When symptoms get worse for a prolonged period of time, often at least a day or a couple of days, it is called an exacerbation, meaning that the symptoms have been exacerbated (made worse). People with bronchiectasis sometimes call these chest infections, but healthcare professionals use the term exacerbation because these exacerbations are sometimes not caused by a chest infection.

Many people with bronchiectasis know when an exacerbation is starting. Possible signs include a day or more of:

• Coughing more than usual.
• More sputum (mucus) is coughed up or it is thicker or harder to cough up.
• The sputum is darker or has changed colour.
• More breathless than usual.
• Feeling more tired, or feeling symptoms of infection like fever and muscle aches.
• Coughing up blood.
• Chest discomfort or tightness.

See also our flowchart of exacerbation management.

Exacerbations are usuallly caused by bacterial infections, viruses or flare ups of other conditions. Exacerbations are usually treated with antibiotics because people with bronchiectasis are very susceptible to infection with bacteria and antibiotics can prevent bacterial infections from getting worse and help you get better faster.

If you feel that you have an exacerbation, you should seek medical help as your doctor will usually want to examine you and prescribe an antibiotic. You should give a sputum sample if you are producing sputum so that any bacteria that are causing the exacerbation can be identified.

Sometimes the sputum samples are negative. This does not mean that the exacerbation was not caused by an infection or that you should stop taking an antibiotic. This is because the sputum test is not perfect and can sometimes be negative when infection is present (sometimes called a false negative).

It is important to complete the course of antibiotics prescribed, even if you are feeling better before you have completed the course. Most guidelines suggest treating exacerbations with two weeks of antibiotics although some people will receive and will benefit from shorter courses e.g. one week.

If you are producing more sputum during a chest infection it may be helpful to do chest physiotherapy exercises more frequently as it is important to keep the airways as clear as possible.

See also our flowchart of exacerbation management.

The average person inhales 1 million bacteria each day as well as dust and other particles from the environment. As a result, the lungs have developed methods for keeping the lungs clear of infection and getting rid of unwanted particles. Mucus is made by special glands in the lungs and lines the lung tubes. When something is inhaled, it is trapped by the mucus so that it cannot travel further in the lungs, and special hairs called cilia “flick” the mucus up towards the mouth where it can be cleared. This happens in healthy people as well as people with chest conditions. When mucus is coughed up, it is called “sputum”.

In people with bronchiectasis the glands make more mucus, and the mucus can be thicker and stickier than usual because of inflammation in the lungs. The cilia hairs cannot clear all of the mucus. The mucus builds and so has to be coughed up from the lungs.

It is very useful to have sputum samples for testing in order to know if there is infection in the lungs. This can help your doctor decide what antibiotic to give in the event of a chest infection, and can also detect some bacteria that need to be treated differently, like Pseudomonas or non-tuberculous Mycobacteria (NTM).

It is important therefore that the samples you provide have come from the lungs. They should be coughed up, rather than from clearing the throat or containing mostly saliva. Ideally, wash the mouth out with water before coughing up a sample as this will help to get rid of saliva and cells from your mouth. Cough or spit the sample directly into a pot or container that your doctor or nurse has given you for the sputum. Samples from tissues or that have touched another object before going into the container will not be useful as they could pick up bacteria from the environment.

Once you have a sample, deliver it straight away to your doctor or whoever requested the sample. Bugs start to die once they are outside the body and so within a few hours the chances of getting a positive test from the sputum go down quite quickly. Therefore, try to give them the sample as soon as possible after coughing it up, and certainly on the same day as it was coughed up.

It is important to send sputum samples to the laboratory, even when you feel well, so that your doctor can see whether you have infection growing in the lungs. This helps to decide the best antibiotics to use if you develop chest infections in the future. The test is more likely to be positive with a good sample from the lungs. Saliva will not usually have a lot of bacteria in it. A positive test suggests that there is infection in the lungs, but this does not necessarily need to be treated with antibiotics.

When you send a sputum sample, it gets taken to a microbiology laboratory where a small amount is taken away and put on a plate to grow. Any bacteria present in the sample will grow over 24 to 48 hours and so the microbiologist will then be able to tell what bacteria were present in the sample.

The bacteria can then be tested against different antibiotics, by seeing if they can grow in the presence of different amounts of antibiotics. This process takes another day or two.

This is why is takes a few days to get the final results of your sputum test, because the microbiologist has to identify the bug, and also find out what antibiotics will kill it.

Bacterial infections

Many people with bronchiectasis have infections in their lungs caused by bacteria. The bacteria live in the lungs and do not go away completely, even with antibiotic treatment. Where these bacteria come from is usually not known. Everyone has bacteria that live in their nose and throat and so it is likely a lot of the bacteria in the lungs travel down from the nose and throat.

Bacteria like Pseudomonas and Haemophilus that are the most common bacteria in bronchiectasis do not cause infections in healthy people. They are only able to cause infections in bronchiectasis because of the damaged areas of lung that let them survive in the lung. There is therefore no evidence that you can pass on infections to people without bronchiectasis.

There is also no evidence that people with bronchiectasis can catch bacteria from other people with bronchiectasis. It is not possible to say that it could never happen, as in cystic fibrosis , an inherited form of bronchiectasis, it has been shown that some bacteria like Pseudomonas can be passed from one person with cystic fibrosis to another on rare occasions. As a result, it is recommended that people with cystic fibrosis are segregated (they do not sit next to each other in clinics) and do not meet socially or in patient support groups.

Bronchiectasis is usually associated with less severe lung disease than cystic fibrosis and bacteria like Pseudomonas are less common. It is therefore not currently recommended that people with bronchiectasis be segregated and individuals should feel free to attend patient support groups, pulmonary rehabilitation classes and other events where they mix with other people with bronchiectasis. If you are invited to an event, like a pulmonary rehabilitation class, where you would mix with other people with bronchiectasis, you should consider the information above and come to your own decision about whether a theoretical risk of catching an infection would outweigh the benefits of treatment and the opportunity to communicate with other people with the condition.

Viral infections

The above advice refers to the bacterial infections in the lungs. It is important to remember that people with bronchiectasis are more likely to pick up viral infections when these are circulating. General advice to avoid picking up infections includes:

1. Make sure you are up to date with influenza and pneumococcal vaccination
2. Wash your hands before meals and after being in contact with others
3. Do not visit anyone with a cold or a chest infection, and ask people not to visit you when they are unwell

Further advice about the risk of infection in bronchiectasis has been published by the EMBARC doctors and ELF patient advisory group.