Bronchiectasis in older adults: daily phlegm clearance, flare-ups and antibiotics

Asthma + Lung UK explains that in bronchiectasis the airways become damaged and widened so phlegm (sputum) builds up in them, and the built-up phlegm makes it easier for bacteria to be trapped and cause infections. The NHS says it happens when the airways are damaged by inflammation, and cannot usually be cured, though treatment can help manage it. It is more common in women than men, and more likely to be diagnosed in people over 70.

The NHS lists a severe infection such as pneumonia, tuberculosis, measles, whooping cough or COVID-19; another lung condition such as asthma or COPD; breathing in something that damages the lungs; a problem with the immune system; and conditions such as rheumatoid arthritis, ulcerative colitis or Crohn's disease. Asthma + Lung UK adds problems with the lungs' cilia, weaker immunity, endobronchial tumours, allergic bronchopulmonary aspergillosis, and accidentally breathing food or drink into the airways (aspiration).

That last cause is relevant in older people with swallowing problems after stroke or with Parkinson's disease or dementia, which our guide to aspiration pneumonia covers. For many people the cause is never found.

The NHS lists a cough that does not go away, coughing up a lot of phlegm that may be clear, white, yellow or green, and frequent chest infections, with other symptoms including wheeze, breathlessness, noises on breathing, tiredness, coughing up blood and chest pain. These overlap with COPD and chest infections, so the diagnosis can be missed in older people with a long smoking history or a long-standing "chesty" cough.

The NHS says a GP will listen to the chest and may arrange a phlegm sample, a chest X-ray, spirometry and blood tests, and if these suggest bronchiectasis you are referred to a specialist for a CT scan to confirm the diagnosis and other tests to find the cause. It advises seeing a GP if you think you could have it or have had a cough for more than 3 weeks.

Asthma + Lung UK says your GP should refer you to a respiratory physiotherapist, who can teach safe airway clearance techniques, such as the Active Cycle of Breathing Technique (changing breathing and gentle huffing), postural drainage and handheld devices that use vibrations and air pressure. It advises speaking to the physiotherapist before trying them first time. If phlegm is thick, mucolytics such as nebulised saltwater solution, carbocisteine or acetylcysteine may be recommended. The NHS adds that a nebuliser with a salt solution can help before exercises, that you may be offered pulmonary rehabilitation if breathless, and that inhalers may be given.

On antibiotics, Asthma + Lung UK says flare-ups caused by bacterial infection are treated with a course usually of 14 days, started after a phlegm sample is taken, and a "rescue pack" may be kept at home to start if there are signs of infection such as a change in phlegm colour or texture; always tell your healthcare team when you use it. The NHS says if you get more than 3 chest infections a year a specialist may recommend long-term antibiotics. It also lists oxygen, surgery for damaged lungs and lung transplant for severe disease. Vaccines advised include annual flu, pneumococcal and COVID-19 (NHS). Because antibiotics can interact with other medicines and cause side effects, older people should take them exactly as prescribed and finish the course.

A flare-up is when usual symptoms get worse. Asthma + Lung UK says signs include more cough or phlegm, a change in phlegm colour or texture, more breathlessness, more tiredness, fever of 38 degrees Celsius or more, bloodstained phlegm and sharp chest pain on breathing. It explains that phlegm becoming darker, thicker or stickier suggests infection, and that flare-ups are usually bacterial but can follow colds, flu, COVID-19 or RSV, when antibiotics will not help. Environmental triggers listed include air pollution, damp, mould, smoking and vaping, pollen and weather extremes.

The NHS says to ask for an urgent GP appointment or NHS 111 if your cough is very bad or quickly worsens, you cough up a few spots or streaks of blood, you are more short of breath than usual, or you have chest infection symptoms such as a high temperature or chest pain. It says to call 999 or go to A&E if you cough up more than a few spots or streaks of blood, or have severe difficulty breathing. Asthma + Lung UK adds cold, clammy skin, light-headedness or dizziness to the 999 signs.

The NHS says you will have check-ups and tests at least once a year, with care from a GP, nurse, physiotherapist and sometimes a specialist doctor, and a plan for managing the condition. Self-help includes regular exercise, a balanced diet and healthy weight, regular hand washing, avoiding people with colds and flu, regular vaccination, and not smoking. Asthma + Lung UK offers a self-management plan, patient passport checklist, symptom diary and Keep Active programme. Some people have bronchiectasis together with asthma or COPD, and for most people it can be well controlled; in rare cases it can be life-threatening.