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Y3 Medicine: Respiratory > Bronchiectasis > Flashcards

Bronchiectasis Flashcards

1
Q

What is bronchiectasis?

A

Bronchiectasis is the permanent dilation of bronchi due to the destruction of the elastic and muscular components of the bronchial wall.

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2
Q

What are the causes of bronchiectasis?

A

The most common cause is previous severe lower respiratory tract infection such as pneumonia, pertussis, pulmonary tuberculosis, mycoplasma, influenza, or other viral infection.

Other causes of bronchiectasis include:

  • Aspiration or inhalation injury
  • COPD and asthma
  • Disorders of mucociliary clearance e.g. CF, primary ciliary dyskinesia
  • Immunodeficiency
  • Endobronchial tumours
  • Allergic bronchopulmonary aspergillosis (ABPA)
  • Connective tissue disorders e.g. rheumatoid arthritis
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3
Q

What are the symptoms of bronchiectasis?

A
  • Sputum production (75% of people)
  • Dyspnoea (60% of people)
  • Fever
  • Fatigue
  • Reduced exercise tolerance.
  • Haemoptysis
  • Rhinosinusitis
  • Weight loss
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4
Q

What are the signs of bronchiectasis?

A
  • Coarse crackles, especially in the lower lung zones
  • Wheeze
  • High-pitched inspiratory squeaks
  • Large airway rhonchi (low pitched snore-like sounds)
  • Palpable chest secretions on coughing or forced expiratory manoeuvre, persisting over time
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5
Q

What investigations should be ordered for bronchiectasis?

A
  • CXR
  • High resolution chest CT (HRCT)
  • FBC
  • Sputum culture and sensitivity
  • Pulmonary function tests
  • Serum alpha-1 antitrypsin pnenotype and level
  • Serum immunoglobulins
  • Sweat chloride test
  • Rheumatoid factor
  • Serum HIV
  • Nasal nitric oxide (NO)
    *
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6
Q

Why investigate CXR?

A

Findings are non-specific and often non-diagnostic, but may show characteristic volume loss obscuring the underlying hemidiaphragm, tram lines, and tubular or ovoid opacities.

Thin-walled ring shadows with or without fluid levels may also be present.

Although chest CT scan is the diagnostic procedure of choice, CXR (posteroanterior and lateral) is sufficient for subsequent monitoring.

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7
Q

Why investigate high-resolution chest CT?

A

Recommended for all patients.

Shows dilation of bronchi with or without airway thickening.

In cross-sectional appearance, the bronchi are larger than their adjacent pulmonary artery (signet ring sign).

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8
Q

Why investigate FBC?

A

The WBC count will aid in determining the presence of a superimposed infection.

If the eosinophil count is high, an underlying allergic bronchopulmonary aspergillosis is possible.

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9
Q

Why investigate sputum culture and sensitivity?

A

Frequently, a pathogenic organism can be recovered in the sputum. There may be single or multiple pathogens present. The most common gram-negative organism is Pseudomonas aeruginosa, present in about 25% of patients; it may be in mucoid form.

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10
Q

Why investigate pulmonary function tests?

A

Reduction of the FEV₁ suggests the presence of infection or worsening bronchiectasis.

Spirometry recommended with most surgery visits.

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11
Q

Why investigate serum alpha-1 antitrypsin level and phenotype?

A

Recommended to identify alpha-1 antitrypsin disease as underlying aetiology in patients with co-existing basal panacinar emphysema.

Referral for consideration of replacement therapy is suggested if abnormal phenotype or level.

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12
Q

Why investigate serum immunoglobulins?

A

Immunoglobulin levels (serum total IgG, IgM, and IgA), IgG subclasses (IgG1, IgG2, IgG3, IgG4), and response to Pneumovax vaccine with Strep pneumo 23 serotype titres are recommended to identify individual immunoglobulin deficiencies as underlying aetiology.

Immunoglobulin replacement reduces the frequency of infectious episodes and prevents further destruction of the airways.

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13
Q

Why investigate sweat chloride test?

A

An abnormal test is diagnostic for cystic fibrosis. Recommended for all children and for adults in whom there is a high index of suspicion since patients may present with variant forms of cystic fibrosis in adulthood.

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14
Q

Why investigate rheumatoid factor?

A

The prevalence of bronchiectasis is increased in patients with rheumatoid arthritis compared with the general population.

The symptoms of bronchiectasis may precede other systemic findings in rheumatoid arthritis.

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15
Q

Why investigate serum HIV?

A

Recommended in all patients.

Patients with HIV infection are predisposed to developing recurrent sinopulmonary infections and bronchiectasis, which is probably due to abnormal B-lymphocyte function.

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16
Q

Why investigate nasal nitric oxide (NNO)?

A

Recommended for the diagnosis of primary ciliary dyskinesia (PCD) in cooperative patients 5 years or older with a clinical phenotype consistent with PCD and with cystic fibrosis excluded.

17
Q

How may an acute exacerbation of bronchiectasis present?

A

An acute exacerbation typically presents as worsening of cough, change in sputum colour, increase in sputum volume, fever or malaise.

18
Q

Briefly describe the treatment options for bronchiectasis

A
  • Exercise and improved nutrition
  • Airway clearance therapy
  • Inhaled bronchodilator?
  • Mucoactive agent?
19
Q

What is the aim of bronchiectasis treatment?

A

The goal of treatment is to decrease baseline clinical symptoms of cough, sputum production, and dyspnoea, to improve quality of life, to decrease the number of acute exacerbations, and to prevent progression of airway damage.

20
Q

Briefly describe airway clearance therapy

A

Airway clearance therapy includes maintenance of oral hydration, postural drainage, percussion, vibration, and the use of oscillatory devices. A primary goal is bronchopulmonary hygiene.

Therapy is generally recommended for 15 to 30 minutes, 2 or 3 times daily. Many of these interventions require the assistance of a carer.

21
Q

When may lung transplantation to treat bronchiectasis be considered?

A

Referral for lung transplantation should be considered in patients with bronchiectasis aged 65 years or younger if their FEV₁ is <30% and they have significant clinical instability or if they have a rapidly progressive respiratory deterioration despite optimal medical management.

22
Q

Briefly describe the treatment for an infective exacerbation of bronchiectasis

A
  • Antibiotic therapy
    • Mild to moderate underlying disease: oral
    • Severe underlying disease: IV
  • Increased airway clearance
  • Continue maintence therapy
23
Q

What empirical antibiotic treatment is used for an infective exacerbation of bronchiectasis?

A

Previous microbiology cultures, where available, should guide antibiotic choice.

When previous microbiology cultures are not available:

  • Prescribe amoxicillin 500 mg three times a day for 10 days.
  • Alternatives for adults with a true allergy to penicillin are clarithromycin 500 mg twice a day for 7–14 days or doxycycline 200 mg on the first day and then 100 mg once a day for a total of 7–14 days.
24
Q

What are the complications of bronchiectasis?

A
  • Massive haemoptysis
  • Respiratory failure
  • Cor pulmonale
  • Ischemic stroke
25
Q

What differentials should be considered for bronchiectasis?

A
  1. COPD
  2. Asthma
  3. Pneumonia
26
Q

How does bronchiectasis and COPD differ?

A

Differentiating signs and symptoms:

  • Diminished breath sounds, characterising COPD, are not found in bronchiectasis
  • In bronchiectasis, rhonchi may be auscultated, but with additional inspiratory squeaks and crackles

Differentiating investigations:

  • Chest CT may be normal or show emphysema in COPD, as opposed to the characteristic abnormal results found in bronchiectasis (thickened, dilated airways with or without air fluid levels, varicose constrictions along airways, ballooned cysts at the end of a bronchus, and/or tree-in-bud pattern)
  • Patients with COPD may also develop bronchiectasis
27
Q

How does bronchiectasis and asthma differ?

A

Differentiating signs and symptoms:

  • Inspiratory squeaks and crackles, often present in bronchiectasis, are not present in asthma

Differentiating investigations:

  • Chest CT may show thickened airways but lack the enlarged or widened airway (signet ring sign) seen in bronchiectasis (thickened, dilated airways with or without air fluid levels, varicose constrictions along airways, ballooned cysts at the end of a bronchus, or tree-in-bud pattern)
  • Airflow obstruction is often reversible in asthma
28
Q

How does bronchiectasis and pneumonia differ?

A

Differentiating signs and symptoms:

  • Patients with pneumonia describe symptoms of short duration (7 to 10 days) as opposed to years in bronchiectasis
  • Auscultation findings (rhonchi, wheezing, crackles) may be similar in bronchiectasis and pneumonia (especially multi-lobar pneumonia)
  • Bronchial breath sounds, which are characteristic of pneumonia, are not present in bronchiectasis

Differentiating investigations:

  • CXR and chest CT results in pneumonia are quite variable and often depend on aetiology
  • In bronchiectasis, there is characteristic dilation of bronchi with or without airway thickening
  • Consolidation, which is seen in pneumonia, is not seen in bronchiectasis

Y3 Medicine: Respiratory (15 decks)

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