Bronchiectasis

Bronchiectasis

Pathophysiology

• Chronic irreversible dilatation of bronchial tree
○ Chronic/recurrent infection leads to permanent dilatation. This causes poor mucous clearance which again causes infection
○ Cycle leading to deterioration
○ Nb no effect on parenchyma and is a disease of the airways

• Certain organisms cause the infections
○ Pneumococcus
○ S Aureus
○ H influenzae
○ Pseudomonas

Aetiology

• All 3 factors in the cycle have different causes
○ Post-infectious – Can be a complication of certain infections
§ Measles
§ Pertussis
§ Bronchiolitis
§ Pneumonia
§ TB

○ Congenital
§ Cystic Fibrosis
§ Ciliary dysfunction syndromes – Kartagener’s or Primary Ciliary Dyskinesia
§ Young’s Syndrome

○ Bronchial obstruction
§ Malignancy – e.g. bronchogenic carcinoma
§ Chronic aspiration
§ Long-standing foreign body

○ Immunodeficiency
§ Hypogammaglobinaemia conditions – e.g. CVID, X-linked agammaglobulinaemia

○ Iatrogenic – Bronchial aspiration and mechanical obstruction

Clinical features:

• Symptoms
○ Chronic cough with copious purulent sputum production
§ Worse in mornings
§ Worse with changes in posture
○ Recurrent intermittent haemoptysis
§ May be massive with a haemorrhage

○ Halitosis

○ Recurrent infections
§ Pseudomonas is a key pathogen but others also occur
§ Sepsis and other signs of infection

• Signs
○ Resp
§ Coarse crackles which are removed by coughing
§ Wheeze
§ Purulent sputum
§ Clubbing
○ Systemic
§ Weight loss

Complications

• Pneumonia
• Pleural effusion
• Pneumothorax
• Pulmonary HTN
• Haemorrhage => Massive haemoptysis
• Cerebral abscess
• Amyloidosis

Investigations

• Generally similar to infections
○ BOBIS

• Orifices
○ Sputum MC&S – Can identify the pathogen
○ Throat swab

• Bloods
○ Routine + CRP
○ Check serum Igs

○ Blood cultures

○ ABG – T1RF as with other infections

• Imaging
a. CXR
§ Tramlines and rings
§ May have consolidation

b. High-Res CT can be used to further investigate the extent and distribution of disease
§ Show bronchial wall thickening -> signet ring sign

• Special
a. Spirometry
§ Shows an obstructive pattern
§ Checking for reversibility can be useful to determine potential treatments

b. Bronchoscopy
§ Identify the area of haemoptysis
§ Biopsy can also be taken => analysis for CF etc

Management

• All patients need education
○ Annual follow-up is required

ABC

• ABC approach – treat the symptoms
○ Similar to acute COPD exacerbation

1. Oxygen and NIV may be required

2. Nebulised Bronchodilators
○ Nebulised salbutamol is used

Acute treatment

1. Nebulised Corticosteroids are needed to reduce inflammation

2. Antibiotics – target the bacteria according to sensitivities
○ Can be given oral, inhaled, nebulised, or IV

Long-term

1. Mucous drainage
○ Chest Physiotherapy
§ Expectoration techniques
§ Postural drainage – done twice daily

○ Mucolytic agents
§ Carbocysteine

2. Preventative long-term antibiotics
○ are given if >3 exacerbations in one year
○ Can also be given oral, inhaled, nebulised, or IV

3. Treat underlying cause
a. E.g. DNAase for CF
b. E.g. IVIg for immunodeficiency

4. Surgery is rarely used – in severe but localised disease or to control haemoptysis