Bronchiectasis and Lung Mass

Question 1

Bonchiectasis What is it?

Answer 1

-Irreversible chronic airway dilatation involving the lung
-May be focal or diffuse
FOCAL: obstruction ie FB or mass
DIFFUSE: Infection, Immunodeficiency (HIV),Genetics (CF, alpha-1 antitrypsin deficiency), Autoimmune or Rheumatologic (RA, Sjogren’s, IBD), Recurrent aspiration, Idiopathic
-Categories: cylindrical, varicose, cystic
-Often leads to recurrent infections*
-Etiology: infectious, noninfectious, idiopathic
Epidemiology:
-incidence increases w/age
-women > men
-adolescence/early adulthood (patients w/CF)
-malnutrition may play a role-developing countries
-higher in areas where Tb is prevalent

Question 2

Bronchiectasis-Pathophysiology

Answer 2

• “Vicious cycle hypothesis”: poor mucus clearance results in colonization of microbes in bronchial tree
• Presence of microbes -> chronic inflammation (release of mediators) -> continued damage to airways -> continued impairment of clearance
• Immune-mediated reactions can also damage the bronchial walls (RA, Sjogren’s)
• Can be caused by a single severe infection (i.e.-pertussis, mycoplasma pneumonia) OR genetic conditions

Question 3

Bonchiectasis Sxs

Answer 3

-persistent, productive cough w/ongoing 	  thick sputum*
PE findings: 
	-wheezing
	-crackles
	-+/-clubbing of digits

Question 4

Bonchiectasis Dx

Answer 4

Dx:

- Typically based on H & P + imaging
- CXR: “tram tracks” (dilated airways), CXR maybe normal in appearance* - CT: “tram tracks”, “signet ring sign”, lack of bronchial wall tapering, bronchial wall 	  thickening, secretions, cysts - Imaging of choice-Chest CT* - Add’l labs to evaluate for underlying pathogen/etiology - PFT’s will likely detect airflow obstruction - Evaluation of focal bronchiectasis almost always requires bronchoscopy to exclude mass

Question 5

Bonchiectasis Tx

Answer 5

Goals:

1. Control active infection (if present)
2. Improve mucus clearance - Antibiotics for exacerbations should target suspected pathogen - Bronchial hygiene-hydration, mucolytics, bronchodilators, chest physiotherapy (chest compression, flutter valve, oscillation vest) - Anti-inflammatories-oral/inhaled steroids may play a role for certain etiologies - In select/advance cases surgery can be considered

Question 6

Lung Abscess

Answer 6

-microbial infection of the lung that leads to tissue death in the lung parenchyma
Classified by:
-progression: acute vs. chronic (4-6 wks dividing line)
-specific pathogen
-absence or presence of underlying lesion
-absence -> primary abscess (i.e.- aspiration, chronic pneumonia, Tb)
-presence (i.e.-tumors, systemic disease) -> secondary abscess
-Non-specific abscess=no pathogen recovered

Question 7

Lung Abscess-Sxs/Signs

Answer 7

Sxs: 
	-gradual infection that evolves (days-wks)
	-fatigue		
	-cough
	-sputum production
	-fever 
	-+/-pleuritic pain (sharp-w/breathing, coughing)
PE findings:
	-fever
	-cough/sputum
	-+/- weight loss
	-+/- night sweats	
	-+/- anemia
	-+/- peridontal disease

Question 8

Lung Abscess-Diagnosis

Answer 8

Dx:

- Abscess can typically be detected on CXR
- Imaging of choice-Chest CT* (more 		helpful for defining borders and location)
- Early stages on CT -> may reveal infiltrate 	  w/central necrosis
- Later stages -> areas of cavitation w/possible air/fluid levels - Microbiologic studies-(gram stains, blood cultures etc.) to detect pathogens - Rarely more invasive techniques are used-(needle biopsies-transthoracic, transtracheal, thoracentesis)

Question 9

Lung Abscess-Tx

Answer 9

Tx:

• Dependent on etiology
• Duration of tx is arbitrary-recommended to continue until lesion has cleared or left a stable scar (often months but shorter courses may be effective)
• Persistence of fever beyond 5-7 days or progression on imaging suggests tx failure-need to evaluate further (consider CT, bronchoscopy)
• Surgery rare-reserved for refractory cases, suspected neoplasm, and bleeding
• Can consider percutaneous drainage-CT guided
• In uncomplicated scenarios-most patients should improve w/in 3-5 days of Abx treatment