Patient profile

In keeping with international studies the majority of patients were women (61–62%) and the mean age was (64–66 years). From the sputum microbiology in the last year, Pseudomonas aeruginosa was isolated in 21% of patients in the 2010 audit. In the 2011 audit P aeruginosa, methicillin-resistant Staphylococcus aureus (MRSA) or enteric gram-negative organisms (if isolated on two or more occasions, eg, Escherichia coli) were isolated in 26% of patients. In the group with P aeruginosa or enteric gram-negative organisms, 18% were resistant to ciprofloxacin and 9% to gentamicin (see figure 1).

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Figure 1

Snapshot of microbiology and antibiotic treatments given. In 2010, 21% had Pseudomonas aeruginosa (PA) but do not have the combined data for methicillin-resistant Staphylococcus aureus (MRSA) and enteric gram-negative organisms. IV, intravenous; LT, long term.

The mean (SD) number of exacerbations was 2.6 (2.5) for both audits. This was lower than expected in a cohort attending secondary care and with 21–26% of patients infected with P aeruginosa, MRSA or enteric gram-negative organisms, groups that would be expected to have multiple exacerbations per year. The accuracy is not known as data were not crosschecked with primary or secondary care records.

A total of 16–17% had received intravenous antibiotics in the past year, 27–33% used long-term (>28 days) oral antibiotics and 9–10% used nebulised antibiotics (76% nebulised colomycin, 12–13% gentamicin and 5–6% tobramycin; 6% used other agents not specified, see figure 1).

Audit of recommendations

There were seven recommendations drawn from the initial bronchiectasis guidelines 1 and the audits were designed to assess whether there was adherence to these recommendations.

Recommendation 1 is that 90% of patients diagnosed with bronchiectasis should have had the diagnosis confirmed with a chest CT scan. In the audits, 93% were diagnosed with a CT scan of the chest, 1% by bronchogram, 2–3% had a clinical diagnosis only and for 3–4% there were no data. The first recommendation was met.

Recommendation 2 is that 90% of patients diagnosed with bronchiectasis should see a respiratory physiotherapist so patients are taught chest clearance techniques. In the audits, 65–69% said their patient had seen a respiratory physiotherapist, 18–23% said they had not and in 12–14% there were no data. The second recommendation was not met which is in keeping with clinical experience that not all patients with bronchiectasis have seen a respiratory physiotherapist to be taught chest clearance techniques.

Recommendation 3 is that all patients being seen should have a record of cough, sputum purulence, estimated or measured 24 h sputum volume and breathlessness when clinically stable. In the audits, 70–73% had a record of cough, 66–68% sputum colour, 49–54% 24 h sputum volume and 55–62% breathlessness. The third recommendation was not met. Most patients with significant bronchiectasis have these symptoms. Estimating their severity will allow consistent assessment to help the ongoing management of such patients.

Recommendation 4 is that all patients diagnosed with bronchiectasis should have immunoglobulins and protein electrophoresis checked along with total IgE, IgE to Aspergillus or skin prick testing to Aspergillus, and for those aged <40 years, tests to exclude CF. In the audits, 73–77% of patients had their immunoglobulins checked and 58–60% had serum sent for protein electrophoresis. Although protein electrophoresis is advocated in the guidelines in addition to measurement of immunoglobulins, the additive value of protein electrophoresis needs to be explored as the primary aim is to identify immunodeficiency. A total of 62–75% had IgE measured and 53–54% had A fumigates radioallergosorbent test or skin prick testing to Aspergillus. The combination of total IgE and IgE to Aspergillus or skin prick testing to Aspergillus is advocated as the results vary depending on the activity of Aspergillus hypersensitivity. For those aged <40, 30–33% had CF gene analysis and 46% had a sweat test carried out. The fourth recommendation was not met. These are recommended investigations for secondary care as the long-term management may differ if an immunodeficiency, allergic bronchopulmonary aspergillosis or CF is identified.

Recommendation 5 is that all children who are old enough (usually age over 5 years) and adults should have measures of forced expiratory volume in 1 s (FEV₁), forced vital capacity (FVC) and peak expiratory flow (PEF) in primary and secondary care. Repeat assessment of FEV₁, FVC and PEF should be made at least annually in patients attending secondary care. FEV₁ and FVC should be measured before and after intravenous antibiotic therapy as this may give objective evidence of improvement. Spirometry should be measured in all patients before and after commencing long-term oral or nebulised antibiotic therapy.

In the audits, 30% had PEF measured and 55–60% had spirometry measured on the day of consultation. For patients who received intravenous antibiotics, 22% had spirometry assessed before and after a course of intravenous antibiotics, 56% did not have this assessment and for 22% there were no data. Of those receiving nebulised antibiotics, 61–63% had spirometry checked at the start of treatment and later on during the course of treatment, 13–20% did not have these checks and for 17–26% there were no data. Of those taking nebulised antibiotics, 82–83% had spirometry checked at least 6 monthly. The fifth recommendation was not met. Spirometry may be useful to monitor disease progression and response to treatments.

Recommendation 6 is that 90% of patients with an exacerbation should have a sputum sample sent for bacteriology culture prior to empirical antibiotic treatment. In the audits, 55–57% had a sputum sample sent for bacteriology culture, 33%–42% did not and for 3–10% there were no data. The sixth recommendation was not met. Monitoring sputum microbiology is key to providing appropriate antimicrobial prescribing.

Recommendation 7 is that pulmonary rehabilitation should be offered to individuals who have Medical Research Council grade 3 or worse breathlessness affecting their activities of daily living. In the audits, 12–15% had been referred, 13–17% had not been referred, 5% were unable to participate in pulmonary rehabilitation, 52–54% did not meet the criteria for pulmonary rehabilitation and for 13–16% there were no data. The seventh recommendation was not met. Pulmonary rehabilitation in such patients has the potential to improve their exercise capacity and general wellbeing.