger patients with no smoking history. Other symptoms include dyspnoea, wheezing, haemoptysis and chest pain.
2. Do baseline investigations before referral.
In most regions you need to refer for confirmation of diagnosis and further assessment. It is useful for GPs to request a baseline chest X-ray, spirometry and sputum culture and sensitivity. Chest X-ray is often normal in bronchiectasis but advanced cases may show thickened dilated bronchi with ‘tram lines', cystic spaces and ring opacities. Tests for cystic fibrosis should be done if indicated – especially in patients younger than 40.
3. Vaccinate against influenza and pneumococcal pneumonia.
Make sure patients with bronchiectasis have their annual flu vaccine and also have had the pneumococcal vaccine.
4. Refer for chest physiotherapy.
All patients with bronchiectasis should see a chest physiotherapist.
This can help improve sputum clearance from the lungs, which reduces symptoms and exacerbations and improves quality of life.
5. Be aware of chronic colonisation.
Two-thirds of bronchiectasis patients chronically colonise bacteria in their lungs – commonly Pseudomonas aeruginosa, Haemophilus influenzae, Staphylococcus aureus, Moraxella catarrhalis and occasionally opportunistic mycobacterium.
Sputum culture and sensitivity will help guide antibiotic treatments and identify patients with pseudomonas colonisation, who often have poor disease progression, increased hospital admissions and poor quality of life.
6. Assess for airway obstruction.
Some bronchiectasis patients have airway obstruction related to the disease, asthma or COPD. Do spirometry on all bronchiectasis patients to detect related airway obstruction and assess for reversibility.
Patients with co-existing asthma or COPD should be managed according to the relevant guidelines.
There is insufficient evidence to determine whether mucolytics are useful in bronchiectasis.
7. Don't delay antibiotics in exacerbations.
Exacerbations are characterised by worsening cough, purulent sputum production, increasing wheeze, breathlessness and haemoptysis or systemic upset.
Don't wait for the results of a sputum sample – start empirical treatment with amoxicillin 500mg TDS or clarithromycin 500mg BD (in penicillin-allergic patients) for 14 days.
Where previous sputum bacteriology is known, antibiotic treatment can be guided by this. Ciprofloxacin should be used in patients known to have pseudomonas colonisation.
8. Consider long-term antibiotics for frequent exacerbations.
Long-term oral antibiotics can be considered in patients with three or more exacerbations a year, or fewer exacerbations if there is significant morbidity.
Long-term nebulised antibiotics can also be considered in similar patients if they chronically colonise Pseudomonas aeruginosa. Refer to a specialist if you are considering long-term antibiotics.
9. Do annual spirometry.
It is useful to do annual spirometry in patients with bronchiectosis to detect and monitor obstructive airway disease.
10. Refer patients with deterioration, chronic colonisation or comorbidities.
Consider specialist referral in patients who have three or more exacerbations a year, deteriorating bronchiectasis with declining lung function, chronic pseudomonas, opportunistic mycobacteria or MRSA colonisation, or who are on long-term antibiotics.
Also consider referring patients who have comorbidities, advanced disease and those considering transplantation or surgery.
Dr Tarek Bakht is a GPSI in respiratory medicine in Bolton, Greater Manchester, and executive board member of the Primary Care Respiratory Society UK
The Primary Care Respiratory Society UK (PCRS-UK) is the UK-wide professional society committed to improving respiratory care in primary care. PCRS-UK is a registered charity, led by its members through a range of committees and faculties dedicated to meeting the vision of ‘optimal respiratory care for all', providing education, policy support and research. As a member you'll have unlimited access to a wealth of specialist respiratory care information, expertise and resources, plus practical everyday tools to help you make a difference in respiratory care. For more information about PCRS-UK and how to join, go to pcrs-uk.org/join.
Further reading
1 Mandal P and Hill A. Bronchiectasis Opinion Sheet. Primary Care Respiratory Society UK, 2011.
2 Pasteur MC, Bilton D and Hill AT. British Thoracic Society guideline for non-CF bronchiectasis. Thorax 2010;65:i1-i58
3 Hill A, Pasteur M, Cornford C et al. Primary care summary of the British Thoracic Society Guideline on the management of non-cystic fibrosis bronchiectasis. Prim Care Respir J 2011; 20:135-40
