Bronchiectasis: Time to take action and implement the British Thoracic Society quality standards

Bronchiectasis, first described by Rene Laennec in 1819, is a common long-term respiratory condition caused by permanently damaged airways. Over 1 in 1000 people in the United Kingdom now has this disease. Although there are a variety of aetiologies, there is a common end point that permanently damaged the airways with impaired mucociliary clearance and neutrophilic airways inflammation. Despite the abundance of neutrophils, over two thirds of the patients are chronically colonised with bacteria.

There has been a long debate whether bronchiectasis remains a local problem in the airway or that advanced local inflammation in the airways can lead to systemic inflammation. The study by Gale and colleagues demonstrated that although patients with bronchiectasis are clinically stable (n = 20) compared with age-matched controls (n = 20), they had increased concentrations of interleukin-6 in peripheral blood, reduced albumin concentrations and increased arterial stiffness using aortic pulse wave velocity. Patients also had reduced exercise tolerance and reduced physical activity score, and only 20% had normal bone mineral density. This study revealed increased systemic inflammation with increased arterial stiffness, the latter thought consequent on the systemic inflammation.

Wilson and colleagues also showed that the patients with bronchiectasis in a stable phase (n = 87) have raised systemic markers of inflammation and some markers, particularly the neutrophil count, which is correlated with disease severity. ¹ Martínez-García and colleagues, in a study of 76 stable adult patients with bronchiectasis, showed that the independent factors associated with an accelerated decline in lung function were due to chronic colonization with Pseudomonas aeruginosa, more frequent severe exacerbations and more systemic inflammation. ² Similarly, our group investigated 385 patients with stable bronchiectasis and patients with sputum bacterial loads of ≥10⁷ colony forming units/ml, showing an evidence of increased concentration of the vascular endothelial adhesion markers, in particular increased serum intercellular adhesion molecule-1 (ICAM-1), which was reduced with both short- and long-term antibiotic treatments. ³

Therefore, it is important to consider bronchiectasis as not only a localised disease but also as a systemic disease. Further studies are needed to see whether bronchiectasis impacts on vascular morbidity and mortality and whether long term interventions impact on this.

It is refreshing that there has been a resurgence of interest in bronchiectasis. The British Thoracic Society (BTS) have published national guidelines in bronchiectasis ⁴ and more recently have published quality standards in bronchiectasis. ⁵

There are 11 quality standards focussed on the following:

Ensuring diagnostic accuracy with confirmation of a clinical diagnosis of bronchiectasis with a computed tomography of the chest using 1-mm slices.

To investigate specific treatable causes (allergic bronchopulmonary aspergillosis, common variable immunodeficiency and cystic fibrosis), as they have specific treatments that differ from standard bronchiectasis management, which may alter the prognosis.

Regular chest clearance techniques are to be taught by a specialist respiratory physiotherapist and are advised on the frequency and duration with which these should be carried out, as this is a key treatment to alleviate symptoms and may reduce chest infections.

Pulmonary rehabilitation to be provided in those with significant breathlessness to improve exercise capacity and health status.

To monitor sputum bacteriology both in stability and exacerbations.

To guide antibiotic therapy and management and improve the assessment and follow-up.

To assess patients before and after intravenous antibiotic therapy in order to allow the patient and the clinicians to objectively assess the response and may guide long-term management.

Suitable patients have an available inhaled antibiotic service as long-term prophylactic treatment that may improve symptoms and reduce the number of chest infections.

Domiciliary intravenous antibiotic treatment is made available for chest infections in selected patients to reduce the need for hospitalisation (which will reduce hospital bed days and the risk of hospital acquired infection) and to promote people-centred care, allowing delivery of intravenous treatment safely at home.

Self-management plan allows people with bronchiectasis to manage their condition and to recognise, respond to and reduce the occurrence of chest infections.

Secondary care follow-up as per BTS national guidelines ⁴ as the clinical course and management in such people is complicated and management would be better under a multidisciplinary team led by a Respiratory physician.

It is the key policy makers, the commissioners and the health care professionals who stop overlooking this debilitating condition and adopt these newly launched quality standards for the disease. The new standards not only aimed to improve patient care, facilitate more treatment at home and improve patient outcomes but it is also hoped that their implementation would be cost effective and save the NHS money.