Bronchiectasis

Question 1

What is the pathophysiology of Bronchiectasis?

Answer 1

• Chronic dilatation of one or more bronchi
• Bronchi exhibit poor mucus clearance and predisposition to recurrent or chronic bacterial inflammation
• Disease is characterised by cycle of:
  
  • Neutrophilic inflammation
  • Recurrent infection and damage to airway which impairs mucociliary clearance
  • Persistent inflammation lead to impairment of immunity

Question 2

What is the Aetiology of Bronchiectasis?

Answer 2

• Congenital: pulmonary sequestration, deficiency of bronchial wall elements
• Mechanical Bronchial Obstruction: foreign body, inspissated mucus, tumour, lymph node
• Post-infective Bronchial Damage: bacterial and viral pneumonia, including pertussis, measles and aspiration pneumonia
• Granuloma: tuberculosis, sarcoidosis
• Diffuse Diseases of Lung Parenchyma: idiopathic pulmonary fibrosis
• Immunological Over-response: allergic bronchopulmonary aspergillosis, post-lung transplant
• Immune Deficiency: HIV, Hypogamaglobulinaemia
• Mucociliary Clearance Defects: cystic fibrosis, young syndrome
• Toxic Insult
• Rheumatoid Arthritis

Question 3

What are common causative organisms in Bronchiectasis?

Answer 3

• Haemophilus influenzae
• Pseudomonas aeruginosa
• Moraxella catarrhalis
• Stenotrophomonas maltophilia
• Fungi – aspergillus, candida
• Non-tuberculous mycobacteria
• Less common - Staphylococcus aureus (think about CF)

Question 4

What are investigations done in Bronchiectasis?

Answer 4

• HRCT is investigation of choice
• Chest X-Ray
• Sputum Culture can be useful for focused antibiotic treatment plan
• Immune assessment
• Sweat test and CF genetic assessment in all patient under 40
• Nasal Nitric Oxide for primary ciliary dyskinesia
• Total IFE and Aspergillus-specific IgE or Aspergillus skin prick testing to exclude bronchopulmonary aspergillosis

Question 5

What does HRCT show in Bronchiectasis?

Answer 5

• Increased bronchoarterial ratio signet ring sign
• Shows Non-tapering Tram Track Airways

Question 6

What does CXR show in Bronchiectasis?

Answer 6

Often normal but tram track airways, ring shadows and cysts may be seen

Question 7

What are preventative treatment methods in patients with Bronchiectasis?

Answer 7

• Daily airway clearance therapies: devices to assist such as Flutter or Acapella which provide positive expiratory pressure with or without airway oscillation
• Anti-inflammatories: Long-term Azithromycin to reduce exacerbation frequency and Inhaled corticosteroids beneficial to some patients
• Supportive: Flu vaccine, Bronchodilators if required

Question 8

How are infections in Bronchiectasis treated?

Answer 8

• High dose Ciprofloxacin useful for oral drug treatment of Pseudomonas
• Oral Antibiotics such as Amoxicillin, Co-amoxiclav or Doxycycline for Haemophilus Influenzae
• Multi-resistant species need Intravenous Cephalosporin treatment

Question 9

How are complications treated in Bronchiectasis?

Answer 9

• Pulmonary Rehabilitation offered to patient with reduced exercise capacity and breathlessness
• Surgery can be used for localized disease
• Respiratory Failure treated with oxygen and non-invasive ventilation
• Massive Haemoptysis is a medical emergency.
  
  • Treatment is resuscitation with airway protection until bronchial artery embolization can be performed to control bleeding.
  • Surgery required if not successful

Question 10

What are complications of Bronchiectasis?

Answer 10

• Reduced exercise capacity and breathlessness
• Localized disease
• Respiratory failure
• Massive haemoptysis