Summary
Definition
History and exam
Key diagnostic factors
- cough
- sputum production
- crackles, high-pitched inspiratory squeaks and rhonchi
- dyspnea
- fever
Other diagnostic factors
- fatigue
- hemoptysis
- rhinosinusitis
- weight loss
- wheezing
- pleuritic chest pain
- clubbing
Risk factors
- cystic fibrosis
- host immunodeficiency
- previous infections
- congenital disorders of the bronchial airways
- primary ciliary dyskinesia
- alpha-1 antitrypsin deficiency
- connective tissue disease
- inflammatory bowel disease
- aspiration or inhalation injury
- focal bronchial obstruction
- tall, thin, white females, age 60 or over
- prematurity
Diagnostic tests
1st tests to order
- high-resolution chest CT
- CXR
- CBC
- sputum culture and sensitivity
- serum alpha-1 antitrypsin phenotype and level
- serum immunoglobulins
- sweat chloride test
- rheumatoid factor
- specific IgE or skin prick test to Aspergillus fumigatus
- serum HIV antibody
- nasal nitric oxide (NNO)
- pulmonary function tests
Tests to consider
- primary ciliary dyskinesia (PCD) testing
- cystic fibrosis transmembrane regulator (CFTR) protein gene mutation testing
- swallow study
- pH monitoring of esophagus
- 6-minute walk test
- tuberculosis testing
- diagnostic bronchoscopy with bronchoalveolar lavage
Treatment algorithm
initial presentation
acute exacerbation: mild to moderate underlying disease
acute exacerbation: severe underlying disease or not responding/resistant to initial antibiotics
3 or more exacerbations per year despite maintenance therapy
first or new isolation of Pseudomonas aeruginosa at outpatient review
Contributors
Authors
Anne E. O'Donnell, MD
Professor of Medicine
Chief, Division of Pulmonary, Critical Care and Sleep Medicine
The Nehemiah and Naomi Cohen Chair in Pulmonary Disease Research
Georgetown University Medical Center
Washington
DC
Disclosures
AEOD has received scientific consulting fees from the following companies: Bayer, Xellia, Horizon, Grifols, Insmed, and Electromed. AEOD is the Principal Investigator for trials sponsored by the following companies (research funding provided directly to Georgetown University): Bayer, Insmed, Aradigm, Parion, Zambon. AEOD has been a faculty member at the annual meetings of CHEST (American College of Chest Physicians), the American Thoracic Society, and the European Respiratory Society. AEOD is the author of a reference cited in this topic.
Acknowledgements
Dr Anne E. O'Donnell would like to gratefully acknowledge Dr Pamela J. McShane and Dr Sangeeta M. Bhorade, previous contributors to this topic.
Disclosures
PJM and SMB declare that they have no competing interests.
Peer reviewers
Philip W. Ind, BA (Cantab), MB BChir, MA (Cantab), FRCP
Emeritus Professor of Practice (Respiratory Medicine)
National Heart and Lung Institute
Imperial College London
London
UK
Disclosures
PWI declares that he has no competing interests.
Meg Coleman, MBBS, BSc, MRCP
Respiratory Consultant
Honorary Senior Clinical Lecturer
Imperial College Hospitals NHS Trust and National Heart and Lung Institute
London
UK
Disclosures
MC has received honoraria from Pfizer and Gilead for delivering educational sessions.
Amanda Messinger, MD, MS
Assistant Professor
Section of Pediatric Pulmonary and Sleep Medicine
Department of Pediatrics
Children's Hospital Colorado
University of Colorado Denver School of Medicine
Aurora
CO
Disclosures
AM declares that she has no competing interests.
Ware Kuschner, MD
Associate Professor of Medicine
Stanford University
Stanford
Staff Physician
US Department of Veterans Affairs
Palo Alto Health Care System
Palo Alto
CA
Disclosures
WK declares that he has no competing interests.
Differentials
- COPD
- Asthma
- Pneumonia
More DifferentialsGuidelines
- European Respiratory Society guidelines for the management of children and adolescents with bronchiectasis
- British Thoracic Society guideline for long-term macrolides in adults with respiratory disease
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