8.6 Pathophysiology, Diagnosis & Treatment of Bronchiectasis Flashcards
Describe the history findings of bronchiectasis
- Productive cough
- Chronic/recurrent episodes [>3] each leasting >4 weeks
- Could have dyspnoea wheeze, growth failure etc.
Aside from its clinical syndrome, what else is needed to diagnose bronchiectasis? If this is not present, what is the new diagnosis?
Needs radiographic features of HRCT
With: bronchiectasis
Without: Chronic suppurative lung disease
What is meant by a suppurative cough
A cough where purulent sputum (i.e. sputum containing pus) is produced
What is the pathological description of bronchiectasis?
Permanent and abnormal dilation of the bronchi; usually in the context of chronic airway infection causing inflammation
HRCT diagnostic features of bronchiectasis
- Diameter of bronchi wider than pulmonary arteries
- Failure of bronchi to taper, causing:
- Visualisation of bronchi in outer 1-2cm of the lung fields
Describe the ‘cycle of bronchiectasis’, starting from inflammation
- Inflammation
- Abnormal airway function
- Infection
- Thickened airway secretions
What innate immune cells are primarily involved in the inflammatory response during bronchiectasis
Neutrophils
Describe the pathophysiology of bronchiectasis
- Impaired drainage, airway obstruction, or a defect in host defense
- Immune effector cells and inflammatory cytokines activated
- Transmural inflammation, mucosal oedema, ulceration in airways
Abnormal airway function can start the cycle of bronchiectasis. What are some ways that this can occur?
- Cystic fibrosis
- Ciliary dyskinesia
Infection can start the cycle of bronchiectasis. What are some ways that this can occur?
Recurrent pneumonia;
- Post-obstruction (e.g. inhaled foreign body)
- Post infection (tuberculosis, adenovirus)
Thickened airway secretions can start the cycle of bronchiectasis. What is one way this can occur?
- Young syndrome (thick production of mucus)
Inflammation can start the cycle of bronchiectasis. What are some ways that this can occur?
- Systemic inflammatory disease (e.g. sarcoidosis)
- Recurrent small volume aspiration (e.g. gastric contents)
- Chronic infection (e.g. TB)
List some common respiratory diseases that can be comorbid with bronchiectasis
- COPD
- Pulmonary fibrosis
- Pneumoconiosis
Is bronchiectasis more common in men or women?
Women
After the age of 60, by what factor does the risk of bronchiectasis increase?
8 to 10
Sputum-related questions to ask during a history
- Volume
- Nature
- Colour
- Frequency
History symptoms indicative of bronchiectasis
- Sputum/haemoptysis
- Dyspnoea/exercise intolerance
- Impaired sleep quality
- Systemic infection (fever/sweats/fatigue)
- Poor appetite/underweight
Vaccines that are important for reducing risk/worsening of bronchiectasis
- Flu
- Pneumococcus
- COVID
Focused history questions for cystic fibrosis
- Family history
- Pancreatitis
- Difficulty maintaining weight (not so much any more)
- Male infertility
Focused history questions for underlying immune deficiency/ciliary dyskinesia
- Recurrent sinusitis
- Extrapulmonary infections (discharging ears/severe dermatitis)
- Male infertility
Focused history questions to ask for recurrent aspiration
- Cough and or choking when eating?
- Cough when laying down/during the night?
List some respiratory comorbidities of bronchiectasis
- COPD
- Asthma
- Pulmonary fibrosis
- MSK issues
How can MSK issues cause bronchiectasis?
- Inability to cough
- Reduced ability to clear irritants/pathogens
- Starts bronchiectasis cycle
How can pulmonary fibrosis cause bronchiectasis?
- Fibrotic tissue
- Creates traction bronchiectasis
- Leads to abnormal airways, and therefore starts the bronchiectasis cycle
Exam findings that are suggestive of bronchiectasis
- Over/underweight
- Clubbing
How can dyspnoea lead to deconditioning and obesity?
- Reduced physical activity
- Leads to deconditioning and weight gain
- Therefore, also causes obesity
What lung sounds are suggestive of bronchiectasis?
Coarse crackles
Underlying diseases that may be found on physical exam for bronchiectasis
- CF (portal hypertension)
- Rheumatological (skin nodules etc.)
- Infection
Investigations for bronchiectasis
- Sputum culture
- CXR
- HRCT
- Lung function (spirometry/DLCO)
Plus or minus:
- 6 minute walk
- ABG
List some HRCT findings of bronchiectasis
- Sputum plugging
- Dilated bronchi
What condition can upper lobe bronchiectasis be reflective of?
Cystic fibrosis
What does sweat test record? If it is elevated, what condition is thought to be more likely?
- It tests for chloride ions
- If chloride is elevated: cystic fibrosis
What is oesophageal pH testing commonly used to diagnose? Why is it considered uncomfortable.
- It is used to diagnose GORD
- Uncomfortable, because it requires a nasogastric tube
Goals of bronchiectasis treatment
- Improve quality of life
- Reduce morbidity and mortality
- Address underlying causes]
- Control exacerbations
How does positive expiratory pressure (PEP) help with airway clearance?
- Creates gas behind mucous
- Helps to push it forward and out of the airways
What is the role of physiotherapists in airway clearance
Can teach exercises and assist in the clearance of mucous from airways
Why are nebulized and inhaled bronchiectasis treatments difficult for most patients to access
- They are not on the PBS
- Therefore, many patients are unable to afford them
Why is it easy for patients to become dependent on prednisolone?
It makes people feel good, and is addictive
Bronchial hyper-reactivity is sometimes cormorbid with bronchiectasis. How can this be tested for and treate?
Tested:
- Mannitol challenge (increasing amount of bronchoconstrictor)
- Spirometry
Treated:
- Inhaled corticosteroids
- Bronchodilators
List some high-risk activities/occupations for patients with bronchiectasis
- Gardening
- Building industry
- Healthcare industry
- Animals
- Tropical regions
List the five main aspects of bronchiectasis treatment
- Physiotherapy
- Management of acute exacerbations
- Psychological help
- Vaccinations
- Palliative care/surgical help
