• Suspect bronchiectasis in:
• Adults with a chronic cough, particularly in the presence of any of the following:
• Daily sputum production.
• Pseudomonas aeruginosa in the sputum.
• A young age at presentation.
• A history of symptoms over many years.
• No history of smoking.
• Adults thought to have chronic obstructive pulmonary disease, who do not smoke, or who have frequent or prolonged exacerbations.
• Children or adults with unexplained haemoptysis (usually recurrent blood-streaked sputum).
• Children with a chronic cough (that is usually productive but may be non-productive).
• Children thought to have asthma, that responds poorly to treatment.
• Identify the clinical features of bronchiectasis.
• Clinical features - children
• Clinical features - adults
• Exclude other causes for chronic cough based on clinical features and chest radiography.
• Refer to a respiratory physician to confirm the diagnosis and determine the underlying cause.

This information is based on expert opinion from the British Thoracic Society [British Thoracic Society, 2010].

• There may be a history of:
• Failure to thrive.
• Recurrent lower respiratory tract infections.
• Symptoms of bronchiectasis include:
• Chronic cough — usually productive but may be unproductive.
• Wheeze.
• Haemoptysis (usually blood-streaked sputum).
• Exertional breathlessness.
• Signs of bronchiectasis include:
• Persistent inspiratory crackles.
• Finger clubbing, cyanosis, and hyperinflation — these are uncommon in bronchiectasis that is not due to cystic fibrosis.
• Signs of malnutrition.

Clinical features of bronchiectasis in children are based on the expert opinion of the British Thoracic Society [British Thoracic Society, 2010].

• There may be a history of:
• A severe lower respiratory tract infection in early childhood.
• Recurrent lower respiratory tract infections.
• Symptoms of bronchiectasis include:
• Cough — in over 90% of adults.
• Cough with daily sputum production — present in over 75% of adults.
• Cough with intermittent sputum production — present in up to 20% of adults.
• Cough that is unproductive — present in up to 8% of adults.
• Breathlessness — present in up to 83% of adults.
• Haemoptysis — occurs in up to 50% of adults.
• Blood-stained sputum in 27% of adults.
• Frank bleeding may occur in up to 20% of adults.
• Massive haemoptysis (more than 235 mL) is rarely seen in adults.
• Chest pain that is present between exacerbations and is usually non-pleuritic — present in 31% of adults.
• Signs of bronchiectasis include:
• Course crackles during early inspiration that are commonest in the lower lung fields — present in approximately 70% of adults.
• Wheeze — present in 34% of people.
• Large airway rhonchi (low pitched snore-like sounds) — present in 44% of adults.
• Finger clubbing — occurs very infrequently.

The prevalence of the clinical features of bronchiectasis in adults is based on evidence summarized by the British Thoracic Society [British Thoracic Society, 2010].

• Chronic cough is a characteristic feature of many disorders, many of which are more common than bronchiectasis.
• Common causes of chronic cough include:
• Smoking.
• Asthma.
• Chronic obstructive pulmonary disease.
• Drug adverse effects (for example angiotensin converting enzyme inhibitors).
• Upper airway cough syndrome (previously known as postnasal drip syndrome).
• Gastro-oesophageal reflux disease.
• Less common but serious causes of chronic cough include:
• Lung cancer.
• Pulmonary fibrosis.
• Tuberculosis.
• Foreign body.

The differential diagnosis is based on expert opinion in review articles and a text book [Lane, 2003; Rosen, 2006; Chung and Pavord, 2008].

• Arrange chest X-ray in all people suspected of having bronchiectasis.
• The chest X-ray is abnormal in 90% of people with bronchiectasis; however, radiological findings are not usually diagnostic.
• The main value of chest X-ray is to exclude other causes of chronic cough (such as lung cancer).
• Consider further investigations to exclude other causes of chronic cough, guided by clinical findings.
• Refer to a respiratory physician to confirm the diagnosis and determine the underlying cause of bronchiectasis.

The recommendation for chest X-ray in all people with suspected bronchiectasis is based on expert opinion [Barker, 2002; Rosen, 2006; ten Hacken et al, 2007; O'Donnell, 2008; British Thoracic Society, 2010]. There is expert consensus:

• That chest X-rays lack sensitivity and specificity for the diagnosis of bronchiectasis.
• The main role is to exclude other causes for symptoms in people suspected of having bronchiectasis.

• High-resolution computed tomography (HRCT) scanning is the investigation of choice to establish the diagnosis of bronchiectasis.
• Investigations to determine the underlying cause of bronchiectasis include:
• Further testing for cystic fibrosis — such as sweat chloride or gene testing for all children and adults up to 40 years of age and adults older than 40 years of age with clinical features consistent with cystic fibrosis.
• Screening for gross antibody deficiency — serum IgG (immunoglobulin G), IgA, IgM and electrophoresis for all people with confirmed bronchiectasis.
• Investigation of immunological disorders — such as alpha-1 antitrypsin level, serum IgE, Aspergillus-specific IgE and precipitins; for people with clinical features or risk factors for immunological disorders.
• Bronchoscopy may be indicated for further investigation of lower respiratory tract infection or bronchial obstruction (for example for suspected foreign body aspiration in children or to exclude an endobronchial lesion in adults).
• Gastrointestinal investigations such as 24-hour pH monitoring for people suspected of having bronchiectasis secondary to gastro-oesophageal reflux and aspiration.

Investigations to make a diagnosis of bronchiectasis

• The recommendation for a high-resolution CT scan to establish the diagnosis of bronchiectasis is based on evidence of [Grenier et al, 1986]:
• A specificity and sensitivity of over 90% when compared with the prior gold standard of bronchography.
• A lower risk of adverse effects compared with bronchography.

Investigations to determine the underlying cause of bronchiectasis

• Recommended investigation of the underlying cause of bronchiectasis is based on expert opinion from the British Thoracic Society [British Thoracic Society, 2010].