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CHRONIC LOWERCHRONIC LOWER
RESPIRATORY TRACTRESPIRATORY TRACT
INFECTIONSINFECTIONS
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BRONCHIECTASISBRONCHIECTASIS
LUNG ABSCESSLUNG ABSCESS
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BronchiectasisBronchiectasis
DefinitionDefinition
Dilation of bronchi.Dilation of bronchi.
EpidemiologyEpidemiology
Incidence low(
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Bronchiectasis contd.Bronchiectasis contd.
PathogenesisPathogenesis
Exact process obscure. Most likelyExact process obscure. Most likely
multifactorial, with the different factorsmultifactorial, with the different factorstaking on different degrees of importance intaking on different degrees of importance in
each patient.each patient.
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Bronchiectasis contd.Bronchiectasis contd.
Mechanistic TheoriesMechanistic Theories
There are 4:There are 4:
i) Pressure of secretion theoryi) Pressure of secretion theory
ii) Atelectasis theoryii) Atelectasis theory
iii)Traction theoryiii)Traction theory
iv)Infection theoryiv)Infection theory
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Pressure of secretion theoryPressure of secretion theory
Thick secretions obstruct, then mechanicallyThick secretions obstruct, then mechanically
distend the airway and the dilation persistsdistend the airway and the dilation persistseven after clearance of the obstruction.even after clearance of the obstruction.
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Atelectasis theoryAtelectasis theory
Collapse of lung parenchyma leads toCollapse of lung parenchyma leads to
increasingly negative intrapleural pressureincreasingly negative intrapleural pressureand later dilation of the bronchus inand later dilation of the bronchus in
question.question.
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Traction theoryTraction theory
Fibrosis and scarring from parenchymalFibrosis and scarring from parenchymal
disease exert traction on the bronchial walls.disease exert traction on the bronchial walls.
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Infection theoryInfection theory
Infection and the inflammatory responseInfection and the inflammatory response
damage the supportive structures of thedamage the supportive structures of thebronchial wall and subsequentbronchial wall and subsequent
bronchiectasis.bronchiectasis.
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SummarySummary
Only the Infection Theory is supported by animal models ofOnly the Infection Theory is supported by animal models ofthis disease. Atelectasis and traction play minimal, if anythis disease. Atelectasis and traction play minimal, if anyroles, in the pathogenesis of bronchiectasis.roles, in the pathogenesis of bronchiectasis.
Bronchial obstruction and poor drainage i.e. retention ofBronchial obstruction and poor drainage i.e. retention ofsecretions (from such cases as foreign bodies) along withsecretions (from such cases as foreign bodies) along withinfection appear to be the major factors in most cases.infection appear to be the major factors in most cases.
Infection or obstruction occurring alone is unlikely to lead toInfection or obstruction occurring alone is unlikely to lead tothe more severe forms of bronchiectasis.the more severe forms of bronchiectasis.
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ClassificationClassification
a) Cylindrical bronchiectasis (Group I)a) Cylindrical bronchiectasis (Group I)
Dilation regular, with the airway continuing to have aDilation regular, with the airway continuing to have aregular outline.regular outline.
b) Varicose bronchiectasis (Group II)b) Varicose bronchiectasis (Group II)
Dilation irregular, with areas of dilation and constriction.Dilation irregular, with areas of dilation and constriction.
c) Saccular bronchiectasis (Group III)c) Saccular bronchiectasis (Group III)
Dilation marked, with destruction of structural componentsDilation marked, with destruction of structural componentsof the airway wall.of the airway wall.
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AETIOLOGYAETIOLOGY
a) Infectiona) Infection
The most common:The most common:
i)Tuberculosisi)Tuberculosisii)Histoplasmosisii)Histoplasmosis
iii)Pertussis, measles(complicated by pneumonia)iii)Pertussis, measles(complicated by pneumonia)
iv)Adenovirus (types 1,3,4,7, and 21) 20 to 64 per centiv)Adenovirus (types 1,3,4,7, and 21) 20 to 64 per centdevelop bronchiectasisdevelop bronchiectasis
v) Herpesvirusv) Herpesvirus
vi)vi)Aspergillus fumigatusAspergillus fumigatus
vii)vii) Mycoplasma pneumoniaeMycoplasma pneumoniae
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b) Congenital and genetic disordersb) Congenital and genetic disorders
i) Cystic fibrosisi) Cystic fibrosis
ii) Williams-Campbell syndromeii) Williams-Campbell syndrome iii) Tracheobronchomegalyiii) Tracheobronchomegaly
iv) Marfan syndromeiv) Marfan syndrome
v)Alpha-1-antiproteinase deficiency[v)Alpha-1-antiproteinase deficiency[-1--1-antitrypsin deficiency]antitrypsin deficiency]
vi) Congenital bronchiectasisvi) Congenital bronchiectasis
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c) Ciliary Abnormalitiesc) Ciliary Abnormalities
i) Congenital : Kartagener syndrome [triad ofi) Congenital : Kartagener syndrome [triad of
situs inversus,sinusitis & bronchiectasis].situs inversus,sinusitis & bronchiectasis].There is an underlying congenital abnormalThere is an underlying congenital abnormal
ciliary function.ciliary function.
ii)Acquired : occurs as a result of infection.ii)Acquired : occurs as a result of infection.
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d) Immunodeficiencyd) Immunodeficiency
e) Foreign body aspiratione) Foreign body aspiration
g) Right middle lobe syndromeg) Right middle lobe syndrome
h) Asthmah) Asthma
i) Others:
-heroin intoxication-heroin intoxication
-intralobar pulmonary sequestration-intralobar pulmonary sequestration-bronchogenic cyst-bronchogenic cyst
-chronic sinusitis-chronic sinusitis
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-recurrent aspiration e.g. tracheo--recurrent aspiration e.g. tracheo-
oesophageal fistula, cerebral palsyoesophageal fistula, cerebral palsy
-inhaltion of noxious gases-inhaltion of noxious gases -racial predilections-racial predilections
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PresentationPresentation
Age: mainly preschool and early school ageAge: mainly preschool and early school age
years.years. Symptoms: manifestations range fromSymptoms: manifestations range from
chronic cough with early morning sputumchronic cough with early morning sputum
production in an overtly healthy child toproduction in an overtly healthy child torecurrent pneumonia with or withoutrecurrent pneumonia with or without
haemoptysis in a chronically ill one.haemoptysis in a chronically ill one.
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Chronic cough worse in the morning.Chronic cough worse in the morning.
Purulent , foul smelling sputum. Halithosis.Purulent , foul smelling sputum. Halithosis.
HaemoptysisHaemoptysis
Others: weight loss, intermittent fever,Others: weight loss, intermittent fever,
wheezing, dyspnoea, chest pain.wheezing, dyspnoea, chest pain.
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Clinical signsClinical signs
Harrisons sulciHarrisons sulci
Finger clubbingFinger clubbingCyanosisCyanosis
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Dullness to percussion, crepitationsDullness to percussion, crepitations
(crackles), rhonchi, decreased air entry,(crackles), rhonchi, decreased air entry,
bronchial breath sounds- usually localizedbronchial breath sounds- usually localized
over the bronchiectatic area when saccularover the bronchiectatic area when saccular
changes are present except in diffusechanges are present except in diffuse
disease.disease.
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DiagnosisDiagnosis
CXray findings not diagnostic but can beCXray findings not diagnostic but can be
suggestivesuggestive In mild cases: segmental accentuation, lossIn mild cases: segmental accentuation, loss
of definition of lung markings.of definition of lung markings.
In severe cases: honeycomb pattern ofIn severe cases: honeycomb pattern ofcystic changes.cystic changes.
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BronchographyBronchography
Flexible fibreoptic bronchoscopyFlexible fibreoptic bronchoscopy
CT ScanCT Scan Magnetic resonance imagingMagnetic resonance imaging
Lung scintigraphyLung scintigraphy
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Differential diagnosesDifferential diagnoses
All underlying causesAll underlying causes
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Evaluation of patients withEvaluation of patients with
bronchiectasisbronchiectasis
Identify cause and predisposing factorsIdentify cause and predisposing factors
Infection:Infection: Sputum or BALF for M/C/SSputum or BALF for M/C/S
Mycobacterial/fungal culturesMycobacterial/fungal culturesViral cultureViral culture
Skin tests (PPD, fungal)Skin tests (PPD, fungal)
Serological studiesSerological studies
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ImmunodeficiencyImmunodeficiency
FBCFBC
Quantitative immunoglobulinsQuantitative immunoglobulins
IgG subclassesIgG subclasses
WBC function (nitroblue tetrazolium dyeWBC function (nitroblue tetrazolium dyetest, chemotactictest, chemotactic assays,assays,
etc.)etc.)
Total haemolytic complementTotal haemolytic complement
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AspirationAspiration
Barium swallowBarium swallow
Extended oesophageal pH monitoringExtended oesophageal pH monitoring
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Ciliary dysfunctionCiliary dysfunction
Nasal/tracheal epithelium: light and electronNasal/tracheal epithelium: light and electron
microscopymicroscopy
Cystic fibrosisCystic fibrosis
Sweat testSweat test
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ComplicationsComplications
Brain and lung abscessBrain and lung abscess
Empyema & pyopneumothoraxEmpyema & pyopneumothorax
Bronchopleural fistulaBronchopleural fistula
Severe atypical pneumoniaSevere atypical pneumonia
HaemoptysisHaemoptysis
AmyloidisisAmyloidisis
Cor pulmonale in advanced diseaseCor pulmonale in advanced disease
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TreatmentTreatment
MedicalMedical
Chest physiotherapyChest physiotherapy
AntibioticsAntibiotics BronchodilatorBronchodilator
Good nutritionGood nutrition
Bronchoscopy: to remove foreign body orBronchoscopy: to remove foreign body orthick secretionthick secretion
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Treatment (contd.)Treatment (contd.)
SurgicalSurgical
Failure of medical treatment, if disease isFailure of medical treatment, if disease is
localizedlocalized
PrognosisPrognosis
Depends on causative factorsDepends on causative factors