Bronchiectasis

 Defined: persistent abnormal dilation of the

bronchi.

 Usually occurs in conjunction with other

respiratory conditions

 Begins, most often, in childhood; symptoms

apparent much later

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Bronchiectasis

 Can be caused by:

 Obstruction of an airway, i.e. mucus plugs
 Atelectasis
 Aspiration of a foreign body
 Infection
 Cystic Fibrosis
 Tuberculosis
 Congenital weakness of bronchial wall
 Impaired defense mechanisms

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Bronchiectasis

Symptoms begin slowly, usually after a respiratory

infection, and worsen gradually over a period of
years.

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Bronchiectasis

 Pathophysiology

Bronchial dilation may be:

CYLINDRICAL… symmetrically dilated airways
Seen after pneumonia
Reversible
SACCULAR… bronchi are large (balloons)
VARICOSE… constrictions & dilations deform the
bronchi.

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Bronchiectasis
 Pathophysiology

 In Varicose & Saccular Bronchiectasis, smaller bronchial

divisions are plugged with secretions or are obliterated by
fibrosis.

 Large connections develop between bronchial and

pulmonary blood vessels, increasing blood flow through
bronchial circulation.

 HEMOPTYSIS

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Bronchiectasis

 Pathophysiology

 Bronchospasm & purulent mucus – from

airway damage.
 hypoxemia
 ↑PaCO2 – in severe cases

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Bronchiectasis

 Signs & Symptoms:

 Cupfuls of purulent sputum

 Hemoptysis
 Clubbing of fingers
 Persistent crackles over lung bases

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Bronchiectasis

 Associated with Bronchitis and Atelectasis

 Hypoxemia leads to Cor Pulmonale

 Diagnosed by CXR and CT

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Bronchiectasis

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Bronchiectasis

 Treatment:

 Remove secretions
 postural drainage

 Prevent infections
 antibiotics

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Cor Pulmonale

 Right Ventricular Enlargement

 Hypertrophy
 Dilation
 Or… Both

 Secondary to Pulmonary Hypertension

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Cor Pulmonale

 Pathophysiology
 Pressure overload in Right Ventricle
 Acute hypoxemia (pneumonia) can exaggerate
Pulmonary HTN and dilate the ventricle.
 Right ventricular filling pressures are normal until
failure occurs.
 Right ventricle fails when PAP EQUALS systemic
blood pressure.

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Cor Pulmonale

 Clinical Manifestations:

 Cardiac Output ↓ with exercise

 EKG: Right Ventricular Hypertrophy
 Chest Pain
 2nd heart sound (d/t pulmonic valve closure)
 Tricuspid or pulmonic valve murmur
 Edema, liver congestion, JVD
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Cor Pulmonale

 Treatment:

 Decrease workload on the Right ventricle

 Lower pulmonary artery pressure
 O2, Digoxin, Diuretics
 Treat underlying cause!

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Questions:

 1. Bronchiectasis is defined as:

 A. Inadequate alveolar ventilation

 B. Ventilation exceeding metabolic demand
 C. Abnormal dilation of bronchi ☺
 D. Decreased arterial oxygenation

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Questions:

 2. The most common cause of

Bronchiectasis is:

 A. α- 1 anti-trypsin deficiency
 B. Cigarette smoking
 C. Recurrent bronchial infections ☺
 D. Air pollution

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Questions
 3. Cor Pulmonale:

 A. Occurs in response to long-standing

pulmonary hypertension.
 B. Is right heart failure.
 C. Is manifested by altered tricuspid and
pulmonic valve sounds.
 D. A and B are correct.
 E. A, B, and C are correct. ☺

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Questions

 4. Treatment of Bronchiectasis includes:

 A. Postural drainage & antibiotic therapy ☺

 B. O2 at 6L/min for 3 consecutive days
 C. Relieving elevated PA pressures
 D. Closing the AaDO2 gradient

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Questions:
 5. A 54 y.o. patient presents with chest pain, right
ventricular hypertrophy on the EKG, pulmonic valve
murmur, peripheral edema, and pronounced JVD.
Your primary course of treatment anticipated would
be:

 A. NTG drip, 1000 cc fluid bolus, ADA diet

 B. Digoxin therapy, 02 NC, Lasix ☺
 C. O2 NC, metabolic study, HCTZ
 D. Heparinization, stat V:Q scan, strict bed rest

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 Lung Abscess

Definition

Pulmonary abscess is a localized area of

liquefactive necrosis of the lung. This would
then include necrotizing gram negative and
gram positive pneumonias eg. Klebsiella,
Staph, Pseudomonas etc. However, by
convention we reserve the term lung abscess
for necrotizing anaerobic pneumonia.

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 Prerequisites and Predisposing Conditions
Aspiration of a Large Bacterial Inoculum:
The aspiration of oropharyngeal contents with a bacterial bolus inoculum
is the prerequisite for development of lung abscess.
Loss of Cough Reflex:
If the cough reflex is intact, significant aspiration is not possible unless it
is overwhelming. Altered sensorium is the most common state when
cough reflex is suppressed, thus CVA, drug overdose, alcoholism, post-op
state or coma from any cause is the most common predisposing factor for
lung abscess.
Trouble with Deglutition:
This occurs with neurological disorders and esophageal diseases.
Aspiration to lungs is frequent in this situation even if the cough reflex is
intact. In many of the Esophageal diseases the mode of presentation is
Lung abscess.
Post Obstructive Pneumonia:
Lung abscess can occur as a complication of post obstructive pneumonia
as seen in some patients with lung cancer or foreign body aspiration.

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 Clinical Picture

•Most of the patients present with subacute onset of

illness and do not seek medical attention for three to
four weeks since the onset of illness.
•Patients complain of cough, low grade fever, anorexia
and weight loss of few weeks duration .
•Patients often have cough with large amounts of foul
smelling sputum.
•Lack of foul smell does not exclude lung abscess, as
50% of anaerobic infections do not produce a foul
smell.

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 Pathology

The abscess is characterized by destruction of

lung tissue forming a cavity. The cavity is filled with
pus (necrotic debris/liquid) or pus and gas (air).
The content of the abscess is extremely foul
smelling. The abscess may be large or small,
single or multiple. The abscess(s) may occur in
any part of the lung.

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Etiology/Pathogenesis
A variety of microorganisms may cause a
lung abscess, but more than 60% of cases
are associated with anaerobic organisms
found normally in the oral cavity. There are
many mechanisms for the development of a
lung abscess but the most frequent
mechanism is aspiration of infective
(contaminated with microorganisms)
material.

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Pathophysiology
Fever, cough producing large
quantity of foul-smelling,
purulent sputum; weight loss,
chest pain and clubbing

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 Method of Obtaining Specimen

The options are as follows:

Sputum Gram Stain:

May occasionally be helpful if there is a large number of white blood cells
and bacteria consistent with oropharyngeal flora.

Bronchoscopy:
Triple lumen catheter: Routine aspirates during bronchoscopy is
useless for anaerobic cultures. The bronchoscope passes through
oropharynx and will be contaminated by the oropharyngeal flora. You
need to use triple lumen catheter to avoid contamination and obtain
material selectively from the involved segment.

Bronchial lavage:
lavage The second option is to obtain a bronchial lavage
from the involved segment and perform quantitative bacterial
cultures.

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 Abscess in
the left
upper lobe
of the lung.

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 Lung abscess
involving the superior
segment of the left
lower lobe.

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Penicillins have been the standard treatment for
anaerobic pleuropulmonary infections.
Penicillin (amoxicillin, 500 mg every 8 hours, or penicillin
G, 1–2 million units intravenously every 4–6 hours) plus
metronidazole (500 mg orally or intravenously every 8–
12 hours)
Antibiotic therapy should be continued until the chest
radiograph improves, a process that may take a month or
more

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