Bronchiectasis Flashcards
When should you suspected bronchiectasis in adults
Persistent production of mucopurulent sputum
Persistent cough(> 8 weeks)
Rheumatoid arthritis if symptoms of chronic productive cough or recurrent chest infections
COPD with frequent exacerbations
Poorly controlled asthma
IBD and chronic productive cough
Clinical features of bronchiectasis
Large volumes of purulent sputum Dyspnoea Fever Fatigue Haemoptysis that can be frank Weight loss Chest pain
What might you find on examination in an individual with bronchiectasis
Coarse crackles, especially in lower lung zones Wheeze High-pitched inspiratory squeaks Large airway rhonchi Palpable chest secretions on coughing Finger clubbing
What is bronchiectasis
Is a permanent dilatation and thickening of the airways, characterised by chronic cough, excessive sputum production, bacterial colonisation and recurrent acute infections
Bronchiectasis aetiology
Cystic fibrosis Post-infection(childhood respiratory viral infections) Immunodeficiency(HIV) Connective tissue diseases(RA) Asthma Immotile ciliary syndrome
Appropriate investigations for bronchiectasis
Sputum culture CXR Spirometry Oxygen sats levels FBC
Investigations for bronchiectasis in secondary care
High-resolution computed tomography(HRCT)
Testing for cystic fibrosis(sweat chloride or gene testing)
Screening for gross antibody deficiency
Serum total immunoglobulin IgE and specific IgE or skin prick test to aspergillus
Which patients with bronchiectasis should be followed up in secondary care
3 or more exacerbations in a year
Chronic pseudomonas aeruginosa, MRSA, or non-TB colonisation
Deteriorating bronchiectasis with declining lung function or advanced disease
Allergic pulmonary aspergillosis
Associated RA, immunodeficiency, IBDetc
Gold standard radiological investigation for diagnosis of bronchiectasis
High resolution CT of the chest
Very high sensitivity and specificity for diagnosis
HRCT features of bronchiectasis
Bronchial wall dilation
Bronchial wall thickening
Why is it necessary to obtain respiratory tract specimens in patients with bronchiectasis
To maximise chances of isolating H.influenzae and S.pneumoniae
What does persistent isolation of S.aureus(or P.aeruginosa in children) indicate
Possible underlying bronchopulmonary aspergillosis or cystic fibrosis
How should patients be tested for aspergillus fumigatus and aspergillosis precipitins
Serum IgE, skin prick testing or serum IgE testing
Use of gastrointestinal investigations in bronchiectasis
Low threshold for GI investigations in children
Gastric aspiration should be considered in patients following lung transplantation
24-hour pH monitoring for those suspected of having bronchiectasis secondary to gastrointestinal reflux or aspiration
When should suspected bronchiectasis be tested for primary ciliary dyskinesia
For children where no other cause for bronchiectasis is identified and if there is a history of continuous rhinitis, neonatal respiratory distress, and/or dextrocardia; and for adults if there is a history of upper respiratory tract problems or otitis media
Use of bronchoscopy in bronchiectasis
Indicated when bronchiectasis affects a single lobe, to exclude a foreign body
In adults with localised disease, it may be indicated to exclude proximal obstruction
Features of general management in bronchiectasis
Healthy diet and physical exercise
Smoking cessation(passive smoking should also be avoided)
Immunisation against influenza and pneumococcus
When should a person with an infective exacerbation of bronchiectasis be admitted to hospital
Significant co-morbidities and/or psychosocial factors Cyanosis Confusion SOB, rapid resp Peripheral oedema Temperature of 38 degrees or higher
Management of bronchiectasis when hospital admission is not required
Reassess and rule out other differentials
Sputum culture
Antibiotic for 7-14 days
Suitable airway clearance technique by resp physiotherapist
Offer trial of long-acting bronchodilator therapy if significant breathlessness
Which antibiotic treatment is suitable in acute exacerbation of bronchiectasis
If microbiology cultures are not available, prescribe amoxicillin
Alternative choice oral antibiotics if at high risk of treatment failure are co-amoxiclav or levofloxacin
Preventative measures for acute exacerbations of bronchiectasis
People with bronchiectasis who have three or move exacerbations per year(azithromycin)
What is the first-line therapy in brochiectasis patients with concurrent pseudomonas aeruginosa infection
Inhaled colistin
What should be investigated before commencing prophylactic oral macrolides
Perform ECG to assess QTc interval
Perform baseline LFTs
Counsel about potential adverse effects, including gastrointestinal upset, hearing and balance disturbance, cardiac effects, and microbiological resistance
Which medication can be used prior to treatment to enhance sputum clearance
Inhaled beta-2 agonists
Non-pharmacological interventions for bronchiectasis
Physiotherapy - airway clearance techniques and exercise
Non-invasive ventilation of intermittent positive pressure breathing
Pulmonary rehabilitation
Sterile water inhalation
Surgical options for management of bronchiectasis
Lung resection surgery in patients with localised disease
Bronchial artery embolisation and/or surgery are first-line therapy for management of massive haemoptysis
Lung transplantation may need to be considered for end-stage disease if pulmonary function is very poor with FEV1 below 30% of predicted
Complications of bronchiectasis
Repeated infection and deteriorating lung function
Empyema
Lung abscess
Pneumothorax
Life-threatening haemoptysis
Respiratory failure
Right heart failure secondary to chronic respiratory disease
Amyloidosis
Conditions which cause decreased mucociliary clearance and should therefore be tested for
Cystic fibrosis
Kartagener’s
HIV
Immunoglobulin deficiency
Which vaccination reduces incidence of bronchiectasis
Pertussis vaccine
Complications of bronchiectasis
Recurrent infections
Life threatening haemoptysis
Cor pulmonale
What is pyemia
Septic focus or embolus in the blood stream
What is empyema
Presence of pus in the pleural cavity
Lobes of lung usually affected by bronchiectasis
Lower lobes
Types of bronchiectasis
Tubular
Cylindrical
Varicose
Cystic
Microscopic findings in bronchiectasis
Bronchial atresia
Inflammatory cells and inflammatory debris
Lung function test findings in bronchiectasis
Obstructive pattern - low FEV1/FVC ratio
CXR findings in bronchiectasis
Usually nonspecific
Might show some filtrates ‘tram-tracking’ dilation of airways
Crowded bronchial markings extending to the periphery
