Bronchiectasis

Question 1

Definition

Answer 1

It is an acquired disorder that is characterized by permanent abnormal dilatation and destruction of the bronchial and bronchiolar walls. this pathology is caused by an infectious insult, impairment of drainage, airway obstruction, and/or a defect in host defence.

Question 2

Etiologies

Answer 2

there are multiple aetiologies that can lead to the pathophysiological processes that cause bronchiectasis. these include airway obstruction (e.g. foreign body aspiration), defective host defences, cystic fibrosis (CF), rheumatic diseases, dyskinetic cilia, smoking, pulmonary infections, and allergic bronchopulmonary aspergillosis.

Question 3

Dx

Answer 3

Bronchiectasis has similar features to COPD, including inflamed and easily collapsible airways, obstruction to airflow, and frequent hospitalizations. the diagnosis is usually established clinically on the basis of a chronic daily cough with thick, mucopurulent sputum production, and radiographically by the presence of bronchial wall thickening and dilatation of the bronchi and bronchioles on chest Ct scans.

Question 4

General considerations

Answer 4

• Patients with bronchiectasis need to be as fit as possible before undergoing any major surgery, which will inhibit coughing and impair respiratory function.
• Once established, bacterial infections can be difficult or impossible to eradicate. Pseudomonas aeruginosa is a common pathogen that may be present for many years and be associated with intermittent exacerbations of respiratory symptoms.
• the mainstay of treatment for bronchiectasis is regular physiotherapy, frequent courses of appropriate antibiotics, and treatment of any asthmatic symptoms.

Question 5

Preoperative assessment

Answer 5

• Before elective surgery, the patient should be as fit as possible. this may mean a planned admission for IV antibiotics and physiotherapy prior to surgery.
• Consultation with the patient’s chest physician is essential.
• Send a sputum sample for culture before surgery. Acourse of IV antibiotics and physiotherapy for 3–10d immediately prior to surgery may be necessary. Prior to major surgery, consider starting IV antibiotics on admission. Use current or most recent sputum cultures, with advice from the microbiologist/local protocols, to guide appropriate prescribing. If in doubt, assume that the patient has P.aeruginosa.
• Maximize bronchodilation by converting to nebulized bronchodilators.
• Increase the dose of prednisolone by 5–10mg/d if on long-term oral steroids.
• Postpone elective surgery if the patient has more respiratory symptoms thanusual.

Question 6

Investigations

Answer 6

• In patients with severe disease, check spirometry and bloodgases.
• Send a sputum sample for culture.

Question 7

Conduct ofanaesthesia

Answer 7

• Choose regional above gA where possible.
• Although it is desirable to avoid intubation, this will be necessary for all but the shortest operations to facilitate intra-operative removal of secretions.
• Use short-acting anaesthetic and analgesic agents where post-operative pain is minimal or regional analgesia can beused.
• Extubate and recover in the sitting position.
• Ensure that the patient receives physiotherapy immediately post-operatively.

Question 8

Post-operativecare

Answer 8

• Ensure that regular physiotherapy is available—three times daily (tds), and at night if severely affected.
• Monitor SpO2, giving supplemental O2 to achieve adequate oxygenation (guided by preoperative value).
• Continue appropriate IV antibiotics for at least 3d post-operatively or until discharged.
• Maintain adequate nutrition, especially if any malabsorption.
• Refer to the respiratory physician early if there is any deterioration in respiratory symptoms.