Bronchiectasis

l PREVALENCE
II. PATHOPHYSIOLOGY
III. CLINICAL FEATURES
IV. CLASSIFICATION USING RADIOLOGY
V. PREDISPOSING OR ASSOCIATED FACTORS
VI. DIAGNOSIS OF BRONCHIECTASIS
VII. BACTERIOLOGY
VIII. TREATMENT
 :Definition
Bronchiectasis

is a morphological term used to describe abnormal

.irreversibly dilated and often thick-walled bronchi

Bronchiectasis represents the end stage of a

variety of pathologic processes that cause
destruction of the bronchial wall and its
surrounding supporting tissues. The clinical
manifestations include chronic cough and
copious mucopurulent expectoration, often
lasting months to years
PREVALENCE:

Bronchiectasis was a common disabling and

fatal condition in the pre-antibiotic era. It
remains an important cause of suppurative
lung disease in the developing world .

the prevalence has recently been

estimated to be 52 per 100,000.
PATHOPHYSIOLOGY

The abnormal bronchial dilatation in bronchiectasis affects

the medium-sized bronchi, but often extends
.to the more distal bronchi and bronchioles

gross examination:
The affected bronchi and bronchioles are so prominent as
.to be visible all the way to the pleural surface
These dilated and ectatic bronchi are commonly filled
with purulent secretions
The affected bronchi show transmural
inflammation,mucosal
edema,cratering,ulceration,and
neovascularization The bronchial epithelium
may show a polypoidal appearance
due to underlying granuloma formation and
mucosal prominence, ridging due to bronchial
smooth muscle hypertrophy, and pitting due
to the dilated bronchial mucous glands
,Microscopically

,bronchiectasis is associated with loss of cilia

cuboidal and squamous metaplasia

hypertrophy of bronchial glands, and lymphoid

hyperplasia. Intense infiltration of the bronchial wall
with neutrophils, lymphocytes and monocytes is
.seen
chronic bacterial endobronchial
infection and inflammation damage or destroy mucociliary
defenses, leading to secretion stasis, which in turn
propagates

furthers bacterial infection, and increases airway

inflammation and bronchial dilatation

Bacterial colonization and/or

infection of the airways alone is not sufficient to produce
true bronchiectasis. It seems likely that focal disturbances
resulting in airway obstruction or impairment of drainage
-and/or systemic conditions, resulting in uncoordinated air
way clearance or impaired immune response are required
Pseudomonas aeruginosa in the respiratory tract
of bronchiectasis patients on a chronic or
recurring basis has
been associated with worsening ciliary function
and deleterious effects on host defenses,
due to the ability of this organism to release
virulent exotoxins, form surrounding biofilms on
tissue surfaces, and easily develop hypermutable
Pseudomonas. aeruginosa strains resistant to
antibiotics, all factors perpetuating and
propagating bronchial
damage
 CLINICAL FEATURES
.cough and mucopurulent sputum production
Cough is invariably present and often may be the only
symptom for years
Purulent, tenacious sputum production, frequently worse
in the morning

“Dry bronchiectasis” presenting as cough, minimal

sputum expectoration, and/or hemoptysis

HEMOPTYSIS MAY BE SEEN IN 40 TO 70 PERCENT OF PATIENTS

AND MAY VARY FROM BLOOD STREAKS TO LARGE CLOTS.

INCREASING COUGH, DYSPNEA, AND VOLUME OF SPUTUM

PRODUCTION, FEVER, HEMOPTYSIS, AND CHEST PAIN ARE
HALLMARKS OF ACUTE EXACERBATION
On physical examination:

Chest auscultation usually reveals findings of early and

mid-inspiratory crackles as well as diffuse brhonchi and
.prolonged expiration

Bronchial breath sounds may be heard in

.severe cases or patients with a complicating pneumonia

Digital clubbing and hypertrophic pulmonary

osteoarthropathy

 In severe advanced cases, there may be evidence of

-respiratory insufficiency
 :CLASSIFICATION USING RADIOLOGY

cylindrical bronchiectasis 1:
the bronchi are regularly outlined (tubular), dilated in
diameter
:Saccular or cystic bronchiectasis 2
Very dilated airways clustered into saccules, cysts,
or grapelike clusters
walls, oftencoming to a straight abrupt end, instead of
a tapering end, due to obstruction of the peripheral
bronchial tree by secretions, casts, and
inflammatory wall edema
Varicose bronchiectasis 3:
is marked by the presence of )illusion to varicose veins(
irregular dilatations, and tortuosity of the airways
Cylindrical
bronchiectasis with
signet-ring
appearance. Note that
the luminal airway
diameter is greater
than the diameter of
the adjacent vessel
Cystic and cylindrical bronchiectasis of the right lower
lobe on a posterior-anterior chest radiograph.
Varicose bronchiectasis with alternating areas of bronchial
dilatation and constriction.
This CT scan depicts areas of both cystic bronchiectasis
and varicose bronchiectasis.
PREDISPOSING OR ASSOCIATED FACTORS:
Previously bronchial damage secondary to childhood respiratory
tract infections such as pneumonia, pertussis, complicated
measles, and tuberculosis were implicated as common causes of
bronchiectasis.
Typical offending organisms that have been known to
cause bronchiectasis include Klebsiella species,
Staphylococcus aureus, Mycobacterium tuberculosis,
Mycoplasma pneumoniae, nontuberculous mycobacteria,
measles virus, pertussis virus, influenza virus, herpes
.simplex virus, and certain types of adenovirus
Once a patient develops bronchiectasis, many of these
same organisms colonize the damaged bronchi and may
result in ongoing damage and episodic infectious
exacerbations. The organisms found most typically
include Haemophilus species and Pseudomonas species
 :Bronchial obstruction
Developed with endobronchial tumors,
broncholithiasis, bronchial stenosis from infections,
encroachment of hilar lymph nodes, foreign body
aspiration. Right-middle lobe syndrome

Allergic bronchopulmonary aspergillosis

•

Allergic bronchopulmonary aspergillosis (ABPA) is a

hypersensitivity reaction to inhaled Aspergillus antigen that
is characterized by bronchospasm, bronchiectasis, and
immunologic evidence of a reaction to Aspergillus species.
 Other features of ABPA include eosinophilia, elevated
immunoglobulin E (IgE) levels, and dramatic responses
to corticosteroids.
 Autoimmune diseases and idiopathic inflammatory disorders
•

Rheumatoid arthritis is associated with bronchiectasis

Sjögren syndrome, bronchiectasis has been noted in these

patients and may be secondary to increased viscosity of mucus

with poor airway clearance
Ankylosing spondylitis
Systematic lupus erythematosus

In relapsing polychondritis, bronchiectasis appears to be

secondary to primary bronchial damage with resultant recurrent

infection
•
With inflammatory bowel disease, bronchiectasis has been
seen in both ulcerative colitis and Crohn disease.

•Sarcoidosis :
cause bronchiectasis by a variety of mechanisms, including
parenchymal scarring, endobronchial granulomatous
inflammation,or extrinsic compression of bronchi
Traction bronchiectasis:
Traction bronchiectasis is distortion of the airways
secondary to mechanical traction on the bronchi
from fibrosis of the surrounding lung parenchyma.
Toxic gas exposure:

Exposure to toxic gas may often cause irreversible

damage to the bronchial airways and cystic
bronchiectasis. Commonly suspected agents include
chlorine gas and ammonia.
DIAGNOSIS OF BRONCHIECTASIS

, history
,clinical features
.radiologic demonstration of bronchiectatic airways

sputumcultures for bacteria,mycobacteria, and fungi

tests or precipitins to Aspergillus.
Chest Radiograph
The chest x-ray may be abnormal and show the presence of increased pulmonary
markings, ring like structures, atelectasis ,
dilated and thickened airways (tram lines), and mucus plugging appearance;
however, the chest radiograph may be normal even in the presence of bronchiectasis
High-Resolution Computed Tomography

localize and describe areas of parenchymal

,abnormality

and identify bronchiolar abnormalities and mucus

.plugging to the level of fifth- and sixth-order bronchi

It also can identify focal areas of air trapping as an

.indicator of small airway disease

It is indicated in the evaluation of bronchiectasis

when surgical resection is contemplated

bronchiectasis is strongly suspected clinically and

routine chest radiographs are normal
Airway dilatation can be detected by finding
.»«tramlines

A luminal diameter more than times the adjacent

vessel is indicative of bronchiectasis

.Bronchial wall thickening may also be seen

small airway plugging with debris may also be seen

:TREATMENT
The treatment of bronchiectasis is aimed at controlling
,infection, reducing inflammation
and improving bronchial hygiene, with surgical
resection of affected areas being useful in
.selected patients
Control of Infection
-Antibiotics are indicated to treat an acute exacer
bation. However, they have been used variably to prevent
recurrent infections by suppression and/or elimination of
.attendant flora
Antibiotics are directed at commonly isolated pathogens
such as Haemophilus influenzae, Str. pneumoniae, and
Pseudomonas aeruginosa. Oral fluoroquinolones are often
used as initial antibiotic choices for treatment durations of
10 to 14 days
In the face of failure to respond to treatment or the
occurrence of frequent exacerbations over short
periods of time, is necessary

sputum cultures and sensitivity tests should be done

to help define antibiotic selection e.g., atypical
.mycobacteria or fungae
Severe exacerbations due to Pseudomonas
aeruginosa require the intravenous administration of
two antipseudomonal antibiotics and potential
.hospitalization
Bronchial Hygiene

Airway mucus clearance is a problem in

bronchiectasis. Chest percussion and postural
drainage have been the traditional method of
.facilitating mucus clearance
.Alternative therapies
Autogenic drainage, mechanical vibration with
,ultrasonic devices, positive expiratory pressure
and Flutter valve use without the assistance of another
caregiver have been shown to achieve good chest
clearance
Mucus Clearance

Mucus hypersecretion is a prominent feature of chronic

.inflammatory airways disease

Maintenance of hydration with oral and/or intravenous fluids

is considered useful in preventing inspissated sputum
.retention

Humidification of inhaled air or oxygen as an adjunct

-to chest physical therapy has been shown to significantly in
.crease the wet weight of sputum produced

The use of nebulized normal or hypertonic saline and

acetylcysteine may be considered as important adjuncts to
.chest physical therapy
Bronchodilators
As these patients show signs of airway obstruction and
hyperreactivity bronchodilators are frequently used

Anti-inflammatoryTherapy
Persistent endobronchial inflammation is known to
play asignificant role in the pathogenesis of
bronchiectasis, and anti-inflammatory therapy may be
beneficial
:Surgery
surgical resection of the most severely affected segments,
bleeding segments, or areas harboring resistant
tuberculosis or atypical mycobacteria
may confer significant benefits in terms of symptom
control, reduction of tenacious sputum production,
elimination of large-volume bronchial bleeding, reduction
.of acute infective episodes, and improved quality of life
Lung transplantation
is now considered a viable option in advanced
.cases
Miscellaneous
vaccinations against Str. pneumoniae and influenza
.Smoking cessation should be emphasized as amatter of routine
If evidence of exercise and/or nocturnal desaturation should be
considered for oxygen supplementation to delay the onset of
pulmonary hypertension and cor pulmonale and improve exercise
.tolerance