Pre Referral Checklists RESPIRATORY

Pre referral checklists RESPIRATORY BRONCHIECTASIS General points:  Chronically inflamed and damaged airways  Typical features: o Chronic cough o sputum production o recurrent LRTIs  CXR can be NORMAL  diagnosis SECONDARY CARE by High resolution CT ( HRCT)  causes- see appendix 1

Are there RED FLAGS Symptoms? = consider 2 week wait referral y/n

 Weight loss/anorexia (unintentional)  Haemoptysis  smokers  Dyspnoea  Chest Pain  Hoarseness  abnormal CXR  fatigue  clubbing  supraclavicular lymphadenopathy

Consider REFERRAL for DIAGNOSIS: y/n  Chronic (persistent) productive cough  Daily expectoration of large volumes of purulent sputum  Frequent lower respiratory tract infections  Young age at presentation  Absence of smoking Hx  Sputum colonisation with Pseudomonas Aeruginosa or Staph aureus  Recurrent haemoptysis (see above-may require 2ww referral)  Persistent course crackles o/e For:  Consideration for High Resolution CT for diagnosis  Assessment of underlying cause  Self-management advice  Consideration for long term abs  Elective intravenous antibiotics  Chest physiotherapy

1 Consider REFERRAL in established BRONCHIECTASIS y/n

 Recurrent exacerbations (> 3/yr)  Worsening exacerbation frequency or respiratory symptoms  Declining lung function  New haemoptysis (see above- may require 2-week wait referral)  New Pseudomonas, opportunistic mycobacterium or MRSA isolation in sputum  Patients with associated rheumatoid arthritis, inflammatory bowel disease or immune deficiency  Consideration for, or already on, long term antibiotics  Advanced disease, consideration for transplantation

Other diagnostic considerations: y/n

Does the patients have COPD or Asthma?  The conditions may coexist  Consider coexistent bronchiectasis if: o Recovery from LRTIs is slow o Recurrent infections o Pseudomonas isolated from sputum o Worsening disease control despite optimal therapy  If so, has their COPD or asthma management been optimised?

PRIMARY CARE MANAGEMENT:

 patient education: smoking, when to seek help  encourage adherence to chest physiotherapy  pneumococcal vac and annual flu vac  consider coexistent asthma or COPD and optimise treatment  spirometry to assess for severity and deterioration  Exacerbations: o sputum culture advised prior to commencing treatment (and encouraged at each review) to guide antibacterials for future chest infections – do not delay antibiotics whilst waiting for sputum result o antibiotics 14 days o use antibiotics based on previous positive sputum cultures or as directed in patient’s self-management plan o if NO previous sputum microbiology available treat empirically: o co-amoxiclav 625MG TDS or if penicillin allergic Doxycycline 200mg od https://www.brit-thoracic.org.uk/document-library/clinical- information/bronchiectasis/bts-guideline-for-non-cf-bronchiectasis/

Thanks to Dr John Steer and Dr Les Ashton, November 2015

2 APPENDIX 1 ATEIOLOGY INCIDENCE HX/ SIGNS Ix

Idiopathic Up to 53% Diagnosis of exclusion Post infection Up to 42% Hx pneumonia, CXR or CT scan pertussis, measles, evidence of previous TB infection Immune defect 8% Decreased immunoglobulin levels or functional ab deficiency allergic 7% Hx asthma Eosinophilia bronchopulminary Raised IgE aspergillosis Aspiration / GORD 4% Hx aspiration / reflux Foreign body or mucus plugging on bronchoscopy RA 3% Hx RA Positive immune screen Cystic Fibrosis 3% Age < 40, Positive sweat test malabsorbtion, male infertility, diabetes Ciliary Dysfunction 1.5% Situs inversus, Abnormal ciliary beat productive cough, pattern deafness, infertility Ulcerative Colitis <1% Diarrhoea . Colonoscopic malabsorption, wt biopsies suggestive loss, joint pain of IBD Congenital <1%