Bronchiectasis

Case & Review

Intern 劉宗灝
Basic Info
 陳X貞
 43 year-old female
 4472086
Brief History
 1993/10 @ 長庚
 Severe respiratory distress + hemoptysis
 Dx: diffuse cystic bronchiectasis. Pulmon
ary HTN and cor pulmonale
 been oxygen-dependent since
 2001
 Cough, purulent sputum, dyspnea worse
ned
 2004 @ 慈濟
 Transplantation evaluation
Brief History
 2004/12 ~2005/06
 Pulmonary TB
 HERZ (2 months) + HER (4 months)
 2005
 Several episodes of acute respiratory exa
cerbation
 2005/05/22
 Tracheostomy
Brief History
 2005/12/26 @ NTUH
 Lung transplantation evaluation
 PFT: severe mixed ventilatory defect
 Cardiac echo: good LV function, moderate TR, p
ulmonary HTN
 2006/08/21 @ NTUH
 Pneumonia
 Massive hemoptysis ~ 300mL @ 08/28
 Despite optimal MV, desaturation w/ severe hyp
oxemia and hypercapnia (7.02/161/72/39)
Brief History
 2006/08/28 @ SICU
 V-V ECMO @ 08/29
 RIJV cannula clot, change V-V ECMO can
nula root @ 09/05
 ARF @ 09/06
 Bronchoscopy: no active bleeder
CXR
08/21
CXR
08/23
CXR
08/28
CXR
08/31
HRCT
08/31
CXR
09/01
CXR
09/09
CXR
09/15
Current Status
 V-V ECMO (RFV to LFV)
 MV(09/15): PCV, FiO2 90%, Pi 25, Ti
1.0 sec, RR 13, Vt 260-360, Ppeak 35
, PEEP 10
 ABG (09/15): 7.474/35.8/51.9/26.5/
3.6/88.6%
 Abx: Ceftazidime for P. aeruginosa
 On waiting list for lung transplant
Bronchiectasis
Introduction
 Chronic daily cough w/ viscid sputum
 Bronchial wall thickening and luminal
dilation on CT
 Prevalence varies
 Associated w/ ↑age, female
 Management
 Infection control
 ↑ bronchial hygiene
 Surgical resection in selected p’t
Epidemiology

Chest 1995;108;955-961
Symptoms and Signs

Chest 1995;108;955-961
COPD vs. Bronchiectasis

Barker A. N Engl J Med 2002;346:1383-1393

Pathophysiology
 Permanent abnormal dilation and
destruction of bronchial walls
 Two factors
 Infection
 Impairment of drainage, airway
obstruction, and/or defect in host
defense
 Biomarkers: inflammatory cells or 8-
iso-prostaglandin F(2α) in sputum
Etiology
 Pulmonary infections
 viral, mycoplasma, TB, MAC
 Airway obstruction
 Defective host defenses
 ABPA (allergic bronchopulmonary aspergillosis)
 Rheumatic and other systemic dz
 RA, Sjogren’s syndrome
 Ulcerative colitis
 Dyskinetic cilia
 Cystic fibrosis ← rare in TW
 Cigarette smoking?
Etiology

Chest 1995;108;955-961
Am J Respir Crit Care Med 2000 Oct;162(4 Pt 1):1277-84.
Diagnostic Evaluation
 CBC w/ differential
 Ig quantification
 Sputum culture and smear
 bacteria, mycobacteria, fungi
 CXR
 Linear atelectasis, tram track, ring shado
w, irregular peripheral opacities
 HRCT: defining test
 PFT
CXR of Bronchiectasis
CXR of Bronchiectasis

Hansell DM - Radiol Clin North Am - 01-JAN-1998; 36(1): 107-28

CXR of Bronchiectasis

Hansell DM - Radiol Clin North Am - 01-JAN-1998; 36(1): 107-28

HRCT
 Sensitivitiy ~97%
 Findings
 Airway dilation
 Lack of tapering of bronchi
 Bronchial wall thickening
 Mucopurulent plugs or debris
 Cyst
 Pneumonia, LAP, emphysema
 Distributions
 Upper lobe
 Central distribution
HRCT

Radiol Clin N Am 43(2005) 513-542

HRCT
HRCT
Management
 Infection control
 ↑ bronchial hygiene
 Surgical resection in selected p’t
Infection Control
 Acute exacerbation
 ↑viscous, dark sputum, lassitude, SOB,
pleurisy
 Fevers and chills generally absent
 CXR rarely show new infiltrates
 H. influenzae and P. aeruginosa
 FQ is reasonable (eg. ciprofloxacin) for 7
~10 days
Prevention
 Daily ciprofloxacin (500~1500mg) in
2~3 doses
 Macrolide daily or three times weekly
 Daily use of a high dose oral antibioti
c, such as amoxicillin 3 g/day
 Aerosolization of an antibiotic
 Intermittent intravenous antibiotics

J Antimicrob Chemother 1994 Jul;34(1):149-56.

Eur Respir J 1999 Feb;13(2):361-4
Q J Med 1990 Aug;76(280):799-816
Chest 2005 Apr;127(4):1420-6
Problematic Pathogen
 Pseudomonas aeruginosa
 Almost impossible to irradicate
 Wilson CB et al.
 Reduced QoL
 More extensive bronchiectasis on CT
 Increased number of hospitalizations
 Ciprofloxacin quickly develops resistance
Bronchial Hygiene
 Oral hydration
 Nebulization
 Normal saline
 Acetylcyteine
 Recombinant DNAase
 Hypertonic saline, mannitol, dextran, lactose
 Physiotherapy
 Chest percussion
 Prone position
 Bronchodilator? Steroid? NSAID?
Surgical Intervention
 Removal of the most involved segme
nts
 Most common: middle and lower lobe
resecton
 Hemoptysis:
 Bronchial a. embolization
 Lung transplantation
Lung Transplantation
 Overall 1-year survival : 68% (54-91%)
 Overall 5-year survival : 62% (41-83%)
 Subgroup
 SLTX : 1 yr survival 57% (20%-94%) n=4
 Mean FEV1 : 50% predicted (34%-61%),
 Mean FVC : 53% predicted (46-63%)
 2 lungs : 1 yr survival 73% (51-96%) n = 10
 Mean FEV1 : 73% predicted (58%-97%),
 Mean FVC : 68% predicted (53%-94%)

Lung transplantation for non-cystic fibrosis bronchiectasis: analysis of a 13-year experience.

J Heart Lung Transplant. 2005 Oct;24(10):1530-5.
Thank you for your attention !
Reference
 Bronchiectasis, Barker, N Engl J Med,
Vol. 346, No. 18, May 2, 2002
 Clinical manifestations and diagnosis
of bronchiectasis, Barker, UpToDate v
er 14.2
 Treatment of bronchiectasis, Barker,
UpToDate ver 14.2