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Copyright © 2006 by Mosby, Inc.Slide 1
Chapter 14Chapter 14 Bronchiectasis Bronchiectasis
Figure 14–1. Bronchiectasis. A, Varicose bronchiectasis. B, Cylindrical bronchiectasis. C, Figure 14–1. Bronchiectasis. A, Varicose bronchiectasis. B, Cylindrical bronchiectasis. C, Saccular bronchiectasis. Also illustrated are excessive bronchial secretions (D) and Saccular bronchiectasis. Also illustrated are excessive bronchial secretions (D) and
atelectasis (E), which are both common anatomic alterations of the lungs in this disease.atelectasis (E), which are both common anatomic alterations of the lungs in this disease.
D
E
AB
C
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Three Forms of BronchiectasisThree Forms of Bronchiectasis
Varicose bronchiectasisVaricose bronchiectasis
Cylindrical bronchiectasisCylindrical bronchiectasis
Saccular bronchiectasisSaccular bronchiectasis
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Anatomic Alterations of the LungsAnatomic Alterations of the Lungs
Chronic dilation and distortion of bronchial airwaysChronic dilation and distortion of bronchial airways
Excessive production of often foul-smelling sputumExcessive production of often foul-smelling sputum
Smooth muscle constriction of bronchial airwaysSmooth muscle constriction of bronchial airways
Hyperinflation of alveoli (air-trapping)Hyperinflation of alveoli (air-trapping)
Atelectasis, consolidation, and parenchymal fibrosisAtelectasis, consolidation, and parenchymal fibrosis
Hemorrhage secondary to bronchial arterial erosionHemorrhage secondary to bronchial arterial erosion
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EtiologyEtiology
Acquired bronchiectasisAcquired bronchiectasis Recurrent pulmonary infectionRecurrent pulmonary infection
Bronchial obstructionBronchial obstruction
Congenital bronchiectasisCongenital bronchiectasis Kartagener’s syndromeKartagener’s syndrome
HypogammaglobulinemiaHypogammaglobulinemia
Cystic fibrosisCystic fibrosis
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Overview of the Cardiopulmonary Overview of the Cardiopulmonary Clinical Manifestations Associated Clinical Manifestations Associated
with BRONCHIECTASISwith BRONCHIECTASIS
The following clinical manifestations result from the The following clinical manifestations result from the pathophysiologic mechanisms caused (or activated) pathophysiologic mechanisms caused (or activated) by by AtelectasisAtelectasis (see Figure 9-12), (see Figure 9-12), Consolidation Consolidation (see Figure 9-8), (see Figure 9-8), Bronchospasm Bronchospasm (see Figure 9-10), (see Figure 9-10), and and Excessive BronchialExcessive Bronchial Secretions Secretions (see Figure (see Figure 9-11)—the major anatomic alterations of the lungs 9-11)—the major anatomic alterations of the lungs associated with bronchiectasis (see Figure 14-1).associated with bronchiectasis (see Figure 14-1).
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Figure 9-7. Atelectasis clinical scenario.Figure 9-7. Atelectasis clinical scenario.
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Figure 9-8. Alveolar consolidation clinical scenario.Figure 9-8. Alveolar consolidation clinical scenario.
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Figure 9-9. Increased alveolar-capillary membrane thickness clinical scenario.Figure 9-9. Increased alveolar-capillary membrane thickness clinical scenario.
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Figure 9-10. Bronchospasm clinical scenario (e.g., asthma).Figure 9-10. Bronchospasm clinical scenario (e.g., asthma).
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Figure 9-11. Excessive bronchial secretions clinical scenario.Figure 9-11. Excessive bronchial secretions clinical scenario.
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Clinical Data Obtained at the Clinical Data Obtained at the Patient’s BedsidePatient’s Bedside
Vital signsVital signs
Increased respiratory rateIncreased respiratory rate
Increased heart rate, cardiac output, Increased heart rate, cardiac output, blood pressureblood pressure
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Clinical Data Obtained at the Clinical Data Obtained at the Patient’s BedsidePatient’s Bedside
Use of accessory muscles of inspirationUse of accessory muscles of inspiration
Use of accessory muscles of expirationUse of accessory muscles of expiration
Pursed-lip breathingPursed-lip breathing
Increased anteroposterior chest diameter Increased anteroposterior chest diameter (barrel chest)(barrel chest)
CyanosisCyanosis
Digital clubbingDigital clubbing
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Figure 2-36. Figure 2-36. The way a patient may appear when using the The way a patient may appear when using the pectoralis major muscles for inspiration.pectoralis major muscles for inspiration.
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Figure 2-41. Figure 2-41. A, Schematic illustration of alveolar compression of weakened bronchiolar A, Schematic illustration of alveolar compression of weakened bronchiolar airways during normal expiration in patients with chronic obstructive pulmonary disease airways during normal expiration in patients with chronic obstructive pulmonary disease (e.g., emphysema). B, Effects of pursed-lip breathing. The weakened bronchiolar airways (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.are kept open by the effects of positive pressure created by pursed lips during expiration.
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Digital Clubbing
Figure 2-46. Digital clubbing.Figure 2-46. Digital clubbing.
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Clinical Data Obtained at the Clinical Data Obtained at the Patient’s BedsidePatient’s Bedside
Peripheral edema and venous distentionPeripheral edema and venous distention Distended neck veinsDistended neck veins
Pitting edemaPitting edema
Enlarged and tender liverEnlarged and tender liver
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DistendedDistendedNeck VeinsNeck Veins
Figure 2-48. Distended neck veins (Figure 2-48. Distended neck veins (arrowsarrows).).
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Figure 2-47. Pitting edema. From Bloom A, Ireland J: Figure 2-47. Pitting edema. From Bloom A, Ireland J: Color atlas of diabetesColor atlas of diabetes, ed 2,, ed 2,London, 1992, Mosby-Wolfe.London, 1992, Mosby-Wolfe.
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Cough, sputum production, and hemoptysisCough, sputum production, and hemoptysis A chronic cough with production of large quantities A chronic cough with production of large quantities
of foul-smelling sputum is a hallmark of of foul-smelling sputum is a hallmark of bronchiectasisbronchiectasis
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Clinical Data Obtained at the Clinical Data Obtained at the Patient’s BedsidePatient’s Bedside
Chest assessment findings (primarily obstructive)Chest assessment findings (primarily obstructive)
Decreased tactile and vocal fremitusDecreased tactile and vocal fremitus
Hyperresonant percussion noteHyperresonant percussion note
Diminished breath soundsDiminished breath sounds
Rhonchi and WheezingRhonchi and Wheezing
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Clinical Data Obtained at the Clinical Data Obtained at the Patient’s BedsidePatient’s Bedside
Chest assessment findings (primarily restrictive)Chest assessment findings (primarily restrictive)
Increased tactile and vocal fremitusIncreased tactile and vocal fremitus
Bronchial breath soundsBronchial breath sounds
CracklesCrackles
Whispered pectoriloquyWhispered pectoriloquy
Dull percussion noteDull percussion note
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Figure 2-12. Figure 2-12. Percussion becomes more hyperresonant with alveolar hyperinflation.Percussion becomes more hyperresonant with alveolar hyperinflation.
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Figure 2-17. Figure 2-17. As air trapping and alveolar hyperinflation develop in obstructive As air trapping and alveolar hyperinflation develop in obstructive lung diseases, breath sounds progressively diminish.lung diseases, breath sounds progressively diminish.
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Clinical Data Obtained from Clinical Data Obtained from Laboratory Tests and Special Laboratory Tests and Special
ProceduresProcedures
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Pulmonary Function Study: Pulmonary Function Study: Expiratory Maneuver FindingsExpiratory Maneuver Findings
Primarily ObstructivePrimarily Obstructive
FVC FEVFVC FEVTT FEF FEF25%-75%25%-75% FEF FEF200-1200200-1200
PEFRPEFR MVV FEFMVV FEF50% 50% FEVFEV1%1%
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Pulmonary Function Study: Pulmonary Function Study: Lung Volume and Capacity FindingsLung Volume and Capacity Findings
Primarily ObstructivePrimarily Obstructive
VVTT RV FRC TLC RV FRC TLC
N or N or N or N or
VCVC IC ERV RV/TLC ratio IC ERV RV/TLC ratio
N or N or
N or N or
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Pulmonary Function Study: Pulmonary Function Study: Expiratory Maneuver Findings Expiratory Maneuver Findings
Primarily RestrictivePrimarily Restrictive
FVC FEVFVC FEVTT FEF FEF25%-75%25%-75% FEF FEF200-1200200-1200
N or N or N or N or N N
PEFRPEFR MVV FEFMVV FEF50% 50% FEVFEV1%1%
N N or N N or N N N or N or
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Pulmonary Function Study: Pulmonary Function Study: Lung Volume and Capacity FindingsLung Volume and Capacity Findings
Primarily RestrictivePrimarily Restrictive
VVTT RV FRC TLC RV FRC TLC
N or N or
VCVC IC ERV RV/TLC ratio IC ERV RV/TLC ratio
N N
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Arterial Blood GasesArterial Blood Gases
Mild to Moderate BronchiectasisMild to Moderate Bronchiectasis
Acute alveolar hyperventilation with Acute alveolar hyperventilation with hypoxemiahypoxemia
pH PaCO2 HCO3- PaO2
(Slightly)
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Time and Progression of Disease Time and Progression of Disease
100100
5050
3030
8080
00
PaCO2
1010
2020
4040
Alveolar HyperventilationAlveolar Hyperventilation
6060
7070
9090 Point at which PaO2 declines enough to stimulate peripheral oxygen receptors
Point at which PaO2 declines enough to stimulate peripheral oxygen receptors
PaO2
Disease OnsetDisease OnsetP
aO2
or
PaC
O2
PaO
2 o
r P
aCO
2
Figure 4-2. PaO2 and PaC02 trends during acute alveolar hyperventilation.
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Arterial Blood GasesArterial Blood Gases
Severe BronchiectasisSevere Bronchiectasis
Chronic ventilatory failure with hypoxemiaChronic ventilatory failure with hypoxemia
pH PaCO2 HCO3- PaO2
Normal (Significantly)
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Time and Progression of DiseaseTime and Progression of Disease
100100
5050
3030
80
0
PaO2
1010
2020
4040
Alveolar HyperventilationAlveolar Hyperventilation
6060
7070
9090Point at which PaO2 declines enough to stimulate peripheral oxygen receptors
Point at which PaO2 declines enough to stimulate peripheral oxygen receptors
PaCO 2
Chronic Ventilatory Failure Chronic Ventilatory FailureDisease OnsetDisease Onset
Point at which disease becomes severe and patient begins to become fatigued
Point at which disease becomes severe and patient begins to become fatigued
Pa0
2 o
r P
aC0 2
Pa0
2 o
r P
aC0 2
Figure 4-7. PaO2 and PaCO2 trends during acute or chronic ventilatory failure.
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Acute Ventilatory Changes on Acute Ventilatory Changes on Chronic Ventilatory FailureChronic Ventilatory Failure
Acute alveolar hyperventilation on chronic Acute alveolar hyperventilation on chronic ventilatory failureventilatory failure
Acute ventilatory failure on chronic ventilatory Acute ventilatory failure on chronic ventilatory failure failure
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Oxygenation IndicesOxygenation Indices
QQSS/Q/QTT D DOO22 V VOO22 C(a-v) C(a-v)OO22
Normal NormalNormal Normal
OO22ER SvER SvOO2 2
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Hemodynamic Indices Hemodynamic Indices (Severe Chronic Bronchiectasis)(Severe Chronic Bronchiectasis)
CVP CVP RAPRAP PAPA PCWPPCWP
NormalNormal
COCO SVSV SVISVI CICI
NormalNormal NormalNormal NormalNormal Normal Normal
RVSWIRVSWI LVSWILVSWI PVRPVR SVRSVR
NormalNormal NormalNormal
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Abnormal Laboratory TestsAbnormal Laboratory Testsand Proceduresand Procedures
Hematology Hematology (Increased hematocrit and hemoglobin) (Increased hematocrit and hemoglobin)
Sputum examinationSputum examination Streptococcus pneumoniaeStreptococcus pneumoniae
Haemophilus influenzaeHaemophilus influenzae
Pseudomonas aeruginosaPseudomonas aeruginosa
Anaerobic organismsAnaerobic organisms
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Radiologic FindingsRadiologic Findings
Chest radiographChest radiograph Translucent (dark) lung fieldsTranslucent (dark) lung fields
Depressed or flattened diaphragmDepressed or flattened diaphragm
Long and narrow heartLong and narrow heart
Enlarged heartEnlarged heart
BronchogramBronchogram
CT scanCT scan
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Figure 14-2. Figure 14-2. Cylindrical bronchiectasis. Left posterior oblique projection of a left bronchogram Cylindrical bronchiectasis. Left posterior oblique projection of a left bronchogram showing cylindrical bronchiectasis affecting the whole of the lower lobe except for the superior 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 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: the lower lobe, a common finding in bronchiectasis. (From Armstrong P et al: Imaging of Imaging of diseases of the chest,diseases of the chest, ed 2, St. Louis, 1995, Mosby.) ed 2, St. Louis, 1995, Mosby.)
Copyright © 2006 by Mosby, Inc.Slide 39
Figure 14-3. Figure 14-3. Saccular bronchiectasis. Right lateral bronchogram showing Saccular bronchiectasis. Right lateral bronchogram showing saccular bronchiectasis affecting mainly the lower lobe and posterior saccular bronchiectasis affecting mainly the lower lobe and posterior
segment of the upper lobe. (From Armstrong P et al: segment of the upper lobe. (From Armstrong P et al: Imaging of diseases Imaging of diseases of the chest,of the chest, ed 2, St. Louis, 1995, Mosby.) ed 2, St. Louis, 1995, Mosby.)
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Figure 14-4. Figure 14-4. Varicose bronchiectasis. Left posterior oblique projection of left Varicose bronchiectasis. Left posterior oblique projection of left bronchogram in a patient with the ciliary dyskinesia syndrome. All basal bronchogram in a patient with the ciliary dyskinesia syndrome. All basal
bronchi are affected by varicose bronchiectasis. (From Armstrong P et al: bronchi are affected by varicose bronchiectasis. (From Armstrong P et al: Imaging of diseases of the chest,Imaging of diseases of the chest, ed 2, St. Louis, 1995, Mosby.) ed 2, St. Louis, 1995, Mosby.)
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Figure 14-5. Figure 14-5. Bronchiectasis. High-resolution thin-section (1.5-mm) computed tomographic Bronchiectasis. High-resolution thin-section (1.5-mm) computed tomographic (HRCT) scan showing numerous oval and rounded ring opacities in the left lower lobe. (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 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 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: bronchiectatic airways from cysts or bullae. (From Armstrong P, Wilson AG, Dee P:
Imaging of diseases of the chest,Imaging of diseases of the chest, St. Louis, 1990, Mosby.) St. Louis, 1990, Mosby.)
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General Management of General Management of BronchiectasisBronchiectasis
General treatment includes:General treatment includes:
Controlling pulmonary infectionsControlling pulmonary infections
Controlling airway secretionsControlling airway secretions
Preventing complicationsPreventing complications
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General Management of General Management of BronchiectasisBronchiectasis
Respiratory care treatment protocolsRespiratory care treatment protocols
Oxygen therapy protocolOxygen therapy protocol
Bronchopulmonary hygiene therapy protocolBronchopulmonary hygiene therapy protocol
Hyperinflation therapy protocolHyperinflation therapy protocol
Aerosolized medication protocolAerosolized medication protocol
Mechanical ventilation protocolMechanical ventilation protocol
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General Management of General Management of BronchiectasisBronchiectasis
Other medications commonly prescribedOther medications commonly prescribedby the physicianby the physician
XanthinesXanthines
ExpectorantsExpectorants
AntibioticsAntibiotics