Bronchiectasis

Question 1

Define

Answer 1

Chronic infection of the bronchi and bronchioles leading to permanent dilatation of these airways

• → Lug airway disease characterised by chronic bronchial dilatation, impaired mucocilliary clearance and frequent bacterial infections
• Followed by pooling of mucus - predisposing to further cycles of infection, damage and fibrosis to bronchial walls

Main organisms:

1. H. influenza
2. Strep pneumoniae
3. Staph aureus
4. Pseudomonas aeruginosa

Question 2

Causes

Answer 2

Chronic lung inflammation leads to fibrosis and permanent dilation of the bronchi

This leads to pooling of mucus, which predisposes to further cycles of infection, damage and fibrosis of bronchial walls

Causes of bronchiectasis:

• Idiopathic (50%)
• Post-infectious (e.g. pneumonia, whooping cough, TB)
• Host-defence defects (e.g. Kartagener’s syndrome, cystic fibrosis)
• Obstruction of bronchi (e.g. foreign body, enlarged lymph nodes)
• GORD
• Inflammatory disorders (e.g. rheumatoid arthritis)

Question 3

Epidemiology

Answer 3

Most often arises initially in CHILDHOOD

Incidence has decreased with the use of antibiotics

1/1000 per year

Question 4

Presentation

Answer 4

• Productive cough with purulent sputum or haemoptysis
• Breathlessness
• Chest pain
• Malaise
• Fever
• Weight loss
• Symptoms usually begin after an acute respiratory illness

Question 5

Signs

Answer 5

Clubbing

Coarse crepitations (usually at lung bases)

• These shift with coughing

Wheeze

Question 6

Investigations

Answer 6

Sputum

• Culture and sensitivity
• Common organisms:

1. Pseudomonas aeruginosa
2. Haemophilus influenzae
3. Staphylococcus aureus
4. Streptococcus pneumoniae
5. Klebsiella
6. Mycobacteria

CXR

• Dilated bronchi (may be seen as parallel lines going from the hilum to the diaphragm (tramline shadows))
• Fibrosis
• Atelectasis
• Pneumonic consolidations
• May be NORMAL

High-Resolution CT

• BEST DIAGNOSTIC METHOD FOR BRONCHIECTASIS
• Shows dilated bronchi with thickened walls

Bronchography - rarely used

Others: swear electrolytes (for cystic fibrosis), serum Ig, mucociliary clearance study

Question 7

Management

Answer 7

• Treat acute exacerbations with TWO IV ANTIBIOTICS, which cover Pseudomonas aeruginosa
• Prophylactic antibiotics should be considered in patients with frequent exacerbations (> 3/year)

1. Inhaled Corticosteroids (e.g. fluticasone) - reduces inflammation and volume of sputum but does NOT affect the frequency of exacerbations or lung function
2. Bronchodilators - considered in patients with responsive disease
3. Maintain hydration
4. Flu vaccination
5. Physiotherapy - enables sputum and mucus clearance. This can reduce frequency of acute exacerbations and aid recovery
6. Bronchial artery embolisation - if life-threatening haemoptysis due to bronchiectasis
7. Surgical - localised resection, lung or heart-lung transplantation

Question 8

Complications

Answer 8

• Life-threatening haemoptysis
• Persistent infections
• Empyema
• Respiratory failure
• Cor pulmonale
• Multi-organ abscesses

Question 9

Prognosis

Answer 9

• Most patients continue to have symptoms after 10 years