Bronchiectasis

Question 1

Define Bronchiectasis

Answer 1

Chronic dilation of the bronchi due to destruction of the elastic and muscular components of the bronchial wall, leading to impaired mucocilliary clearance and frequent bacterial infections

Question 2

Aetiology of Bronchiectasis

Answer 2

Severe inflammation in the lung causes fibrosis and dilation of the bronchi
Followed by pooling of mucous, predisposing to further cycles of infection, damage and fibrosis to the bronchial walls

Post-infectious (30%)
Prior childhood resp. Infections due to viruses e.g. measles, influenza, pertussis, whooping cough

Immunodeficiency - Ig deficiency, HIV infection

Genetic - Cystic fibrosis, Kartagener’s syndrome (autosomal recessive - ciliary dyskinesia, situs inverts, Cronic sinusitis), alpha-1 antitrypsin deficiency

Aspiration or inhalation

Connective tissue disease e.g. RA, Sjogrens

IBD

COPD and asthma

Question 3

Symptoms of Bronchiectasis

Answer 3

Productive cough with purulent sputum or haemoptysis 
Breathelessness/dyspnoea 
Chest pain
Malaise
Fever
Weight loss 

Symptoms often begin after acute resp. Illness

Question 4

Signs of Bronchiectasis on examination

Answer 4

Clubbing
Coarse crepitations (usually at the bases) which shift with coughing
Wheeze, high-pitch inspirations squeaks

Question 5

Investigations for Bronchiectasis

Answer 5

HRCT: Dilated bronchi with thickened walls, Signet ring sign

Sputum C+S: causative factor e.g. pseudomonas, H. Influenzae, s. Aureus etc.

FBC: Raised WCC, raised eosinophil (bronchopulmonary aspergillosis), raised neutrophils in superimposed infection
Rheumatoid factor: rule out RA
Pulmonary function tests: Reduced FEV1, Elevated residual volume/total lung capacity
Immunoglobulins: rule out immunodeficiency
Sweat chloride: rule out cystic fibrosis

CXR: Dilated bronchi (tram line shadows), fibrosis, atelectasis, pneumonic consolidation, may be normal
Thickened bronchial walls
Ring shadows (thickened airways seen end-on)
Volume loss secondary to mucous plugging
Air-fluid levels may be visible within dilated bronchi

Question 6

Management for chronic Bronchiectasis

Answer 6

Conservative: Exercise + improve nutrition, vaccinations - esp. flu

Airway clearance therapy: physiotherapist, high frequency oscillation, nebuliser hypertonic saline
Inhaled bronchodilator
Mucoactive agent e.g. carbocysteine
Consider prophylactic Abxs (oral or aerosolise) for frequent exacerbation (>3/year)

Question 7

Management for a Bronchiectasis acute exacerbation

Answer 7

2 IV antibiotics (should have pseudomonas efficacy)
Inhaled corticosteroids e.g. flute as one
Bronchodilators e.g. salbutamol, ipratropium

Airway clearance therapy: hydration, postural drainage, percussion, vibration, oscillatory device use

Physiotherapist, exercise, improve nutrition

Life threatening haemoptysis: Bronchial artery embolisation
Severe: Lung resection or transplant

Question 8

Complications of Bronchiectasis

Answer 8

Life-threatening haemoptysis 
Persistent infections
Emphysema 
Resp. Failure 
Cor pulmonale 
Multi-organ abscesses