- Chronic respiratory disease defined by recurrent bronchial infection and abnormal permanently dilated airways.
- Can occur at any age, but more common in women and age > 60.
- Is a heterogenous disease with many causative or contributing factors, including:
- Cystic fibrosis
- Pulmonary infection
- Chronic obstructive pulmonary disease
- Immune deficiency
- Airway obstruction
- Rheumatoid arthritis
- Inflammatory bowel disease
- Connective tissue disorders
- Primary ciliary dyskinesia
- Allergic bronchopulmonary aspergillosis
- Present with new undiagnosed bronchiectasis, or more typically an acute exacerbation of existing bronchiectasis.
- Bronchiectasis exacerbations are currently understood to be caused by pulmonary infections, typically bacterial, but also non-tuberculosis mycobacterial, viral, and fungal.
Signs and Symptoms
The most common symptom of bronchiectasis is chronic cough (>8 weeks) with the production of tenacious purulent or mucopurulent sputum. Other symptoms include:
- Shortness of breath
- Chest pain
- Recurrent respiratory infections
Physical findings include crackles and wheezing on auscultation.
New Diagnosis of Bronchiectasis
Consider investigation for bronchiectasis in individuals with suspicious symptoms or chest radiographic features, especially in those with relevant risk factors.
- Chest radiograph: Not diagnostic but often initially ordered. People with bronchiectasis will typically have an abnormal chest radiograph, including linear atelectasis, dilated and thickened airways, and irregular opacities.
Definitive diagnosis of bronchiectasis is made via thin section computed tomography (≤1mm slice thickness). Findings include airway dilatation, lack of airway tapering, bronchial wall thickening, and airway visibility within 1cm of the costal pleura or touching the mediastinal pleura.
Investigations depend on the clinical picture, and may include:
- CBC with differential.
- Sputum gram stain and culture for bacteria, mycobacteria, and fungus.
Further investigations can be initiated in the ED but are typically performed by Family or consultant physician:
- Serum immunoglobulins (IgG, IgA and IgM) and IgG subclasses.
- Sweat chloride or cystic fibrosis transmembrane conductance regulator (CFTR) mutation analysis.
- Total serum IgE and specific aspergillus IgE (or skin prick test).
- Pneumococcal antibody titres before and after (4-8 weeks) polysaccharide pneumococcal vaccine.
- Rheumatoid factor.
- Alpha-1 antitrypsin level.
- Pulmonary function tests assess severity and aid in monitoring; patients with bronchiectasis typically present with obstructive impairment on spirometry (low/normal FVC, low FEV1, low FEV1/FVC).
Exacerbation of Existing Bronchiectasis
Two criteria diagnose an exacerbation of existing bronchiectasis:
- A deterioration in three or more of the following symptoms over a ≥48-hour period:
- Sputum volume or consistency
- Sputum purulence
- Breathlessness or exercise tolerance
- Fatigue or malaise
- It is determined by a clinician that a change in management is necessary.
All patients should receive a sputum gram stain and culture for bacteria, mycobacteria, and fungus to aid in antibiotic selection.
Consider other causes for deteriorating respiratory symptoms.
- Chest x-ray.
Consider testing for viral infections in patients presenting with an acute exacerbation of bronchiectasis.
Quality Of Evidence?
We are highly confident that the true effect lies close to that of the estimate of the effect. There is a wide range of studies included in the analyses with no major limitations, there is little variation between studies, and the summary estimate has a narrow confidence interval.
We consider that the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. There are only a few studies and some have limitations but not major flaws, there are some variations between studies, or the confidence interval of the summary estimate is wide.
When the true effect may be substantially different from the estimate of the effect. The studies have major flaws, there is important variations between studies, of the confidence interval of the summary estimate is very wide.
Clinical practice guideline recommendations are based on scientific evidence of variable quality, ranging from meta-analyses to case reports. Recommendations are based on expert consensus alone where evidence is lacking. See guidelines for grading of specific recommendations.
The purpose of this document is to provide health care professionals with key facts and recommendations for the diagnosis and treatment of patients in the emergency department. This summary was produced by the BC Emergency Medicine Network and uses the best available knowledge at the time of publication. However, healthcare professionals should continue to use their own judgment and take into consideration context, resources and other relevant factors. The BC Emergency Medicine Network is not liable for any damages, claims, liabilities, costs or obligations arising from the use of this document including loss or damages arising from any claims made by a third party. The BC Emergency Medicine Network also assumes no responsibility or liability for changes made to this document without its consent.
Last Updated Jul 29, 2021
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