<ul><li>VI. DIAGNOSIS OF BRONCHIECTASIS </li></ul><ul><li>VII. BACTERIOLOGY </li></ul><ul><li>VIII. TREATMENT </li></ul>l PREVALENCE II. PATHOPHYSIOLOGY III. CLINICAL FEATURES IV. CLASSIFICATION USING RADIOLOGY V. PREDISPOSING OR ASSOCIATED FACTORS
Bronchiectasis (broncos, airways; ectasia, dilatation) is amorphological term used to describe abnormal irreversibly dilated and often thick-walled bronchi. Deﬁnition : Bronchiectasis represents the end stage of a variety of pathologic processes that cause destruction of the bronchial wall and its surrounding supporting tissues. The clinical manifestations include chronic cough and copious mucopurulent expectoration, often lasting months to years
PREVALENCE: Bronchiectasis was a common disabling and fatal condition in the pre-antibiotic era. It remains an important cause of suppurative lung disease in the developing world . the prevalence has recently been estimated to be 52 per 100,000.
PATHOPHYSIOLOGY The abnormal bronchial dilatation in bronchiectasis affects the medium-sized bronchi, but often extends to the more distal bronchi and bronchioles. : gross examination The affected bronchi and bronchioles are so prominent as to be visible all the way to the pleural surface. These dilated and ectatic bronchi are commonly ﬁlled with purulent secretions
<ul><li>The affected bronchi show transmural inﬂammation,mucosal edema,cratering,ulceration,and neovascularization The bronchial epithelium may show a polypoidal appearance </li></ul><ul><li>due to underlying granuloma formation and mucosal prominence, ridging due to bronchial smooth muscle hypertrophy, and pitting due to the dilated bronchial mucous glands </li></ul>
Microscopically, bronchiectasis is associated with loss of cilia, cuboidal and squamous metaplasia hypertrophy of bronchial glands, and lymphoid hyperplasia. Intense inﬁltration of the bronchial wall with neutrophils, lymphocytes and monocytes is seen.
chronic bacterial endobronchial infection and inﬂammation damage or destroy mucociliary defenses, leading to secretion stasis, which in turn propagates furthers bacterial infection, and increases airway inﬂammation and bronchial dilatation Bacterial colonization and/or infection of the airways alone is not sufﬁcient to produce true bronchiectasis. It seems likely that focal disturbances resulting in airway obstruction or impairment of drainage and/or systemic conditions, resulting in uncoordinated air - way clearance or impaired immune response are required
<ul><li>NB </li></ul><ul><li>Pseudomonas aeruginosa in the respiratory tract </li></ul><ul><li>of bronchiectasis patients on a chronic or recurring basis has </li></ul><ul><li>been associated with worsening ciliary function and deleterious effects on host defenses, </li></ul><ul><li>due to the ability of this organism to release virulent exotoxins, form surrounding bioﬁlms on tissue surfaces, and easily develop hypermutable P. aeruginosa strains resistant to antibiotics, all factors perpetuating and propagating bronchial </li></ul><ul><li>damage </li></ul>
HEMOPTYSIS MAY BE SEEN IN 40 TO 70 PERCENT OF PATIENTS AND MAY VARY FROM BLOOD STREAKS TO LARGE CLOTS. INCREASING COUGH, DYSPNEA, AND VOLUME OF SPUTUM PRODUCTION, FEVER, HEMOPTYSIS, AND CHEST PAIN ARE HALLMARKS OF ACUTEEXACERBATION <ul><li>“ Dry bronchiectasis” presenting as cough, minimal sputum expectoration, and/or hemoptys is </li></ul>CLINICAL FEATURES cough and mucopurulent sputum production. Cough is invariably present and often may be the only symptom for years Purulent, tenacious sputum production, frequently worse in the morning
<ul><li>In severe advanced cases, there may be evidence of - respiratory insufﬁciency and corpulmonale </li></ul>: On physical examination Chest auscultation usually reveals ﬁndings of early and mid-inspiratory crackles as well as diffuse rhonchi and prolonged expiration . Bronchial breath sounds may be heard in severe cases or patients with a complicating pneumonia. Digital clubbing and hypertrophic pulmonary osteoarthropathy
CLASSIFICATION USING RADIOLOGY: : 1 cylindrical bronchiectasis the bronchi are regularly outlined (tubular), dilated in diameter 2 Saccular or cystic bronchiectasis : Very dilated airways clustered into saccules, cysts, or grapelike clusters walls, oftencoming to a straight abrupt end, instead of a taper ing end, due to obstruction of the peripheral bronchial tree by secretions, casts, and inﬂammatory wall edema : 3 Varicose bronchiectasis (illusion to varicose veins) is marked by the presence of irregular dilatations, and tortuosity of the airways
Cylindrical bronchiectasis with signet-ring appearance. Note that the luminal airway diameter is greater than the diameter of the adjacent vessel
Cystic and cylindrical bronchiectasis of the right lower lobe on a posterior-anterior chest radiograph .
Varicose bronchiectasis with alternating areas of bronchial dilatation and constriction.
This CT scan depicts areas of both cystic bronchiectasis and varicose bronchiectasis.
PREDISPOSING OR ASSOCIATED FACTORS: Previously bronchial damage secondary to childhood respiratory tract infections such as pneumonia, pertussis, complicated measles, and tuberculosis were implicated as common causes of bronchiectasis. Typical offending organisms that have been known to cause bronchiectasis include Klebsiella species, Staphylococcus aureus, Mycobacterium tuberculosis, Mycoplasma pneumoniae, nontuberculous mycobacteria, measles virus, pertussis virus, influenza virus, herpes simplex virus, and certain types of adenovirus. Once a patient develops bronchiectasis , many of these same organisms colonize the damaged bronchi and may result in ongoing damage and episodic infectious exacerbations. The organisms found most typically include Haemophilus species and Pseudomonas species
: Bronchial obstruction <ul><ul><li>endobronchial tumors, broncholithiasis, bronchial stenosis from infections, encroachment of hilar lymph nodes, foreign body aspiration). Right-middle lobe syndrome </li></ul></ul><ul><li>Allergic bronchopulmonary aspergillosis </li></ul><ul><ul><li>Allergic bronchopulmonary aspergillosis (ABPA) is a hypersensitivity reaction to inhaled Aspergillus antigen that is characterized by bronchospasm, bronchiectasis, and immunologic evidence of a reaction to Aspergillus species. </li></ul></ul><ul><ul><ul><ul><ul><li>Other features of ABPA include eosinophilia, elevated immunoglobulin E (IgE) levels, and dramatic responses to corticosteroids. </li></ul></ul></ul></ul></ul>
<ul><li>Autoimmune diseases and idiopathic inflammatory disorders </li></ul><ul><li>Rheumatoid arthritis is associated with bronchiectasis </li></ul><ul><ul><li>Sjögren syndrome , bronchiectasis has been noted in these patients and may be secondary to increased viscosity of mucus with poor airway clearance </li></ul></ul><ul><ul><li>Ankylosing spondylitis </li></ul></ul><ul><ul><li>Systematic lupus erythematosus </li></ul></ul><ul><ul><li>In relapsing polychondritis , bronchiectasis appears to be secondary to primary bronchial damage with resultant recurrent infection </li></ul></ul><ul><ul><li>With inflammatory bowel disease , bronchiectasis has been seen in both ulcerative colitis and Crohn disease . </li></ul></ul><ul><li> • Sarcoidosis : </li></ul>cause bronchiectasis by a variety of mechanisms, including parenchymal scarring, endobronchial granulomatous inflammation,or extrinsic compression of bronchi
Traction bronchiectasis : Traction bronchiectasis is distortion of the airways secondary to mechanical traction on the bronchi from fibrosis of the surrounding lung parenchyma. Toxic gas exposure: Exposure to toxic gas may often cause irreversible damage to the bronchial airways and cystic bronchiectasis. Commonly suspected agents include chlorine gas and ammonia.
DIAGNOSIS OF BRONCHIECTASIS <ul><li>sputumcultures for bacteria,mycobacteria, and fungi </li></ul><ul><li>tests or precipitins to Aspergillus spp . </li></ul><ul><li>Chest Radiograph </li></ul><ul><li>The chest x-ray may be abnormal and show the presence of increased pulmonary markings, ring like structures, atelectasis , </li></ul><ul><li>dilated and thickened airways (tram lines), and mucus plugging (ﬁnger-in-glove) appearance; </li></ul><ul><li>however, the chest radiograph may be normal even in the presence of bronchiectasis </li></ul>history , clinical features, radiologic demonstration of bronchiectatic airways.
High - Resolution Computed Tomography localize and describe areas of parenchymal abnormality, and identify bronchiolar abnormalities and mucus plugging to the level of ﬁfth- and sixth-order bronchi. It also can identify focal areas of air trapping as an indicator of small airway disease. It is indicated in the evaluation of bronchiectasis when surgical resection is contemplated, bronchiectasis is strongly suspected clinically and routine chest radiographs are normal
Airway dilatation can be detected by ﬁnding tramlines or end-on-ring appearance. A luminal diameter more than times the adjacent vessel is indicative of bronchiectasis Bronchial wall thickeningmay also be seen. small airway plugging with debris (tree-in-bud) may also be seen
BACTERIOLOGY The most frequent microorganisms are H. inﬂuenzae and P. aeruginosa and are often implicated as the cause of periodic exacerbations Colonization with P. aeruginosa, in particular, has been associated with more severe impairment of lung func- tion, more intense inﬂammatory response, and more extensive lung disease. Other pathogens that may require speciﬁc treatment include Nocardia asteroides, Aspergillus fumigatus, and environmental Mycobacterium spp.
TREATMENT: The treatment of bronchiectasis is aimed at controlling infection, reducing inﬂammation, and improving bronchial hygiene, with surgical resection of affected areas being useful in selected patients. Control of Infection Antibiotics are indicated to treat an acute exacer- bation. However, they have been used variably to prevent recurrent infections by suppression and/or elimination of attendant ﬂora. Antibiotics are directed at commonly isolated pathogens such as H. inﬂuenzae, S. pneumoniae, and P. aeruginosa. Oral ﬂuoroquinolones are often used as ini- tial antibiotic choices for treatment durations of 10 to 14 days.
In the face of failure to respond to treatment or the occurrence of frequent exacerbations over short periods of time sputum cultures and sensitivity tests should be done to help deﬁne antibiotic selection e.g., atypical mycobacteria or fungae. Severe exacerbations due to P. aeruginosa require the intravenous administration of two antipseudomonal antibiotics and potential hospitalization.
Bronchial Hygiene Airway mucus clearance is a problem in bronchiectasis. Chest percussion and postural drainage have been the traditional method of facilitating mucus clearance. Alternative therapies . Autogenic drainage, mechanical vibration with ultrasonic devices, positive expiratory pressure, and Flutter valve use without the assistance of another caregiver have been shown to achieve good chest clearance
Mucus Clearance Mucus hypersecretion is a prominent feature of chronic inﬂammatory airways disease .Maintenance of hydration with oral and/or intravenous ﬂuids is considered useful in preventing inspissated sputum retention Humidiﬁcation of inhaled air or oxygen as an adjunct to chest physical therapy has been shown to signiﬁcantly in- crease the wet weight of sputum produced. The use of nebulized normal or hypertonic saline and acetylcysteine may be considered as important adjuncts to chest physical therapy,
Bronchodilators As these patients show signs of airway obstruction and hyperreactivity Bronchodilators are frequently used Anti - inflammatoryTherapy Persistent endobronchial inﬂammation isknown to play asigniﬁcant role in the pathogenesis of bronchiectasis, and anti - inﬂammatory therapy may be beneﬁcial
Surgery: surgical resection of the most severely affected segments, bleeding segments, or areas harboring resistant tuberculosis or atypical mycobacteria may confer signiﬁcant beneﬁts in terms of symptom control, reduction of tenacious sputum production, elimination of large-volume bronchial bleeding, reduction of acute infective episodes, and improved quality of life. Lung transplantation is now considered a viable option in advanced cases, vaccinations against S. pneumoniae and inﬂuenza Smoking cessation should be emphasized as amatter of routine. If evidence of exercise and/or nocturnal desaturation should be considered for oxygen supplementation to delay the onset of pulmonary hypertension and cor pulmonale and improve exercise tolerance. Miscellaneous