Bronchiectasis

Bronchiectasis is defined as having inflamed, permanently and irreversibly damaged and dilated airways leading to symptoms of chronic cough, chronic sputum production and recurrent respiratory tract infections.

The disease is life-long, and the prognosis depends on the severity of the bronchiectasis. In severe cases, life expectancy will be reduced.

Patients chronically colonised with Pseudomonas aeruginosa tend to have poorer health related quality of life, more exacerbations and increased mortality.

Refer all patients suspected of having bronchiectasis. Please let the patient know that they are likely to receive an appointment for a CT scan of their chest (looking for radiological signs of bronchiectasis) in advance of their clinic appointment.

Royal Infirmary of Edinburgh (Lead Centre) – Dr Anna Lithgow

St John’s Hospital – General Respiratory Physician

Western General Hospital – General Respiratory Physician

Definition of Severity

The Bronchiectasis Severity Index (BSI) may also be used to define severity of bronchiectasis. The table below documents the variables within the BSI index and its scoring system. A total score 0 – 4 indicates mild disease, 5 – 8 moderate disease and ≥ 9 severe disease. The BSI can be used as an adjunct when assessing a patient and deciding on their management.

Variables involved in calculating the severity score in the Bronchiectasis severity index

Factor and points for scoring system
Age (years)	<50 (0 points)	50-69 (2 points)	70-79 (4 points)	>80 (6 points)
BMI (Kg/m²)	<18.5 (2 points)	18.5-25 (0 points)	26-30 (0 points)	>30 (0 points)
FEV₁% predicted	>80 (0 points)	50-80 (1 point)	30-49 (2 points)	<30 (3 points)
Hospital admission within last 2 years	No (0 points)		Yes (5 points)
Number of exacerbations in previous 12 months	0 (0 points)	1 – 2 (0 points)	≥3 (2 points)
Modified MRC breathlessness score	0-2 (0 points)	3 (2 points)	4 (3 points)
*P. Aeruginosa* colonisations	No (0 points)		Yes (3 points)
Colonisation with other organisms	No (0 points)		Yes (1 point)
Radiological severity	<3 lobes affected(0 points)	≥3 lobes of cystic bronchiectasis in any lobe (1 point)

^{0-4 point s =mild disease; 5–8 = moderate disease; 9 and over = severe disease}^{The BTS Guideline for Bronchiectasis in Adults, BTS (2019)}

Who to refer:

Suspected bronchiectasis – new referral

Patients with persistent cough productive of mucopurulent or purulent sputum.
≥ 2 chest infections in the past year with evidence of positive sputum bacterial cultures
Patients with COPD who have had their treatment optimised but still have a chronic productive cough with positive sputum bacterial cultures whilst stable, or have had 2 or more exacerbations with positive sputum bacterial cultures in the preceding 12 months.

Please let the patients know that they are likely to receive an appointment for a CT scan of their chest (looking for radiological signs of bronchiectasis) in advance of their clinic appointment.

For mild cases, care will be in the community. For severe cases, care will be with regular hospital review.

For new cough (no known pathology) greater > 3 weeks think Detect Cancer Early (DCE) pathway

Known bronchiectasis – indications for re-referral

Patients with chronic Pseudomonas aeruginosa, non-tuberculous mycobacteria (NTM) or methicillin-resistant Staphylococcus aureus colonisation (MRSA)
Deteriorating bronchiectasis with declining lung function
Recurrent exacerbations (≥3 per year)
Haemoptysis: new or unusual. Large volumes (>10 mls over 24 hours) will need emergency admission.
Patients receiving long term antibiotic therapy (oral, inhaled or nebulised)
Patients with bronchiectasis and associated rheumatoid arthritis, immune deficiency, inflammatory bowel disease, primary ciliary dyskinesia and allergic bronchopulmonary aspergillosis (ABPA)
Patients with advanced disease and those considering transplantation.

Indications for IV antibiotics and hospital admissions

Who not to refer:

Patients with occasional LRTI and an already established respiratory disease

How to refer:

Refer via SCI-Gateway (Respiratory)
Recommended investigations:

sputum culture (commonly Haemophilus influenzae, Moraxella catarrhalis, Staphylococcus aureus, Streptococcus pneumoniae and Pseudomonas aeruginosa)
CXR (a normal CXR does not exclude bronchiectasis)

If a CXR shows radiological signs of lung cancer, then refer URGENTLY via lung cancer pathway.

Structured Secondary Care Letters

Secondary care clinic letters, from the RIE outpatient settings are structured. The first section contains the most relevant information for primary care. The second section includes further background information.

Diagnosis
Recommended antibiotic for exacerbation
Radiology – CT scan result
Plan, Investigations and Follow-up
For GP: please consider KIS e.g. recommended antibiotics for exacerbations, current O2 sats, last FEV_1,whether on long-term antibiotics, usual level of breathlessness if present
Long Term Antibiotics
Date of last IV antibiotics/hospital admission
Number of antibiotic courses since last assessment
Weight/BMI
Spirometry and O2 saturations
Sputum production and sputum colour
Whether chronically colonised
Microbiology since last seen
Current Medication
Bronchiectasis status – stable or exacerbation

Further background information

Date of bronchiectasis diagnosis
Smoking history
Presence of rhinitis/GORD
Usual and previous sputum pathogens
Whether performing regular chest physiotherapy
Annual flu vaccination and pneumococcal vaccination status
Last CT chest scan and CXR results
Results of previous relevant investigations e.g. immunology, aspergillus, echo

Resources

Hill AT, Sullivan AL, Chalmers JD, et al. BTS Guidelines for Bronchiectasis in Adults. Thorax 2019; 74 (Suppl 1):1–69
Gruffydd-Jones, K., Keeley, D., Knowles, V. et al. Primary care implications of the British Thoracic Society Guidelines for bronchiectasis in adults 2019. npj Prim. Care Respir. Med. 29, 24 (2019)

Cornerstone of Bronchiectasis Management in Primary Care

Self-management advice for patients is available on the NHS Lothian Patient Bronchiectasis website: www.bronchiectasis.scot.nhs.uk. Patient should also have a personalised bronchiectasis self-management plan booklet.

Consider a KIS which can include the following information: recommended antibiotics for exacerbations, current O2 sats, last FEV₁, whether on long-term antibiotics and usual level of breathlessness if present.
Encourage chest physiotherapy (chest clearance) once or twice per day and increase during bronchiectasis exacerbations. Direct patients to www.bronchiectasis.scot.nhs.uk for a reminder on chest clearance techniques.
Recommend annual flu vaccinations.
For bronchiectasis exacerbations/chest infections send a sputum sample for routine bacterial culture and start prompt antibiotics (don’t wait until the sputum cultures are available). This should be for 14 days (7 days may suffice in mild bronchiectasis).
Antibiotics for exacerbations of bronchiectasis should (if possible) be based on previous sputum pathogen/s and sensitivities. If there are no previous sputum pathogen/s or sensitivities, below are the recommended antibiotics and doses for common sputum organisms found in bronchiectasis.

Recommended antibiotics and doses for common sputum pathogens found in bronchiectasis.

Sputum Pathogen	Antibiotics (14 days)
*Haemophilus Influenzae* β*-lactamase negative*	Amoxicillin 500mg TDS or clarithromycin 500mg BD
*Haemophilus Influenzae* β*-lactamase positive*	Co-amoxiclav 625mg TDS or doxycycline 100mg BD
*Moraxella catarrhalis*	Co-amoxiclav 625mg or doxycycline 100mg BD
*Streptococcus pneumonia*	Amoxicillin 500mg TDS or clarithromycin 500mg BD
*Staphylococcus aureus*	Flucloxacillin 500mg QDS or clarithromycin 500mg BD
*Pseudomonas aeruginosa*	Ciprofloxacin 500mg BD
*Methicillin-resistant Staphylococcus aureus (MRSA)*	Doxycycline 100mg BDIf there is no response or the patient is unwell then refer to secondary care for IV antibiotics