Bronchiectasis + Fungal Flashcards
What is bronchiectasis
Permanent irreversible dilatation of the bronchi + airways
Due to damaged caused by chronic infection or inflammation
What leads to more damage after initial insult
Impaired ciliary clearance Accumulation of secretion / mucous Leads to obstruction Microbial colonisation Leads to dilatation, scarring and obstruction Leads to vicious circle and more damage
What causes bronchiectasis
Post infection
- Bacterial - pneumonia can cause specific area
- Viral - serious childhood illness important - pertussis
- Mycobacterial - TB / non-TB
Immune deficiency = more vicious and prolonged inflammation
- Primary
- Secondary - HIV
APBA
- Hypersensitivity to specific fungal
- Common in asthmatic
Systemic
- RA, IBD, sarcoid, yellow nail
Impaired mucociliary dysfunction
- CF
- Primary ciliary dyskinesia
- Kartagener’s (organs on wrong side)
Bronchial obstruction
- Tumour
- FB
Other lung
- COPD
- Fibrosis
What are the symptoms of bronchiectasis
Chronic cough
Purulent sputum
Recurrent chest infection
Airflow obstruction on spirometry
Other daily Sx Cough Wheeze SOB Pleuritic chest pain Intermittent haemoptysis - Often with exacerbation Lethargy Weight loss Fever Coarse crackles Clubbing
What can you get on top of bronchiectasis
Recurrent infection
- H.influenza
- Pseudomona’s
- Influenza
- Klebsiella
- S.pneumonia
- S.aureus
- Aeruginosia
How do you Dx bronchiectasis
What do you do if haemoptysis
History and exam Bloods Sputum culture Spirometry CT thorax = gold standard CXR Spirometry = obstructive Bronchoscopy for haemoptysis / check no obstructing lesion
What are other tests you can do
CF genotype Primary ciliary dyskinesia Serum total IgE Aspergillosis Serum Ig
What does CT show
Signet ring
Thickened wall
Traction
Tramline - parallel lines
How do you treat bronchiectasis
When do you give long-term Ax
When is surgical eiciion recommended
Address underlying cause
Clear sputum
Treat infection
Conservative Chest physio - good for non-CF - Very important - Allows postural drainage of mucous Pulmonary rehab Specialist nurse / dietician
Medical Mucolytic Ax if exacerbation / long term >3 exacerbations in a year Bronchodilator drugs e.g. neb SABA Influenza and pneumococcal vaccine
Surgical
Surgical excision if local / severe hemoptysis
Transplant if fit and <65
What is specific treatment
Relieve obstruction
Iv Ig replacement
Steroids for APBA
What are complications of bronchiectasis
More prone to infection Infective exacerbation Haemoptysis - Due to exacerbation - mostly mild - Can be due to enlarged blood vessels Pneumonia Pleural effusion Pneumothorax Cerebral abscess
What do you want to know in Hx of PC of bronchiectasis
Resp symptoms Breathlessness - Always quantify how far can walk now / last year Recurrent infection Systemic Sx for cause - weight loss - joint pain - diarrhoea - sinusitis - GORD
PMH / DH / Hx / FH
Birth - resp support / pre-term Childhood illness Asthma Other infections Previous transplant Immunosuppression / chemo Inhaler use FH resp infection / bronciectaiss
What could you ask that may prompt certain investigation
Fertility
What bloods
Basic blood RF Total IgE IgE to aspergillus (sign of ABPA) Total IgG - can replace if deficeicny HIV / specific Ab
What do you send sputum for
MC+S
AFB
Why is spirometry useful
See baseline and decline
What is important to do in infection exacerbation
Check last sputum culture to see organism cultured Look right back Give longer course of Ax - 10-14 days Mucolytics Diet support
What do you do for haemoptysis
ABCDE Call for help Ax Tranexamic acid CT aorta to visualise bronchial artery Arterial emoblization if bleeding from there May need intubation and ventilation Lobectomy Palliation
Why is it dangerous
Clots of blood can block airway
Even small amounts can be life threatening
What causes the haemoptysis
Infection damaging airway
Cough = trauma
Engorged blood vessels - common in CF / ABPA which rupture
What is useful Q
How far can you walk and for how long
What are important organisms to know
Pseudomona eruginosa
Non TB mycobacteria
Aspergillus fumigateurs
Why is psuedomona important
Prongostic indicato if colonised
Naturally resistant to most oral Ax so always look back to see if grown
What Ax
Quinolones - ciprofloxacin
Usually neb or IV
Why is nonTB importat
Causes deterioration in symptoms and lung function
Requires very long Rx
Grow on AFB
Why is aspergillum fumitas important
Cause of ABPA
Can cause dilated bronchial artery and massive rupture
What is an exam question about ABPA
Bronchiectasis with raised IgE
What is ABPA
Type 1+3 hypersensitivity to aspergillus spores
What are the Sx
Wheeze Cough SOB May be labelled as asthmatic but progresses Bronchiectasis develops due to damage Recurrent pneumonia
What puts you at higher risk
Asthma
CF
How do you Rx
Steroid in attack
Bronchodilator
Intracanazole
What are complications
Aspergilloma (fungal ball)
What is aspergilloma
Fungal ball that forms in pre-existing cavity
- TB / sarcoid / emphysema
What are Sx
Cough Haemoptysis Lethargy Weight loss No response to. Ax
How do you Rx
CXR - round opacity
Sputum culture
Aspergillis skin test
How do you Rx
Surgical excision
Oral Icanazole
What puts you at risk of invasive fungal
Immunocompromised HIV Leukaemia Wegners SLE Broad spec Ax
How do you Dx
BAL
Sputum culture
Biopsy = Dx
CXR show abscess or consolidation
How do you Rx
IV anti-fugal
Other fungal lung
Asthma = type 1 to fungal spore
Extrinsic allergic alveolitis
Candida
Cryptococcus
