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Bronchiectasis Care Pathway Overview

This pathway has been published in order to aid GPs and Practice Nurses in delivering care for patients with bronchiectasis. This includes developing a more consistent countywide approach, improving the quality of primary care diagnosis and management as well as accessing secondary care at the right time.

Please click the relevant flowchart box to be taken directly to textual information.

                                                            

Red Flags
  • haemoptysis
Presentation

  • chronic cough with sputum
  • recurrent "chest infections"
  • recurrent "pleurisy"
  • breathlessness and wheeze
  • green or yellow sputum in stable clinical state
  • fatigue

  • productive cough with:
    • young age at presentation
    • symptoms over many years
    • especially if never smoked
    • daily sputum production
    • sputum positive for Pseudomonas
  • unexplained haemoptysis or cough without sputum
  • patients with particularly troublesome chronic obstructive pulmonary disease (COPD) or asthma with frequent exacerbations.
Differential Diagnosis
Initial Assessment

A high-resolution computed tomography (HRCT) scan is the gold standard indicator for bronchiectasis. This can be accessed directly-please click here for the link to direct access HRCT. All patients being referred to the bronchiectasis clinic in secondary care should have had a HRCT performed.

In bronchiectasis, the bronchi appear larger and more dilated than the accompanying bronchial artery. There may also be bronchial wall thickening (harder to define) and the CT scan may help to define aetiology. 

  • sputum examination (state bronchiectasis on form)
  • spirometry
  • chest x-ray
  • Assess for presence of anxiety or depression
  • Document the person’s smoking history
  • Calculate the person’s BMI

  • total immunoglobulin E (IgE) and radioallergosorbent (RAST) to Aspergillus
  • serum immunoglobulins and protein electrophoresis
  • if joint problems or systemic symptoms consider rheumatoid factor/antinuclear antibodies (ANA)
  • sputum for acid-fast bacillus (AFB) testing
Initial Management Principles
  • Identify and treat underlying causes to prevent progression of disease
  • Maintain or improve lung function
  • Improve quality of life by reducing daily symptoms and exacerbations
  • Seek consultant opinion (via advice and guidance) for support on managing more moderate or severe confirmed or suspected cases

Please find below leaflets that your patient may find useful:

Airway Clearance

Patients that are having difficulty with sputum clearance or are experiencing a high sputum burden should see a physiotherapist for advice about airway clearance to develop a patient-centred regimen.

Physiotherapists may request the prescription of certain therapies to improve the efficiency and effort involved in airway clearance. Please consult a respiratory physiotherapist prior to prescribing any of these therapies as it is vital that their use can be applied to an airway clearance regimen and not just taken in isolation. Independent non-medical prescribing physiotherapists will prescribe the adjunct themselves, however there may be times where you are asked to support treatment with a prescription following the advice of the physiotherapist.

For example:

  • nebulised normal saline
  • nebulised hypertonic saline
  • nebulised bronchodilators
  • mucolytics/inhaled mannitol
  • adjuncts (e.g. Acapella)
Pulmonary Rehabilitation

Pulmonary Rehabilitation is delivered in sites throughout the county by physiotherapists, occupational therapists and nurses.  It is a course that offers respiratory patients group sessions that include activity and education about their respiratory disease and improves the patient’s confidence and ability to self-manage.  It is an intensive course of two 2 hourly sessions over seven weeks and is highly recommended upon hospital discharge.   Please send referrals to: glos-care.glosrespiratoryteam@nhs.net & refer to the criteria checklist on the Referral Form.

myCOPD is an online education, self-management and Pulmonary Rehabilitation platform that has recently been made available on the NHS Digital & Innovation Tariff.

myCOPD is adopted by the Pulmonary Rehabilitation team as an option for individuals that either cannot commit to the time requirement of Pulmonary Rehabilitation or are faced with a wait of three months or more prior to being offered a place on a PR programme.

Continue to refer patients to Pulmonary Rehabilitation, the entry points that the patients will be offered myCOPD will at triage and post assessment by the respiratory specialist at GCS.

On referral to Pulmonary Rehabilitation a Patient information leaflet can be passed to patient to provide information on myCOPD in preparation for PR.

Referral to Secondary Care

All patients with a high-resolution computed tomography (HRCT) confirmed diagnosis of bronchiectasis/recent HRCT, that meet the below criteria should be referred to secondary care:

  • Recurrent culture of pseudomonas or S. aureus (inc. MRSA)
  • Frequent exacerbations despite antibiotics
  • Consideration of prophylactic antibiotics
  • Deteriorating lung function
  • Suspicion of complex underlying cause
  • Diagnostic uncertainty  
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