chronic pulmonary sepsis

[balado]

HRCT july '05 "widespread bronchiectasis present,particularly marked in middle lobe & lingula,dilated bronchi filled with mucus/pus. Also some mild bron'in upper&lower lobes bilaterally. There is a little inflammatory change present where this is a tree in bud appearance.." This damage having been caused by legionnaires 10 years ago. Since diag' no more flareups or problems except continued fatigue and daily production of 20ml purulent grey/yellow (never green)sputum, plus 20ml clear, all from one drainage session. No breathlesness, no chronic cough.
Treatment by consultant after CT resultwas 56days 2x500 clarithromycin in an unsuccessful attempt to "clear any underlying infection which may be causing the purulence"Recent sputum and 2xAFB cultures have been negative.
My specific concern is whether a more pro-active approach should be made to overcome this purulence which has been present for about a year. The two most recent visits to my consultant have resulted in no treatment and being told"see how things go"as if no other options exist, and yet he still wants to see me every 4 months.
Can you please give me your view regarding possible treatment options, or am I misleading myself that my current stable state cannot be improved.
I am a physicaly active 65 yr male 175lbs 6' tall, a UK resident and being treated by the NHS.
I would be most grateful for any input or advice.
Thanks in advance

[National Jewish]

Even if your bronchiectasis is not due to cystic fibrosis (CF), treatments prescribed for people with CF might be helpful to you.
· Hypertonic saline by nebulizer twice a day from the New England Journal of Medicine, January 19, 2006, Volume 354, pages 229-240.
· Antibiotic therapy based on culture of your purulent sputum.
· The lysis of viscous DNA with the recombinant enzyme DNase offers benefit to many people with purulent sputum.  When taken once daily, aerolized DNase reduced the relative risk of respiratory exacerbations by 28% in people with bronchiectasis due to CF.
· Chest percussion and drainage 3 to 4 times daily.

If your doctors do not wish to treat your bronchiectasis aggressively, you may benefit from the assistance of doctors experienced in treating CF associated bronchiectasis.  Even at the age of 65, it is possible that your bronchiectasis could be on the basis of CF.  In addition, a condition called alpha1-antitrypsin deficiency, in the incomplete form, has been noted to be associated with bronchiectasis, especially in those with nontuberculous mycobacterial (NTM) infection.

[bactitech]

I cannot comment on treatment. The only thing I can comment on is your microbiology results. Apparently they have cultured your sputum for "regular" bacteria and AFB (translation = acid fast bacteria). These include M. tuberculosis and other types of mycobacteria. It looks like your cultures are negative, so that is a good thing.

Please keep in mind, however, that getting good respiratory specimens is difficult. It's good you're producing sputum in that respect only, as saliva is worthless for lower respiratory tract culture. First morning specimens are THE BEST. If you need to recollect, always get your first morning's deep cough (do NOT just swish and spit in a cup). Keep your specimen collector by your bed. This specimen is the least diluted as it's what collects in your airways overnight. Your specimen should be taken to your laboratory with only minimal delay at that point. Hopefully you can get it there within a couple of hours.

The rest of it I'll leave to the RN who comments on this site.

[balado]

Thanks for the response. I clearly understand all you say, but here's the rub! I don't/can't produce sputum first thing in the morning. I have tried, but to no avail. It seems like its presence becomes tangible late afternoon, at which stage I put my hips on three pillows on the bed and my head on the bed and lie on each side in turn. I then take 10 normal breaths followed by 10 deap slow release breathes after which the sputum is more than ready to be coughed out. After the initial few very productive coughs I then make a series of "huffing" exhalations until no more comes out. Excuse the detail, but hopefully this indicates the thorougness I endevour to apply to the procedure. This then is the same process which I have previously attempted first thing in the morning, but results in my only "huffing" whats feels and hears like dry air passages. My consultant seems intrigued but noncommital about this. I sometimes wonder if my daily sputum is the product of an accumulation of post nasal drip? Probably not, but I have read that bronchiectasis sputum separates into three layers, the bottom one being the purulence, whereas with myself the purulence is on the top with the clear underneath. Thank you very much again for your interest and input

[bactitech]

I can't comment on the three layer description (yuck) but I have seen hundreds of sputum specimens over the years. Usually the clear stuff is saliva and not sputum. There is a difference. Saliva does NOT belong in your collection container. I can't comment on bronchiectasis as I don't know if that statement is true or not.

Perhaps you are dehydrated overnight and cannot produce a specimen. You are producing one later on because you have had stuff to drink during the day.

We screen all expectorated sputum specimens for specimen integrity. If there are >25 squamous epithelial cells per high power [microscope] field (these are cells commonly found in saliva and not lower down in the respiratory tract) these specimens are not even cultured as they are improperly collected. Screening sputum specimens is required by lab inspectors in the US.