Bronchiectasis

Question 1

Explain bronchiectasis.

Answer 1

Chronic inflammation of the bronchi and bronchioles leading to permanent irregular dilation and thinning of the airways.

There is more mucus in airways and loss of cilia.

Fibrosis can be seen in surrounding parenchyma as well.

Question 2

Symptoms of bronchiectasis.

Answer 2

Chronically productive cough with large aounts of sputum

Dyspnoea

Rhinosinusitis with blocked nose and post-nasal drip

Fatigue

Haemoptysis (usually streaky but in infection it can become fresh and massive)

Infection

Pleuritic chest pain (can be due to infection)

Coarse crackles

Clubbing especially in CF

Question 3

Bronchiectasis on examination.

Answer 3

Dyspnoea

Coarse crackles usually at the base

Wheeze

Clubbing

Weight loss

Question 4

Complications of bronchiectasis

Answer 4

Penumonia

Pleural effusion

Pneumothorax

Haemoptysis

Cerebral abscess

Amyloidosis

Pulm HTN

Heart failure

Question 5

Causes of bronchiectasis.

Answer 5

CF, Young’s, Primary ciliary dyskinesia, Kartagener’s

Idiopathic

Post-ifectious - measles, pertussis, bronchiolitis, pneumonia, TB, HIV

ASpiration

RA

IBD

Atypical pneumonia

Allergic bronchopulmonary aspergillosis

Hypogammaglobulinaemia

Question 6

Investigations of bronchiectasis.

Answer 6

CXR

HRCT golden standard

Sputum culture

Spirometry

Bronchoscopy

Serum immunoglobulins

CF sweat test

Aspergillus precipitins

Total IgE

Question 7

Findings on CXR.

Answer 7

Cystic shadows

Thickened bronchial walls with tramline tracks and signet ring shadows.

Question 8

Findings on HRCT.

Answer 8

Non-tapering tram track lines.

Broncial wall thickening

Mucous impaction

Increased broncho-arterial ratio > 1.5

Signet ring sign

String of pearl sign

Cluster of grapes sign

Cystic lesions

Air trapping and mosaic perfusion

Question 9

Findings on spirometry.

Answer 9

Obstructive pattern

Question 10

When is bronchoscopy done in bronchiectasis?

Answer 10

To locate site of haemoptysis
To exclude obstruction

Obtain samples for culture

Question 11

Management of bronchiectasis.

Answer 11

Physiotherapy with airway clearance techniques and mucolytics.

Antibiotics.

Patients known to culture pseudomonas will require oral ciprofloxacin or sutiable IV antibiotics.

Flu vaccine

Pulmonary rehab if MRC dyspnoea score 3 or more.

If there are 3 or more exacerbations in a year consider long-term antibiotics.

Bronchodilators

Corticosteroids and itraconazole for ABPA

Surgery if severe haemoptysis

Question 12

Massive haemoptysis can happen in bronchiectasis.

It is a medical emergency.

How should it be treated?

Answer 12

Resuscitation with airway protection until bronchial artery embolisation can be performed to control the bleeding.

If this is not successful surgery might be required.

Question 13

Common organisms in bronchiectasis.

Answer 13

H. influenzae

S. pneumoniae

Pseudomonas aeruginosa

M. catarrhalis

Stenotrophomonas maltophilia

Fungi - aspergillus and candida

Non-tuberculous mycobacteria

S. aureus

Question 14

Define massive haemoptysis

Answer 14

>240 mls in 24 hours

or

>100 mls/ day over consecutive days

Question 15

Management of massive haemoptysis

Answer 15

ABCDE

Lie patient on side of susepceted lesion if it is known

Give oral tranexamic acid for 5 days or IV

Stop NSAIDs, aspirin, anticoag

Abx if evidence of infection

Consider vitamin K

CT aortogram for bronchial artery embolisation might be done