Bronchiectasis in Primary Care – Key Questions Answered
Did you attend our virtual respiratory event on 10 October 2023? Jo Brown, Senior Respiratory Research Nurse, Liverpool University Hospitals NHS Foundation Trust answers some of the questions about bronchiectasis that we didn’t have time to answer on the day.
Bronchiectasis in Primary Care – Key Questions Answered
Should people with bronchiectasis be under the community respiratory team? How do we decide if oxygen is needed?
Some patients are managed in the community. The consultant I work with has clinics both in the community and at hospital outpatients departments. If a patient presents with a Sp02 <94% at rest, they may be referred for an oxygen assessment. There are three types of oxygen that can be prescribed:
- Long Term Oxygen Therapy (LTOT) – usually prescribed for a minimum of 16 hours a day, and it’s aim is to perfuse the tissues/organs.
- Short Burst Oxygen Therapy (SBOT) – this might be prescribed for someone recovering from a significant lung injury. It might not be permanent. Patients who have had a particularly bad episode of pneumonia might be prescribed this, to help them recover.
- Ambulatory Oxygen (AOT) – this can be considered for patients who de-saturate when they’re mobile. Patients with a normal Sa02 at rest, but a Sp02 <88% when mobile might be considered. A six minute walk test is normally conducted (6MWT) to determine eligibility. More information can be found here.
Can you tell us about acopella, aerobika and flutter?
Management of NCFB places a heavy emphasis on airway clearance techniques (ACTs), which aim to mobilise secretions, aiding effective expectoration and airway clearance. This increases ventilation efficiency, reducing dyspnoea, thoracic pain, and further daily sputum production. ACTs are therefore important to consider in the wider context of therapies offered to patients in multidisciplinary care.
Some patients exhale into a hand-held device to help break up mucus. Some of these devices are Oscillating Positive Expiratory Pressure (PEP), Intrapulmonary Percussive Ventilation (IPV) and Postural Drainage. Chest Physical Therapy (CPT), or chest physiotherapy, is a popular respiratory therapist technique that involves clapping on the chest in a certain way that helps loosen mucus from the lungs so it can be expelled. Electronic chest clappers or vests are now available to make it easier to perform CPT at home. You can watch a video to see how to use it here.
When a patient has haemoptysis, how do you know if it is infection, if they need bronchoscopy or chronic lung disease?
If a patient presents with haemoptysis, it can be a number of things. A High Resolution CT scan (HRCT) will demonstrate if there are any lung nodules or lesions that need further investigation (including having a bronchoscopy). But the most important thing is a detailed patient history. With any severe bouts of coughing, there is always the risk of rupturing one of the smaller blood vessels, which can be the cause.
If a patient attended with possible Bronchiectasis, what antibiotic/ management can we start the patient on when they attend Urgent care? (Assuming observations are stable)
If a patient is presenting with signs of an acute infection, they should be prescribed with the antibiotics according to your antibiotic prescribing guidelines. We only make specific ab recommendations, when we have isolated specific bacteria. If a patient is having regular infections, they should be referred to a respiratory consultant (either based in primary or secondary care) for more specialist assessment. Recommendations should be made if a patient becomes colonized with a particular bug.
Are there specific markers for the commencement of oxygen?
If a patient presents with a Sp02 <94% at rest, they may be referred for an oxygen assessment. There are three types of oxygen that can be prescribed:
- Long Term Oxygen Therapy (LTOT) – usually prescribed for a minimum of 16 hours a day, and it’s aim is to perfuse the tissues/organs.
- Short Burst Oxygen Therapy (SBOT) – this might be prescribed for someone recovering from a significant lung injury. It might not be permanent. Patients who have had a particularly bad episode of pneumonia might be prescribed this, to help them recover.
- Ambulatory Oxygen (AOT) – this can be considered for patients who de-saturate when they’re mobile. Patients with a normal Sa02 at rest, but a Sp02 <88% when mobile might be considered. A six minute walk test is normally conducted (6MWT) to determine eligibility. More information can be found here.
To use SABA OR LABA/LAMA?
It depends on the patient. Most patients will be prescribed a SABA, then if they are using it more than twice a week (in the absence of infection), they should be considered for a LABA/LAMA. It will all depend on the patient’s clinical presentation. There won’t ever be one rule for all.
With the history of the death of a child from mould, could this in the future be a causative factor of childhood infections leading to bronchiectasis?
Yes, mould-associated BE can be due to sensitization to mould allergens in the presence of fungal infection.
Are patients more affected in colder months?
Yes, usually.
What work up do you do pre-initiation of long-term azithromycin in your area?
Nebulized antibiotics are prescribed for BE patients who have regular chest infections, who are usually colonized with Pseudomonas aeruginosa. Spirometry is usually done before and after the initial nebulized antibiotic. If the patient feels worse (after the nebulized antibiotic), a SABA will be administered to open up the airways. The process will continue if the patient feels well enough.
Spirometry will be conducted on a regular basis, to check that the long-term use of nebulized antibiotics is not causing any long term lung damage.
Do you do spirometry pre-nebulised antibiotics?
Nebulized antibiotics are prescribed for BE patients who have regular chest infections, who are usually colonized with Pseudomonas aeruginosa. Spirometry is usually done before and after the initial nebulized antibiotic. If the patient feels worse (after the nebulized antibiotic), a SABA will be administered to open up the airways. The process will continue if the patient feels well enough.
Spirometry will be conducted on a regular basis, to check that the long-term use of nebulized antibiotics is not causing any long term lung damage.