Transcript Linde-Gas - American Lung Association

Bronchiectasis
William Grimm, RRT
33rd Annual Mountain Air Symposum
10/9/2014
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The Challenge
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Presentation Agenda
• Bronchiectasis
- Types
- Causes
- Symptoms
- Effects on the Body
- Diagnosis
- Treatment
- Bronchiectasis Research Registry
• Airway Clearance
• High Frequency Chest Wall Oscillation (HFCWO)
• Patient Satisfaction with the SmartVest® Airway
Clearance System
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What is Bronchiectasis?
• Abnormal stretching and enlarging of the respiratory
passages caused by mucus blockage
• The blockage and accompanying infection cause
inflammation, leading to the weakening and widening of
the passages*
• Bronchiectasis = dilation of proximal and medium-sized
bronchi >2mm with transmural inflammation, edema
scarring, and ulceration
– Laennec, 1819
– Osler, late 1800s
– Reid, 1950s
*Source: American Lung Association
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Bronchiectasis
A. Normal lung and airway
B. Bronchiectasis lower lobes,
most common, saccular
dilatations and grape-like
clusters with pools of mucus
Source: Barker AF. Bronchiectasis. NEJM 2002; 346(18):1383-93
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COPD Education
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Types of Bronchiectasis
• Focal Bronchiectasis
– Occurs in a single lobe of the lung and can be
the result of an obstruction by a large foreign
object, a tumor, or an unusual development in
the airway
• Diffuse Bronchiectasis
– Occurs in more than a single lobe
– An underlying immune deficiency, infection, or
toxic exposure that involves multiple lobes
– Cystic Fibrosis and Primary Ciliary Dyskinesia
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What Historically Caused Bronchiectasis?
• The most common causes have been severe lung
infections during childhood such as whooping cough or
severe viral infections
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What Causes Bronchiectasis Today?
• Tuberculosis is the single leading cause worldwide
• Genetic disorders such as CF and PCD are the leading
causes in Western countries
• Aspiration (focal bronchiectasis)
• GERD
• Complications of primary infections such as bronchitis,
pneumonia, whooping cough, or tuberculosis
• Not all cases are caused by infection or genetic defect
– Exact cause is never determined in many cases
• Higher incidence in older women and native American
population in Alaska
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Prevalence of Bronchiectasis
• USA - 52 in 100,000
• South Korea Study
– 1,409 patients ages 23 to 86
– HR CT Scan
» 129 of study group had bronchiectasis on HR CT
Scan (9.1%)
» 53% of the 9.1% above exhibited respiratory
Symptoms
Source: Kwak, et al., Highprevalence of bronchiectasis in adults: analysis of CT findings in a
health screening program, Department of Internal Medicine, Hanyang University of Medicine,
Seongdong-gu, Seoul, Korea
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Economic Burden of Bronchiectasis in the USA
• Annual cost of care in 2001 = $13,244
- Greater than the cost of heart disease ($12,000)
and COPD ($11,000 to $13,000)
• For the estimated 110,000 patients with
Bronchiectasis the total medical care cost annually =
$1.4 billion
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Chronic Respiratory Symptoms
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Cough and sputum production (90 to 100%)
Areas of scarring
Mucus gland enlargement
Coughing up blood occasionally
Wheezing, possibly from asthma
Shortness of breath (75%)
Pleurisy or chest pain with breathing (50%)
Source: Barker AF. Bronchiectasis. NEJM 2002; 346(18):1383-93
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Bronchiectasis Symptoms
• Persistent productive cough
• Production of large quantities of purulent (infected)
sputum
• Chronic respiratory infection, including infection with rare
and/or opportunistic organisms
• Shortness of breath
• Cyanosis
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Effects on the Body
• Vicious Cycles
– Once bronchiectasis is established in the lobe
or lobes of the lung, it compromises airway
clearance which leads to respiratory infections
– These infections take up in the nooks,
crannies, and pockets of the airway which the
bronchiectasis has created
• Inflammation
– Loss of structural integrity of muscle, elastic
tissue, and sometimes bronchial cartilage
making the airway susceptible to infection
which leads to inflammation
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3-Layer Sputum
1. Top - Foamy mucus
2. Middle - Watery layer
3. Bottom - Cell debris
Source: Barker AF and Albert: Clinical Respiratory Medicine, 2nd ed., © 2004 Mosby
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Infections Associated with Bronchiectasis
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Staphylococcus aureus
Haemophilus influenza
Mycoplasma pneumoniae
Mycobaterium tuberculosis
Nontuberculous Mycobacterium (avium-complex)
Pseudomonas aeruginosa
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How is Bronchiectasis Diagnosed?
• Computed Tomography (CT Scan) of the chest, required
by Medicare
• Chest X-ray
• Bronchoscopy
• Lung function tests
• Blood tests
• Sputum culture
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Physical Exam
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Adventitious breath sounds
Crackles (70%)
Rhonchi (44%)
Wheezing (34%)
Clubbing (3%)
Findings of primary causative disease (eg. rash, joint
deformities, situs inversus, lymphadenopathy, dwarfism,
yellow nails, IV needle tracks, etc.)
Source: Barker AF. Bronchiectasis. NEJM 2002; 346(18):1383-93
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Treating Bronchiectasis
• Airway Clearance Therapy (ACT)
– Reduces obstruction and infection of the bronchi
– Examples: exercise, CPT, inhaled medications,
and mechanical devices
• Antibiotics
– To control infections
– Tobi, which is inhaled, for P. Aeruginosa
– Azithromycin, which is taken orally
• Lung Transplants
– For those who are approaching respiratory failure
– For focal bronchiectasis, possible treatments
include a lobectomy, or partial lung resection
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Bronchiectasis Registry
• Consolidated database of non-CF bronchiectasis patients
from multiple clinic institutions
– Stores information about bronchiectasis patients and
the disease itself
– Enrolled 10,000 patients in October 2011
Source: COPDFoundation.org
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Bronchiectasis Study via Registry
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54 Stable COPD Patients
Mean age = 69
Mean FEV1 = 0.96
50% had Bronchiectasis in HRCT Scan
Increased in reported COPD exacerbations, sputum
markers, and bacterial colonization
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Normal Airway Clearance
Natural airway clearance includes three essential
components
Mucus traps impurities
Cilia beat carry mucus to large airways
A strong cough clears mobilized secretions
In most individuals, these three components
work in harmony to keep our airways clear
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Inadequate Airway Clearance
Inadequate
clearance
Loss of
productivity
Increased
health
costs
Decrease
pulmonary
function
Scarring
Infections
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Inadequate Airway Clearance
Problems may occur with diseases or conditions
characterized by
Mucociliary System
Disorders
• Cystic Fibrosis (CF)
• Primary Ciliary
Dyskinesia
• Immotile Ciliary
Syndromes
Neuromotor
Disease/Conditions
• Cerebral Palsy
• Multiple Sclerosis
• Spinal Cord
Injuries
Obstructive
Pulmonary
Conditions
Neuromuscular
Disease
• COPD
• ALS
• Muscular Dystrophy
• Spinal Muscular
Atrophy
• Post Polio
- Chronic
Bronchitis
- Emphysema
• Bronchiectasis
Restrictive Airway
Disorders
• Scoliosis
• Kyphoscoliosis
Acute Care in
Hospital setting
• Post surgical
• Ventilator
• Etc.
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Complications of Retained Secretions
Atelectasis
Increased Work of Breathing
Hypoxemia
Infection
Lung Damage
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High Frequency Chest Wall Oscillation
(HFCWO) - Considerations for Use
• High Frequency Chest Wall Oscillation is designed
specifically for airway clearance therapy to enhance
mucus transport and improve bronchial drainage.
• Indications for HFCWO are not diagnosis specific;
however, it can be considered when retained
secretions cause pulmonary compromise. Thus,
individual assessment of each patient is appropriate.
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Patient Satisfaction with HFCWO via the
SmartVest® Airway Clearance System
The SmartVest® incorporates many features designed
for the comfort and convenience of the user. These
features are intended to increase the ease of use to
encourage better cooperation and compliance for all
ages – small children to adults.
What do patients say they like about the SmartVest®?
• The SmartVest® is gentler on the body, with
comparable efficacy
• Only soft, breathable, washable fabrics touch the skin
(SmartVest Wrap® must be spot cleaned)
• All Velcro™-type closures make adjustments and “on
and off” simple
• A single offset hose improves maneuverability during
treatment
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THANK YOU
QUESTIONS?
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