Transcript Bronchiectasis

Bronchiectasis
Hu Suping
Pulmonary Department
1st clinical college, Wuhan University
Definition
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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
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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
Pathological changes
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Cylindrical or tubular bronchiectasis: dilated
airways alone, sometimes seen as a residual effect of
pneumonia
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Varicose bronchiectasis: focal constrictive areas
along the dilated airways that result from defects in the
bronchial wall
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Saccular or cystic bronchiectasis: progressive
dilatation of the airways, which end in large cysts,
saccules, or grape-like clusters (the most severe form )
The lumen of the bronchus is dilated and
there is prominent chronic inflammation
in the bronchial wall
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
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
Pathophysiology and Etiology
Infections
Childhood respiratory tract infections (pertussis or
whooping cough)
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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
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half have Kartagener’s 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
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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
Chest radiography
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 > 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
Normal lung
Bronchiectasis
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.
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
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
(1) to confirm the diagnosis of bronchiectasis
(2) to identify potentially treatable underlying
causes
(3) to provide functional assessment
Imaging of the chest is always necessary to
confirm the diagnosis
Differential diagnosis
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Chronic bronchitis
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Lung abscess
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Pulmonary tuberculosis
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Congenital bronchocele
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Diffuse panbronchiolitis
Therapy
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Control infections：administration of antibiotics
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Treatment of underlying conditions
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Promotion of bronchial hygiene
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Control of bronchial hemorrhage
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Surgical therapy
Acute Exacerbations
An exacerbation: including four of the nine
symptoms
change in sputum production; increased dyspnea;
increased cough; fever (>38.0°C); increased
wheezing; malaise, fatigue, lethargy, or decreased
exercise tolerance; changes in chest sounds；
reduced pulmonary function; radiographic
changes
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
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
Hemoptysis
life-threatening hemoptysis: > 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
Surgery
Removal of an obstructing tumor or residue of a
foreign body
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Elimination of the segments or lobes the most
damaged and suspected of contributing to acute
exacerbations, overwhelming viscous secretions,
mucous impaction, and plugs
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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
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Double-lung
transplantation is now considered
for patients with cystic fibrosis and respiratory
failure (one year survival rate 75% and 48% at
five years)