Bronchiectasis flare that won't go away

23 Mar 2025

Posted by:

Viral Thakerar J

Topics:

Bronchiectasis including CF

4:00pm - ? bronchiectasis flare

A middle aged man with bronchiectasis has a flare that has been going on for 5 weeks, and only partially responding to antibiotics. The specific symptoms of this flare are a persistent cough with thick, green sputum. There is no sputum in his cough normally. There is no haemoptysis or chest pain. There is no wheeze. His exercise tolerance has good days and bad days, but at present he is able to walk 10-15 mins on the flat OK. However, on some days 5-10 minutes walking may be difficult. There was some initial fever and body aches but these have subsided. No rhinitis/sinusitis symptoms or post nasal symptoms. No reflux symptoms. No obvious allergens trigger. The household does have a smoker (he himself does not smoke). No calf pain/swelling.

On respiratory examination, there is no accessory muscle use and he is talking in full sentences. RR 16, sats 97% on air, pulse 92, temperature 37.2. A chest radiograph shows no interval changes since the last xray 2 years ago and nothing focal. A sputum sample after the third antibiotic did not grow anything. A sputum sample 2 years ago grew Haemophilus influenzae.

He had tried: Amoxicillin 500mg TDS for 5 days Clarithyomycin 500mg BD for 7 days Azithromycin 500mg OD for 3 days Each time there was a temporary improvement for 3 days or so, before it worsened again.

What is going on in bronchiectasis?

Bronchiectasis is the 3rd most common chronic airway disease (after COPD and asthma). The airways have been exposed to lots of inflammation. [basic science that makes it more memorable] The cycle of neutrophils releasing neutrophil elastase in particular that the bronchial walls This leads to wall thickening, bronchial lumen dilation and cilia dysfunction. This means mucous doesn’t get drained well, providing a breeding ground for further infection and a vicious cycle. The main risk factor is therefore repeated and/or prolonged infections (like TB or pertussis).

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In addition to assessing for respiratory distress, what else is particularly helpful to track how a flare is progressing?

Sputum colour is a simple and effective biomarker, both for baseline and during flares. The more purulent (towards green) and less mucoid (clear or tinged yellow) the sputum, the more severe the bronchiectasis is.

Why might this person’s bronchiectasis be only partially responding to antibiotics?

Antibiotic resistance
Inadequate delivery of antibiotics to the infection site
Significant mucous blockage/drainage issues
Non-bacterial contributors, such as allergy, GORD, immunodeficiency, autoimmune flare

Why might the sputum sample have been negative?

Samples should be coughed up, rather than from the throat / saliva-y
The longer the delay between producing the sample and analysing it, the less bugs are grown

What should be done rather than repeating rounds of oral antibiotics?

Any antibiotic course must be at least 10-14 days long and based on sputum samples ideally; repeat samples may be needed.
Increase physiotherapy. Often people have a baseline of once or twice a day of active cycle of breathing and/or postural drainage. This may be increased to around four times a day.
Make the mucous thinner – carbocisteine can do this, and/or saline nebulisers if they have a nebuliser.
If this isn’t working, the person may need nebulised or IV antibiotics from the specialist.
If certain bacteria are grown (such as Pseudomonas and non-tuberculous Mycobacteria) this needs discussion with specialists.

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