Synopsis
Recognise the clinical syndrome, confirm bronchial dilatation on thin-section CT, complete a cause-changing aetiology screen, and organise airway clearance, vaccination, rehabilitation and longitudinal review.
- Bronchiectasis is a clinical-radiological syndrome: permanent bronchial dilatation on thin-section CT must be interpreted with chronic cough, sputum, infection, haemoptysis or another compatible presentation.
- Suspect it with persistent mucopurulent sputum, recurrent lower-respiratory infections or unexplained haemoptysis, especially with rheumatoid disease, inflammatory bowel disease, childhood infection or chronic rhinosinusitis.
- A baseline cause panel matters because immune deficiency, allergic bronchopulmonary aspergillosis, cystic fibrosis, primary ciliary dyskinesia and aspiration can change treatment and family advice.
- Obtain routine bacterial and mycobacterial sputum cultures while clinically stable; the microbiological history becomes the map for future exacerbation treatment.
- Every patient with clinically significant disease should be taught an individual airway-clearance technique by a respiratory physiotherapist and have technique and adherence reviewed.
- Do not prescribe inhaled corticosteroids solely for bronchiectasis; use them for a separate indication such as asthma, COPD or active ABPA.
- Vaccination, smoking cessation, exercise, nutritional assessment and pulmonary rehabilitation for limiting breathlessness are core management rather than optional extras.
- Chronic Pseudomonas, frequent exacerbations, declining lung function, NTM, ABPA, immune deficiency or advanced disease warrants ongoing specialist follow-up.
Key red flags
Blood-streaking may accompany an exacerbation, but recurrent or substantial bleeding requires assessment for malignancy, tuberculosis, pulmonary embolism and vascular complications rather than automatic attribution to known bronchiectasis.
Investigation priorities
Confirm abnormal airway dilatation and map extent, mucus plugging and associated lung disease.
Management branches
Persistent productive cough, repeated chest infection, unexplained haemoptysis or suggestive imaging.
- Document sputum pattern, prior pneumonia or tuberculosis, childhood and ENT history, aspiration symptoms, inflammatory disease, fertility and family history, then obtain baseline radiography and diagnostic thin-section CT.
- Send stable routine and mycobacterial sputum, perform the BTS core blood panel and add CF, PCD, immune, autoimmune, aspiration or AAT tests only where phenotype and guideline criteria support them.
- Record aetiology, lobar distribution, exacerbation and admission history, lung function, microbiology and comorbidity; use a severity score to support, not replace, clinical judgement.
Key medicines
Nebulised hypertonic saline as a mucoactive trialConcentration, volume and frequency should follow the respiratory physiotherapist's local bronchiectasis protocol after an observed airway-reactivity assessment; there is no single universal UK schedule.Can provoke cough, wheeze or bronchospasm. Demonstrate nebuliser hygiene, consider bronchodilator pre-treatment only when indicated, avoid continuing an ineffective burdensome treatment and never substitute it for taught airway clearance.