Krall notes for bronchiectasis

I’d say with the newer image I agree on there being bronchiectasis. Agree with rechecking all of those even with having them checked in the past. They can be abnormal now when previously was normal or borderline. I would def try to get her to do the PFTs - saw that she cancelled that or something. Would see if she has COPD or asthma. Her CBC diff from not too long ago had 300 eos. So if you can get one of those diagnosed that would open up the option for biologics +/- Ohtuvayre. If she is having frequent exacerbations, you can consider Brinsupri for the bronchiectasis but so far I haven’t seen drastic changes in my patients. I have low threshold to put them on Brinsupri though because its a pill and lower risk for side effects. If she hasn’t already been on this, you could also consider azithromycin 500 MWF or 250 daily. Some insurances make you have them on azithromycin first before approving Brinsupri but I have had some approve without trial on azithromycin.

Other things to consider if she has not had these checked:

—CF testing - can start with sweat test or go straight to genetic sequencing (but then would have to go back to sweat test if she has some abnormal genes). For her age, I think she can yield good amount of sweat.

—alpha 1 antitrypsin testing

—Screening for autoimmune, consider sending RF/anti CCP +/- ANA

—testing for aspiration or GERD

—If she has sinus disease, consider testing for PCD

On the airway clearance, I didn’t look to see if you have her on flutter valve or vest but I’d make sure she is using a flutter valve and doing airway clearance twice a day consistently. If flutter valve isnt helping to bring up mucous, I’d have her switch over to vest. This is part of a dot phrase I have for bronchiectasis patients:

Airway clearance is a key part of managing bronchiectasis. It helps move mucus out of the lungs, reduces coughing, and lowers the risk of infections and flare-ups. All forms of airway clearance depend on good coughs to move loose mucus out. You can learn techniques to improve your cough strength and effort. You want to bring mucus up and out of the lungs! The following instructions explain how to do airway clearance every day and what to do if symptoms get worse.

Daily Airway Clearance:

· Do your airway clearance routine every day, even if you feel well.

· Use albuterol - this can be the nebulizer or inhaler

· Then use hypertonic saline nebulizer

· Then use a handheld positive expiratory pressure device (PEP, flutter valve) or vest. This can be used at the same time as nebulizer treatments.

· Then do your breathing exercises to loosen and clear mucus: Active cycle of breathing techniques (ACBT) typically involves three phases: breathing control (gentle, relaxed breathing to prevent bronchospasm), thoracic expansion exercises (deep breaths with or without breath holds to loosen secretions), and forced expiratory technique (huff coughing to move mucus up and out of the airways)

Other techniques to consider for airway clearance:

· Gravity-assisted drainage (postural drainage): lying in certain positions to help mucus drain from your lungs.

· Regular exercise, such as walking or cycling, can also help clear your lungs.

Breathing techniques can help with managing breathlessness with exertion and exercise as well: https://www.bronchiectasisandntminitiative.org/Learn-More/I-am-a-Patient-or-Caregiver/Breathing-Techniques

Sick Plan (When You Have a Flare-Up or Infection):

· Increase your airway clearance sessions to 4-6 times per day if you notice more coughing, more mucus, a change in mucus color, or if you feel more short of breath.

· Drink plenty of fluids to help keep mucus thin.

· If you cough up blood (hemoptysis), stop airway clearance and contact your healthcare team right away.

· If you fail to improve, call the pulmonary clinic for further guidance.

· If you feel much worse, cannot clear mucus, or have worsening trouble breathing, seek medical help immediately.

Other Important Tips:

· Stay up to date with vaccines, including flu, pneumonia, and COVID-19.

· Avoid smoking and secondhand smoke.

· Eat a healthy diet to keep your body strong.

· Wash your hands often and avoid people who are sick to lower your risk of infection.

ACBT video: https://www.mylungsmylife.org/topics/group-1/how-to-clear-your-chest/active-cycle-of-breathing-technique-acbt/

What is Bronchiectasis: https://www.bronchiectasisandntminitiative.org/Portals/0/Files/bronchiectasis-pt1.pdf?ver=2017-11-29-205027-643

Treating Bronchiectasis: https://www.bronchiectasisandntminitiative.org/Portals/0/Files/bronchiectasis-pt2.pdf?ver=2017-11-29-205026-277

Medicines for Airway Clearance: https://www.bronchiectasisandntminitiative.org/Learn-More/I-am-a-Patient-or-Caregiver/Coping-with-Airway-Mucus/Medicines-for-Airway-Clearance

Inhaler and nebulizer education: https://www.copdfoundation.org/Learn-More/Educational-Materials-Resources/Educational-Video-Series.aspx