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CME Respiratory medicine Non-cystic fibrosis bronchiectasis tomography of the chest. The defining characteristic is bronchial dilatation with the internal diameter of the bronchial Pathologically, there is abnormal perma- lumen greater than that of the adjacent Maeve P Murray MB ChB MRCP, Clinical nent dilatation of the airways. This leads artery, categorised as tubular, varicose or Research Fellow to impaired mucociliary clearance, which cystic (Figs 1(a), 1(b) and 1(c)).5 Adam T Hill MB ChB MD FRCPE, Consultant Respiratory Physician and Honorary Senior in turn leads to a vicious cycle of bacterial Lecturer colonisation in normally sterile airways Aetiology Department of Respiratory Medicine, Royal and excessive bronchial inflammation. This review explores current clinical No underlying cause is identified in up to Infirmary of Edinburgh, Scotland practice for this complex condition. 50% of cases and is post-infective in up Clin Med 2009;9:164–9 to 42%.6,7 The common causes, appro- priate investigations and expected Diagnosis abnormal findings are listed in Table 1.6,7 Originally described by Laennac in 1819,1 There is usually a history of a chronic bronchiectasis is a chronic, debilitating productive cough and recurrent chest Assessment of severity condition characterised by persistent infections. There may be symptoms cough, excessive sputum production and related to airways obstruction (wheeze Clinical, radiological and microbiological recurrent chest infections. The precise and breathlessness), mucus plugging features guide clinicians to the severity of prevalence is unknown, but figures quoted (chest pain) and also systemic symp- bronchiectasis. These investigations not vary from about 4 × 105 aged 18–34 years toms.4 The diagnosis of bronchiectasis is only provide clinicians with a quantitative to 272 × 105 aged 75 years and over.2,3 confirmed radiologically with computed assessment of disease severity but may also help in the management of both stable disease and exacerbations. Key Points • Sputum colour and volume. Colour is graded as mucoid, mucopurulent or Bronchiectasis should be considered in patients with a chronic, productive cough purulent (Fig 2) and volume is and a history of recurrent chest infections measured over a 24-hour collection The gold standard for diagnosis is computed tomography of the chest period. Patients with severe bronchiectasis usually have purulent The aetiology is unknown in up to 50% of cases and post-infective in up to 42% sputum and volumes that may The mainstays of treatment are regular chest physiotherapy, annual influenza exceed 25 ml/day, even when stable. vaccination and prompt administration of antibiotics for exacerbations • Exacerbation frequency. In severe disease there are often multiple Long-term antibiotics should be considered for patients with recurrent chest infections impacting on their health-related quality of life exacerbations (usually ≥3 a year) and inpatient management may be KEY WORDS: bronchiectasis, exacerbations, investigations, management necessary. (a) (b) (c) Fig 1. (a) Tubular dilation of airways (see arrow); (b) varicose dilatation of airways (arrow shows irregular, dilated airway); (c) cystic dilatation of airways with thickened bronchi and mucus plugging (see arrow). 164 Clinical Medicine Vol 9 No 2 April 2009 © Royal College of Physicians, 2009. All rights reserved. CME Respiratory medicine • Lung function. There can be usually varicose or cystic with with severe bronchiectasis are advanced airflow obstruction in
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