What is the semiology of bronchiectasis?

Semiology of Bronchiectasis

The cardinal symptom of bronchiectasis is chronic productive cough with mucopurulent or purulent sputum production, often accompanied by recurrent respiratory infections. 1

Core Clinical Presentation

Primary Symptoms:

• Chronic productive cough is the hallmark symptom, with persistent mucopurulent or purulent sputum production in the stable state 1
• Recurrent respiratory infections occur frequently, with patients experiencing repeated chest infections requiring antibiotic therapy 2
• Daily sputum production is characteristic, with the sputum often being foul-smelling and purulent 1, 3
• Hemoptysis may occur due to increased bronchial arterial proliferation and arteriovenous malformations 4

Secondary Symptoms:

• Breathlessness develops from airflow obstruction, impaired gas transfer, and exercise deconditioning 2
• Chronic rhinosinusitis is frequently present, particularly in patients with a history of major respiratory infections 1
• Clubbing may be observed on physical examination in some patients 2
• Wheeze can occur, especially in patients with coexisting asthma or COPD 5

Clinical Context and Risk Factors

Historical Red Flags:

The British Thoracic Society emphasizes that persistent mucopurulent or purulent sputum production should raise suspicion for bronchiectasis, particularly when accompanied by: 1

• Past history of major respiratory infections including measles, whooping cough, severe pneumonia, or tuberculosis 1, 3
• Ongoing chronic rhinosinusitis with upper airway symptoms 1
• Childhood respiratory illnesses that were severe or recurrent 2

Associated Conditions:

Bronchiectasis presents with higher frequency in specific patient populations: 1

• COPD patients with frequent exacerbations (≥2 annually), particularly those with positive sputum cultures for Pseudomonas aeruginosa while stable 1
• Rheumatoid arthritis patients with chronic productive cough or recurrent chest infections (4-58% prevalence on CT) 1
• Inflammatory bowel disease patients with chronic productive cough, often developing respiratory symptoms following IBD surgery 1
• Severe or poorly-controlled asthma patients with persistent productive cough 1
• Alpha-1 antitrypsin deficiency (particularly PiZZ phenotype) 1

Sputum Characteristics

Key Features:

• Purulent or mucopurulent quality in the stable state distinguishes bronchiectasis from simple chronic bronchitis 1
• Large volumes of daily sputum production are common 1
• Foul-smelling sputum suggests chronic bacterial colonization 3
• Isolation of potentially pathogenic microorganisms (PPMs), particularly P. aeruginosa, from sputum cultures is characteristic 1

Exacerbation Patterns

Clinical Features of Acute Exacerbations:

• Increased sputum volume and purulence beyond baseline 6
• Worsening breathlessness and increased cough frequency 7
• Systemic symptoms including fever and malaise 8
• Increased airway inflammation with accelerated lung function decline 2

Critical Pitfall: Exacerbations are associated with up to 30% mortality at 1-year follow-up, particularly in patients with coexisting COPD, making prompt recognition and treatment essential 2

Diagnostic Suspicion Algorithm

Investigate for bronchiectasis when patients present with: 1

1. Persistent mucopurulent/purulent sputum production PLUS any of:

   • History of severe childhood respiratory infections
   • Chronic rhinosinusitis
   • Recurrent chest infections requiring antibiotics

2. COPD with ≥2 exacerbations annually PLUS:

   • Positive sputum culture for P. aeruginosa while stable
   • Chronic productive cough with PPM colonization

3. Rheumatoid arthritis or other connective tissue disease PLUS:

   • Chronic productive cough
   • Recurrent chest infections

4. Inflammatory bowel disease PLUS:

   • Chronic productive cough
   • Respiratory symptoms developing post-IBD surgery

Confirmation requires high-resolution CT scanning, which is the diagnostic procedure of choice with sensitivity and specificity exceeding 90% 4

Quality of Life Impact

Bronchiectasis causes significant impairment in quality of life equivalent to severe COPD, with progressive disease leading to respiratory failure if untreated 2. The chronic nature of symptoms, particularly persistent cough and daily sputum production, substantially affects patients' daily functioning 7, 8.