Bronchiectasis
Chapter 14 – Des Jardins
P. 584-589 – Merck Manual
Objectives
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State the clinical definition for Bronchieactasis
Describe the anatomic alterations of the lungs
in Bronchieactasis
Describe the etiology of Bronchieactasis
List the clinical manifestations seen in
Bronchieactasis. Include findings of the
physical examination, laboratory tests,
pulmonary function tests, chest x-rays, arterial
blood-gas values, and hemodynamic indices.
Describe the management of Bronchieactasis.
Definition
• A chronic dilation and distortion of one or
more bronchi due to extensive
inflammation and destruction of the
bronchial wall cartilage, blood vessels,
elastic tissue and smooth muscle.
Etiology
• Usually occurs secondary to:
• Repeated, severe pneumonia
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Measles, Pertussis, Adenovirus in children
Klebsiella
Staphylococci
Influenza virus
Fungal infections
Myocbacteria
Mycoplasma
• Bronchial Obstruction
• Congenital Defect
• Manifestation of Cystic Fibrosis
• Kartagener’s Syndrome
• Primary ciliary dyskinesia (PCD)
Etiology (cont.)
• Idiopathic
• Accounts for roughly 50 to 80% of cases
• Possible immunologic defect or autoimmune
abnormality.
• Immune-related diseases
• Allergic bronchopulmonary aspergillosis (ABPA)
• Collagen Vascular diseases
• Rheumatoid arthritis
• Sjögren syndrome
• Ulcerative colitis
• Crohn’s disease
• Immune deficiencies (?)
Pathophysiology
• Either one or both lungs may be involved.
• It is commonly limited to a lobe or segment and is
frequently found in the lower lobes.
• Right Middle Lobe and Left Lingula also possible.
• Extent and character of pathologic changes
determines the functional abnormalities.
• Increased mucus production with impaired mucociliary
clearance
• Changes in lung volumes distal to obstruction
• Increased due to Ball-Valve effect
• Decreased due to atelectasis
• Reduced flow rates
• / defects with hypoxemia
Types of Bronchiectasis
Varicose
Saccular
Technically there are 2 other
kinds: Follicular and Traction.
But….who cares?
Cylindrical
Varicose Bronchiectasis
• Bronchi are dilated and constricted in an
irregular fashion similar to varicose veins.
• Varicose bronchiectasis is also called
fusiform.
Cylindrical Bronchiectasis
• Bronchi are dilated and have regular
outlines similar to a tube. The dilated
bronchi fail to taper for 6-10 generations
and then in the bronchogram appear to end
squarely because of mucous obstruction
Saccular Bronchiectasis
• Bronchi progressively increase in diameter
until they end in large, cyst-like sacs in the
lung parenchyma.
• This form causes the greatest damage to the
tracheobronchial tree.
• The bronchial walls become composed of
fibrous tissue.
• Cartilage, elastic tissue and smooth muscle
are all absent.
Anatomic Alterations
• Copious amounts of bronchial secretions.
• Mucociliary clearance mechanism is impaired.
• Foul smelling mucous from anaerobic
organisms.
• Mucous plugs cause partial or complete
obstruction.
• Hyperinflation of the distal alveoli as a result
of an expiratory check valve obstruction.
• Atelectasis, consolidation, and fibrosis results
from complete bronchial obstruction.
Pathophysiology
• Obstructive Lung Diseases but can have a
restrictive component if alveolar lung
volumes are reduced.
• Obstructive and Restrictive Disease
Physical Examination
• Vital Signs:
• f: Increased (tachypnea).
• HR: Increased
• BP: Increased (Increased CO)
• Inspection:
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Pursed lip breathing.
Cyanosis.
Prolonged expiratory phase.
Increased A-P diameter
Digital clubbing
Physical Examination
• Palpation:
• Use of accessory muscles during I & E.
• Percussion:
• Hyperresonant if obstructive, Dull if restrictive.
• Auscultation:
• Inspiratory crackles and/or rhonchi.
• May be diminished if obstructive, bronchial
with restrictive.
Physical Assessment
• Chief complaint:
• Cough with large volume of sputum
• Hemoptysis
• Sputum settles into distinct layers with streaks of
blood often seen
• Thick, tenacious sputum
• Chronic sinusitis is a common complaint.
• Also nasal polyps
• Kartagener’s Syndrome (Bronchiectasis,
dextrocardia & paranasal sinusitis).
• 20% of Bronchieactasis is as a result of
Kartagener’s.
ABG
• Mild to Moderate Bronchiectasis
• Acute alveolar hyperventilation with
hypoxemia.
• Severe Bronchiectasis
• Chronic ventilatory failure with hypoxemia.
• Oxygenation Indices
• Increased shunting.
• Decreased oxygen delivery.
Pulmonary Function Studies
• Obstructive Disease
• Decreased FVC and FEV1.0
• Decreased Flowrates
• Increased RV, FRC, TLC, RV/TLC
• Restrictive Defect
• Reduced RV, FRC, TLC
• RV/TLC ratio normal
• Flows are normal.
Chest X-ray
• Obstructive Lung Disease
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Translucent (dark) lung fields
Depressed, flattened diaphragms
Long, narrow hearts
Right ventricular enlargement
• Restrictive Process
• Atelectasis and consolidation
• Increased opacity
Laboratory Findings
• Culture and Sensitivity
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Haemophilus influenzae
Streptococcus pneumoniae
Staphylococcus aureus
Pseudomonas aeruginosa
Anaerobic organisms
Sputum separates into layers
• CBC
• Polycythemia and increased WBC (infection).
Diagnosis
• Bronchography (Bronchogram)
• Injection of opaque contrast material into the
TB tree
• Rarely done.
• High-Resolution CT Scan
• Bronchial walls appear thick, dilated.
• Replaced standard CT scan and
Bronchography as gold standard.
Prophylaxis
• Awareness and early identification may
allow for earlier intervention.
• Childhood immunizations.
• Reduce exacerbations.
Treatment Goals
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Reduce infections/exacerbations
Manage secretions
Reduce airway obstruction
Treat complications
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Hemoptysis
Hypoxemia
Respiratory Failure
Cor Pulmonale
Treatment
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Antibiotics to treat pneumonia
Inhaled steroids to reduce inflammation
Oxygen therapy (low FiO2)
Bronchial Hygiene Protocol
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CPT/PD
Hydration
Deep breathing/coughing
Humidification
Therapy
• Aerosol Therapy
• Mucolytics
• Bronchodilators
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Flu shots/Pneumonia Vaccinations
Bronchoscopy
Avoidance of respiratory irritants
Surgical resection
• Saccular is most suitable for surgery
Prognosis
• Mild Bronchiectasis – may have a normal
life span
• Extensive Bronchiectasis – shorter life
span
• Result of respiratory infection and
complications
• Disease of slow deterioration interspersed
by episodes of exacerbation