Bronchiectasis is an abnormal, permanent dilatation of the bronchi. It can be focal or diffuse. It was first discovered in 1819 by René Laennec, the inventor of the stethoscope. Common causes include infections, cystic fibrosis, and obstructive lung diseases. Symptoms include chronic cough with sputum, recurrent lung infections, and sometimes hemoptysis or dyspnea. Diagnosis involves patient history, physical exam, sputum analysis, imaging like CT scan, and pulmonary function tests. Treatment focuses on clearing secretions, treating infections, reducing inflammation, and addressing the underlying cause with antibiotics, airway clearance techniques, and sometimes surgery.
Bronchiectasis is an abnormal, permanent dilatation of the bronchi. It can be focal or diffuse. It was first discovered in 1819 by René Laennec, the inventor of the stethoscope. Common causes include infections, cystic fibrosis, and obstructive lung diseases. Symptoms include chronic cough with sputum, recurrent lung infections, and sometimes hemoptysis or dyspnea. Diagnosis involves patient history, physical exam, sputum analysis, imaging like CT scan, and pulmonary function tests. Treatment focuses on clearing secretions, treating infections, reducing inflammation, and addressing the underlying cause with antibiotics, airway clearance techniques, and sometimes surgery.
Bronchiectasis is an abnormal, permanent dilatation of the bronchi. It can be focal or diffuse. It was first discovered in 1819 by René Laennec, the inventor of the stethoscope. Common causes include infections, cystic fibrosis, and obstructive lung diseases. Symptoms include chronic cough with sputum, recurrent lung infections, and sometimes hemoptysis or dyspnea. Diagnosis involves patient history, physical exam, sputum analysis, imaging like CT scan, and pulmonary function tests. Treatment focuses on clearing secretions, treating infections, reducing inflammation, and addressing the underlying cause with antibiotics, airway clearance techniques, and sometimes surgery.
Bronchiectasis is an abnormal, permanent dilatation of the bronchi. It can be focal or diffuse. It was first discovered in 1819 by René Laennec, the inventor of the stethoscope. Common causes include infections, cystic fibrosis, and obstructive lung diseases. Symptoms include chronic cough with sputum, recurrent lung infections, and sometimes hemoptysis or dyspnea. Diagnosis involves patient history, physical exam, sputum analysis, imaging like CT scan, and pulmonary function tests. Treatment focuses on clearing secretions, treating infections, reducing inflammation, and addressing the underlying cause with antibiotics, airway clearance techniques, and sometimes surgery.
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SANA BASHIR DPT,MS-CPPT Definitio nDefined as - It is an abnormal dilatation of bronchi. It maybe either focal, involving the airways supplying a limited region of lung parenchyma or diffuse, airways including a more widespread distribution. HISTOR Y René Laennec, the man who invented the stethoscope, used his invention to first discover bronchiectasis in 1819.The disease was researched in greater detail by Sir William Osler in the late 1800s; it is suspected that Osler actually died of complications from undiagnosed bronchiectasis. Epidemiolog y of the socio-economic conditions of No systematic data are available but it is considered as the reflection the population under study. In 20th century the cases of bronchiectasis significantly reduced due to emergence of anti-biotics and vaccines. Race, sex and age related demography : -no racial prelidiction. -CF related bronchiectasis more common in white - In pre antibiotic era the disease used to start as early as in the first decade. But now the disease has found itself in the age group > 60yrs. Etiolog y 1.Focal: -obstruction. For eg: Aspirated foreign body, tumor mass. 2. Diffuse: - Cystic fibrosis, Necrotising and suppurative pneumonia (Staphylococcus Aureus and Klebsiella), Post tubercular sequale. 1. Childhood Pertussis, measles, Necrotizing pneumonia 2. Primary infections klebsiella species staphylococcal species Mycoplasma pneumoniae Mycobacterium tuberculosis Measles virus Influenza virus Herpes simplex virus Adenovirus Pertusis virus MAC infections (Mycobacterium avium complex (MAC) are bacteria that can cause a life-threatening bacterial infection. The disease is also called MAC and it affects people with HIV who have a severely suppressed immune system and are not taking anti- HIV drugs (ART) or medication to prevent MAC has increased propensity to occur in HIV infection as well as in immuno compromised individual) It is found mainly in women >60yrs who are non- smokers, who don’t have any predisposing pulmonary disorder and who tend to suppress cough. 3. Obstruction Foreign body 4. Tumor Laryngeal papillomatosis, adenoma, 5. Hilar adenopathy Tuberculosis 6. Mucoid impaction Allergic bronchopulmonary aspergillosis, Congenital anatomic defect Williams-Campbell syndrome (congenital cartilage deficiency), Mounier-Kuhn syndrome (tracheo-bronchomegaly), Swyer-James syndrome(unilateral hyperlucent lung), pulmonary sequestration, pulmonary artery aneurysm, yellow nail syndrome(Hypoplastic lymphatics, pleural effusion, yellow nails ) 8. Immunodeficiency state IgG subclass deficiency, X-linked, agammaglobulinemia, selective IgA, IgM, or IgE deficiency, bare lymphocyte syndrome, chronic granulomatous disease, Nezelof syndrome (Thymic dysplasia with normal immunoglobulins) 9. Hereditary abnormality Dyskinetic cilia syndrome, Kartagener’s syndrome (situs inversus, nasal polyposis and bronchiectasis) , cystic fibrosis etc Pathogenesi s and destruction of structural component of the Bronchieactasis is a consequence of inflammatory
bronchial tree mainly mid sized airways, segmental
and sub- segmental bronchi. Micro-organisms such as staphylococcus aureus , klebsiella, psuedomonas aeruginosa, haemophilus influenzae etc.
protease and other toxins
Up-regulation of neutrophils (Elastase and Matrix metallo-protinases)
Destruction of wall structures- cartilage,muscle,elastic
tissue and replaced by fibrous connective tissue
Dilatation of the bronchi leading to accumulation of
the thick pool of purulent material and occlusion due to fibrous thickening
Increased vascularity due to enlargement of
bronchial arteries and increased anastonosis between bronchial artery and pulmonary artery patholog y Clinical Symptoms Features 1.Persistent and recurrent cough with purulent and sputum production. 2.Repeated respiratory tract infection. 3.Haemoptysis 50-70% of cases. 4.Systemic symptoms like : fatigue, weight loss and myalgia 5.Pneumonia type- chronic cough and sputum production. 6.Few patients give an history of insidious (gradual) onset of symptoms. 7.Some remain asymptomatic. 8.Some give history of non-productive cough termed as ‘Dry-bronchiectasis’. 9.Dyspnea in around 72% cases. 10.Wheezing 11.Pleuretic chest pain In past the severity of the bronchiectasis was classified according the amount of sputum production. <10ml – Mild bronciectasis 10-150ml- Moderate Bronchiectasis >150ml – Sever Bronchiectasis. • At present it is classified accorrding to the radiological findings Sign 1. Many s a times combination of crackles(73%), wheeze and ronchi are heard. 2. Clubbing(2-3%) may be present. 3. In severe cases with hypoxemia it may be associated with cor-pulmonale and features of right ventricular failure. 4. Cyanosis. WORK- UP Patient history Childhood infections, exposure to pulmonary pathogens, aspiration of foreign bodies, pulmonary symptoms in siblings Physical examination Auscultation for focal wheezes examination of nares and upper respiratory tract for polyps or evidence of chronic sinusitis Laboratory tests Routine hematology is non specific but may show anaemia and increased white blood count. Sputum analysis when sputum is allowed to settle may reveal Dittrich plugs (masses of fat globules, fatty acid crystals, and bacteria sometimes seen in the bronchi in bronchitis and bronchiectasis), small, white or yellow concretions. Gram’s stain may reveal Pseudomonas and E-coli suggestive of CF but not diagnostic. Presence of non-mucoid sputum is suggestive of pseudomonas aeruginosa, while presence of eosinophilia and golden plugs containing hyphae is suggestive of aspergillous species. Routine bacterial, fungal, and mycobacterial cultures may reveal other organisms.
Pilocarpine ionophoresis (Sweat test)
for the evaluation of CF Aspergillus Precipitin test (Aspergillosis precipitin is a laboratory test to detect antibodies in the blood resulting from exposure to the fungus aspergillus) Diagnostic criteria 1000 ml or a greater than 2 folds increase from the base-line Auto-immune screening test For RA and other auto-immune diseases. Computerized tomography the HRCT is has almost completely replaced bronchography. The sensitivity and specificity are 84- 89% and 82-99% respectively. additional advantages include non invasiveness, avoidance of possible allergen to contrast media and information regarding other pulmonary processes. Reid’s classification : depending on the findings of the CT scan it is classified as : Certain descriptive terms have been used in reporting of bronchiectasis. These only describe the appearance of the involved airways but do not elude to a specific cause. These terms include: • Cylindrical (tram track sign): This description applies to dilated airways seen in a horizontal orientation. • Signet-ring: This describes airways viewed in a transverse plane. The dilated airway lies adjacent to a pulmonary artery branch giving the appearance of a ring • Varicose: Implies non uniform bronchial dilatation. • Cystic or saccular: A cluster of thin walled cystic spaces Cystic and cylindrical bronchiectasis of the right lower lobe on a posterior-anterior chest radiograph Computed tomography scan depicting early bilateral honeycomb changes of the lower lobes of the lung. Radiography A.and lateral chest radiographs should be taken. Expected findings : 1. Increased pulmonary markings 2. Honey combing 3. Atelectasis 4. Plueral changes Specific findings – Tram –tracking, dilated bronchi, clustered cysts. Pulmonary function tests : Patients with bronchiectasis show yearly rapid deterioration in FEV-1 than a patient without bronchiectasis. Electron microscopy examination to observe the evidence of primary ciliary structural abnormalities and dyskinesia. Bronchography Its being significantly replaced by CT. It is performed by instilling contrast via a catheter or bronchoscope and performing plane radiographic imaging. In current practice, its only of potential value in conforming the location of focal bronchiectasis It carries a high risk of acute broncho- constriction. Bronchoscopy Not helpful in diagnosing bronchiectasis but useful in identifying abnormalities such as tumors, foreign bodies or other lesions. It may also used along with lavage for collection of specimens for culture and staining. Treatmen t Supportive Treatment Cessation of smoking Avoidance of second-hand smoking Adequate nutritional intake Immunizations for influenza and pneumococcal pneumonia Conformation of immunizations for measles, rubella and pertusis Oxygen therapy is reserved for patients with hypoxemia and end stage complications such as cor- pulmonale 1. Treatment of infection 2. Clearance of the secretion 3. Reduction of the inflammation 4. Treatment of the underlying problem Antibiotics- Initially during the acute phase amoxicillin, or levofloxacin should be started and later proper antibiotic should be chosen accordingly to the Sputum culture and Gram’s stain. There is no firm guidelines for therapy and hence should be continued for 10-14 days. Aerosolized antibiotics It delivers relatively high concentration of drugs with relatively lesser systemic side-effects. It is beneficial in treating Pseudomonas infection. Currently, inhaled Tobramycin is most widely used. Gentamycin is also been used Bronchial hygiene Proper mechanical and devices with proper positioning of the patient can help the patients with copious secretions. Postural drainage with percussion and vibration helps in effective clearance. Devices like Flutter device and incentive spirometry are available. Newest device is the ‘Vest’ system wherein a pneumatic compression vest is worn by the patient periodically throughout the day. Vest therapy is a safe, effective, non-invasive airway clearance method that clears excess mucus from lungs and airways. This uses a vest attached to a machine that creates compressions to the chest, helping to loosen, thin and move mucus through the lungs. Tapping of the chest wall to dislodge the secretions Positional drainage and physiotherapy Use of oscillator Use of Flutter Use of a vest Use of mucolytics can help thinning out the thick mucous secretions. Bronchodilators help in the obstruction and clearance e of the bronchus. Use of nebulizations concentrated with 7% NaCl have shown beneficial in CF-related Bronchiectasis. Anti-inflammatory therapy Reduce the inflammation caused by the organisms and subsequently reduce the tissue damage. Inhaled corticosteroids, and NSAID can be given. Studies have shown use of inhaled corticosteroids have shown qualitative improvement in the quality of life. Azithromycin has known anti-inflammatory properties and its long term use has shown ,marked improvement in CF and non-CF bronchiectasis. Surgical resection Helpful in advanced or complicated disease. Indications : 1.Patients who have focal disease that is poorly controlled by anti-biotics. 2.Reduction of acute infective episodes 3.Massive haemoptysis(Alternatively bronchial artery embolization may be attempted) 4. Foreign body or tumor removal 5.Consideration in the treatment of MAC or Aspergillus specific infections Complications : empyema, haemmorrhage, prolonged air leak and persistent atelectasis. Mortality is <1 %. Lung transplantation Single or double lung transplantation for severe bronchiectasis, predominantly related to CF. FEV1 < 30 and in younger patients it may be considered.
