Critical Alerts

• Massive hemoptysis can occur and requires emergent management
• Pseudomonas aeruginosa is common - consider antipseudomonal coverage
• Respiratory failure may develop in severe exacerbations
• Chronic colonization differs from acute infection - know patient's baseline
• Non-tuberculous mycobacteria (NTM) may be present - consider if not responding

Key Diagnostics

• Chest X-ray (may show bronchial wall thickening, "tram tracks")
• CT chest (gold standard for diagnosis - bronchial dilation)
• Sputum culture including AFB (guide antibiotic therapy)
• CBC, CRP (inflammatory markers)
• ABG/VBG if respiratory distress

Emergency Treatments

• Oxygen therapy: Target SpO2 88-92% (may have chronic hypercapnia)
• Antibiotics: Empiric based on prior cultures; cover Pseudomonas if colonized
• Bronchodilators: Nebulized salbutamol and ipratropium
• Airway clearance: Physiotherapy, nebulized hypertonic saline
• Hemoptysis management: Tranexamic acid, bronchial artery embolization if massive

Bronchiectasis is a chronic respiratory disease characterized by irreversible, abnormal dilation of the bronchi with impaired mucociliary clearance, chronic infection, and inflammation. Patients experience recurrent respiratory infections and progressive lung damage.

Pathological Classification

Epidemiology

• Prevalence: 50-500 per 100,000 (increasing with CT availability)
• Age: Can occur at any age; prevalence increases with age
• Sex: Female predominance in non-CF bronchiectasis
• Mortality: Increased compared to general population

Etiology

Critical Presentations

Massive Hemoptysis Management

Immediate Actions:
1. Position bleeding lung down (if known)
2. Protect airway - suction
3. Large-bore IV access
4. Type and crossmatch
5. Tranexamic acid 1g IV
6. Urgent CXR (lateralize source)
7. Call for help - ICU, interventional radiology, thoracic surgery

Definitive Treatment:
- Bronchial artery embolization (first-line)
- Bronchoscopy for localization
- Surgery if embolization fails

Conditions with Similar Presentations

Causes of Chronic Productive Cough

• Bronchiectasis
• COPD
• Chronic sinusitis with post-nasal drip
• GERD-related cough
• ACE inhibitor-related cough
• Lung cancer

Clinical Assessment

Key History

• Duration and characteristics of symptoms
• Sputum volume and color daily vs during exacerbation
• Prior cultures and antibiotic sensitivities
• Exacerbation frequency
• Prior hospitalizations
• Known colonizing organisms
• Baseline pulse oximetry and FEV1

Laboratory Studies

Imaging

Chest X-ray

• May be normal in mild disease
• "Tram track" sign (thickened bronchial walls)
• Ring shadows (dilated bronchi en face)
• Air-fluid levels in dilated bronchi
• Consolidation if infection

High-Resolution CT (HRCT) - Gold Standard

Pulmonary Function Tests

• Often obstructive pattern
• FEV1/FVC <0.7
• Reduced FVC in advanced disease
• Air trapping (increased RV/TLC)

Admission Criteria

• Hypoxia requiring supplemental oxygen
• Severe exacerbation with respiratory distress
• Failure of outpatient antibiotics
• Inability to manage at home
• Significant hemoptysis
• Need for IV antibiotics
• Comorbidities complicating management

ICU Admission Criteria

• Respiratory failure requiring NIV or intubation
• Massive hemoptysis
• Sepsis or hemodynamic instability
• Hypercapnia with pH <7.25

Discharge Criteria

• Stable or improving symptoms
• Oxygen at or near baseline
• Able to take oral medications
• Airway clearance education provided
• Follow-up arranged
• Exacerbation action plan in place

Follow-up Recommendations

Understanding Bronchiectasis

• Bronchiectasis is a chronic lung condition with widened airways
• Airways become damaged and prone to repeated infections
• Daily airway clearance is essential
• Complete antibiotic courses as prescribed

Daily Management

Airway Clearance

• Perform twice daily (more during exacerbations)
• Techniques include huff coughing, active cycle breathing
• Use hypertonic saline nebulizer if prescribed
• Devices like flutter valves or vest therapy may help

Hydration

• Good hydration helps thin secretions
• Aim for 2-3L fluid daily unless restricted

Exacerbation Recognition

Seek care if:

• Increased sputum volume or color change
• Increased breathlessness
• New or increased fever
• Worsening fatigue
• Blood in sputum

Prevention

• Annual influenza vaccination
• Pneumococcal vaccination
• COVID-19 vaccination
• Avoid respiratory irritants
• Good hand hygiene
• Treat GERD if present

Cystic Fibrosis-Related Bronchiectasis

• Earlier onset, more severe
• Pseudomonas colonization very common
• Pancreatic insufficiency, diabetes, sinusitis
• CF transmembrane conductance regulator (CFTR) modulators
• Dornase alfa (Pulmozyme) effective for sputum

Immunodeficiency-Associated

• Screen for immunoglobulin deficiency
• IgG replacement therapy if deficient
• More aggressive infection management

Non-Tuberculous Mycobacterial Infection

Suspect if:

• Not responding to standard antibiotics
• Nodular or cavitary disease
• Low BMI, older female
• MAC is most common

Management:

• Multiple drug regimen (macrolide + rifampin + ethambutol)
• Prolonged treatment (12+ months after culture negative)
• Specialist involvement essential

ABPA (Allergic Bronchopulmonary Aspergillosis)

• Sensitization to Aspergillus in airway
• Eosinophilia, elevated IgE
• Central bronchiectasis characteristic
• Treatment: Oral corticosteroids, itraconazole

Performance Indicators

Documentation Requirements

• Baseline pulmonary status (FEV1, usual SpO2)
• Prior cultures and sensitivities
• Current symptoms vs baseline
• Antibiotic choice rationale
• Airway clearance plan
• Discharge instructions

Diagnostic Pearls

1. CT chest is gold standard - don't rely on CXR alone
2. Know the patient's baseline - colonization vs acute infection
3. Always send sputum during exacerbations
4. Consider NTM if not responding to standard therapy
5. Screen for underlying causes - immunodeficiency, CF, ABPA

Treatment Pearls

1. Pseudomonas requires specific coverage - ciprofloxacin or IV antipseudomonal
2. 14 days of antibiotics is standard for exacerbations
3. Airway clearance is as important as antibiotics
4. Avoid over-oxygenation in chronic CO2 retainers
5. Tranexamic acid is first-line for hemoptysis

Disposition Pearls

1. Low threshold for admission in severe exacerbation
2. Ensure baseline is documented for future reference
3. Follow-up is essential - chronic disease requires continuity
4. Exacerbation action plan empowers patients
5. Pulmonology referral for new diagnosis or frequent exacerbations