Non CF Broncheactasis

Question 1

Ct features of Bronchiectasis

Answer 1

Bronchiectasis is defined by bronchial dilatation as suggested by one or more of the following:
º Bronchoarterial ratio >1 (internal airway
lumen vs adjacent pulmonary artery)

º Lack of tapering

º Airway visibility within 1cm of costal
pleural surface or touching mediastinal Pleural

Question 2

The following indirect signs are commonly associated with bronchiectasis:

Answer 2

º Bronchial wall thickening
º Mucus impaction

º Mosaic perfusion / air trapping on expir-

atory CT

Question 3

in whom should the diagnosis of bronchiectasis be suspected?

Answer 3

persistent production of mucopurulent or purulent sputum particularly with relevant associated risk factors :|( RA , COPD )

COPD with recurrent exacerbation or Psudomonus

IBD

HIV / immunsuppresent medication

Chronic rhinosisistis

GERD

CTD

HEALTY :- cough persistent more than 8 weeks

Question 4

Investigation for Bronchiectasis in Healthy

Answer 4

IF cough with sputum last more than 8 Weeks

Question 5

Investigation of bronchiectasis :-

Answer 5

Baseline :- CBC , full blood , serum total IgE and IgE or skin test for aspergillus

IgM , G , A

baseline specific antibody levels against capsular polysaccharides of Streptococcus pneumoniae in all patients to investigate for specific antibody deficiency. If pneumococcal antibodies are low, immunise with 23 valent polysaccharide pneumococcal vaccine, followed by measurement of specific antibody levels 4–8 weeks later

CF :- in early onset , male inferteilty , malabsorption and pancreatitis

PCD Hx of neonatal distress , sx form childhood , recurrent otitis media rhinosinistiis or infertility

Sputum culture and for TB

Question 6

Suspect of CF :-

Answer 6

CF :- in early onset , male inferteilty , malabsorption and pancreatitis

Question 7

Suspect of PCD

Answer 7

PCD Hx of neonatal distress , sx form childhood , recurrent otitis media rhinosinistiis or infertility

Question 8

Consider bronchoscopy for patients with localised disease to rule out an endobronchial lesion or foreign body as the cause of bronchiectasis.

Answer 8

True

Question 9

A bronchial aspiration or bronchial wash targeting the areas of bronchiectasis from CT scan of the chest should be considered in patients who do not expectorate and can be particularly helpful in the diagnosis of NTM pulmonary disease.

Answer 9

True

Question 10

Serum protein electrophoresis should be performed in all patients with bronchiectasis with raised immunoglobulins.

Answer 10

True

Question 11

Which airway clearance techniques should be taught?

Answer 11

Offer active cycle of breathing techniques or oscillating positive expiratory pressure to individuals with bronchiectasis. (D) Consider gravity assisted positioning (where not contraindicated) to enhance the effectiveness of an airway clearance technique. (D

Question 12

Pt with broncheactasis

Patients should be encouraged to perform regular physical exercise (plus the forced expiration technique/huff) to promote airway clearance.

Answer 12

True

Question 13

How often should patients carry out airway clearance techniques?

Answer 13

Advise individuals to perform their airway clearance technique for a minimum of 10 minutes (up to a maximum of 30 minutes). After this time they should continue until two clear huffs or coughs are completed, or until the patient is starting to become fatigued

Question 14

How soon should the patient be reviewed after the initial assessment?

Answer 14

3 M

Question 15

mucoactives in bronchiectasis Recommendations

➢ ➢

Answer 15

Do not routinely use recombinant human DNase in adults with bronchiectasis. (A) Consider the use of humidification with sterile water or normal saline to facilitate airway clearance

Question 16

What is the evidence for long term anti-inflammatory therapies in bronchiectasis

Answer 16

Do not routinely offer inhaled corticosteroids to patients with bronchiectasis without other indications (such as ABPA, chronic asthma, COPD and inflammatory bowel disease

Do not offer long-term oral corticosteroids for patients with bronchiectasis without other indications

Question 17

What treatments improve outcomes for patients with stable bronchiectasis?

Answer 17

long term antibiotics in patients with bronchiectasis who experience 3 or more exacerbations per year.

Question 18

P. aeruginosa colonised patients

Answer 18

1- Inhaled Colistin / aztronam
2- Gentamicin as second line
3- oral azithromhycin add on inhaled ABx ( If high exacerbation frequency )

Question 19

Non- P. aeruginosa colonised patients

Answer 19

Use azithromycin or erythromycin for patient with bronchiectasis. (A)

f. Consider inhaled gentamicin as a second line alternative to azithromycin or erythromycin. (B)

g. Consider doxycycline as an alternative in patients intolerant of macrolides or in whom they are ineffective.

Question 20

Before starting Macrolide :-

Answer 20

1- rule out active NTM with at least one negative culture
Caution if hearing loss

Question 21

Before inhaled aminiglycosides

Answer 21

Avoid if Creatinine clearance less than 30
Significant hearing loss
Avoid nephro toxic medications \

Question 22

Stepwise therapy of broncheactasis
Step 1

Answer 22

In PIC
Step 1
1- Treat underline cause if Any ( asthma . RA , COPD , GERD , HIV , CF , CDS , IBD )
2- airway clearance technique’s -+ rehabilitation
3- vaccine Influanza
4- abx if excerabtion
5- self management plan

Question 23

Stepwise therapy of broncheactasis
Step 2
IF 3 or more despite step 1

Answer 23

Physiotherapy reassessment and consider mucoactive treatment

Question 24

Stepwise therapy of broncheactasis
Step 3
IF 3 or more despite step 2

Answer 24

1) If Pseudomonas aeruginosa, long term inhaled antipseudomonal antibiotic or alternatively long term macrolide

• 2) If other Potentially Pathogenic Microorganisms, long term macrolides or alternatively long term oral or inhaled targeted antibiotic

• 3) If no pathogen, long term macrolides

If
Step 4

Long term macrolide and long term inhaled antibiotic

Question 25

If 5 or more exacerbations/yr despite Step 4* ( oral and inhaled abx 0

Answer 25

Consider regular intravenous antibiotics every 2-3 months

Question 26

Offer pulmonary rehabilitation to individuals who are functionally limited by shortness of breath (Modified Medical Research Council (MMRC) Dyspnoea Scale ≥ 1).

Question 27

What is the role of surgery in managing bronchiectasis?

Answer 27

Consider lung resection in patients with localised disease whose symptoms are not controlled by medical treatment optimised by a bronchiectasis specialist.

Question 28

Lung transplantation for bronchiectasis

Answer 28

Conisider in patient aged 65 or less IF :-
FEV less than 30
With significant instability
Or rapid progressive respiratory deteriortation despite optimal medical therapy

Consider earlier transplant referral in bronchiectasis patients with poor lung function and the following additional factors: massive haemoptysis, severe secondary pulmonary hypertension, ICU admissions or respiratory failure (particularly if requiring NIV)

Question 29

LOT

Answer 29

using the same eligibility criteria as for COPD.

Question 30

Do not routinely recommend alternative treatments (for example cough suppression, nutritional supplementation, complementary therapy/homeopathy, supplemental treatments) as part of the management of patients with bronchiectasis.

Answer 30

TRUE

Question 31

Consider patients with chronic P. aeruginosa colonisation at higher risk of bronchiectasis-related complications

Answer 31

TRUE

Question 32

What is the evidence for the role of viruses/fungal disease in patients with bronchiectasis?

Answer 32

Testing to detect viral infection should be considered in patients with an exacerbation of bronchiectasis.

Do not routinely use anti-fungal therapy without evidence of fungal disease. Fungal cultures can be positive on those receiving long-term antibiotic therapy.

Question 33

does eradication of potentially pathogenic microorganisms improve outcomes in patients with stable bronchiectasis?

Answer 33

Offer patients with bronchiectasis associated with clinical deterioration and a new growth of P. aeruginosa (1st isolation or regrowth in the context of intermittently positive cultures) eradication antibiotic treatment. (first line treatment: ciprofloxacin 500–750 mg bd for 2 weeks;
second line treatment: iv antipseudomonal beta-lactam ± an iv aminoglycoside for 2 weeks,

followed by a 3 month course of nebulised colistin, gentamicin or tobramycin).

Question 34

First P.aeruginosa in sputum with Bronchactasis

Answer 34

Eradication therapy :-
1- Cipro 500 or 750 BD for two weeks
2- IV anti Pseudomonam beta lactane -+ aninoglocosied for 2 weeks

Followed by 3 M course of Nebulised colistin , gentamicin or tobramycin

Question 35

\exacerbation

Answer 35

In general, antibiotic courses for 14 days are standard and should always be used in patients infected with P. aeruginosa. Shorter courses may suffice in patients with mild bronchiectasis.

Question 36

What treatments improve outcomes in patients with bronchiectasis and allergic broncho-pulmonary aspergillosis?

Answer 36

Offer oral corticosteroid to patients with active ABPA. An initial dose of 0.5 mg/kg/d, for 2 weeks is recommended. Wean steroids according to clinical response and serum IgE levels. (D)

Consider itraconazole as a steroid sparing agent for patients dependent on oral corticosteroids where difficulty in weaning is experienced. (B)

Monitor patients with active ABPA with total IgE level to assess treatment response.

Question 37

does immunoglobulin replacement treatment therapy improve outcomes in patients with bronchiectasis due to antibody deficiency?

Answer 37

Consider IgG therapy for patients with specific polysaccharide antibody deficiency and/or IgA deficiency or IgG subclass deficiencies with absent/impaired pneumococcal vaccine antibody responses who continue to have objective evidence of bacterial sino-pulmonary infection and progressive disease despite appropriate management of bronchiectasis. (C)

Question 38

Monitor patients with co-morbid COPD and bronchiectasis as they are at higher risk of death. (D)

Question 39

Complication of broncheactasis

Answer 39

Haemoptysis IF 10 ml or less treat with ABx

Question 40

Tt of significant haemoptysis

Answer 40

Is Bronchial artery embolization