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bronchiectasis 4TH YER

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									   BRONCHIECTASIS

         BRIG S B H ZAIDI
MBBS, MD(USA), FCPS, MRCP(UK), FRCP(Edin)
                CONTENTS
•   Definition
•   Aetiology
•   Pathogenesis
•   Clinical manifestations
•   Diagnosis
•   Treatment
          BRONCHIECTASIS
Definition:
Abnormal and permanent dilation of bronchi.

Focal or diffuse distribution
Clinical consequences
    chronic and recurrent infection
    Pooling of secretions in dilated airways.
• First described by Laennec in 1819,
• Later detailed by Sir William Osler in the
  late 1800s,
• Further defined by Reid in the 1950s,
• Bronchiectasis has undergone significant
  changes in regard to its prevalence,
  etiology, presentation, and treatment.
A chronic obstructive pulmonary lung
  disease manifested by
• airways that are inflamed
• easily collapsible,
• result in air flow obstruction with
  – shortness of breath,
  – impaired clearance of secretions
  – often with disabling cough,
  – occasionally hemoptysis.
  – Severe cases can result in progressive
    impairment with respiratory failure
• most often presents as
• a focal process involving a lobe, segment,
  or subsegment of the lung or

• a diffuse process involving both lungs
Abnormal dilation of the proximal and
 medium-sized bronchi (>2 mm in
 diameter) caused by weakening or
 destruction of the muscular and elastic
 components of the bronchial walls
Classification:
1. Cylindrical (fusiform)
2. Saccular
3. Varicose
Clylinderical
Cyctic and cyliderical RLL
vericose
•   Frequency
•   Mortality
•   Age
•   Gender
•   Race
    Aetiology: A. Infections-
       Micro-organisms
• Measles and            •   Atypical mycobacteria
  Pertussis              •   Mycoplasma
• Adeno & Influenza
  virus                  •   HIV/MAC
• Bacterial infection    •   Tuberculosis
  with virulent          •   Fungi
  organisms: S.aureus,
  Klebsiella Anaerobes
  AETIOLOGY : IMPAIRED
     HOST DEFENCE
• Local causes:
• Endobronchial obstruction
   – endobronchial tumors,
   – broncholithiasis,
   – bronchial stenosis from infections,
   – encroachment of hilar lymph nodes,
   – foreign body aspiration

  – Right-middle lobe syndrome
• Generalised impairment:
  – 1. Immunoglobulin deficiency
  – 2. Primary ciliary disorders
  – 3. Cystic fibrosis
         AETIOLOGY : NON-
           INFECTIOUS
• Toxins or toxic substances NH3; gastric contents
• Immune responses, ABPA
• Inflammatory diseases: ulcerative colitis,
  rheumatoid arthritis, Sjögren syndrome.
• -1-Antitrypsin deficiency
• Yellow nail syndrome
 CLINICAL MANIFESTATIONS
• Persistent or recurrent cough with purulent
  sputum.
• Haemoptysis
• Initiating episode: Severe pneumonia, or
  insidious onset of symptoms or asymptomatic or
  non-productive cough – dry bronchiectasis in
  upper lobe,
• Dyspnoea, wheezing – widespread
  bronchiectasis or underlying COPD.
• Exacerbation of infection: Sputum volume
  increase, purulence or blood.
   PHYSICAL EXAMINATION
• Any combination of rhonchi, creps or wheezes.
• Clubbing of digits.
• Chronic hypoxaemia  cor pulmonale  R
  heart failure
• Amiloidosis (rare)
Clinical Data Obtained at the
      Patient’s Bedside
Vital signs
• Increased respiratory rate
• Increased heart rate, cardiac output,
  blood pressure
    Clinical Data Obtained at the
          Patient’s Bedside
• Use of accessory muscles of inspiration
• Use of accessory muscles of expiration
• Pursed-lip breathing
• Increased anteroposterior chest diameter
  (barrel chest)
• Cyanosis
• Digital clubbing
 Figure 2-36. The way a patient may appear
when using the pectoralis major muscles for
                inspiration.
   Figure 2-41. A, Schematic illustration of alveolar compression of
 weakened bronchiolar airways during normal expiration in patients
  with chronic obstructive pulmonary disease (e.g., emphysema). B,
Effects of pursed-lip breathing. The weakened bronchiolar airways are
 kept open by the effects of positive pressure created by pursed lips
                           during expiration.
 Digital
Clubbing




           Figure 2-46. Digital clubbing.
  Clinical Data Obtained at the
        Patient’s Bedside
• Peripheral edema and venous distention
  – Distended neck veins
  – Pitting edema
  – Enlarged and tender liver
                                     Distended
                                     Neck Veins




Figure 2-48. Distended neck veins (arrows).
Figure 2-47. Pitting edema. From Bloom A, Ireland J: Color atlas
of diabetes, ed 2,
London, 1992, Mosby-Wolfe.
• Cough, sputum production, and
  hemoptysis
  – A chronic cough with production of large
    quantities of foul-smelling sputum is a
    hallmark of bronchiectasis
  Clinical Data Obtained at the
        Patient’s Bedside
Chest assessment findings (primarily
  obstructive)
• Decreased tactile and vocal fremitus
• Hyperresonant percussion note
• Diminished breath sounds
• Rhonchi and Wheezing
  Clinical Data Obtained at the
        Patient’s Bedside
 Chest assessment findings (primarily
  restrictive)
• Increased tactile and vocal fremitus
• Bronchial breath sounds
• Crackles
• Whispered pectoriloquy
• Dull percussion note
             DIAGNOSIS - 1

• Clinical

• Haematology and Microbiology

• Immunology

• Radiology:
   Abnormal Laboratory Tests
       and Procedures
• Hematology
     (Increased hematocrit and
  hemoglobin)
• Sputum examination
  – Streptococcus pneumoniae
  – Haemophilus influenzae
  – Pseudomonas aeruginosa
  – Anaerobic organisms
        Radiologic Findings
• Chest radiograph
  – Translucent (dark) lung fields
  – Depressed or flattened diaphragm
  – Long and narrow heart
  – Enlarged heart
• Bronchogram
• CT scan
Figure 14-2. Cylindrical bronchiectasis. Left posterior oblique projection of
a left bronchogram showing cylindrical bronchiectasis affecting the whole
 of the lower lobe except for the superior segment. Few side branches fill.
 Basal airways are crowded together, indicating volume loss of the lower
    lobe, a common finding in bronchiectasis. (From Armstrong P et al:
       Imaging of diseases of the chest, ed 2, St. Louis, 1995, Mosby.)
    Figure 14-3. Saccular bronchiectasis. Right lateral
 bronchogram showing saccular bronchiectasis affecting
mainly the lower lobe and posterior segment of the upper
lobe. (From Armstrong P et al: Imaging of diseases of the
Figure 14-4. Varicose bronchiectasis. Left posterior oblique
 projection of left bronchogram in a patient with the ciliary
  dyskinesia syndrome. All basal bronchi are affected by
varicose bronchiectasis. (From Armstrong P et al: Imaging
 Figure 14-5. Bronchiectasis. High-resolution thin-section (1.5-mm)
 computed tomographic (HRCT) scan showing numerous oval and
rounded ring opacities in the left lower lobe. The right lung appears
  normal. The fact that the airways tend to be arranged in a linear
    fashion and have walls of more than hairline thickness helps
distinguish these bronchiectatic airways from cysts or bullae. (From
Armstrong P, Wilson AG, Dee P: Imaging of diseases of the chest, St.
                        Louis, 1990, Mosby.)
            DIAGNOSIS - 2
• Lung function: Airflow obstruction – FEV1
  decreased.
                    Air trapping - RV increased
• Sweat test – increased sodium and chloride in
  cystic fibrosis
• Bronchoscopy: Obstruction – foreign body,
  tumor.
• Immunoglobulin
• Cilia function and structure – Kartagener
  syndrome.
           TREATMENT - 1
• 4 Goals: 1.   Eliminate cause
           2.   Improve tracheo bronchial
                clearance
           3.   Control infection
           4.   Reverse airflow obstruction
          TREATMENT - 2
•    1. Immunoglobulin
     2. Antituberculous drugs
     3. Corticosteroids (ABPA)
     4. Remove aspirated material

•   Chest physical therapy
•   Mucolytics
•   Bronchodilators
           TREATMENT - 3

• Antibiotics – short course, prolonged course,
  intermittent regular courses, inhalation.
• Initial empiric Rx: Ampi, Amox, Cefaclor,
  Septran
   Ps.aeruginosa – Quinolone, aminoglycoside,
  3rd generation cephalosporin, pipracillin.
• Surgery:
• Oxygen and diuretics
• Lung transplant
THANK YOU

								
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