Common: Childhood pneumonia, cystic fibrosis, severe infections, asthma, COPD
Less Common: RA, GORD/aspiration, ABPA, non-TB mycobacteria, immunodeficiency, primary ciliary dyskinesia
Rare: Alpha-1 antitrypsin deficiency, yellow nail syndrome, foreign body

Presentation

Investigations

HRCT: Gold standard (bronchial diameter > adjacent vessel)
Spirometry: Obstructive pattern
Sputum Culture: Key for pathogens (e.g. Pseudomonas, Haemophilus)
Consider:
- FBC, immunoglobulins (IgG, IgA, IgM)
- Autoimmune markers (e.g., RF, ANA)
- CF sweat test (esp. children)
- Aspergillus-specific IgE or skin-prick testing

Diagnosis

Clinical features + HRCT: Persistent symptoms despite treatment
Refer If:
- Wet cough >4 weeks, recurrent pneumonia, parenchymal changes
- Consider bronchoscopy for obstruction or foreign body

Management

General:

Stable Disease:

Exacerbations:

Mild: Oral antibiotics if signs of bacterial infection (e.g., increased sputum purulence) (e.g. doxycycline 100 mg BD for 14 days)
Severe: Hospital admission, IV antibiotics
- If Pseudomonas colonisation: Ciprofloxacin 750 mg BD for 14 days
- If no colonisation: Amoxicillin 1 g TDS or doxycycline 100 mg BD for 14 days

Haemoptysis:

Bronchiectasis

Causes

Category	Examples
Common	Childhood pneumonia, cystic fibrosis, severe infections, asthma, COPD
Less Common	Rheumatoid arthritis, GORD/aspiration, allergic bronchopulmonary aspergillosis (ABPA), non-TB mycobacteria, immunodeficiency, primary ciliary dyskinesia
Rare	Alpha-1 antitrypsin deficiency, yellow nail syndrome, foreign body

Presentation

Investigations

High-resolution CT (HRCT) is the gold standard, showing bronchial diameter greater than the accompanying vessel
Spirometry typically shows an obstructive pattern
Sputum culture is essential to identify key pathogens (e.g. Pseudomonas aeruginosa, Haemophilus influenzae)
Additional tests may include:
- Full blood count (FBC)
- Immunoglobulins (IgG, IgA, IgM)
- Autoimmune markers (RF, ANA)
- Sweat chloride or CFTR genotyping (especially in children)
- Tests for Aspergillus (skin-prick or IgE)

Diagnosis

Based on a combination of clinical features and HRCT findings
Typically involves persistent symptoms despite usual treatment
Referral is indicated for a wet cough lasting more than four weeks, recurrent pneumonia, or if parenchymal changes are seen
Bronchoscopy may be needed to rule out obstruction or foreign body

Management

General Measures:
- Airway clearance with physiotherapy
- Regular exercise (e.g. 30 minutes a day)
- Yearly pneumococcal and influenza vaccinations
- Smoking cessation
- Optimal nutrition
Stable Disease:
- Pulmonary rehabilitation and bronchodilators may help symptom relief in select patients
- A written action plan for exacerbations is useful
- For frequent exacerbations, long-term macrolide therapy (e.g. azithromycin) may reduce flare-ups
- Patients with chronic Pseudomonas colonisation might benefit from inhaled antibiotics (e.g. tobramycin)
Exacerbations:
- Mild:
  - Oral antibiotics if signs of bacterial infection (e.g. increased sputum purulence)
  - Example: doxycycline 100 mg BD for 14 days
- Severe:
  - Consider hospital admission and intravenous antibiotics
  - If Pseudomonas colonised, use ciprofloxacin 750 mg BD for 14 days
  - If no Pseudomonas, options include:
    - Amoxicillin 1 g TDS
    - Doxycycline 100 mg BD for 14 days
Haemoptysis:
- Massive haemoptysis requires urgent transfer for possible embolisation or surgical management
- Recurrent haemoptysis warrants specialist referral
Notes:
- Regularly monitor for new or resistant pathogens and adjust therapy accordingly
- Consider immunoglobulin replacement if immunodeficiency is identified
- Emphasise adherence to airway clearance techniques to reduce exacerbation frequency and improve quality of life

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