Pre referral checklists RESPIRATORY
BRONCHIECTASIS
General points:
 Chronically inflamed and damaged airways
 Typical features:
o Chronic cough
o sputum production
o recurrent LRTIs
 CXR can be NORMAL
 diagnosis SECONDARY CARE by High resolution CT ( HRCT)
 causes- see appendix 1
Are there RED FLAGS Symptoms? = consider 2 week wait referral
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y/n
Weight loss/anorexia (unintentional)
Haemoptysis
smokers
Dyspnoea
Chest Pain
Hoarseness
abnormal CXR
fatigue
clubbing
supraclavicular lymphadenopathy
Consider REFERRAL for DIAGNOSIS:
 Chronic (persistent) productive cough
 Daily expectoration of large volumes of purulent sputum
 Frequent lower respiratory tract infections
 Young age at presentation
 Absence of smoking Hx
 Sputum colonisation with Pseudomonas Aeruginosa or Staph aureus
 Recurrent haemoptysis (see above-may require 2ww referral)
 Persistent course crackles o/e
For:
 Consideration for High Resolution CT for diagnosis
 Assessment of underlying cause
 Self-management advice
 Consideration for long term abs
 Elective intravenous antibiotics
 Chest physiotherapy
y/n
1
Consider REFERRAL in established BRONCHIECTASIS

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y/n
Recurrent exacerbations (> 3/yr)
Worsening exacerbation frequency or respiratory symptoms
Declining lung function
New haemoptysis (see above- may require 2-week wait referral)
New Pseudomonas, opportunistic mycobacterium or MRSA isolation in
sputum
Patients with associated rheumatoid arthritis, inflammatory bowel disease
or immune deficiency
Consideration for, or already on, long term antibiotics
Advanced disease, consideration for transplantation
Other diagnostic considerations:
y/n
Does the patients have COPD or Asthma?
 The conditions may coexist
 Consider coexistent bronchiectasis if:
o Recovery from LRTIs is slow
o Recurrent infections
o Pseudomonas isolated from sputum
o Worsening disease control despite optimal therapy
 If so, has their COPD or asthma management been optimised?
PRIMARY CARE MANAGEMENT:
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patient education: smoking, when to seek help
encourage adherence to chest physiotherapy
pneumococcal vac and annual flu vac
consider coexistent asthma or COPD and optimise treatment
spirometry to assess for severity and deterioration
Exacerbations:
o sputum culture advised prior to commencing treatment (and
encouraged at each review) to guide antibacterials for future chest
infections – do not delay antibiotics whilst waiting for sputum result
o antibiotics 14 days
o use antibiotics based on previous positive sputum cultures or as
directed in patient’s self-management plan
o if NO previous sputum microbiology available treat empirically:
o co-amoxiclav 625MG TDS or if penicillin allergic
Doxycycline 200mg od
https://www.brit-thoracic.org.uk/document-library/clinicalinformation/bronchiectasis/bts-guideline-for-non-cf-bronchiectasis/
Thanks to Dr John Steer and Dr Les Ashton, November 2015
2
APPENDIX 1
ATEIOLOGY
INCIDENCE
Idiopathic
Up to 53%
Post infection
Up to 42%
Immune defect
8%
allergic
bronchopulminary
aspergillosis
Aspiration / GORD
7%
Hx asthma
4%
Hx aspiration / reflux
RA
3%
Hx RA
Cystic Fibrosis
3%
Ciliary Dysfunction
1.5%
Ulcerative Colitis
<1%
Age < 40,
malabsorbtion, male
infertility, diabetes
Situs inversus,
productive cough,
deafness, infertility
Diarrhoea .
malabsorption, wt
loss, joint pain
Congenital
<1%
HX/ SIGNS
Hx pneumonia,
pertussis, measles,
TB
Ix
Diagnosis of
exclusion
CXR or CT scan
evidence of previous
infection
Decreased
immunoglobulin
levels or functional
ab deficiency
Eosinophilia
Raised IgE
Foreign body or
mucus plugging on
bronchoscopy
Positive immune
screen
Positive sweat test
Abnormal ciliary beat
pattern
Colonoscopic
biopsies suggestive
of IBD
3