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or minus dyspnoea) is generally thought to be appropriate but there is little consensus as to what drug or drugs to use. If the patient is not known to be colonized with P. aeruginosa, empirical treatment with amoxycillin while awaiting the results of sputum culture is reasonable.

Higher doses may be necessary. If the patient has a history of penicillin sensitivity, doxycyline, clarithromycin and other macrolides have been shown to penetrate the airways sufficiently well to be helpful for nonpseudomonal infections.

If the sputum grows P. aeruginosa, oral ciprofloxacin is an appropriate first choice for infective exacerbations. If the patient with a P. aeruginosa-positive exacerbation does not respond to ciprofloxacin within a few days, consider recommending a 10- to 14-day course of intravenous antipseudomonal therapy with 2 agents to which the organism is sensitive (eg. gentamicin and ceftazidime). Dual agent therapy is recommended as it may be clinically more effective than monotherapy and it is thought likely to reduce the possibility that antibiotic resistance will develop.

(C) Management of hemorrhage

Massive haemoptysis can occur with bronchiectasis. When this happens the patient needs urgent referral to a thoracic physician or surgeon. Treatment options include bronchial artery embolization and lobectomy. Lesser hemorrhages may be managed conservatively and often settle. In conservative management, antibiotic therapy is generally recommended together with the cessation of any agents that may promote hemorrhage (eg. nonsteroidal anti-inflammatory drugs and anticoagulants).

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