Lec: 3 Bronchiectasis

Lec: 3 Dr. Mohammed Alhamdany
Bronchiectasis
Bronchiectasis means abnormal dilatation of the bronchi. Chronic suppurative airway infection with sputum production, progressive scarring and lung damage occur, whatever the cause.
Causes of bronchiectasis
A-Congenital
1- Cystic fibrosis
2- Ciliary dysfunction syndromes: Primary ciliary dyskinesia (immotile cilia syndrome) Kartagener’s syndrome (sinusitis and transposition of the viscera)
3- Primary hypogammaglobulinaemia.
B-Acquired: children
1- Pneumonia (complicating whooping cough or measles)
2- Primary TB
3- Inhaled foreign body
C-Acquired: adults
1- Suppurative pneumonia
2- Pulmonary TB usually apical
3- Allergic bronchopulmonary aspergillosis complicating asthma
4- Bronchial tumours
D- Localised bronchiectasis: may occur due to the accumulation of pus beyond an obstructing bronchial lesion:
1- Enlarged tuberculous hilar lymph nodes.
2- a bronchial tumor
3- An inhaled foreign body (e.g. an aspirated peanut).

Symptoms of bronchiectasis
• Cough: chronic, daily, and persistent
• Sputum: copious, continuously purulent
• Pleuritic pain: when infection spreads to involve pleura, or with segmental collapse due to retained secretions
• Hemoptysis:
Streaks of blood common, larger volumes with exacerbations of infection
• Infective exacerbation: increased sputum volume with fever, malaise, anorexia.
• Halitosis (Bad odor): frequently accompanies purulent sputum
• General debility: difficulty maintaining weight, anorexia, exertional breathlessness.


Physical signs: general signs include clubbing of fingers, cachexia, halitosiss.
The signs in the chest may be unilateral or bilateral. If the bronchiectatic airways do not contain secretions and there is no associated lobar collapse, there are no abnormal physical signs. When there are large amounts of sputum in the bronchiectatic spaces, numerous coarse crackles may be heard over the affected areas.
Collapse with retained secretions blocking a proximal bronchus may lead to locally diminished breath sounds .
Investigation:
1- sputum culture may reveal common respiratory pathogene in addition to Pseudomonas aeruginosa, fungi such as Aspergillus and various mycobacteria.
2- CXR: Bronchiectasis, unless very gross, is not usually apparent on a chest X-ray. It may show thick airway wall, ring shadows, tramlines and tubular shadows, or complication such as pneumonia or collapse.
3- CT is much more sensitive, and shows thickened, dilated airways.
4- Pulmonary function test show obstructive pattern
5- Ciliary function: a screening test can be performed in patients suspected of having a ciliary dysfunction syndrome by measuring the time taken for a small pellet of saccharin placed in the anterior chamber of the nose to reach the pharynx, at which point the patient can taste it. This time should not exceed 20 minutes but is greatly prolonged in patients with ciliary dysfunction.
Management
In patients with airflow obstruction, inhaled bronchodilators and corticosteroids should be used to enhance airway patency.
Other measure includes:
Smoking cessation, adequate nutritional intake with supplementation. If necessary, immunizations for influenza and pneumococcal pneumonia, and Confirmation of immunizations for TB, measles, and pertussis

Physiotherapy
Regular daily physiotherapy to assist the drainage of excess bronchial secretions is of great value both in reducing the amount of cough and sputum, and in preventing recurrent episodes of bronchopulmonary infection.
Patients should lie in a position in which the lobe to be drained is uppermost, with frequent taping on the segment to be drained for about 5–10 minutes twice daily.
Antibiotic therapy
For most patients with bronchiectasis, the appropriate antibiotics for respiratory pathogen such as penicillin, cephalosporin and macrolide, in rotating pattern (to prevent resistance), with larger doses and longer courses, and resolution of symptoms is often incomplete. When secondary infection occurs with staphylococci and Gram-negative bacilli, in particular Pseudomonas species, antibiotic therapy becomes more challenging and should be guided by the microbiological sensitivities. For Pseudomonas, oral ciprofloxacin (500–750 mg twice daily) or ceftazidime by intravenous injection or infusion may be required.
Hemoptysis in bronchiectasis often responds to treatment of the underlying infection with antifibrinolytic treatment such as Tranexamic acid ampoule (cyclocaprone), although, in severe cases, may need bronchoscopic measure and if failed percutaneous embolization of the bronchial circulation by an interventional radiologist may be necessary ,if this failed so urgent surgery may require.
Surgical treatment
Excision of bronchiectatic areas is only indicated in a small proportion of cases. These are usually patients in whom the bronchiectasis is confined to a single lobe or segment on CT in patients with unsuccessful medical treatment provided that the disease is non-progressive.
Complication:
1- Local: Pneumonia, collapse, pleural effusion, lung abscess, pneumothorax, haemoptysis (which may be massive with or without sputum (dry haemoptysis)).
2- Metastatic abscess: such as Brain abscess
3- Chronic inflammation: Amyloidosis
4- Chronic hypoxia such as corpulmanale, and polycythaemia.



With best regard