Bronchiectasis
Description Diagnostic criteria General and supportive measures Medicine treatment Surgical treatment Role of chemoprophylaxis Referral ICD-10 code: J47 DESCRIPTION Irreversible dilatation of the subsegmental airways, inflammatory destruction of bronchial and peribronchial tissue, and accumulation of exudative material in dependent bronchi that occurs as a result of recurrent bacterial infe
Description
Diagnostic criteria
General and supportive measures
Medicine treatment
Surgical treatment
Role of chemoprophylaxis
Referral
ICD-10 code: J47
DESCRIPTION
Irreversible dilatation of the subsegmental airways, inflammatory destruction of bronchial and peribronchial tissue, and accumulation of exudative material in dependent bronchi that occurs as a result of recurrent bacterial infections and aspiration pneumonia. There is bronchial luminal obstruction; ciliary dyskinesia; thick, tenacious secretions and lung tissue damage.
Complications include pulmonary hypertension, cor-pulmonale and respiratory failure. Predisposing conditions include HIV, TB, cystic fibrosis, primary ciliary dyskinesia and primary immunodeficiency syndromes.
DIAGNOSTIC CRITERIA
- Chronic cough, usually with mucopurulent sputum and occasional haemoptysis.
- Clubbing and halitosis.
- Recurrent and persistent lower respiratory tract infections.
- A bout of coughing on physical activity or change in posture, particularly while reclining.
- Fever, malaise, anorexia, poor weight gain.
- Respiratory failure, cyanosis.
- Pulmonary hypertension and cor-pulmonale.
- Chest X-ray showing cystic dilatation and tram-tracking.
- If diagnosis is uncertain or where localised disease on chest X-ray is suspected, perform high-resolution computed tomography. Features include cystic dilatation, 'signet ring' sign and tram-tracking.
- Usual pathogens are community acquired, including Streptococcus pneumoniae, non-typeable Haemophilus influenzae, Staphylococcus aureus. Must exclude tuberculosis and fungal infections.
GENERAL AND SUPPORTIVE MEASURES
- Identify and treat the underlying disorder or bacterial source.
- Clear secretions effectively with postural drainage and physiotherapy.
- Eliminate all foci of infection.
- Nutritional support.
Method of sputum induction
Precaution: If undertaking this procedure in an acutely sick child with respiratory compromise, be prepared to manage acute bronchospasm as this may be an associated adverse effect.
- Nebulise with sodium chloride 0.9% or sodium chloride 3% (hypertonic saline) to aid sputum expectoration. Mix 3 mL of 5% sodium chloride with 2 mL sterile water to make 3% solution.
In the acutely sick child:
Nebulise with a bronchodilator:
- Salbutamol, solution, 0.15–0.3 mg/kg/dose in 2–4mL of sodium chloride 3% delivered at a flow of 5 L/minute with oxygen for 20 minutes.
- Perform physiotherapy.
- Encourage patient to cough up sputum or if infant or small child obtain nasopharyngeal aspirate post physiotherapy.
- Send sample for culture and cytology as indicated.
MEDICINE TREATMENT
Acute lung infections: worsening cough accompanied by increased dyspnoea or tachypnoea and/or signs of sepsis.
Empiric antibiotic therapy for acute lung infections:
- Amoxicillin/clavulanate, IV, 25 mg/kg/dose of amoxicillin component 8 hourly (do not exceed 10 mg/kg/day of clavulanate component).
Change antibiotics according to culture and sensitivity results.
If poor response and no culture to guide antibiotic choice, consider infection due to S. aureus, TB or fungal infection.
If there is evidence of good clinical response, change to:
- Amoxicillin/clavulanic acid, oral, 45 mg/kg/dose of amoxicillin component 12 hourly.
- Total antibiotic duration of 10 days.
Note: These antibiotic regimens do not apply to children with cystic fibrosis, seek specialist advice.
In the acute phase if wheeze is present:
- Salbutamol solution, 5 mg/mL, nebulise 4 hourly.
- 5 mg salbutamol in 2–4 mL sodium chloride 0.9%.
- Annual influenza vaccination.
- Pneumococcal vaccine (conjugated), 2 additional doses 8 weeks apart.
SURGICAL TREATMENT
Consider surgery in localised severe disease or progressive disease despite adequate medical treatment.
ROLE OF CHEMOPROPHYLAXIS
- Azithromycin, oral, 5 mg/kg/dose daily for 3 alternate days per week for 3 months duration and then repeat after 6 months.
REFERRAL
- All patients for confirmation of the diagnosis, assessment of severity and evaluation of underlying condition.
- Poor response to therapy, increased frequency of exacerbations, poor lung function.
- For early surgical intervention of localised disease.
Standard Treatment Guidelines and Essential Medicines List for South Africa, Hospital Level, Paediatrics, 2023 Edition
Chapter 15: Respiratory System, 15.3 Chronic Lung Infections, 15.3.1 Bronchiectasis