treatment of bronchiectactasis by dr bashir ahmed dar associate professor medicine sopore kashmir

8/9/2019 Treatment of Bronchiectactasis by Dr Bashir Ahmed Dar Associate Professor Medicine Sopore Kashmir

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BRONCHIECTASISBY

DR.BASHIR AHMED DAR

ASSOCIATE PROFESSOR MEDICINE

CHINKIPORA SOPORE KASHMIR

EMAIL- [email protected]


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BRONCHIECTASIS Bronchiectasis is

defined as the

irreversible dilatationof the cartilage-containing airwaysbronchi or

bronchioles.


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BRONCHIECTASIS Bronchiectasis is

defined as the

irreversible dilatationof the cartilage-containing airwaysbronchi or

bronchioles.


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BRONCHIECTASIS The airways are

dilated up to 4 times

the normal size Bronchi and

bronchioles are sodilated they can befollowed out to thepleural surfaces


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Respiratory tract The trachea is approximately 22 cm

long, with a cross-sectional area of 2

cm.At the tracheal carina it divides into two

major bronchi.

Conductive structures of a size down to2 mm are termed bronchi. Smaller onesare called bronchioles .


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Histology Respiratory tract The epithelium lining the

trachea is ciliatedpseudostratified columnarwhich contains numerousgoblet cells. Thisepithelium has anunusually thick basementmembrane, . This

epithelium plus itsunderlying layer of looseconnective tissue (thelamina propria) make upthe tracheal mucosa.


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Histology Respiratory tract The layer under the

mucosa is the

submucosa whereinyou'll find numerousseromucous glands.The mucosa isseparated from thesubmucosa by alayer of longitudinalelastic fibers.


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Histology Respiratory tract The layer under the

mucosa is the

submucosa whereinyou'll find numerousseromucous glands.The mucosa isseparated from thesubmucosa by alayer of longitudinalelastic fibers.


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Histology Respiratory tract Outside the

connective tissue

layers, observe theC-shaped rings ofhyaline cartilagewhich help to keep

the lumen of thetrachea fromcollapsing.


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Histology Respiratory tract Mucous

Membrane.The

mucous membraneis continuous abovewith that of thelarynx, and below

with that of thebronchi


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Histology Respiratory tract Mucus membrane

consists ofareolar andlymphoid tissue, and

presents a well-markedbasement membrane,supporting a stratifiedepithelium, the surfacelayer of which is

columnar and ciliated,while the deeper layersare composed of oval orrounded cells.


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Histology Respiratory tract Beneath the

basement

membrane there is adistinct layer oflongitudinal elasticfibers with a small

amount ofintervening areolartissue.


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Histology Respiratory tract The submucous layer is

composed of a loose

mesh-work ofconnective tissue,containing large bloodvessels, nerves, andmucous glands; the

ducts of the latterpierce the overlyinglayers and open on thesurface


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A. Bronchi The bronchial tree is

aptly named for its

resemblance to thebranches of a tree,as larger tubesperpetually concede

to smaller tube in anintricate frameworkof branches.


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Bronchi The trachea bifurcates into two primary

bronchi, which enter the lung and then

branch several times to give rise tosmaller secondary and tertiary bronchi.Bronchi differ from the trachea inhaving plates rather than rings of

cartilage, and in having a layer ofsmooth muscle between the laminapropria and submucosa.


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Bronchi The Right Bronchus (bronchus dexter),

wider, shorter, and more vertical in

direction than the left, is about 2.5 cm.long, and enters the right lung nearlyopposite the fifth thoracic vertebra.


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Bronchi Bronchioles are

smaller branches of

the bronchi, and aredistinguished fromthem by theabsence of cartilage

and glands


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Bronchi In larger bronchioles,

the epithelium is still

ciliated, but is nowusually simplecolumnar, whereas inthe smallestbronchioles, the

epithelium will besimple cuboidal (mostlycontaining Clara cells)and lack cilia altogether.


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Bronchi The smooth muscle

layer is generally

quite prominentinthese structurescircularly arrangedbundles of smooth

muscle in thebronchiolar wall.


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Bronchi As mentioned above,

the smallest conducting

bronchioles consist of asimple cuboidal (orperhaps "lowcolumnar") epitheliumof mostly Clara cells, a

few ciliated cells, andno goblet cells, and arecalled terminalbronchioles .


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Bronchi In smaller branches, the amount of

cartilage decreases, whereas the

amount of smooth muscle increases.Also, the number of glands and gobletcells decreases or absent.


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B. Bronchioles

Bronchioles are smaller branches of thebronchi, and are distinguished from

them by the absence of cartilage andglands. In larger bronchioles, theepithelium is still ciliated, but is nowusually simple columnar, whereas in the

smallest bronchioles, the epithelium willbe simple cuboidal (mostly Clara cells)and lack cilia altogether.


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Bronchioles Nearly 50 distinct types of cells have

been identified in the lungs, of which at

least 12 can be found in the airways.Mucus is secreted onto the bronchialsurfaces by submucous glands and by

"goblet cells" that are present inabundance on the bronchial epithelialsurface.


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Bronchioles It is this "mucociliary

elevator" which is

largely responsiblefor removing foreignmaterial, includingorganisms that land

on the bronchialsurfaces.


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Bronchioles Injury to these ciliated cells is characteristic in

smokers, who are likely to develop chronic

bronchitis, with colonization of the tracheaand bronchi by oral organisms and productionof excessive amounts of mucus. Patients withcongenital abnormalities of ciliary function(Kartagener's syndrome) must raise mucus

from the airways by coughing.They are proneto develop respiratory infections and dilationof the bronchi, referred to as bronchiectasis.


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Bronchioles Excess bronchoconstriction of small

bronchi between 2 and 5 mm in

diameter appears to be responsible forincreased airway resistance in mostpatients with asthma.


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Bronchioles The bronchioles contain very little cartilage,

and are controlled via thicker, smoother

muscles. The muscle controls whether or notthese smaller airways contract or expand.Asit refers to air flow resistance, bronchiolesprovide the most resistance of the air flow

passages, similar to the functions associateswith the arterioles in the circulatory system.


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Mechanisms of development

of Bronchiectasis Bronchiectasis may

result from one of threemain mechanisms:

A.Bronchial wall injury

Desquamation of theepithelium andnecrotising ulceration


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of Bronchiectasis Chronic inflammation of bronchial wall:

.lymphocytes predominate

.Unusually squamous metaplasia

More Advanced Stage

Granulation tissue in lamina propria

Cartilage fragmented or destroyed Muscle erased or focal hyperplastic changes


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of Bronchiectasis Mucous glands persist longer than

other structures.

Bronchial arteries: often greatlyenlarged

tortuous

Adjacent lung parenchyma Showsvarying changes from none to advancedorganizing pneumonia


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of Bronchiectasis B.Bronchial lumen

obstruction

Focal Congenitalbronchial atresia

Foreign body

Broncholithiasis

Endobronchialneoplasm

Rt mid lobe synd


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of Bronchiectasis

C.And traction fromadjacent fibrosis


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of Bronchiectasis Many conditions may lead to bronchial wall

injury.These include infections like

Recurrent infections Impaired host defense leading to infection

Exaggerated immune response

Congenital structural defects of the bronchial

wall And extrinsic insults damaging the airway

wall


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of Bronchiectasis These conditions share the common

denominator ofmucus plugging and

superimposed bacterial colonization. Themucus plugging is either a result of abnormalmucus constituency or abnormal mucusclearance. The toxins released by the bacteriaand the cytokines and enzymes released by

the surrounding inflammatory cells create avicious cycle ofprogressive wall damage,mucus plugging, and increased bacterialproliferation.Once bronchiectasis begins,

therefore, it is sure to progress.


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of BronchiectasisAirway obstruction is most commonly

caused by an intraluminal lesion such as

Carcinoid tumor,

Inflammatory myofibroblastic tumor,

Or a fibrous stricture usually from priorgranulomatous infection such ashistoplasmosis or tuberculosis.


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of Bronchiectasis When bronchiectasis is from bronchial

wall damage or bronchial obstruction,

the bronchial wall becomes thickenedbecause of infiltration by mononuclearcells and fibrosis.


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of Bronchiectasis Traction bronchiectasis, as its name implies,

is caused by retraction of mature fibrosis of

the parenchyma around the bronchi. Suchbronchiectasis follows the distribution of theunderlying fibrosis. The tractionbronchiectasis has an upper lobe distribution

in cases ofradiation fibrosis, sarcoidosis, andsequela oftuberculosis .


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of Bronchiectasis In cases of usual interstitial pneumonitis

(UIP) (idiopathic pulmonary fibrosis)

and fibrosing nonspecific interstitialpneumonitis (NSIP), the tractionbronchiectasis tends to be mostly in the

periphery and the lung bases.


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of Bronchiectasis Congenital defects of the cartilage,

collagen, or other components of the

bronchial wall lead to abnormalphysiologic clearing of mucoidexcretions, predisposing the bronchial

epithelium to repeated infections and avicious cycle of progressive bronchialdilatation.


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of Bronchiectasis Structural wall defectis the common

feature ofMounier-Kuhn disease or

tracheobronchomegaly, William-Campbell syndrome, and congenitalbronchial atresia.


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of Bronchiectasis Tracheobronchomegaly (Mounier-Kuhn

disease)

Tracheobronchomegaly is an uncommondisease that presents mostly in men, in thefourth and fifth decades. Although believed tobe congenital, it may be associated with

Ehlers-Danlos syndrome, Marfan syndrome,and generalized elastosis (cutis laxa).


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Tracheobronchomegaly

(Mounier-Kuhn disease) Pathological thinning of the muscle, cartilage,

and elastic tissue of the airway walls is seen.

This results in uniform dilatation of thetracheal and bronchial lumina and increaseddistensibility of the tracheal and bronchialwalls. This tracheobronchomalacia leads to

recurrent infections in the dependent lungs.


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of Bronchiectasis Congenital bronchial atresia or mucocele

This condition is characterized by congenital

focal obliteration of the lumen of a segmentalbronchus, resulting in focal bronchiectasisand air trapping more distally. The dilatedairway is commonly filled by inspissated

mucus, which may occasionally calcify andlooks like nodule .


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of Bronchiectasis Conversely, acquired mucocele is caused by

focal scarring of a segmental bronchus

because of prior granulomatous infection orfrom an endobronchial lesion. It should bedifferentiated from congenital bronchialatresia by the absence of air trapping of thedistal lung parenchyma.The presence of an

acquired mucocele should prompt furtherinterrogation to exclude the possibility of anendobronchial neoplasm.


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Abnormalities

Abnormalities of the structure andfunction of the cilia of the airway

epithelium, as seen in primary ciliarydyskinesia or immotile ciliary syndrome,leads to ineffective mucus clearanceand secondary colonization of the

airway lumina by bacteria. This chronicinfection and repeated bouts ofpneumonia lead to bronchiectasis.


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Mucociliary Clearance

Abnormalities Kartagener's syndrome or triad is

present in half of the PCD patients. This

triad consists ofsitus inversus,bronchiectasis, and sinusitis.


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Cystic fibrosis as cause of

Bronchiectasis Cystic fibrosis--- CF is an autosomal recessive

trait and occurs in approximately 1 in 3000

live births in the United States and Europe. Failed secretion of chloride leading to

dehydration of the endobronchial secretions.

This thickened mucus cannot be efficiently

cleared by the mucociliary system, leading toobstructed airways and bacterialinfection.Colonization and recurrent infection


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Hyper-Immune Response as a

cause for Bronchiectasis Inflammatory bowel disease, rheumatoid

arthritis, Sjogren disease, antineutrophilic

cytoplasmic antibody (c-ANCA)positivevasculitis (Wegener disease), and allergicbronchopulmonary aspergillosis all can lead tobronchiectasis, possibly because ofinflammation of the airway wall in the setting

of a hyperimmune response to internal orexternal antigens. The chronic inflammationdamages the bronchial walls, leading tobronchiectasis.


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Hyper-Immune Response as a

cause for Bronchiectasis Granulomata in the bronchi and

bronchioles, associated with mucus

impaction.

It is most commonly seen in patientswith atopic rhinitis, asthma, or CF


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of Bronchiectasis It should be noted thatbronchioles are

also line by surfactantand that

displacement of surfactant byinflammatory exudates leads to thebronchiolar instability and thus impairs

their function.


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of BronchiectasisVaccines and antibiotics have

dramatically reduced the frequency and

the importance of bronchiectasis.At present, the most common cause of

bronchiectasis is adenovirus infection.

Post-infectious conditions

e.g. necrotising bacterial, viral orfungal pneumonia


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of Bronchiectasis Rubella,whooping cough

(B.pertusis),measles in childhood


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Post infective

Bronchiectasis Measles and Pertusis

Adeno & Influenza virus

Bacterial infection withvirulent organisms:S.aureus, Klebsiella

Anaerobes

Atypical mycobacteria

Mycoplasma HIV

TB

Fungi


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Types of Bronchiectasis

1. Cylindrical or tubular bronchiectasis

2. Varicose bronchiectasis

3. Saccular or cystic bronchiectasis


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1.Cylindrical or tubular or

fusiform bronchiectasis1.Cylindrical/tubular

bronchiectasis

The luminal dilatation isuniform and the wall

thickening is smooth and

there is failure of normal

tapering of the bronchi.

2 Varicose


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2.Varicosebronchiectasis

The bronchi resemble like varicose veins and also

like serpentine.The luminal dilatation ischaracterized by alternating areas of luminaldilatation and constriction, creating a beadedappearance, and the wall thickening is

irregular.This varicose bronchiectasis serves as anintermediate step before the development ofgrossly dilated, cystic airways.


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3.Saccular or cystic

bronchiectasis Most severe form of

bronchiectasis.The

bronchi are severely

dilated and the bronchi

end blindly in a dilated

thick-walled cyst


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Clinical Manifestation of

Bronchiectasis Chronic Cough (90 %)

Dyspnea (72%)

Hemoptysis (56%)

Chest pain

Malnutrition/wasting

Anemia


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Bronchiectasis Use of accessory muscles

Pursed lip breathing

Cyanosis

Signs of Cor pulmonale

Increased respiratory rate

Increased heart rate


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Bronchiectasis

Copious postural foul smellingmucopurlant sputum

Sputum production

Mild 150 cc/d


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Bronchiectasis Clubbing of fingers

Wheez

Rhonchi


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Symptoms of acute

exacerbation of Bronchiectasis Change in sputum production

Increased dyspnea

Increased cough Fever

Increased wheezing

Malaise,fatigue,lethargy or decreased

tolerance Reduced pulmonary function

Changes in chest sounds

New radiographic changes


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Bronchiectasis Complications Pneumonia

Lung abscess

Empyema Septicaemia

Cor pulmonale

Metastatic cerebral abscesses

Secondary Amyloidosis with nephroticsyndrome

Recurrent pleurisy


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Bronchiectasis Complications Broncho pleural fistula

Purulent pericarditis

Respiratory failure

Metastic abcesses in bones etc


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Investigations Bronchiectasis CRP

Increased Sed rate

Anaemia


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Radiological features of

Bronchiectasis Bronchi, bronchioles

are dilated the

bronchial walls arethickened andshown as ringshadows on plain x

ray.


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Bronchiectasis Dilated and

thickened airwaysthat appear as ring-like shadows (ofairways that areseen on end) ortram lines (in the

case of airways thatare perpendicular tothe x-ray beam)


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Bronchiectasis Dilated and

thickened airwaysthat appear as ring-like shadows (ofairways that areseen on end) ortram lines (in the

case of airways thatare perpendicular tothe x-ray beam)


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Bronchiectasis

In mild cases x ray may be normal.


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RADIOLOGY - CXRBronchiectasis

- vessel crowding

- loss of vessel markings- tramline/ring shadows

- cystic lesions/ air-fluidlevels

- evidence of TB

Poor: diagnostic sensitivity

monitoring ofprogression


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CT Scan of Bronchiectasis

Shows peribronchial

thickening, dilatedbronchioles.


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Shows peribronchial

thickening, dilatedbronchioles


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CT Scan of Bronchiectasis CT scan also may show

Internal bronchialdiameter greater than

that of the adjacentpulmonary artery Lackof bronchial tapering,Presence of bronchiwithin 1 cm of the

costal pleura, Presenceof bronchi abutting themediastinal pleura,Bronchial wallthickening


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Marked airwaydilatation both upperlobes.


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CT Scan of Bronchiectasis- Bronchial dilatation

- Bronchial wallthickening

F th i ti ti f


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Further investigations of

Bronchiectasis IgE , IgM, IgG levels.

Aspergillus precipitin .

Sputum culture: fungi / Pseudomonasaeuruginosa, H.influenzae.etc

EKG.

Film PNS

F th i ti ti f


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Bronchiectasis Diffuse bronchiectasis Yellow nail

syndrome Pleural fluid TG/Chol

lymphedema. Diffuse panbronchiolitis HRCT(bizzare

nodules) transbronchial biopsy.

F th i ti ti f


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Bronchiectasis Lung function:

Airflow obstruction FEV1 decreased.

Air trapping - RV increased

F th i ti ti f


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Bronchiectasis Sweat test - Increased sodium and

chloride in cystic fibrosis

Bronchoscopy: Obstruction foreignbody, tumor.

Immunoglobulin levels

Cilia function and structure Kartagener's syndrome

Alpha-1 antrip level.

T f B hi i


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Treatment of Bronchiectasis

Treatment Goals:

1.Eliminate cause

2.Improve tracheo bronchial clearance

3.Control infection

4.Reverse airflow obstruction

T t t f B hi t i


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Proposed courses of treatment

Short course

Prolonged course

Intermittent regular courses

Inhalation


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Treatment of BronchiectasisAntibiotics and anti inflammatory

agents.

Are used in these proposed courses

To treat acute exacerbation,To prevent

infection or to reduce bacterial burden


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Treatment of Bronchiectasis Drainage Procedures

Postural drainage consists of adopting a

position in which the lobe to be drainedis uppermost.postural drainage shouldbe performed for a minimum of 5-10

minutes twice a day.


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Treatment of Bronchiectasis Gentle percussion of the chest wall with

cupped hands aids dislodgement of sputum.

Baroscopic removal of inspissated secretionsis rarely required.

Role of mucolytic agents is controversial.


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Treatment of Bronchiectasis Antibiotic theraphy.

Choice of antibiotic sould primarily be basedon the results of culture and sensitivity.

When no specific pathogen is identified andthe patient is not seriously ill,an oral agentlike


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Treatment of BronchiectasisAmoxycillin

Ampicillin

TetracyclineCotrimoxazole

or a fixed combination of amoxycillin andclavulanic acid should be used.moreseriously ill patients with pneumonitisshould be given parenteral antibiotics.


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Treatment of Bronchiectasis Duration of theraphy is variable.

A 5-10 days course is usually

sufficient.in some patients it may needto be prolonged for several weeks.


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Treatment of Bronchiectasis Brochiodilators

Brochiodilators to improve obstruction

and aid clearance of secretions areparticularly usefull when some elementof reversible airway obstruction is

present.


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Treatment of Bronchiectasis Primary Hypogammaglubolinemia

should be treated with human immune

serum albumin. Complicated cases may require nasal

oxygen on a chronic basis, to maintain

adequate oxygenation


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3 Strategies

1. High oral dose for prolonged period(at least 4 weeks) (macrolideand FQ) Azithromycin 500mg plus

Levofloxacin 250mg 2/wk x 6Mn(reduced exacerbation)


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Treatment of Bronchiectasis2. Aerosolized antibiotic (e.g during

alternate month) (Gentamicin 40mg bid

x 3 days. Tobramycin 300mg bid x 4wk,

(Gatifloxacin) Fortum 1g + Tobramycin

100mg bid x 12mn.


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Treatment of Bronchiectasis 3. Regular pulsed course of iv antibiotic

(e.g.2-3 wk courses with 1 or 2

months in between).


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Treatment of Bronchiectasis These episodic or suppressive

antibiotics

Decrease inflammation

Slow progression

Eradication


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Treatment of Bronchiectasis Anti-inflammatory agents :

Inhaled Fluticasone 500ug bid decreaseddensity of leucocyte, concentration of -inflammatory mediator 1B, IL-8 and LT-B4 insputum -improved sputum volume but no

change frequent of exacerbation, lungfunction and purulence sputum.


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Treatment of BronchiectasisAnti-inflammatory agents :Systemic

corticosteroid May better at penetrating

the bronchial wall and therefore bemore effective but available data onlyfor CF-Bronchiectasis.inhibit neutrophilmediated inflammation.


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Treatment of Bronchiectasis NSAIDS inhibit neutrophil function and

release of elastase

(Indocid25mgtidx4wk but opened labelstudy, lung function, sputum vol/qualitydid not change but high dose Ibuprofenx 4 yr found significantly slowedprogression of lung disease in CF-Bronchiectasis.


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Treatment of Bronchiectasis 3 Months of Clarithromycin decreased

total No. of leucocyte, proportion of

PMN and concentration of IL-8.


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Treatment of Bronchiectasis Brochiodilators

Anticholinergic or oral Methylxanthine inpatient with non-CF bronchiectasis.

Bronchopulmonary hygiene


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physical therapy That aims to remove lung secretions in

pt with acute and chronic airway

disease. Many active and passivetechnique are available Evidence isvariable and the literature is conflicting.



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Physical therapy Rhythmic Chest clapping or cupping and

of back, while the patient assumes a

number of positions (head down,primarily), may help the lungs to drainmore effectively. This is called chestphysical therapy, or percussion andpostural drainage.



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Physical therapy Inflatable vests or mechanical

vibrators.Oral devices that apply

positive end-expiratory pressuremaintain the potency of the airwayduring exhalation.

Inspiratory muscle training X 8WKS.


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Mucolytics Medications are available to help thin

the sputum, so that it can be more

effectively coughed up.


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Mucolytics Maintain adequate systemic hydration

by normal saline,enhanced by

nebulization with saline.Acetylcysteine delivered by nebulizer

thins secretions.Aerosolized

recombinant human DNase (rhDNase)in patients with cystic fibrosis.


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Alpha-1 antrip def Alpha-1 antritrip

replacement.

Oxygen and diuretics


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Treatment of BronchiectasisAnti-inflammatory agents Macrolide

(Azithromycin) suppress inflammation.

Azithromycin 500mg twice a week x6mn Decrease daily sputum production

and exacerbation.

Surgical treatment of


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Bronchiectasis Surgery :

If the area of bronchiectasis is localized

and symptoms are debilitating or lifethreatening.



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Bronchiectasis When bleeding occurs from irritated

bronchial tubes and overgrown

bronchial blood vessels, surgery may berequired either to remove an area ofthe bronchial tube, or to inject thebleeding blood vessel with a material tostop the bleeding.


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Bronchiectasis Surgery

Localized bronchiectasis

Proximal obstructive lesion,Obstructionmay require the removal of a foreignobject or tumor or aspirated material

Massive hemoptysis

Recurrent infections

Lung transplant


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Treatment of Bronchiectasis Prevention of Bronchiectasis

Adequate treatment and prophylaxis ofchildhood whooping cough, measles,and primary tuberculosis.

Genetic counseling in cystic fibrosis.


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PSEUDOBRONCHIECTASISA true bronchiectasis is not

reversible.whereas the

pseudobronchiectasis is reversible.


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PSEUDOBRONCHIECTASIS The bronchographic abnormalities displayed

by atelectasis and tracheo bronchitis

with ulceration of bronchial mucosa simulatecylindrical bronchiectasis.but re expansion ofcollapsed lung in atelectasis and regenerationof mucosa in trachiobroncitis result in

reversibility of bronchographicappearance.this is known aspseudobronchiectasis.


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Bronchiectasis sicca ( dry bronchiectasis)

This is a condition where bronchiectasispresents with repeated episodes ofhemoptysis without sputum

production.this usually occurs in upperlobe bronchiectasis of post tuberculousvariety.


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Middle lobe syndrome Or Brocks syndrome post obstructive.

bronchiectasis


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THANK YOU SO MUCH

Trust the Physician and the teacher , and drink his

remedy in silence and tranquility: For his hand,though heavy and hard, is guided by the tenderhand of the unseen,And the cup he brings, thoughit burn your lips, has been fashioned of the clay

which the Potter have moistened with His tears andsacred feelings.

treatment of bronchiectactasis by dr bashir ahmed dar associate professor medicine sopore kashmir

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