What are the key components of a physical examination and management plan for a patient with bronchiectasis (bronchioectasis)?

Physical Examination Findings in Bronchiectasis

Physical examination findings in bronchiectasis are often nonspecific and may even be completely normal, making imaging with high-resolution CT scanning essential for diagnosis rather than relying on auscultation, percussion, or palpation alone. 1, 2

Key Physical Examination Components

Auscultation Findings

• Crackles and rhonchi are the most common auscultatory findings, though they vary in degree and may be absent entirely 1
• The presence or absence of crackles does not correlate with the presence of bronchiectasis as confirmed by high-resolution CT scanning 1
• Auscultatory findings are nonspecific and can be normal even in confirmed bronchiectasis 1

Inspection Findings

• Digital clubbing may be present in variable degrees, though this is not a consistent finding 1
• Look for signs of chronic respiratory disease including increased work of breathing during exacerbations 3
• Fetid breath is a hallmark of severe bronchiectasis and indicates chronic airway sepsis 3

Percussion and Palpation

• The provided guidelines do not specify particular percussion or palpation findings, as these examination techniques have limited diagnostic value in bronchiectasis 1, 2
• These techniques are generally unremarkable unless there is significant consolidation or pleural involvement

Critical Diagnostic Approach

Imaging is Essential

• Do not rely on physical examination alone to diagnose or exclude bronchiectasis - radiological bronchiectasis may exist in asymptomatic individuals with normal examination 2
• High-resolution CT scanning is the diagnostic procedure of choice with sensitivity and specificity exceeding 90% 1
• Physical examination findings should prompt appropriate imaging rather than serve as diagnostic criteria 2

Clinical Features That Should Trigger Investigation

• Chronic productive cough with mucopurulent or purulent sputum is the cardinal feature 1, 4
• Cough persisting longer than 8 weeks with sputum production 1, 2
• Recurrent chest infections in at-risk populations 1, 2
• Daily sputum production (>30 mL per day warrants systematic evaluation) 1

Management Plan Framework

Initial Assessment and Severity Stratification

• Use the bronchiectasis severity index to guide management intensity 1, 2
• Perform baseline chest X-ray followed by thin-section CT scan during clinically stable disease 2
• Obtain sputum for culture and sensitivity testing (spontaneous or induced) prior to starting antibiotics 1

Core Management Components

Airway Clearance (Cornerstone of Therapy)

• Offer active cycle of breathing techniques or oscillating positive expiratory pressure as first-line airway clearance 1
• Consider gravity-assisted positioning where not contraindicated to enhance effectiveness 1
• Airway clearance techniques must be taught by a respiratory physiotherapist 1
• Perform for minimum 10 minutes up to maximum 30 minutes, continuing until two clear huffs/coughs are completed 1

Alternative Airway Clearance Options

• Consider autogenic drainage, positive expiratory pressure, high frequency chest wall oscillation, or intrapulmonary percussive ventilation if standard techniques are ineffective or unacceptable 1
• Modified postural drainage (no head-down tilt) for patients with contraindications or gastroesophageal reflux 1
• Regular physical exercise plus forced expiration technique to promote clearance 1

Pharmacological Management

• Consider humidification with sterile water or normal saline to facilitate airway clearance 1
• Do not routinely use recombinant human DNase in adults with bronchiectasis 1
• Do not routinely offer inhaled corticosteroids unless other indications exist (ABPA, asthma, COPD, inflammatory bowel disease) 1
• Inhaled bronchodilators are indicated only for patients with coexisting asthma or COPD 4

Exacerbation Management

• Treat exacerbations with oral or intravenous antibiotics for 14 days (standard duration, always for P. aeruginosa) 1, 4
• Empirical antibiotics can be started while awaiting sputum microbiology, then modified based on sensitivity results if no clinical improvement 1
• Intravenous antibiotics for severely unwell patients, resistant organisms, or failed oral therapy 1

Long-term Antibiotic Therapy

• Consider long-term inhaled antibiotics or daily oral macrolides for patients with ≥3 exacerbations annually 4, 5

Monitoring and Follow-up

• Assess patients annually, more frequently in severe disease 1
• Patients admitted with exacerbations should be seen daily by respiratory physiotherapist until airway clearance is optimized 1
• Review airway clearance technique within 3 months of initial assessment 1
• Annual review should include respiratory physiotherapist assessment to optimize airway clearance regimen 1

Common Pitfalls to Avoid

• Never diagnose bronchiectasis based on physical examination alone - always confirm with high-resolution CT 1, 2
• Do not assume normal auscultation excludes bronchiectasis 1
• Avoid attributing chronic productive cough solely to bronchiectasis without excluding more common causes (chronic bronchitis, asthma, upper airway cough syndrome, GERD) 1
• Do not use inhaled corticosteroids routinely without specific indications 1
• Recognize that sputum cultures positive for common pathogens (H. influenzae, S. aureus, S. pneumoniae, P. aeruginosa) are nonspecific and can occur in chronic bronchitis 1