Complications of copd- bronchiectasis

1. Bronchiectasis
Dr Murali Krishna MD
Senior resident
Dept of Pulmonary medicine.

2. Introduction
 Bronchion -- wind pipe / air ways
 Ektasis -- streching out
 Term coined by Laennec.
 Abnormal irreversible dilatation and destruction of
cartilage containg airways/bronchi. ( i.e medium
sized sub segmental bronchi from 4 -9 th generations
)

3. Mechanism Disease ex
Congenital defects Mounier-Kuhn syndrome
William-Campbell syndrome
Alpha 1 anti-trypsin def
Infection Tuberculosis,
Pnemonias
Pertussis
Abnormal mucociliary clearance Cystic fibrosis
Primary ciliary dyskinesia
Decreased systemic immunity Hypo-gammaglobulinemia
Lung and bone transplantation
Exaggerated immune response ABPA
Inflammatory bowel disease
Rheumatoid arthritis
Inhalational injury Smoke and gaseous toxins
Chronic GERD and aspiration
Infection secondary to bronchial
obstruction
Slow-growing tumour,
aspirated foreign body
Lymphadenopathy

4. Tracheo-Bronchomegaly (Mounier-kuhn
dis )
 Pathological thinning of the elastic and muscular
layers of the airway walls.
 Involves the entire trachea and bronchi of first to
fourth order
 Tracheal diameter exceeds 3 cm in both coronal
and sagittal planes.
 Intrathoracic trachea and main bronchi dilate during
inspiration and collapse on expiration.
 Associated with Ehlers-Danlos syndrome, Marfan
syndrome, generalized elastosis (cutis laxa).

6. Bronchomalacia (Williams–Campbell
syndrome)
 Defective / completely absent bronchial wall cartilage.
 Cartilage of the fourth-, fifth-, and sixth-generation
bronchi is defective
 Associated with congenital heart disease, poly-spleenia,
bronchial isomerism, and situs inversus.
 Dynamic CT imaging reveals ballooning on inspiration
and collapse on exhalation.
 Tracheo bronchomalacia- EDAC >50 %

7. Primariy ciliary dyskinesia
 Immotile cilia syndrome
 Absence of one or both rows of dynein arms
 Prevent normal mucocilary escalator and result in
impairment of the lungs defence systems.
 Kartagener syndrome or triad is present in half of the
PCD patients. This triad consists of situs inversus,
bronchiectasis, and sinusitis .

10. Pathogenesis :
 Atelectatic theory:
Atelectasis gives loss of lung volume ,increases intra
pulmonary negative pressure; it dilates bronchi
proximal to the obstruction.
 Pressure secretion theory:
Following plugging of bronchus with mucus,
secretions distal to the obstruction accumulate and
mechanically distended bronchi beyond the block.
 Traction theory : bronchial dilatation occurs
secondary to fibrosis of lung parenchyma.

11. Role of obstruction in Pathogenesis

12. Types :
 Tubular / cylendrical
 Varicose- beaded apperance
 Cystic / sacular – grape like clusters
- severe form

13. Tubular Cystic

14. Varicose

15. Clinical features :
 Symptoms :
Cough - productive( wet )
- dry - upper lobes –TB
Haemoptysis – mild/ mod/massive
Dyspnoea – late symptom/advanced stages
 Signs :
Coarse crackles -persistent early and
mid-inspiratory crackles
not altered with coughing
Clubbing : fingers and/or toes

16.  Signs of collapse/ fibrosis.
 Advanced cases : Cyanosis,
Signs of pulmonary hypertension
Right heart failure
PFT : Obstructive defect
Decreased DLCO

17. Complictions :
 Infective exacerbations
 Suppurative pneumonia and lung abscess
 Extensive lung fibrosis may progress to respiratory
failure and cor pulmonale.
 Haemoptysis- BAE
 Sinusitis - rx steroids ,FESS
 Amyloidosis- proteinuria, hepato spleenomegaly

18. Diagnosis :
 Radiological :
Chest X ray
Bronchogram
HRCT
 Other supportives :
Sputum/LRT aspirates for C/S
PFT
2D echo

19.  Chest X ray : unreliable
Dilated bronchi appear as
Ring shadows : seen on end-on view
Parallel lines : seen on side-on view
Solid tubular opacities :bronchi contain mucopus
gloved finger shadows (ABPA)
 PAH -prominent proximal pulmonary artery
cardiac enlargement
 Volume loss apperance

22. Bronchogram :
• A Liquid contrast medium is instilled into the
tracheobronchial tree and X ray is taken.
• Most commonly used is Propyl-iodone
• Out dated procedure now.

23. HRCT : gold standard
 Major signs :
1.Bronchial dilatation –
* horizontal bronchi- signet ring appearance
bronchus/artery ratio > 1.5
* vertical bronchi – tram lines
2. Presence of bronchi in the outer lung fields
 Minor signs :
1. Bronchial wall thickening.
2. Mucus impaction.
3. Crowding of bronchi.
4. Areas of low attenuation/mosaic pattern

25.  SPUTUM C/S :
usually yields H. influenzae
Strep. pneumoniae
Staph. aureus
Ps.aeruginosa & Klebsiella spp – chronic
and severe cases.
antibiotics directed against these microbes.

26. Treatment :
 Medical - to relieve and control the symptoms
 Surgical - to eliminate the disease itself.
 Physiotherapy – to aid in the drainage of secretions

27. Antimicrobial therapy
 Guided against sputum/LRT secretions culture &
sensitivity – best
 Empirical Rx –
* Pencillins + B-lactams
( Amoxycillin- clavulonic acid 625 mg tid )
* 3 rd gen Cephalosporins
( Ceftriaxone 1 gm , i.v, bid )
*Macrolides
( Azithromycin 500 mg p.o )

28.  Pseudomonas infections – chronic / severe cases,
- cystic fibrosis pt
* ceftazidim 1-2 gm i.v bid
* piperacillin +tazobzctam 4.5 gm i.v tid
 Nebulised antibiotics - CF patients
* colistin 1-2 m.u bid
* tobramycin
 Mucolytics - rhDNAase in CF.
Preventive/ supressive therapy :
 To prevent relapses and acute excerabations.
Azithromycin 500 mg p.o weekly three times.

29. Postural drainage therapy
 usual sputum clearance mechanisms are disrupted by
(i) swamping of the normal blanket of mucus via
excessive secretion
 (ii) the replacement of ciliated epithelium with
squamous cells so that the mucociliary escalator
cannot operate well
 PDT helps in gravity aided drainage of sump
 Basal bronchi- leaning forwards over the edge of a low
bed using the arms as a support against the floor.
 Middle or lingular bronchi-supine posture with the
foot of the bed elevated and the affected side lifted off
the bed by pillows.

30.  Other techniques like
 Huffing- traditional postural drainage with the forced
expiration technique.
reduce the bronchial collapse induced by coughing.
 High-frequency chest wall compression.
 Active Cycle of Breathing Technique( ACBT )
 Autogenic drainage ( AD )

31. Role of lung transplantation ? ? ?
Severe bronchiectasis in CF patients :
 FEV1 <30% of predicted, or rapidly declining lung
function if FEV1 >30% (females and patients <18 years
of age have a poorer prognosis) and/or any of the
following:
 Increasing oxygen requirements
 Hypercapnia
 Pulmonary hypertension
usually Double lung transplantation done.