Bronchiectasis in Adults - Suspected

Transcription

1 Bronchiectasis in Adults - Suspected Clinical symptoms which may indicate bronchiectasis for patients Take full respiratory history including presenting symptoms, past medical & family history Factors favouring further investigation young age at presentation history of symptoms over many years absence of smoking history daily expectoration of large volumes of very purulent sputum See Cough - Chronic Persistent: See Asthma in Adults Suspected: Under development See Diagnosing COPD: Exclusion of differential diagnoses is essential in chronic cough upper airway cough syndrome, e.g. post nasal drip syndrome gastroesophageal reflux disease (GORD) lung malignancy allergic bronchopulmonary aspergillosis (ABPA) pulmonary fibrosis pneumonia tuberculosis foreign body Investigations Radiological investigations Sputum microbiology Spirometry Blood testing Potential lung malignancy Refer urgently for chest X-ray or 2WW suspected lung cancer See Lung Cancer Suspected: Radiological investigations Sputum microbiology investigations Spirometry investigations Blood testing Refer For CT scan (chest) Diagnosis of bronchiectasis confirmed by CT Symptomatic diagnosis of bronchiectasis? Yes No Immunoglobulin testing If <40yrs old, genetic testing for CF See Bronchiectasis in Adults - Management in Primary Care: Refer to secondary care respiratory consultant

2 Clinical symptoms which may indicate bronchiectasis chronic cough with daily mucopurulent sputum frequent lower respiratory tract infections (LRTI) - may be the only presenting feature breathlessness general malaise, lethargy, fatigue, and weight loss chronic rhinosinusitis haemoptysis: typically mild with bloody specks in the sputum chest pain that is present between exacerbations asthma that is not responding to treatment

3 Take full respiratory history including presenting symptoms, past medical & family history age of onset and duration of symptoms nature of cough and associated upper airway features, e.g. sinusitis, middle ear infection asthmatic features shortness of breath, wheezing, chest pain COPD and recurrent LRTI or slow recovery from these general systemic health including, weight loss, gastrointestinal symptoms, particularly symptoms of gastroesophageal reflux disease, rheumatological symptoms, conjunctivitis, UTI, urinary incontinence and/or subfertility, skin or soft tissue infections

4 Potential lung malignancy Lung cancer can present with a number of symptoms, these include: cough shortness of breath chest pain haemoptysis weight loss appetite loss fatigue persistent chest infection Pleural mesothelioma may also present with symptoms including: cough shortness of breath chest pain weight loss An urgent X-ray (to be performed within 2 weeks) to assess for lung cancer in patients aged 40 years: should be offered if they have 2 or, or if they have ever smoked or been exposed to asbestos and have 1 or of the following unexplained symptoms: cough fatigue shortness of breath chest pain weight loss appetite loss should be considered if the patient has any of the following: persistent or recurrent chest infection finger clubbing supraclavicular lymphadenopathy or persistent cervical lymphadenopathy chest signs consistent with lung cancer thrombocytosis should be considered to assess for mesothelioma if the patient has either: finger clubbing; or chest signs compatible with pleural disease Refer urgently, using a suspected cancer referral, for an appointment within 2 weeks: patients age 40 years with unexplained haemoptysis any patients with CXR findings suggestive of lung cancer or mesothelioma

5 Blood testing FBC, urea, electrolytes, and LFTs ESR CRP consider serum immunoglobulins (IgG, IgA, IgM) and serum electrophoresis consider serum IgE, skin prick testing, or serum IgE testing to Aspergillus fumigatus and Aspergillus precipitins findings may include: anaemia secondary polycythaemia neutrophilia eosinophilia (allergic bronchopulmonary aspergillosis)

6 Information for patients 'Bronchiectasis' from Patient UK: 'Coughing up blood (haemoptysis)' from Patient UK: 'Wheeze' from Patient UK: 'Bronchiectasis' from the British Lung Foundation: Nebuliser Support from the British Lung Foundation: 'Breathlessness' from the British Lung Foundation: 'Living with a lung condition' from the British Lung Foundation:

7 Radiological investigations Baseline CXR in all patients: CXR is abnormal in 90% of people with bronchiectasis, but is not diagnostic. Findings on CXR may be nonspecific and the patient should be referred if there is clinical suspicion from history and examination CXR may demonstrate, lung lobes involved, dilated, thickened airways: parallel lines ring shadows in cross section

8 Sputum microbiology investigations All patients to have an assessment of LRT microbiology persistent isolation of Staphylococcus aureus should lead to consideration of underlying allergic bronchopulmonary aspergillosis (ABPA) or CF consider sending multiple samples if sputum is purulent and the first sample is negative if these are negative, consider sputum for acid-fast bacilli (AFB) culture (three samples) If there is excess sputum: Refer to physiotherapist for sputum clearance

9 Spirometry investigations All patients should have measures of FEV1, FVC, and PEF to investigate degree of functional impairment may be normal or demonstrate an obstructive pattern (reduced FEV1:FVC ratio)

10 Referral criteria for secondary care respiratory consultant a clinical diagnosis of bronchiectasis requires a HRCT for confirmation of diagnosis haemoptysis deteriorating bronchiectasis with declining lung function patients colonised with: chronic Pseudomonas aeruginosa opportunist mycobacteria meticillin-resistant Staphylococcus aureus (MRSA) recurrent LRTI - than three per annum patients being considered for long-term prophylactic antibiotic therapy (oral or nebulised). patients with bronchiectasis and associated rheumatoid arthritis, immune deficiency, inflammatory bowel disease, and primary ciliary dyskinesia (PCD) patients with allergic bronchopulmonary aspergillosis (ABPA) patients with advanced disease and those considering transplantation family history abnormal spirometry, e.g. FEV1 < 70% predicted