Original article
Bronchiectasis in secondary care: a comprehensive profile of a neglected disease

https://doi.org/10.1016/j.ejim.2003.10.002Get rights and content

Abstract

Background: Bronchiectasis is poorly characterised in secondary care. Methods: Over 6 months, 410 bronchiectasis patients attended our clinics. One hundred randomly selected patients were characterised in detail. Results: Patients had a mean and standard error of mean (S.E.M.) age of 57 (2) years and a median and interquartile range (IQR) of three (two to four) reviews in the last 12 months. Aetiologies identified included tuberculosis (n=15), childhood pneumonia (n=7), fibrosis (n=6), connective tissue disease (n=6), whooping cough (n=5), childhood measles (n=4) and others (n=5). There was widespread use of inhaled therapy. Treatments included oral antibiotics (n=77), corticosteroid courses (n=27) and intravenous antimicrobials (n=27, 12 domicillary) in the last year. Thirty patients had hospital admissions (13 because of the inability to administer domicillary antibiotics). Haemophilus influenzae and Pseudomonas spp. were the commonest bacterial isolates. Patients culturing Pseudomonas spp. were older and had had more reviews and intravenous antibiotic courses. Conclusions: Bronchiectasis imposes a considerable burden on hospital services. Patients culturing Pseudomonas spp. impose a greater burden. Aetiology is often unknown. Therapies with unproven benefit are often used.

Introduction

Bronchiectasis is a chronic inflammatory pulmonary disorder that is characterised clinically by daily cough, mucopurulent or purulent tenacious sputum, breathlessness and wheeze [1], [2], [3]. Haemoptysis is a common feature, especially during exacerbations. Patients frequently have finger clubbing, may have cyanosis and often will have expiratory rhonchi and inspiratory coarse crackles. Exacerbations are characterised by increased sputum volume and purulence, increased shortness of breath and cough, haemoptysis and quite frequently, chest pain. This may or may not be pleuritic in nature. Pathophysiologically, there is abnormal, fixed dilation of the subsegmental airways [1], [2]. Airway lumen and mucosa contain a predominantly neutrophilic infiltrate. Proinflammatory mediators are detected at high concentrations [3], [4], [5], [6].

The aetiology of bronchiectasis can be difficult to elucidate and many cases are idiopathic. It is associated with childhood diseases (e.g. measles, whooping cough, childhood pneumonia or pulmonary tuberculosis), with a subsequent lag period before bronchiectasis clinically manifests itself. As a consequence, recollection of these childhood events many years later is likely to be poor. A small group of patients may have a definable aetiology, for example, immunodeficiency, immunosuppression, inhaled foreign body, connective tissue disease, α1-antitrypsin deficiency, allergic bronchopulmonary aspergillosis (ABPA) or ciliary defects [1], [2], [3].

Bronchiectasis is a poorly characterised disease [1], [3], [7], [8], [9]. It is often not considered as a diagnosis in respiratory patients, and it is poorly investigated. There is a perception that its incidence is decreasing since the advent of effective treatment for tuberculosis [3], [8], [9]. However, although there is evidence that gross cystic bronchiectasis that was associated with uncontrolled mycobacterial infection has been decreasing, it appears that there has been better detection of milder forms of the disease [3]. This is especially true since the advent of high resolution computed tomogram (HRCT) scanning, allowing the detection of these milder forms.

Few studies have characterised in detail an outpatient population of patients attending with bronchiectasis [8], [9]. At our hospital, we were unsure of the burden being placed by this condition. Local patterns of disease were particularly unclear. The purpose of this audit was to determine the prevalence of bronchiectasis in secondary care respiratory clinics and to assess how it is diagnosed and managed.

Section snippets

Patient selection

Over a 6-month period, all patients attending chest clinics at the Belfast City Hospital (eight general respiratory clinics run by four respiratory physicians) with a diagnosis of bronchiectasis were recorded. One hundred of these patients were selected at random and their clinical records were examined. Patients with cystic fibrosis (CF) were excluded.

Data collection

The selected case notes were examined by two of the authors, applying a pro forma to extract the relevant information. Demographics, method of

Demographics, diagnosis and aetiology

Over a 6-month period, a total of 410 patients were documented as having attended the chest clinic with a diagnosis of bronchiectasis. The 100 randomly selected patients (57 female) had a mean (S.E.M.) age of 57 (2) years, median (IQR) 3 (1–12) years since diagnosis and median (IQR) of three (two to four) reviews in the last 12 months. They made a total of 321 clinic attendances, 39 attending on four or more occasions. In 41 patients, a possible aetiological factor was identified. Factors

Discussion

In this study, we have described a heterogeneous population of patients attending respiratory clinics at a tertiary referral centre in a University Hospital with a diagnosis of bronchiectasis. Most had had CT to make the diagnosis, but few had had further investigations to look for specific aetiologies. The most frequently identified aetiological agent was a previous history of tuberculosis. This is not surprising, since the incidence of tuberculosis was high in Northern Ireland until

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