2. CASE STUDY
• 62 year old lady, retiree,
ex smoker
• History of completing
anti TB 3 years ago
• 2 EHRZ 4 HR
• Referred for hemoptysis
• On MDI berodual 2puff
PRN
3. INTRODUCTION
• Shares clinical features with COPD
• inflamed and easily collapsible airways, obstruction to
airflow, and frequent office visits and hospitalizations
• DIAGNOSIS - clinically on the basis of cough on most
days with copious sputum production, often one or
more exacerbations / year
• RADIOLOGICALLY- bronchial wall thickening and
airway dilatation on chest computed tomographic (CT)
scans
4. HOW BAD IS IT?
• 350,000 to 500,000 adults have bronchiectasis in the
United States
• Increases with age with a 8 to 10-fold difference in
prevalence after the age of 60
• Patients with bronchiectasis use extensive healthcare
resources (eg, frequent ambulatory visits, antibiotic
usage, chest computed tomography, hospitalization)
8. BRONCHIECTASIS: CLINICAL
Note: Bronchiectasis may happen 2’ COPD or may be a
separate process with very similar symptoms
Clinical:
• Cough (90 %)
• Daily copious/excessive sputum production (76%)
• Dyspnea (72%)
• Hemoptysis (56%)
• Recurrent pleurisy
9. • Physical findings – crackles (75 %) and wheezing (22
%) were common, clubbing occurring in only 2 percent
of patients
• COPD Assessment Test (CAT), may be useful in the
assessment of bronchiectasis patients
• Higher scores on the CAT correlate with clinical &
physiologic parameters
• Increasing fatigue was noted in 43 %
10. DIAGNOSTIC EVALUATION
• Radiographic confirmation of the diagnosis
• Identification of potentially treatable causes and
microbiologic pathogens
• Functional assessment
• By laboratory testing, radiographic imaging, and
pulmonary function testing
14. LABORATORY TESTS
• A complete blood count with differential
• Immunoglobulin quantitation to measure the levels of
the immunoglobulins IgG, IgM, and IgA (Humoral
immunodeficiency)
• Testing for cystic fibrosis: Sweat
chloride and/or mutation analysis of the cystic fibrosis
transmembrane regulator (CFTR) gene
• Sputum smear and culture for bacteria, mycobacteria,
and fungi
• Specific aspergillus IgE and IgG antibodies, total serum
IgE level (ABPA)
15. CHEST RADIOGRAPH
• abnormal in most patients with bronchiectasis
• linear atelectasis, dilated and thickened airways (tram
– track or parallel lines, ring shadows on cross
section)
20. CT SCAN
• HRCT- thin sections of 1 to 1.25 mm with high spatial
frequency and is the preferred imaging modality for
bronchiectasis.
• Detect lung disease in symptomatic patients with a
normal chest radiograph
• Accurate assessment of the pattern, distribution, and
to a lesser degree, assess the activity and potential
reversibility of diffuse lung disease.
21. HRCT FINDINGS
• Airway dilatation; "signet-ring" sign, which is a classic
feature of bronchiectasis
• Bronchial wall thickening observed in dilated airways
may be the best correlate and predictor of functional
decline
• Airways affected by bronchiectasis may contain
mucopurulent plugs accompanied by post-obstructive
air trapping
31. EXACERBATION: ETIOLOGY +RX
Colonization/infection:
• Hemophilus
• Pseudomonas
• Aspergillus (ABPA)
Very difficult to distinguish colonization from acute infection with
these bugs.
Effect of sputum bacteriology on the quality of life of patients with bronchiectasis. Wilson CB; Jones PW; O'Leary CJ; Hansell DM; Cole PJ;
Wilson R Eur Respir J 1997 Aug;10(8):1754-60.
32. TREATMENT
• High burden of bacterial pathogens and inflammation.
• Antibiotics reduces the bacterial load and airway and
systemic inflammatory mediators
• Deciding when a patient has an acute exacerbation
depends upon symptomatic changes rather than any
specific laboratory feature
33. • Acute bacterial infections -increased production of
sputum that is more viscous with darker color, and
may be accompanied by lethargy, shortness of breath,
pleuritic chest pain, or hemoptysis
• Sputum is obtained for Gram stain and culture prior to
antibiotic administration- (Haemophilus
influenzae, Moraxella catarrhalis, Staphylococcus
aureus, Pseudomonas aeruginosa)
• Viral infection may also be a contributor- coronavirus,
rhinovirus, and influenza
34. • Oral antibiotic treatment - clinically stable patients
• Initial selection of an oral antibiotic- based on
previous sputum bacteriology results, history of
success or failure of prior regimens
• sputum Pseudomonas aeruginosa is associated with
increased death, exacerbations, and hospital
admissions
• In known airway infection with Pseudomonas, initial
antibiotic selection depends on the sensitivity
• If none, T ciprofloxacin 750mg bd
• European Respiratory Society (ERS) guidelines 2017
suggest a 14-day course of antibiotics based on
consensus
35. INTRAVENOUS TREATMENT
• Hospitalized patients - increased respiratory
rate ≥25/minute, hypotension, temperature ≥38˚C,
hypoxemia (pulse oxygen saturation <92 percent), or
failure to improve after oral antibiotics
• Controversial whether single or dual (eg, beta-lactam
plus aminoglycoside) antibiotic therapy is preferable
for flares of bronchiectasis due to Pseudomonas
• Typically single anti-pseudomonal antibiotics (pip-
tazo/ ceftazidime)
36. • Duration: resistant organisms such as P. aeruginosa or
requiring intravenous antibiotics, a 14 day course is
preferred
• Occasionally, a longer course is needed if the patient
has resistant organisms or is improved but not yet
back to baseline.
