BRONCHIECTASIS

Dr. B.B. Mathur

Professor and Head
Dept. of Respiratory Medicine
JNU Medical College, Jaipur
 DEFINITION

• Bronchiectasis is permanent abnormal dilatation

of the central and medium sized bronchi as a
result of vicious cycle of transmural infection and
inflammation with mediator release.
 Pathological Types

• Cylindrical or Tubular

• Varicose

• Saccular or Cystic
• Pseudobronchiectasis

• Dry bronchiectasis
Normal & Bronchiectatic Lung
 Forms

• Focal presentation

• Diffuse presentation
Conditions Associated with Bronchiectasis
• Post infectious damage
• Mechanical obstruction
• Congenital
• Inflammatory pneumonitis
• Allergic broncho pulmonary aspergillosis
• Abnormal mucous clearance
• Fibrosis
• Inflammatory bowel disease
• Deficient immune response
• Connective tissue disease
• Alpha 1 anti trypsine deficiency
 Etiology and Pathogenesis

• Inifection—
• Obstruction---
• Congenital anatomical defects
• Immunodeficiency states
• Hereditary abnormality
• Miscellaneous
 Etiology and Pathogenesis

• Inifection—Childhood infection
Nectrotizing pneumonias
Pulmonary tuberculosis
Fungal--ABPA
• Obstruction---Foreign body
Tumour
Lymphadenopathy
Bronchostenosis
 Etiology and Pathogenesis
• Congenital anatomical defects
William Compbell syndrome
Mounier Kohn syndrome
Sequestration of lung
• Immunodeficiency states
Agammaglobulenemia
Hypogammaglobulenemia
 Etiology and Pathogenesis

• Hereditary abnormality
Immotile cilia syndrome
Kartagener syndrome
Alpha 1 anti trypsin deficiency
Cystic fibrosis
 Clinical Presentation
• Cough
• Sputum
• Dyspnea, Wheezing
• Hemoptysis
• Recurrent infection
• Dry bronchiectasis
• Acute exacerbation
• Late-hypoxemia & hypercapnia
• Systemic ill health
 Physical examination
• Medium or coarse crepitations
• Clubbing
• Corpulmonale
• Amyloidosis
• Late-hypoxemia & hypercapnia
Symptoms of acute exacerbation of
Bronchiectasis

• Change in sputum production

• Increase Dyspnea
• Increase Cough
• Fever
• Increase wheezing
• Change in chest sound
• Malaise Fatigue Lethargy
• Radiographic changes
 Diagnosis
• Clinical history and examination
• Radiological Imaging
-skiagram chest
– Bronchography: obsolete procedure
– HRCT Thorax
• Further Investigation
 Skiagram Chest

• Normal
• Cystic dilated areas may be visible
• Ring shadows may be seen
• Tram line shadow or band shadow
• Consolidation or lung abscess
• Featuree of volume loss
• Cor Pulmonale
Skiagram Chest
Bronchography
Bronchogram
 CT Finding
• Internal bronchial diameter greater than that
of adjacent pulmonary artery
• Lack of bronchial tapering
• Presence of bronchi within 1cm of costal
pleura
• Presence of bronchi abutting mediastinal
pleura
• Bronchial wall thickening & irregularity
• Presence of mucoid impactaton
• Tracheomegaly
HRCT images of bronchiectasis
HRCT images of bronchiectasis
High-Resolution Computed Tomographic Images of Lungs
with Bronchiectasis
 Other Investigations

• Sputum examination----gram stain

pyogenic culture
• F.O.B.----to rule out obstruction
• Immunoglobulin
• Sweat chloride test---(Cystic fibrosis)
• Eosinophil count, skin test,precipitin test
(ABPA)
 Complications
• Local
• Pneumonia,Lung abscess,Empyema
Haemoptysis
• Pulmonary hypertension
• Corpulmonale, C H F, Respiratory failure
• Systemic:
• Clubbing,Anemia,Hypoprotenemia,
Amyloidosis,Pul. osteoarthropathy
 Management

• Acute exacerbation
• Specific disease
• Stable disease
• Complication-eg.Hemoptysis
 Management

• Non Pharmacological treatment

• Pharmacological treatment
-Antibiotic
-Mucolytic
-Anti-inflammatory
-Immunomodulator
-Bronchodilator
 Antibiotics

• Used to treat acute exacerbation,

to prevent infection and
to reduce bacterial burden
• Mild to moderate bronchiectasis-infection
can be completely eradicated
• Severe disease – bronchial tree remain
chronically colonized
• Antibiotics with high penetrance are
recommended in severe cases
Antibiotics…

• Severe disease – high concentration of

bacteria are located intraluminally in
association with mucus. thickening and
scarring of bronchial wall may reduce local
bioavailability of drug.
• Pseudomonas aeruginosa is inherently
resistant to most antibiotics
• Not responder- admission- iv antibiotics
Microbiology in bronchiectasis
 Antibiotics

• Choice of antibiotic- likely pathogen present

in lower respiratory tract
Episodic, targeted antibiotics- sampling
of respiratory secretion,on the basis of
culture & sensitivity
Rotating antibiotic therapy-
1week/month cycle of arbitrarily selected
antibiotic
Initial empirical followed by targeted
antibiotic- advantage of prompt
treatment.sampling before starting therapy
Antibiotics…

• Patients who relapse quickly might need

prophylactic antibiotics.
•3 Strategy
•1) High oral dose for prolonged period
(at least 4 weeks)
•2) Aerosolised antibiotic
(during alternate months)
•3) Regular pulse of iv antibiotic
(2-3week courses with 1or 2 month in
between)
 Inhaled antibiotics

• Gentamycin 40mg. twice daily by inhalation for 3

days improved sputum production, sputum
neutrophil activity, airway obstruction, exercise
activity, nocturnal desaturation compared with
placebo.
• Tobramycin 300mg. Inhaled twice daily for 4 weeks
eradicated P auruginosa in 35% pts. & improved
the condition of 62%.
• Ceftazidime 1gm. & Tobramycin 100mg. Inhaled
twice daily over 12 months decreased the no. of
hospital admission & in patient days.
 Postural drainage
• Postural drainage is the method of draining
excessive secretion assisted by force of
gravity. Excessive secretion in the
dependent part of lung act as force behind
acute exacerbation.
• A knowledge of the affected lobe is
necessary to achieve optimal drainage.
• Dependent zone-positioning in prone head
down, trendelenburg and/or lateral
decubitus
 Postural drainage

• Chest percussion may be used as an

adjunct to tipping.
• Other supporting devices pneumatic
powered jacket may be useful.
 Bronchodilator

• Cochrane reviews found no RCT on SABA,

LABA, anticholinergic or oral
Methylxanthine in patient with non CF
bronchiectasis.

• IBAs may accelerate ciliary beat frequency

as well as relieve bronchospasm present in
some BXSIS patients
 Bronchodilator

• Some pts may benefit with inhaled

anticholinergic bronchodilator not provided
by IBAs

• Oral theophylline might augment

bronchodilation, enhance mucus clearance
and enhance diaphragmatic contractility .
However side effects drug interaction and
GER promoting effect may cause problem
Management of specific disease

• Focal bronchiectasis
– Airway obstruction-Bronchoscopic removal,
Laser
MAC — Clarithro+RIF+ETB
 Management of specific disease

• Diffuse bronchiectasis

ABPA Oral steroids

CF Dnase, Tobra, gene therapy
Immunodef Immunoglobulin
Alpha1antitryp def Alpha1anti replacement
Diffuse panbronchiolitis Macrolides
 Surgery

• Surgery is a possibility if the area of

bronchiectasis is localized & symptoms
are debilitating or life threatening.
THANKS