Bronchiectasis is an abnormal widening of one or more airways. Extra mucus is made in the abnormal airways. This collection of mucus is more prone to infection. The main symptom is a cough which produces a lot of phlegm (sputum). Treatment often includes regular physiotherapy and courses of antibiotic medication. Long-term antibiotic treatment is needed in some cases. Inhalers are sometimes used. Surgery is occasionally needed. You should not smoke as smoking can make things worse. Immunisation against flu and pneumococcus is advised.
Understanding the airways
Air passes into the lungs via the windpipe (trachea) which divides into a series of branching airways called bronchi.
Air passes from the bronchi into millions of tiny air sacs (alveoli). Oxygen from the air is passed into the bloodstream through the thin walls of the alveoli.
Tiny glands in the lining of the airways make a small amount of mucus. The mucus keeps the airways moist but also traps any dust and dirt in the inhaled air. There are many tiny hairs (cilia) on the surface of the cells lining the airways. The millions of cilia lining the airways sweep the mucus to the back of the throat to form phlegm (sputum) which is swallowed. Coughing also helps to clear the airways.
What is bronchiectasis?
Bronchiectasis is a permanent abnormal widening (dilation) in one or more of the airways (bronchi). Extra mucus tends to form and pool in the parts of the airways that are widened. Widened airways with extra mucus are prone to infection.
The airways in bronchiectasis
The extent of bronchiectasis can vary greatly. There may be only one section of one airway that is widened and abnormal. At the other extreme, many airways may be widened. Many affected people fall somewhere between these extremes.
The widened parts of the airways are damaged and inflamed. This causes extra mucus to form which is less easily cleared. These parts of the airways are also more floppy and liable to collapse inwards which may affect airflow through the affected airways. The severity of symptoms depends on how many of the airways are affected and how badly.
The lung tissue next to a badly inflamed section of airway may also become inflamed and damaged.
What causes bronchiectasis?
The cause is often not clear and no cause can be found in half the people affected. An underlying cause is found in one in two cases. Some conditions that affect or damage airways can cause bronchiectasis. Examples include the following:
- Severe lung infections such as tuberculosis (TB), whooping cough, pneumonia or measles, which can damage the airways at the time of infection. Ongoing bronchiectasis may then develop. Infections are by far the most common cause of bronchiectasis. Around two in five cases are the result of a severe infection.
- Conditions which make a person prone to infections may also be a cause, such as the immune system not working properly. For example, in those with acquired immune deficiency syndrome (AIDS).
- Some inherited conditions. For example, a condition called primary ciliary dyskinesia affects the tiny hairs (cilia) so they do not beat correctly to clear the mucus. Cystic fibrosis is another condition that affects the lungs and causes damaged airways. Some rare immune problems can cause lung infections and damage to airways.
- Inhaled objects, such as peanuts, can become stuck and block an airway. This may lead to local damage to that airway. Acid from the stomach, which is regurgitated and inhaled, can damage airways. Inhaling poisonous gases may also cause damage.
- Some diseases that cause inflammation in other parts of the body can occasionally cause inflammation and damage in the branching airways (bronchi) and lead to bronchiectasis. For example: ulcerative colitis, Crohn's disease, rheumatoid arthritis, systemic lupus erythematosus.
How common is bronchiectasis?
About two to three people in a thousand in the UK have bronchiectasis. In fact, the figure may be higher, as it is thought that some people diagnosed with other long-term lung conditions may actually have bronchiectasis. More women than men develop bronchiectasis. It can occur at any age, even in children, but is most common in older people.
What are the symptoms of bronchiectasis?
- Coughing up lots of phlegm (sputum) is the main symptom. The amount of sputum can vary, depending on the severity. It can be very tiring to cough up large amounts of sputum each day.
- Tiredness and poor concentration are common.
- Wheeziness is common.
- Some people become breathless, particularly when exercising or exerting themselves.
- You may cough up some blood from an inflamed airway. This is typically just small amounts of blood now and then. Occasionally, a large amount of blood can be coughed up.
- Repeated (recurring) chest infections are common. This is because an inflamed airway with extra mucus that does not clear easily is ideal for germs (bacteria) to grow and multiply. Sputum turns greeny/yellow when it is infected.
The severity of symptoms varies greatly:
- Some people have only mild symptoms and become used to an intermittent cough. They may have the occasional chest infection but a diagnosis of bronchiectasis is never made, or is made years after symptoms begin.
- At the other extreme, some people have severe symptoms with an almost permanent chest infection.
- Many people with bronchiectasis fall somewhere in between these extremes.
How is bronchiectasis diagnosed?
If your symptoms suggest bronchiectasis then the diagnosis can be confirmed by a special type of CT scan. A CT scan is a type of X-ray test which uses computers to generate detailed images. CT scans can determine the width of the branching airways (bronchi). Widened bronchi seen on a CT scan confirm bronchiectasis. Various other tests may be advised if an underlying cause is suspected.
What are the treatments for bronchiectasis?
Your doctor may advise one or more of the following. The treatment options chosen may depend on the severity of the condition.
Antibiotics are the mainstay of treatment. If you have mild bronchiectasis, you are likely to need a course of antibiotics every now and then to clear chest infections as and when they occur. Antibiotics may not be necessary if your phlegm (sputum) changes colour to green. But, if your cough or breathlessness gets worse or you start to feel generally unwell, your doctor may advise them. The most commonly used antibiotic is amoxicillin. However, the choice will depend on your allergies, the germs (bacteria) you have, and local guidelines about the best ones to use.
If you have more severe bronchiectasis, chest infections may return quickly once you stop taking antibiotics. In this situation you may be advised to take antibiotics regularly to prevent infections from developing. One option for this is pulsed antibiotic treatment. This means regular short courses of antibiotics with breaks in treatment between the courses. Another option is to take antibiotics every day indefinitely. Sometimes regular antibiotics can be taken with the help of a machine called a nebuliser. This makes the medicine into a mist which can be breathed in with the help of a face mask. This can deliver high doses of the antibiotic directly into the airways with relatively small amounts getting into the body. This reduces the problem of possible side-effects.
Physiotherapy and other exercise therapies
The aim of physiotherapy and other exercise therapies is to help you to cough up and clear the mucus and to improve your overall lung fitness. This is called airway clearance therapy. This can help prevent a build-up of infected mucus, which may prevent chest infections. A physiotherapist will advise on the different airway clearance techniques available and the one that may suit you best. Typically, people with bronchiectasis are encouraged to perform their chosen airways clearance therapy for 20-30 minutes, once or twice a day.
In addition, if you are able, a daily exercise activity such as running, brisk walking, swimming, dancing, aerobics, etc, may help to clear the mucus too and help you to keep fit.
Other medicines and immunisation
Occasionally other medicines such as aminophylline or theophylline can help symptoms. These treatments are only used for those who find they make their symptoms better. If they don't help, they are stopped.
Bronchodilator inhalers are commonly used in asthma to relax and open wide (dilate) the airways. They are also useful if the wheezing and breathlessness of bronchiectasis become severe (this is known as an acute attack). There are a number of types of inhalers- for example, salbutamol, tiotropium, ipratropium. These are only used for some people who find they help their symptoms. If they are not helpful, they are stopped. Steroid inhalers are no longer recommended for bronchiectasis unless there is also underlying asthma.
Your doctor may advise hospital admission if your symptoms become severe. Rapid breathing and chest pain are signs that your condition may not be responding to treatment at home.
Do not smoke
Smoking makes symptoms worse and smokers are very strongly advised to stop smoking. Also, avoid passive smoking - that is, breathing in the smoke from people smoking nearby.
Treatment of underlying conditions
As mentioned above, about 4 in 10 people with bronchiectasis have an underlying cause. In some of these cases additional treatments may be advised, depending on the cause.
An operation may be an option if you have a small local area of lung damage causing symptoms. Cutting out the damaged airway may cure the problem. Surgery may be occasionally considered even if you have widespread bronchiectasis. This may be to cut out a particularly bad area of lung that is acting as a reservoir for mucus and infection. A lung transplant may be considered in very severe cases.
What is the outlook (prognosis)?
Most people with bronchiectasis (with no underlying cause) have a good outlook. Symptoms in many affected people do not become severe. Treatment, in particular with antibiotics when an infection occurs, or regularly when needed, keeps most people reasonably well.
The condition becomes worse in some cases and breathing problems may develop. In a small number of cases the condition becomes gradually worse over time as more and more of the airways become affected.
A life-threatening bleed from a damaged airway may also occur but is rare.
The outlook for people where bronchiectasis is part of another condition depends on the underlying cause.
Further help & information
Dr Tim Kenny
Dr Mary Harding
Prof Cathy Jackson