2. Bronchiectasis

📄Definition

Bronchiectasis is an irreversible abnormal dilatation of the bronchi due to chronic infection and inflammation, resulting in impaired mucus clearance and persistent cough with sputum production.

🔬 Pathophysiology

🧠 Mnemonic: CYCLE

  • Chronic infection →

  • Yielding inflammation

  • Ciliary damage

  • Loss of airway tone

  • Expansion of bronchi (permanent dilatation)

→ Leads to mucus stasis, colonisation, and recurrent infections.

📋 Causes

🧠 Mnemonic: ABCD SHIRT

  • Abnormal cilia (e.g. Kartagener’s, PCD)

  • Bronchial obstruction (tumour, foreign body)

  • Cystic Fibrosis

  • Deficiency (immune – IgA, IgG)

  • Systemic disease (RA, IBD, Sjogren’s)

  • Hypersensitivity (ABPA – allergic bronchopulmonary aspergillosis)

  • Infection (childhood measles, TB, pertussis)

  • Reflux/aspiration

  • Tuberculosis or other granulomatous infection

📋Clinical Features

🧠 Mnemonic: COUGH SPIT

  • Chronic productive cough

  • Overproduction of sputum (purulent, foul-smelling)

  • Up to 2+ exacerbations per year

  • Green/yellow mucus plugs

  • Haemoptysis (mild to massive)

  • Shortness of breath

  • Pleuritic chest pain

  • Infections recurrent

  • Tiredness (systemic symptoms)

🩺Physical Examination Findings

  • Bilateral coarse crackles ± wheeze

  • Clubbing

  • Signs of underlying cause (e.g. nasal polyps in CF, rash in vasculitis)

🔬 Investigation Ladder for Bronchiectasis 

StepTestWhy / Key Notes
1️⃣ First-line (basic assessment)CXRMay be normal; look for tram-track lines, ring shadows. Screening test in suspected cases.
 Spirometry (with reversibility)Obstructive pattern (↓FEV₁, ↓FEV₁/FVC, little/no reversibility). Helps distinguish from asthma.
 Sputum cultureEssential before antibiotics. Common bugs: H. influenzae, Pseudomonas, Staph aureus.
2️⃣ Second-line (confirm diagnosis)High-resolution CT (HRCT)Gold standard – confirms permanent bronchial dilatation. Classic signs: tram-track, signet-ring sign, cystic changes.
3️⃣ Third-line (identify cause)Immunoglobulins (IgA, IgG, IgM)Detect immune deficiency.
 Sweat test ± CFTR genetic testingRule out Cystic Fibrosis in young/adult-onset cases.
 Aspergillus IgE / precipitinsDiagnose ABPA.
 ANCA / autoimmune screenIf vasculitis/systemic disease suspected (e.g. GPA, RA, IBD).
 HIV testIf immunosuppression suspected.
4️⃣ Special / targetedBronchoscopyIf focal bronchiectasis → exclude foreign body, tumour, obstruction.
 Baseline bloods (FBC, U&E, LFTs)Safety for long-term therapy, monitor systemic effects.
 

💊 Management Ladder for Bronchiectasis 

StepInterventionKey Notes
1️⃣ First-line (all patients)Airway clearance physiotherapyChest physio + postural drainage = cornerstone of management. Daily routine.
 Smoking cessation + vaccinationsFlu + pneumococcal essential.
 Treat underlying causee.g. stop aspiration, treat immune deficiency, ABPA, CF.
2️⃣ During Exacerbation14-day antibiotics (oral, guided by sputum culture)Empirical if no result: amoxicillin/clarithromycin/doxycycline. Pseudomonas → ciprofloxacin.
 Sputum culture at each exacerbationGuides therapy + resistance monitoring.
3️⃣ Long-term / frequent exacerbatorsLong-term macrolides (azithromycin 3x/week)If ≥3 exacerbations/year. Reduces exacerbation frequency.
 Inhaled antibiotics (colistin, tobramycin)For chronic Pseudomonas colonisation. Specialist-led.
4️⃣ Adjunctive therapyMucolytics (e.g. carbocisteine)May help sputum clearance.
 BronchodilatorsIf asthma/COPD overlap or reversible obstruction.
5️⃣ Specialist referral / advanced careSurgical resection (lobectomy)Rare – for localised, severe, resistant disease.
 Lung transplantEnd-stage bronchiectasis with severe respiratory failure.

⚠️ Complications

  • Respiratory failure

  • Massive haemoptysis

  • Pseudomonas colonisation

  • Pulmonary hypertension

  • Cor pulmonale

  • ABPA (allergic bronchopulmonary aspergillosis)

🧐Differentials

🧠 Mnemonic: CHAPS

  • COPD

  • Haemoptysis from TB/lung cancer

  • Asthma

  • Pneumonia

  • Sinusitis/post-nasal drip

📌 PARA Revision Tips

  • HRCT is gold standard → tram-track sign, ring shadows

  • Always send sputum culture, especially in exacerbations

  • Cough + sputum + coarse crackles = high yield

  • Daily chest physio is first-line management

  • Long-term abx for frequent exacerbators

🔎 Last updated in line with NICE NG117 – Bronchiectasis
Published: December 2018 • Last updated: February 2024
Last reviewed: July 2025
🔒 PASSMAP ensures all content is NICE-aligned and reviewed for Physician Associate Registration Assessment (PARA) success.

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