Dr Kevin Gruffydd-Jones identifies six key learning points for primary care from the British Thoracic Society guideline on bronchiectasis

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Dr Kevin Gruffydd-Jones

  • how to recognise, investigate, and manage bronchiectasis in primary care
  • co-existing conditions that increase the risk of bronchiectasis
  • key points for primary care on the routine review of patients with bronchiectasis.

Read this article online at: GinP.co.uk/455944.article

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Bronchiectasis is a chronic condition in which irreversible damage to and dilation of the bronchi lead to symptoms of persistent or recurrent bronchial sepsis.1 A GP practice of 10,000 patients will have around 50 adult patients with bronchiectasis.2

The British Thoracic Society guideline for bronchiectasis in adults was published in 2019.3 The implications of this guidance for primary care were set out in an article targeted at a specialist global primary care audience.1 This article outlines the key points for primary care from the guideline and from the summary article for primary care.

1. Learn to recognise and diagnose bronchiectasis

A diagnosis of bronchiectasis should be suspected in patients with a recurrent or persistent cough that has lasted for more than 8 weeks and features the production of purulent or mucopurulent sputum.1,3 There should be a lower index of suspicion for bronchiectasis if there are co-existing factors, as outlined in Box 1.2 In particular, a study of UK general practices showed the presence of bronchiectasis in 29% of patients aged 40–80 years who presented to their GP with an acute exacerbation of chronic obstructive pulmonary disease (COPD).4

Box 1: Co-existing conditions raising the probability of bronchiectasis in patients presenting with chronic, productive cough2

  • COPD (especially with a history of frequent exacerbations, low FEV1, and/or persistent sputum pathogens)
  • Difficult-to-treat asthma
  • Rheumatoid arthritis
  • Inflammatory bowel disease
  • Chronic rhinosinusitis
  • Presence of persistent pathogenic organisms (especially P. aeruginosa) in sputum.

COPD=chronic obstructive pulmonary disease; FEV1 =forced expiratory volume in 1 second; P. aeruginosa =Pseudomonas aeruginosa

Although it was an element that was not covered by the British Thoracic Society (BTS) guideline, healthcare professionals should consider whether the patient has COVID-19 or a history of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection (see COVID-19 considerations box at the end of this article). For more information on the long-term effects of COVID-19, refer to guidance issued by NICE and the Primary Care Respiratory Society.5,6

To exclude other causes of chronic cough, such as COPD, asthma, lung cancer, or gastro-oesophageal reflux, a full history should be taken and an examination conducted.1 In patients with bronchiectasis, examination of the chest may or may not reveal the presence of characteristic persistent inspiratory basal crackles.1 The upper airway should be examined for the presence of chronic rhinosinusitis.3

Investigations should include a chest X-ray (which may be normal), diagnostic spirometry (which may be normal, restrictive, or obstructive), and sputum culture to identify persistent pathogens, such as Pseudomonas aeruginosa (the presence of which indicates a worse prognosis).1,3

Definitive diagnosis of bronchiectasis is carried out by thin-section computed tomography (CT) scanning of the chest.1,3 This may be arranged by direct access or via specialist referral.

Figure 1 shows a proposed algorithm for the diagnosis of bronchiectasis after presentation in primary care.1

Figure 1- Algorithm showing the diagnostic pathway in primary care for patients with suspected bronchiectasis

Figure 1: Algorithm showing the diagnostic pathway in primary care for patients with suspected bronchiectasis1

Gruffydd-Jones K, Keely D, Knowles V et al. Primary care implications of the British Thoracic Society Guidelines for bronchiectasis in adults 2019. NPJ Prim Care Respir Med 2019; 29: 24.

Reproduced with permission. Available under the CC-BY 4.0 licence.

2. Know when to refer to a specialist

Once a firm diagnosis is made, it is recommended that the initial assessment should be conducted by a specialist respiratory team in order to elucidate any underlying causes, evaluate any co-morbid conditions, and formulate a joint management plan. This assessment should take into consideration details of routine treatment, investigations, place of routine review, and actions to take in case of flare up, including relevant contact details.1

A proposed algorithm for the review and management of patients with bronchiectasis in primary care is provided in Figure 2.1

Figure 2- Algorithm showing the review and management of patients with bronchiectasis in primary care

Figure 2: Algorithm showing the review and management of patients with bronchiectasis in primary care1

Gruffydd-Jones K, Keely D, Knowles V et al. Primary care implications of the British Thoracic Society Guidelines for bronchiectasis in adults 2019. NPJ Prim Care Respir Med 2019; 29: 24.

Reproduced with permission. Available under the CC-BY 4.0 licence.

3. Understand the aims of management

The overall aims of the management of bronchiectasis are to prevent further lung damage, maximise lung function and quality of life, and prevent and treat exacerbations.1 The cornerstones of management are summarised in Box 2.

Box 2: Cornerstones of bronchiectasis management

  • Treat any underlying causes—a single-centre study found that investigations into the causes of bronchiectasis in secondary care result in a change in management in 5–37% of patients1
  • Recommend physiotherapy to mobilise secretions and improve expectoration;1 pulmonary rehabilitation can improve health status, increase exercise capacity, and reduce exacerbations7
  • Offer pneumococcal and annual influenza vaccinations3
  • Optimise airway pharmacotherapy in patients with co-existing airway disease (asthma or COPD) or significant breathlessness3,[A]
  • Undertake prompt treatment of acute exacerbations1
  • Treat patients with bronchiectasis who experience three or more exacerbations per year with long-term antibiotics (initiated in secondary care and prescribed in primary care as ongoing), such as azithromycin.3

[A] Treatment with inhaled corticosteroids should not be routinely offered to patients with bronchiectasis without other indications (such as COPD or asthma). There is no evidence to support the use of short-acting beta-2 agonists, although it is recommended to offer a trial, usually lasting 6 months, of long-acting inhaled bronchodilators in patients with significant breathlessness. If the patient benefits, the bronchodilator should be continued.3

COPD=chronic obstructive pulmonary disease

Physiotherapy

All patients with bronchiectasis should be assessed by a respiratory physiotherapist.3 Chest physiotherapy can mobilise secretions and aid effective expectoration, providing an improvement in cough scores.1

Figure 2 shows the key physiotherapeutic interventions for bronchiectasis.1 In addition, some excellent downloadable videos on chest clearance techniques are available at bit.ly/3qOQ np7.

Long-term antibiotic therapy

Long-term antibiotic therapy—that is, antibiotic therapy lasting for 3 months or more—should be considered for patients who experience three or more exacerbations per year, and this treatment should be initiated and monitored by specialists in secondary care.1 The BTS guideline recommends a starting dose of azithromycin 250 mg, to be taken orally three times a week for 1 year, to reduce the incidence of exacerbations in these patients with bronchiectasis.1,3 A recent two-step meta-analysis of long-term macrolide therapy (published pre-peer review) found that the frequency of exacerbations was reduced by 51% in patients with two or more exacerbations per year, irrespective of whether they were colonised with P. aeruginosa.8 Patients whose symptoms do not respond to long-term antibiotic therapy with azithromycin, or in whom macrolides are contraindicated, may be offered long-term inhaled antibiotic therapy (such as colistin or gentamicin) or long-term intravenous antibiotics.1,3

4. Know when to refer patients to secondary care

Patients should be referred to secondary care for:

Patients should also be referred to secondary care if their bronchiectasis is established and they have any of the following:1

  • three or more exacerbations per year
  • chronic colonisation with P. aeruginosa, methicillin-resistant Staphylococcus aureus, or non-tuberculous mycobacteria
  • allergic bronchopulmonary aspergillosis
  • long-term antibiotic therapy (oral, inhaled, or nebulised)
  • associated inflammatory bowel disease, rheumatoid arthritis, primary ciliary dyskinesia, or immune deficiency
  • advanced disease, or are considering transplantation
  • deterioration of lung function.

5. Conduct a routine review in primary care

Patients will have been assessed by the specialist team as suitable for review in primary care, and the frequency of review will be stated in the management plan (but will be annual as a minimum).

The key elements of this routine review are to:1

  • check spirometry (for evidence of disease deterioration and co-morbid airway disease)
  • ensure that a recent sputum culture has been conducted
  • perform pulse oximetry
  • assess co-morbidities, such as asthma and COPD
  • check that pneumococcal and annual influenza vaccinations have been given
  • record exacerbation history
  • check compliance with airway clearance techniques (if in doubt, re-refer to physiotherapy)
  • review the patient’s action plan.

Although not covered by the BTS guideline, healthcare professionals should also consider whether patients have been vaccinated against COVID-19.

6. Manage acute flare ups

Initial assessment should determine if a patient needs urgent hospital admission. Hospital admission should be considered if the patient is experiencing respiratory distress, exhibiting features of sepsis, or has significant co-morbidities.1

Ideally, patients who are managed in primary care should have a sputum sample taken prior to antibiotic treatment.1 If suitable, patients should be provided with antibiotics to keep at home.

Choice of antibiotic will be determined by culture and local sensitivities; if not known, empirical treatment should be started with amoxicillin 500 mg three times daily (doxycycline 100 mg twice daily if allergic to penicillin) or ciprofloxacin 500 mg twice daily if P. aeruginosa infection has been identified (750 mg twice daily for severe infection) while awaiting the results of sputum culture.1 Most patients with moderate and severe bronchiectasis should undergo 14 days of antibiotic therapy, although in patients with mild bronchiectasis a 7–10-day course may suffice.1

Advice to aid expectoration should be reinforced, and the treatment plan should be reviewed, especially the need for re-referral for physiotherapy or to secondary care.

Kevin Gruffydd-Jones

GP, Box, Wiltshire

COVID-19 considerations

  • Ensure that patients have an up-to-date management plan, including adequate supplies of stand-by antibiotics
  • Explain that symptoms of a flare up of bronchiectasis can be difficult to differentiate from COVID-19 symptoms; advise patients to seek medical help if the symptoms are different from their usual flare up (e.g. fever, loss of smell, dry cough)
  • Patients with bronchiectasis assessed for shielding using the University of Oxford’s QCovid® risk calculator available through the NHS Digital website9 will tend to be patients who experience three or more exacerbations per year and/or have significant co-morbidities.10

Key points

  • A diagnosis of bronchiectasis should be suspected in patients presenting with a recurrent or persistent productive cough lasting for >8 weeks) and featuring production of purulent or mucopurulent sputum
  • A definitive diagnosis of bronchiectasis is made using thin-section CT scanning
  • Initial assessment should be carried out in secondary care and a shared management plan formulated with the patient and primary care
  • The cornerstones of primary care management are:
    • minimum of annual review
    • physiotherapy to improve airway sputum clearance, and pulmonary rehabilitation if needed
    • review of co-morbidities (e.g. COPD)
    • pneumococcal and annual influenza vaccinations
    • prompt treatment of acute exacerbations, including provision of antibiotics to keep at home
  • Patients who have three or more exacerbations per year, colonisation with P. aeruginosa, deteriorating disease control, and significant co-morbidities should be reviewed in secondary care.

CT=computed tomography; COPD=chronic obstructive pulmonary disease; P. aeruginosa=Pseudomonas aeruginosa

Implementation actions for STPs and ICSs

written by Dr David Jenner, GP, Cullompton, Devon

The following implementation actions are designed to support STPs and ICSs with the challenges involved in implementing new guidance at a system level. Our aim is to help you consider how to deliver improvements to healthcare within the available resources.

  • Establish a multidisciplinary team to agree and devise a local system care pathway for patients with bronchiectasis.
  • Share clear guidelines for primary care detailing how to identify new cases of bronchiectasis and establish a formal diagnosis
  • Agree whose responsibility it is to refer for diagnostic CT scans in the care pathway, and establish referral criteria for this key investigation
  • Consider employing specialist nurses to support patients with bronchiectasis in the community
  • Publish templates for local patient care plans that primary care can adapt to individual patients, with treatment guidelines for exacerbations at annual review
  • Update local formularies to reflect antibiotic choices.

STP=sustainability and transformation partnership; ICS=integrated care system; CT=computed tomography

Guidelines Learningcpd logo

After reading this article, ‘Test and reflect’ on your updated knowledge with our multiple-choice questions. We estimate that this activity will take you 30 minutes—worth 0.5 CPD credits.

References

  1. Gruffydd-Jones K, Keely D, Knowles V et al. Primary care implications of the British Thoracic Society Guidelines for bronchiectasis in adults 2019. NPJ Prim Care Respir Med 2019; 29: 24.
  2. Quint J, Millett E, M Joshi et al. Changes in the incidence, prevalence and mortality of bronchiectasis in the UK from 2004 to 2013: a population-based cohort study. Eur Respir J 2016; 47 (1): 186–193.
  3. Hill A, Sullivan A, Chalmers J et al. British Thoracic Society guideline for bronchiectasis in adults. Thorax 2019; 74 (Suppl 1): 1–69.
  4. O’Brien C, Guest P, Hill S, Stockley R. Physiological and radiological characterisation of patients diagnosed with chronic obstructive disease in primary care. Thorax 2000; 55 (8): 635–642.
  5. NICE. COVID-19 rapid guideline: managing the long-term effects of COVID-19. NICE Guideline 188. NICE, 2020. Available at: www.nice.org.uk/ng188
  6. Primary Care Respiratory Society. Recovering after COVID-19—a practical guide for clinicians and commissioners. Solihull, UK: PCRS, 2020. Available at: www.pcrs-uk.org/sites/pcrs-uk.org/files/RecoveryPostCovid19_FINAL_0.pdf
  7. Lee A, Hill C, Cecins N et al. The short and long term effects of exercise training in non-cystic fibrosis bronchiectasis—a randomised controlled trial. Respir Res 2014: 15 (1): 44.
  8. Chalmers J, Boersma W, Lonergan M et al. Long-term macrolide antibiotics for the treatment of bronchiectasis in adults: an individual participant data meta-analysis. Lancet Respir Med 2019; 7 (10): 845–854.
  9. NHS Digital. COVID-19 population risk assessment. digital.nhs.uk/coronavirus/risk-assessment/population (accessed 26 February 2021).
  10. British Thoracic Society. COVID-19: identifying patients for shielding. www.brit-thoracic.org.uk/covid-19/covid-19-identifying-patients-for-shielding (accessed 26 February 2021).