Referral Pathways in Bronchiectasis: When to Send Patients to a Specialist

This episode, "Referral Pathways in Bronchiectasis: When to Send Patients to a Specialist," features the panel addressing why so many bronchiectasis diagnoses arrive later than they should.

Dr. Basavaraj asks Dr. ElMaraachli who typically makes the initial diagnosis of bronchiectasis and what should prompt referral to a specialty center. Dr. ElMaraachli explains that primary care physicians are usually the first to order the CT scan that reveals the diagnosis, though general pulmonologists and infectious disease physicians occasionally initiate imaging as well. He notes that chronic cough algorithms in primary care typically work through common causes such as acid reflux and upper airway cough syndrome first, and the process of moving to CT imaging after those treatments fail often takes too long.

Dr. ElMaraachli adds that patient demographics matter when building suspicion. Older patients are statistically more likely to have bronchiectasis, while younger patients warrant questions about family history or infertility that might point toward a genetic cause. In his own clinic, he says the majority of patients arrive with the diagnosis already established, frequently through an incidental finding on a CT scan ordered for an unrelated reason, such as a coronary CT. Many of these patients, when questioned, reveal they had a mild chronic cough for years before the scan was obtained.

Turning to referral criteria, Dr. ElMaraachli explains that not every patient needs specialty care. Those with mild disease or infrequent exacerbations, requiring perhaps one antibiotic course every two years, can generally be managed by general pulmonologists. Referral to a specialty center becomes appropriate for patients experiencing two or more exacerbations per year, colonization with drug-resistant organisms such as pseudomonas, a need for intravenous antibiotics, or a requirement for aggressive airway clearance therapy that depends on access to a dedicated respiratory therapist. These factors, he says, distinguish patients who benefit most from a more resourced, multidisciplinary care setting.

Our next episode, "Inside a Bronchiectasis Care Center: Building the Team," turns to the multidisciplinary team that a dedicated bronchiectasis center brings together.