Out of the shadows

There are a variety of causes but the most common risk is previous infection such as whooping cough, pneumonia or tuberculosis. In up to half of patients however we cannot identify a specific cause.

From a recent UK national audit in bronchiectasis, people attending hospital clinics have on average around three chest infections per year requiring antibiotic therapy. In more severe cases people have problems with wheeze and breathlessness, chest pain and general tiredness.

This condition has received little attention until recent years because of the perception that little can be offered because it is a chronic condition. This has been compounded by the limited research in bronchiectasis to support evidence-based therapies. The British Thoracic Society national audit over the last two years has shown that even in hospitals, many patients are not receiving management as recommended by the British Thoracic Society National Guidelines.

NICE has already been commissioned to produce some quality standards but cannot cover every condition. The British Thoracic Society has taken on this role for bronchiectasis using the NICE model. The availability of quality standards will help healthcare professionals provide a consistently high standard of care for patients with the disease. The bronchiectasis quality standards aim to improve patient care, facilitate more treatment at home and improve patient outcomes.

British Thoracic Society Quality Standards are intended for:

• Health care professionals to allow decisions to be made about care based on the latest evidence and best practice.
• Patients with bronchiectasis and their carersto enable understanding of what services they should expect from their health and social care provider.
• Service providers to be able to quickly and easily examine the clinical performance of their organisation and assess the standards of care they provide.
• Commissioners so that they can be confident that the services they are purchasing are high quality and cost effective.

There are 11 quality statements. Each quality standard includes the quality statement, how to measure this, a description of the quality statement for service providers, healthcare professionals, commissioners and people with bronchiectasis, evidence used to collate the standard and finally the rationale for the standards. The quality statements and rationale are summarised here:

People with a clinical diagnosis of bronchiectasis have the diagnosis confirmed by Computed Tomography (CT) scan of the chest:

• People with a clinical diagnosis of bronchiectasis should have the diagnosis confirmed by chest CT as there are other causes of chronic cough and sputum production. This statement will ensure that the correct people are labelled with this condition.

People with bronchiectasis are taught appropriate airway clearance techniques by a specialist respiratoryphysiotherapist and advised of the frequency and duration with which these should be carried out:

• Regular airway clearance is regarded as a key component in the management of bronchiectasis because it may improve symptoms and reduce the number of chest infections.

People with bronchiectasis have sputum bacteriology culture when clinically stable recorded at least once each year:

• This is a sputum sample collected by the patient and sent to the microbiology laboratory in hospital to see if they grow an organism or not. This will allow healthcare professionals to identify potential organisms infecting the airways so help guide antibiotic therapy and management. It will also improve the assessment and follow up of patients with bronchiectasis, so that such patients at least have an annual review.

Sputum is sent for bacterial culture at the start of an exacerbation before starting antibiotics. Empirical antibiotic therapy to start as soon as feasible and not await the sputum culture results:

• This will guide clinicians to future antibiotic management of chest infections and if the patient fails to improve.

People with bronchiectasis to attend pulmonary rehabilitation if they have breathlessness affecting their activities of daily living:

• Pulmonary rehabilitation can be defined as a multidisciplinary programme of care for patients with chronic respiratory impairment that is individually tailored and designed to optimise each patient’s physical and social performance and autonomy. Most programmes are hospital based and comprise individualised exercise programmes and educational talks. The aim of this is to improve exercise capacity and make people feel better.

People with bronchiectasis receiving intravenous antibiotic therapy to have an objective evaluation of the efficacy of their treatment and the result recorded:

• An objective assessment allows the patient and clinicians to objectively assess the response to intravenous therapy and may guide long term management.

Services for people with bronchiectasis to include provision of nebulised prophylactic antibiotics for suitable patients supervised by a respiratory specialist:

• Patients are considered for a long term antibiotic by a respiratory specialist if people have three or more chest infections per year requiring antibiotic therapy or patients with fewer chest infections that are causing significant morbidity. The rationale is that long term prophylactic treatment may improve symptoms and reduce the number of chest infections.

People with bronchiectasis to be investigated for specific treatable causes:

• These causes, as recommended in the national guidelines, should be investigated as they have specific treatments that differ from standard bronchiectasis management, which may alter the prognosis.

People with bronchiectasis to have an individualised written self-management plan:

• The development of an individualised written self-management is intended to allow people with bronchiectasis to manage their condition and to recognise, respond to and reduce the occurrence of chest infections.

People with bronchiectasis who meet the criteria for continuing secondary care to be managed by a multidisciplinary team led by a Respiratory physician:

• The criteria are laid out in the national guidelines. The clinical course and management in such people is complicated and management would be better under a multidisciplinary team led by a Respiratory physician.

Services for people with bronchiectasis to include provision of home intravenous antibiotic therapy for exacerbations in selected patients:

• The rationale for domiciliary intravenous treatment is to reduce the need for hospitalisation (which will reduce hospital bed days and the risk of hospital acquired infection) and promote people-centred care allowing delivery of intravenous treatment safely at home.

The British Thoracic Society is calling on policy makers, commissioners and healthcare professionals to stop overlooking this debilitating condition and adopt newly launched quality standards for the disease. The new standards not only aim to improve patient care, facilitate more treatment at home and improve patient outcomes but it is also hoped that their implementation will be cost effective and save the NHS money.

Dr Adam Hill is Consultant Respiratory Physician at the Royal Infirmary of Edinburgh and Council Member of the British Thoracic Society