Research

Medical management of bronchiectasis: more MDT would help


Patients with bronchiectasis may be missing out on some aspects of best practice care, according to a Melbourne study.

The retrospective review of 145 patients with bronchiectasis managed in the general respiratory clinic at the Royal Melbourne Hospital between 2015 and 2016 found many aspects of patient care were concordant with guidelines.

Comprehensive assessment of lung function by spirometry was available for 98% of patients.

Long-term antibiotics were appropriately limited to a minority of patients (34%) including those with indications such as frequent exacerbations and pathogenic organisms cultured in sputum.

As well, the prescription of oral corticosteroids was restricted to only 18% of patients – “almost all of whom had comorbidities requiring steroid treatment”.

However the study, published in the Internal Medicine Journal, found documentation regarding essential recommendations such as airway clearance, vaccination, sputum clearance, pulmonary rehabilitation and written action plans was relatively low.

The Bronchiectasis Severity Index (BSI) score was not documented in the medical records for any patients, however severe disease (BSI >9) was common (34-48%) when calculated retrospectively.

“Patients with severe disease (scores of ≥9) were significantly more likely to receive long term antibiotics (OR 4.1, 95% CI 2.0-8.6, p<0.001), influenza vaccination (OR 3.1, 95% CI 1.5-6.5, p=0.003), pneumococcal vaccination (OR 3.3, 95% CI 1.5-67.0, p=0.002), pulmonary rehabilitation (OR 5.3, 95% CI 2.3-12.4, p<0.001), and mucolytic therapy (OR 3.9, 95% CI 1.5-10.4, p=0.005).”

The study, led by Associate Professor Megan Rees, said the BSI and several components of the BSI also helped predict mortality.

Associate Professor Rees said there were now online calculators for BSI which made it easier to use than ever before and the next logical step would be to integrate them with the electronic health record.

She said the study highlighted the importance of a multidisciplinary team approach to bronchiectasis.

“The main deficiency was that patients weren’t regularly referred for chest physiotherapy which is a key integral therapy for bronchiectasis. Physically clearing the phlegm out of the chest is one of the best things to break the cycle of inflammation and infection that occurs with bronchiectasis and results in more lung damage.”

She said there was no lack of goodwill between the professions and that patients enjoyed being managed by a team.

“Having a physiotherapist embedded in our clinic would be highly desirable but there are some funding and structural hurdles to achieving that.”

She said the multidisciplinary approach had been highly successful in cystic fibrosis – extending life expectancy from childhood only to patients living well into their adulthood.

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