An anatomical diagnosis with persistent or progressive dilatation of bronchi, leading to chronic inflammation and/or infection. The cause is either an impaired lung defence as a consequence of acquired damage (prior pneumonia or pneumonitis, gastric aspiration), impaired immunity (hypogammaglobulinaemia, CVID), or an innate defect (cystic fibrosis, ciliary dyskinesia). Approximately half of patients have no definite identifiable cause.

When bronchiectasis is suspected (or already diagnosed):

History/Examination

• Chronic moist cough

• Chronic respiratory symptoms PLUS positive sputum culture for S. aureas, H. influenzae, P. aeruginosa, atypical mycobacterium

• Recurrent pneumonia: ask all patients the number of acute infections/episodes per year

Specific enquiry: Any evidence of rheumatoid arthritis, inflammatory bowel disease or malabsorbtion (especially children), asthma (aspergillus related lung disease/ABPA), infection in multiple sites (immune deficiency), yellow-nail syndrome, infertility (CF)

Investigations

Radiology CXR and HRCT thorax

Sputum MCS, AFB culture

**(Fungal stains in specific circumstances, as guided by respiratory team)

Bloods IgG/M/A and serum electrophoresis

Specific antibodies to H. influenza (b) and Streptococcus pneumonia

Total IgE, Aspergillus specific IgG and IgE

**Further testing (e.g. IgG subclasses) to discuss with Consultant

Spirometry Perform at diagnosis and annually if followed up in secondary care.

Sweat testing Consider CF in all patients under 40 or those with additional extra pulmonary clinical features of CF.

Bronchoscopy Localised bronchiectasis, or if atypical mycobacterial disease suspected and sputum negative, or sputum negative/not able to be expectorated.

Maintenance treatment

The aim is to reduce the rate of acute exacerbations which are associated with faster decline. This is usually done with a combination of good airway clearance, adequate treatment of infection and management of underlying causes.

1. Treat/optimise any underlying cause

2. Physiotherapy - Offer chest clearance advice to all patients +/- pulmonary rehabilitation

3. Recommend annual influenza +/- covid vaccination +/- RSV and ensure pneumonia vaccine has been offered.

4. Offer prompt oral antibiotic treatment for exacerbations (10-14 days as standard); guided by previous sputum results

Refer to respiratory medicine for review as an inpatient and for consideration of ongoing secondary care:

• Patients with chronic Pseudomonas aeruginosa, non-tuberculous mycobacteria (NTM) or methicillin-resistant Staphylococcus aureus colonisation (MRSA) in sputum

• Deteriorating bronchiectasis with declining lung function

• Recurrent exacerbations (≥3 per year)

• Patients receiving long term antibiotic therapy (oral, inhaled, or nebulised)

• Patients with bronchiectasis and associated rheumatoid arthritis, immune deficiency, inflammatory bowel disease and primary ciliary dyskinesia.

• Patients with allergic bronchopulmonary aspergillosis (ABPA)

• Patients with advanced disease and those considering lung resection/transplantation.

Consider nebulised 0.9% saline (5mls QDS/PRN) to assist with clearance if reviewed and recommended by the Physiotherapy team

**Use of hypertonic (7%) saline (if secretions very tenacious) should be discussed with a respiratory consultant and physiotherapy; pre-treat with nebulised salbutamol 2.5mg to 5mg when used.

Inhaled therapy - offer inhaled bronchodilators to patients with airflow obstruction and breathlessness.

Offer pulmonary rehabilitation to all patients with breathlessness during their daily routine.

Corticosteroid preparations reserved for patients with additional features of asthma and are not evidence based for bronchiectasis alone

Antibiotic prophylaxis - offer to patients experiencing 3 or more exacerbations per year despite optimal management (Refer to Trust antibiotic guidelines for choice of agent and route of delivery and discuss with Respiratory +/- Microbiology consultant, although this will usually be an outpatient-led decision).

This guideline has been registered with the Trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt, contact a senior colleague or expert. Caution is advised when using guidelines after the review date.

This guideline is for use in Frimley Health NHS Foundation Trust hospitals only. Any use outside this location will not be supported by the Trust and will be at the risk of the individual using it.

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