BRONCHIECTASIS

Dr. Aswini Kumar Mohapatra

Professor & HeadDept. of Pulmonary

Medicine

Definition : Characterized by chronic permanent

and abnormal dilatation of bronchi, which contain cartilage and bronchial glands. It occurs due to destruction of the elastic and muscular components of the bronchial wall

Chronic mucopurulent expectoration and recurrent acute pulmonary infections

Causes of Bronchiectasis :I. Congenital :

- Cystic fibrosis - Ciliary dysfunction syndromes

Primary ciliary dyskinesis Kartagener’s syndrome

(Immotile cilia syndrome) (Sinusitis and transposition of the viscera)

- Primary hypogammaglobulinemia

II. Acquired: A. Children - Pneumonia (complicating whooping cough

and measles) Primary TB Inhaled foreign body B. Adults - Suppurative pneumonia Pulmonary TB Allergic bronchopulmonary aspergillosis Bronchial tumours

Pathogenesis : Infection and obstruction-two

important key features Repeated pulmonary infections

coupled with defective host defenses with impaired clearing mechanism

Mechanical obstruction or obstruction due to muscus impaction impairs clearance leading to repeated infection

Vicious cycle of infection Obstruction infection goes on.

Microorganisms attract neutrophils to the sites of inflammation

Neutrophils Proteolytic enzymes

Neutrophil elastase

Epithelial damage Bronchial gland hyperplasia Connective tissue

damage

Bronchial distortion

Types:

1. Cylindrical or fusiform 2. Varicose 3. Cystic or saccular 4. Follicular

Symptoms: Cough: Chronic productive with purulent

expectoration Halitosis ± Pneumonia and pleurisy-Due to

inflammatory changes in the airways. Fever, malaise and increased cough and sputum volume. Chest pain and recurrent pleurisy in the same site

Haemoptysis Poor personal health Extensive disease+ purulent sputum

anorexia, weight loss, lassitude , low grade fever and failure thrive in children

Signs: May be unilateral or bilateral No secretions in the bronchiectatic airways

no abnormal physical signs Large amount of secretions in the airways

Coarse crackles Collapse with retained secretions blocking

proximal bronchus. Diminished breath sounds

Advanced Disease Dilatation of the bronchi bronchial breathing clubbing

Investigations:1. Bacteriological and mycological

examination of the sputum2. Radiological examinations -

A. Plain chest x-ray- ‘ring shadows’ or ‘honey coombing’ due

to cystic dilated bronchi ‘tramline shadows’ or ‘band shadows’

B.Bronchography : Most accurate diagnostic procedure for

evaluating Bronchiectasis, particularly when contemplating surgery.

Contrast used- Dianosil Main indication is to find out whether

apparently looking dilations show any evidence of Bronchiectasis, so that surgery can be or can not be undertaken

replaced by CT-scan

C. HRCT thorax :

Use of 1.0 to 1.5mm window every 1cm with acquisition times of one second

Most sensitive and specific test for diagnosing Bronchiectasis

3. Assessment of ciliary function:

Pellets of saccharin placed in the anterior chamber of the nose to reach the pharynx, when patient can taste it. This time greatly prolonged in patients with ciliary dysfunction

Structural abnormality of the Cilia

detected by election microscopy

Management : 1.Chest physiotherapy/broncho-pulmonary

hygiene -

Helps in the drainage of excessive bronchial secretions

Patient should adopt a position in which the lobe to be drained is uppermost

Deep breathing followed by forced expiratory man oeuvres helps in moving secretions in the dilated bronchi towards the trachea, from which they can be cleared by vigorous coughing

Percussion of the chest wall with cupped hands

Devices-o Positive expiratory pressure maskso flutter valve aid sputum clearance Duration - Optimum duration and frequency of

physiotherapy depend on the amount of sputum. 5-10 minutes/once or twice daily

Maintaining adequate systemic hydration

2. AntibioticsDepend on the organisms isolated from the

sputum.Most common bacteria:- H. influenzae P. aeruginosa S. aureus - Penicillin or ampicillin + aminoglycocide

covers H.influenzae and S,.aureus - For pseudomonas –antibiotic therapy more

challenging

I.V ceftazidime (1-2gm/8hrly) Or Oral Ciprofloxain 250-750mg / 12hrly

3. Surgery Role of surgery for Bronchiectasis has declined

but not disappeared

Indications -

a) Failure of medical therapy with repeatd exacerbations

b) Uncontrolled haemoptysisc) Obstructive lesions i.e. tumour surgery it contemplated , in whom the Bronchiectasis

is unilateral and confined to a single lobe or segment on CT

main stay of surgery resection of destroyed areas of lung which are acting as a reservoir of infection

Complications:

Local Systemic Local : recurrent pneumonia Lung abscess Empyema Haemoptysis Pulmonary artery hypertension with Cor-pulmonale Congestive cardiac failure and Respiratory failure

Systemic : Hypoproteinemia- generalised edema Amyloidosis-nephrotic syndrome due to secondary

amyloidosis