ABsTRAcr Sputum samples from 34 patients with bronchiectasis were assessed subjectively and the results related to objective measurements of elastase activity and albumin content. The results suggest that the macroscopic appearance of the sample is related to the elastase content, 88-7% of the purulent samples but none of the mucoid samples showing elastase activity. The macroscopic appearance was also associated with changes in protein transudation into the secretions. The median sputum:serum albumin concentration ratio was 0-71 x 10-2 (range 0.22-4.7) in the mucoid samples but was greater in purulent samples (p < 0.005), with a median value of 1-52 x 10-2 (range 0*55-12.72), suggesting that purulence in the stable state was associated with low grade pulmonary inflammation or epithelial damage or both. Abnormalities of air flow were found in 24 of the patients (70.6%) but there was a significantly higher ratio of residual volume to total lung capacity (p < 0.025) in patients who regularly produced purulent sputum (mean (SD) RV/TLC 44-4% (9.0%)) than in those with mucoid or mucopurulent secretions (38.0% (9.9%)). A similar difference was found between those who produced elastase positive secretions and those who produced elastase negative ones.

The effect of three amoxycillin treatment regimens on purulent secretions of patients with bronchiectasis has been studied. On the basis of information recorded on a diary card the patients were divided into three groups, according to the usual nature of their secretions: seven who produced mucoid sputum, which occasionally became purulent; seven whose secretions were usually mucopurulent but occasionally purulent; and 19 whose secretions were persistently purulent. Treatment with capsules of amoxycillin in a dosage of 250 mg three times a day resulted in clearance of purulent secretions in patients of the mucoid group when they were treated for a clinical exacerbation. The sputum remained clear in these patients for long periods before a further exacerbation (median 6 l/2, range 1-11 months). The mucopurulent-purulent group also responded to this dosage but sputum purulence returned more rapidly (median 9, range 4-31 days). Only three of the 19 (17%) patients with persistently purulent secretions showed a macroscopic response to this dosage, whereas seven (60%) of 12 patients who received the higher dosage (3 g sachets twice a day) responded. Among the failures, some responded to nebulised amoxycillin, suggesting that higher levels of amoxycillin in secretions are required in these patients. Macroscopic clearance of purulent secretions was finally achieved in most of the patients studied. The response was not always predictable from the results of sputum culture. Clearance of secretions by antibiotics was also identified by the patients, using a diary card score. Improvements in well being and in symptoms were noticed even in the group who usually produced mucopurulent and purulent secretions even though they appeared to be clinically stable before treatment.

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Broad spectrum antibiotic treatment was given on 21 occasions to 15 patients with bronchiectasis who regularly produced purulent, elastase positive secretions. Although the results showed that sputum clearing-that is, changing from purulent to mucoid-largely depended on the pathogenic organism isolated, this was not exclusively the case and in some cases sputum growing sensitive organisms failed to clear whereas clearing occurred in other samples containing resistant organisms or no obvious pathogens. Clearing of sputum was achieved eventually in 12 of the patients and this was associated with the disappearance of elastase activity, although it returned in 10 patients within one week of stopping treatment. There was no change in sputum elastase where the sputum failed to clear. The clearance of elastase activity was associated with a decrease in protein transudation into the lung secretions. The sputum:serum albumin concentration ratio fell (p < 0.005) from a mean (SD) of 2-32 (1.56) x 10-2 in these 12 patients before treatment to 1*09 (0-40) x 10-2 within the first week of treatment, but rose again to 2-07 (1.29) x 10-2 within one week of stopping treatment. The results suggest that antibiotic treatment when patients are in a stable state may have a beneficial effect on the pathogenic nature of lung secretions and inflammation within the lung.Elastase activity is frequently a feature of purulent secretions' and it is found regularly in sputum from patients with bronchiectasis2 and cystic fibrosis3 even when they are in a clinically stable state. It has been suggested that this proteolytic activity may be relevant to the pathogenesis of the lung disease since purified neutrophil elastase has been shown to damage ciliated epithelium and reduce ciliary beat frequency in vitro.4Direct evidence of such effects in vivo is lacking but can be inferred from several related studies.Firstly, the secretions of patients with bronchiectasis often contain elastolytic activity and this is associated with an increase in protein transudation into the lung from serum, suggesting a degree of bronchial epithelial damage or inflammation even in a stable clinical state.2 Secondly, ciliary activity has been shown to be reduced in patients with bronchiectasis5 and, finally, the bronchial epithelium in such patients shows histological damage.6 The association of these changes with elastase activity Address for reprint requests: Dr RA Stockley, General Hospital,Accepted 3 February 1984 does not necessarily indicate a cause and effect relationship; but such enzyme activity is of potential importance at least in the pathogenesis of progressive lung disease, which occurs in a proportion of such patients.Previous studies in patients with chronic bronchitis have shown that the presence of elastase activity and a rise in the ratio of sputum to serum albumin are a feature of acute infection rather than the stable clinical state.' Such episodes are associated with a change in sputum from mucoid to purulent, which is usually reversed ...