Bronchiectasis

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Bronchiectasis Hu
Suping Pulmonary Department 1st clinical college,
Wuhan University
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• Definition
• an acquired disorder of the major bronchi and
  bronchioles characterized by permanent abnormal
  dilation and destruction of bronchial walls
• the most common symptoms are chronic cough with
  large amounts of purulent sputum and/or recurrent
  hemoptysis

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• it involves chronic respiratory tract infection
  and an up-regulation of the host inflammatory
  response
• Enhanced cellular and mediator responses
  bronchial mucosal biopsies reveal infiltration by
  neutrophils and T lymphocytes expectorated
  sputum has increased concentrations of elastase
  and the chemoattractants IL-8, TNFa, and
  prostanoids

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• Pathological changes
• Cylindrical or tubular bronchiectasis dilated
  airways alone, sometimes seen as a residual
  effect of pneumonia
• Varicose bronchiectasis focal constrictive
  areas along the dilated airways that result from
  defects in the bronchial wall
• Saccular or cystic bronchiectasis progressive
  dilatation of the airways, which end in large
  cysts, saccules, or grape-like clusters (the
  most severe form )

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• The lumen of the bronchus is dilated and there is
  prominent chronic inflammation in the bronchial
  wall

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Bronchiectasis can present in either of two forms
a local or focal obstructive process of a lobe
or segment of a lung or a diffuse process
involving much of both lungs and often
accompanied by other sinopulmonary diseases, such
as sinusitis and asthma
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Pathophysiology and Etiology Three types of
focal airway obstruction (1) luminal blockage by
a foreign body, broncholith, or slowly growing
benign tumor (2) extrinsic narrowing due to
enlarged lymph nodes (middle lobe syndrome) (3)
twisting or displacement of the airways after a
lobar resection or chronic infection
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• Pathophysiology and Etiology
• Infections
• Childhood respiratory tract infections
  (pertussis or whooping cough)
• Chronic infections( chronic lung abscess, TB)
• Primary Ciliary Dyskinesia
• an autosomal recessive syndrome, estimated
  frequency at birth is 1 in 15,000 to 1 in 40,000
• half have Kartageners syndrome (bronchiectasis,
  sinusitis, and situs inversus viscerum)

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• Pathophysiology and Etiology
• Immunodeficiency
• humoral immunodeficiency syndromes (deficiencies
  of IgG, IgM, and IgA) at risk for recurrent
  suppurative sinopulmonary infections and
  bronchiectasis
• immune globulin replacement reduces the
  frequency of infectious episodes and prevents
  further destruction of the airways

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Clinical findings Symptoms daily cough
productive of mucopurulent phlegm intermittent
hemoptysis recurrent lung infections shortness
of breath Physical findings crackles, cyanosis
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Chest radiography
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High-resolution computed tomographic scanning
(HRCT) the defining modality for diagnosis of
bronchiectasis Specific abnormalities found on
HRCT include (1) dilatation of an airway lumen gt
1.5 times as wide as a nearby vessel (2) lack of
tapering of an airway toward the periphery (3)
varicose constrictions along airways (4)
ballooned cysts at the end of a bronchus
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Bronchiectasis
Normal lung
Normal Lung and the Lung of a Patient with
Bronchiectasis. Bronchiectasis is primarily in
the lower lobe, which is the most common
distribution. The saccular dilatations and
grapelike clusters with pools of mucus are signs
of severe bronchiectasis.
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• Bronchoscopy
• an important diagnostic tool to examine for
  obstruction ( foreign body, tumor, structural
  deformity, or extrinsic compression from lymph
  nodes) and to help localize the bleeding,to
  identify pathogen

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Pulmonary function tests

• obstructive impairment ( low FEV1 and/or low
  FEV1/FVC)
• airway hyperresponsiveness ( 40 with a positive
  reversibility test result, and 30 to 69 with a
  positive bronchial provocative test result)

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• Diagnostic evaluation
• to confirm the diagnosis of bronchiectasis
• to identify potentially treatable underlying
  causes
• to provide functional assessment
• Imaging of the chest is always necessary to
  confirm the diagnosis

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• Differential diagnosis
• Chronic bronchitis
• Lung abscess
• Pulmonary tuberculosis
• Congenital bronchocele
• Diffuse panbronchiolitis

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• Therapy
• Control infectionsadministration of antibiotics
  
• Treatment of underlying conditions
• Promotion of bronchial hygiene
• Control of bronchial hemorrhage
• Surgical therapy

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Acute Exacerbations An exacerbation including
four of the nine symptoms change in sputum
production increased dyspnea increased cough
fever (gt38.0C) increased wheezing malaise,
fatigue, lethargy, or decreased exercise
tolerance changes in chest sounds reduced
pulmonary function radiographic changes
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Early antibiotic therapy fluoroquinolone as
levofloxacin or ciprofloxacin for at least 7 to
10 days Sputum culture and sensitivity testing
who fail to respond to the initial antibiotic or
who have repeated symptomatic attacks in a short
interval
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Bronchopulmonary Hygiene Postural drainage, chest
physiotherapy, thinning and loosening of
secretions, the administration of a
bronchodilator and of inhaled corticosteroids
part of maintenance therapy and treatment for
acute exacerbations
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Hemoptysis life-threatening hemoptysis gt 600 ml/
day bronchoscopy or CT of the chest is warranted
to help determine which lobe or side is
bleeding interventional radiology selective
bronchial arteries embolization surgery may be
required to resect an area suspected of bleeding
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• Surgery
• Removal of an obstructing tumor or residue of a
  foreign body
• Elimination of the segments or lobes the most
  damaged and suspected of contributing to acute
  exacerbations, overwhelming viscous secretions,
  mucous impaction, and plugs
• Elimination of areas that are subject to
  uncontrolled hemorrhage

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• Removal of damaged lung suspected of harboring
  problematic organisms such as multidrug-resistant
  M. tuberculosis or M. avium
• Double-lung transplantation is now considered for
  patients with cystic fibrosis and respiratory
  failure (one year survival rate 75 and 48 at
  five years)

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