Bronchiectasis

BRONCHIECTASIS

الدكتور خلدون ذنون- كلية طب نينوى- المرحله الرابعه
Objectives The following should be known:
1. Bronchiectasis is a chronic obstructive respiratory disease with congenital and acquired causes, frequent chest infection, a lot of sputum.
2. Main feature is productive cough, chest crackles and clubbing.
3. Diagnosis: clinical picture, CXR, CT chest.
4. Management: postural drainage, antibiotics, bronchodilators and some benefits from surgery.
5. Childhood vaccination is essential, removal of foreign body and tumors.

Definition

Abnormal dilatation of the brochi.
Chronic suppurative airway infection.
Excessive sputum production.
Progressive scarring and lung damage.

Causes

Congenital 1. Cystic fibrosis
2. Ciliary dysfunction syndromes (primary ciliary dyskinesia,
Kartageners syndrome).
3. Primary hypogammaglobulinaemia

B- Acquired
Children
Pneumonia after whooping cough & measles.
primary T.B
Foreign body obstrucion
Adults
Suppurative pneumonia
Pulmonary T.B
Allergic bronchopulmonary aspergillosis complicating asthma.
Bronchial tumours


Pathology
Small cavities lined by granulation tissue, squamous epithelium or normal ciliated epithelium.
Inflammation of deeper layers of bronchial walls & hypertrophy of bronchial arteries.
Chronic inflammatioin & fibrosis of surrounding lung tissue.
Clinical features
Symptoms
Any area of the lung may be involved.
Chronic productive cough, copious purulent sputum, usually worse in the mornings. Halitosis is common.
Pneumonia & pleurisy: fever, chest pain, and increased sputum.
Haemoptysis: slight or massive, and can be the only symptom in dry brochiectasis.
Poor general health: anorexia, weight loss, fever, & failure to thrive in children.
Physical signs
No signs in mild disease.
Unilateral or bilateral signs.
Numerous coarse crepitations & clubbing of fingers.
Sign of collapse, major or minor bronchial obstruction with diminished vesicular breathing.
Scarring in advanced disease with overlying bronchial breathing.

Investigations

Sputum exam.( gram stain & culture). Culture may reveal pseudomonas, staphylococci, mycobacteria, aspergillus.
Chest x-ray: normal in mild disease, areas of pneumonic consolidation, if severe: cystic spaces, fibrosis & collapse.
High resolution CT for certain diagnosis, shows thickened dilated airways.
Assessments of ciliary function by saccharin test: normally put in anterior nares after not more than 20 minute sweet taste is felt in the mouth, if delayed then cilia are defective. Ciliary beat frequency (nasal biopsy) & ciliary ultrastructure study by electron microscope.


Management
1. Physiotherapy: aids Postural drainage of sputum.
Empty bronchi from secretions by adopting a position that the drained lobe is uppermost.
Deep breathing followed by forced expiratory maneuvers and vigorous coughing expel sputum.
Percussion of chest wall with cupped hands or mechanical devices like flutter valves.
Use of positive expiratory pressure mask.
Timing and frequency of physiotherapy is at least 5-10 minutes once or twice daily.

2. Antibiotics

Longer courses and larger doses of antibiotics are needed.
Amoxil, clarithromycin, amoxiclav, cephalosporins can be used for most cases.
Cystic fibrosis: do culture, staph.aureus, pseudomonas & Aspergillus fumigates are common.
Anti-pseudomonal gram negative: Give oral ciprofloxacin, or i.v B-lactam (piperacillin- tazobactam, ceftazidime).

4. Mild hemoptysis responds to usual therapy, but in severe hemoptysis

percutaneous embolisation of bronchial circulation is useful.

5. Surgery
Benefits small minority of patients.
Suitable for patients in whom the lesion is confined to single lobe or segment on CT.
Many with extensive disease or chronic lung disease surgery is not suitable or used as a last resort.
Prognosis
Progressive in cystic fibrosis & ciliary dysfunction which lead to respiratory failure & RV failure.
Others: relatively good if proper antibiotics and physiotherapy are used regularly.


Prevention
Childhood prophylaxis against measles, whooping cough & primary tuberculosis.
Treat bronchial obstruction early e.g foreign body & tumors.










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