bronchiectasis final
TRANSCRIPT
BRONCHIECTASIS
Dr. Aswini Kumar Mohapatra
Professor & HeadDept. of Pulmonary
Medicine
Definition : Characterized by chronic permanent
and abnormal dilatation of bronchi, which contain cartilage and bronchial glands. It occurs due to destruction of the elastic and muscular components of the bronchial wall
Chronic mucopurulent expectoration and recurrent acute pulmonary infections
Causes of Bronchiectasis :I. Congenital :
- Cystic fibrosis - Ciliary dysfunction syndromes
Primary ciliary dyskinesis Kartagener’s syndrome
(Immotile cilia syndrome) (Sinusitis and transposition of the viscera)
- Primary hypogammaglobulinemia
II. Acquired: A. Children - Pneumonia (complicating whooping cough
and measles) Primary TB Inhaled foreign body B. Adults - Suppurative pneumonia Pulmonary TB Allergic bronchopulmonary aspergillosis Bronchial tumours
Pathogenesis : Infection and obstruction-two
important key features Repeated pulmonary infections
coupled with defective host defenses with impaired clearing mechanism
Mechanical obstruction or obstruction due to muscus impaction impairs clearance leading to repeated infection
Vicious cycle of infection Obstruction infection goes on.
Microorganisms attract neutrophils to the sites of inflammation
Neutrophils Proteolytic enzymes
Neutrophil elastase
Epithelial damage Bronchial gland hyperplasia Connective tissue
damage
Bronchial distortion
Types:
1. Cylindrical or fusiform 2. Varicose 3. Cystic or saccular 4. Follicular
Symptoms: Cough: Chronic productive with purulent
expectoration Halitosis ± Pneumonia and pleurisy-Due to
inflammatory changes in the airways. Fever, malaise and increased cough and sputum volume. Chest pain and recurrent pleurisy in the same site
Haemoptysis Poor personal health Extensive disease+ purulent sputum
anorexia, weight loss, lassitude , low grade fever and failure thrive in children
Signs: May be unilateral or bilateral No secretions in the bronchiectatic airways
no abnormal physical signs Large amount of secretions in the airways
Coarse crackles Collapse with retained secretions blocking
proximal bronchus. Diminished breath sounds
Advanced Disease Dilatation of the bronchi bronchial breathing clubbing
Investigations:1. Bacteriological and mycological
examination of the sputum2. Radiological examinations -
A. Plain chest x-ray- ‘ring shadows’ or ‘honey coombing’ due
to cystic dilated bronchi ‘tramline shadows’ or ‘band shadows’
B.Bronchography : Most accurate diagnostic procedure for
evaluating Bronchiectasis, particularly when contemplating surgery.
Contrast used- Dianosil Main indication is to find out whether
apparently looking dilations show any evidence of Bronchiectasis, so that surgery can be or can not be undertaken
replaced by CT-scan
C. HRCT thorax :
Use of 1.0 to 1.5mm window every 1cm with acquisition times of one second
Most sensitive and specific test for diagnosing Bronchiectasis
3. Assessment of ciliary function:
Pellets of saccharin placed in the anterior chamber of the nose to reach the pharynx, when patient can taste it. This time greatly prolonged in patients with ciliary dysfunction
Structural abnormality of the Cilia
detected by election microscopy
Management : 1.Chest physiotherapy/broncho-pulmonary
hygiene -
Helps in the drainage of excessive bronchial secretions
Patient should adopt a position in which the lobe to be drained is uppermost
Deep breathing followed by forced expiratory man oeuvres helps in moving secretions in the dilated bronchi towards the trachea, from which they can be cleared by vigorous coughing
Percussion of the chest wall with cupped hands
Devices-o Positive expiratory pressure maskso flutter valve aid sputum clearance Duration - Optimum duration and frequency of
physiotherapy depend on the amount of sputum. 5-10 minutes/once or twice daily
Maintaining adequate systemic hydration
2. AntibioticsDepend on the organisms isolated from the
sputum.Most common bacteria:- H. influenzae P. aeruginosa S. aureus - Penicillin or ampicillin + aminoglycocide
covers H.influenzae and S,.aureus - For pseudomonas –antibiotic therapy more
challenging
I.V ceftazidime (1-2gm/8hrly) Or Oral Ciprofloxain 250-750mg / 12hrly
3. Surgery Role of surgery for Bronchiectasis has declined
but not disappeared
Indications -
a) Failure of medical therapy with repeatd exacerbations
b) Uncontrolled haemoptysisc) Obstructive lesions i.e. tumour surgery it contemplated , in whom the Bronchiectasis
is unilateral and confined to a single lobe or segment on CT
main stay of surgery resection of destroyed areas of lung which are acting as a reservoir of infection
Complications:
Local Systemic Local : recurrent pneumonia Lung abscess Empyema Haemoptysis Pulmonary artery hypertension with Cor-pulmonale Congestive cardiac failure and Respiratory failure
Systemic : Hypoproteinemia- generalised edema Amyloidosis-nephrotic syndrome due to secondary
amyloidosis