non cf bronchiectasis - rcp london
TRANSCRIPT
Aim
• Convince you why you need to know about bronchiectasis?
• Overview of investigations & principles of management of bronchiectasis.
• Know how to manage a simple exacerbation.
• Not talk for more than 40 minutes
Irreversibly damaged & dilated bronchi resulting in chronic airway inflammation & recurrent infections.
Bronchiectasis
The dilatation of the bronchi without being a very common affection, is, however, much less rare than I long conceived it to be (Laennec 1835)
Bronchiectasis is common
• Prevalence is approximately 1 in 1000.
• Recent UK & German studies have demonstrated increasing prevalence & hospitalisation rates.
• My patients with bronchiectasis experience:
• High rate of exacerbations
• Frequent hospital admissions
• Increased mortality
When should you suspect bronchiectasis?
• Chronic cough
• Chronic sputum production • Often large amounts
• Recurrent respiratory tract infections
• Dyspnoea
• Haemoptysis
• Colonisation with pseudomonas
• Coarse inspiratory & expiratory crackles
So always think about the cause
Bronchiectasis is an endpoint
Investigations
• HRCT “Gold Standard”
• FBC, ESR, CRP, U&E, LFTs
• Sputum culture
• 3 sputum samples for AAFB (smear & culture)
• Immunological screen & auto-antibodies
• Total IgE & Aspergillus screen
• PFTs
Further tests dependent on clinical suspicion eg ciliary investigations
Exclude cystic fibrosis
• All patients aged <40 presenting with bronchiectasis should have investigations for cystic fibrosis
• sweat chloride
• CFTR genetic mutation analysis
• Consider if aged >40 if:
• persistent isolation of Staphylococcus aureus
• features of malabsorption
• male primary infertility
• upper lobe bronchiectasis
CXR: low sensitivity, limited information Cylindrical bronchiectasis with tramline opacities
Cystic bronchiectasis
HRCT: Features of bronchiectasis Severity: although CT does not reliably correlate with QoL
Bronchial wall dilatation
Bronchial wall thickening & mucus plugging
Distribution
Investigating bronchiectasis does makes a
difference
• Pasteur at al 2000
• Cause identified 47% (70 / 150)
• Affected management 15%
• Li et al 2005 (Paediatric cohort)
• Cause identified 82% (111 / 136)
• Affected management 56%
• Shoemark et al 2007
• Cause identified 74% (122/165)
• Affected management 37%
Start with the underlying cause.
Treating bronchiectasis
Aims of Treatment
• Prevent progression of disease
• Maintain or improve lung function
• Decrease exacerbations
• Improve symptoms
• Improve quality of life
Increased volume & purulence of sputum, cough, breathlessness and/or systemic symptoms
Defining an Exacerbation
Always send a sputum sample Green is bad
Infections matter to the patient
Empirical Treatment
• Amoxicillin 1g tds [14/7] • Clarithromycin 500mg bd [14/7] • If colonised with P aeruginosa:
ciprofloxacin 500-750g bd
Modifying antibiotics
• Based on sputum culture or if
failure to improve. • Consider IVs if very unwell • If P. aeuruginosa use ≥1
antipseudomonal antibiotics eg β-lactamase & an aminoglycoside
Pseudomonas
• Associated with more severe
disease
• More rapid decline in FEV1
• Increased admissions
• Worse quality of life
• Reduced survival
• Consider eradication after 1st culture
BTS Guidelines
Nebulised Antibiotics
• Increased drug concentrations locally
• Reduce systemic adverse effects
• Can be done at home
• Use for chronic disease management or:
• Prophylaxis
• Eradication of pseudomonas
• Acute treatment
Any Questions?