Non CF Broncheactasis Flashcards
Ct features of Bronchiectasis
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
The following indirect signs are commonly associated with bronchiectasis:
º Bronchial wall thickening
º Mucus impaction
º Mosaic perfusion / air trapping on expir-
atory CT
in whom should the diagnosis of bronchiectasis be suspected?
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
Investigation for Bronchiectasis in Healthy
IF cough with sputum last more than 8 Weeks
Investigation of bronchiectasis :-
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
Suspect of CF :-
CF :- in early onset , male inferteilty , malabsorption and pancreatitis
Suspect of PCD
PCD Hx of neonatal distress , sx form childhood , recurrent otitis media rhinosinistiis or infertility
Consider bronchoscopy for patients with localised disease to rule out an endobronchial lesion or foreign body as the cause of bronchiectasis.
True
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.
True
Serum protein electrophoresis should be performed in all patients with bronchiectasis with raised immunoglobulins.
True
Which airway clearance techniques should be taught?
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
Pt with broncheactasis
Patients should be encouraged to perform regular physical exercise (plus the forced expiration technique/huff) to promote airway clearance.
True
How often should patients carry out airway clearance techniques?
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
How soon should the patient be reviewed after the initial assessment?
3 M
mucoactives in bronchiectasis Recommendations
➢ ➢
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
What is the evidence for long term anti-inflammatory therapies in bronchiectasis
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
What treatments improve outcomes for patients with stable bronchiectasis?
long term antibiotics in patients with bronchiectasis who experience 3 or more exacerbations per year.
P. aeruginosa colonised patients
1- Inhaled Colistin / aztronam
2- Gentamicin as second line
3- oral azithromhycin add on inhaled ABx ( If high exacerbation frequency )
Non- P. aeruginosa colonised patients
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.
Before starting Macrolide :-
1- rule out active NTM with at least one negative culture
Caution if hearing loss
Before inhaled aminiglycosides
Avoid if Creatinine clearance less than 30
Significant hearing loss
Avoid nephro toxic medications \
Stepwise therapy of broncheactasis
Step 1
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
Stepwise therapy of broncheactasis
Step 2
IF 3 or more despite step 1
Physiotherapy reassessment and consider mucoactive treatment
Stepwise therapy of broncheactasis
Step 3
IF 3 or more despite step 2
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
If 5 or more exacerbations/yr despite Step 4* ( oral and inhaled abx 0
Consider regular intravenous antibiotics every 2-3 months
Offer pulmonary rehabilitation to individuals who are functionally limited by shortness of breath (Modified Medical Research Council (MMRC) Dyspnoea Scale ≥ 1).
What is the role of surgery in managing bronchiectasis?
Consider lung resection in patients with localised disease whose symptoms are not controlled by medical treatment optimised by a bronchiectasis specialist.
Lung transplantation for bronchiectasis
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)
LOT
using the same eligibility criteria as for COPD.
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.
TRUE
Consider patients with chronic P. aeruginosa colonisation at higher risk of bronchiectasis-related complications
TRUE
What is the evidence for the role of viruses/fungal disease in patients with bronchiectasis?
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.
does eradication of potentially pathogenic microorganisms improve outcomes in patients with stable bronchiectasis?
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).
First P.aeruginosa in sputum with Bronchactasis
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
\exacerbation
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.
What treatments improve outcomes in patients with bronchiectasis and allergic broncho-pulmonary aspergillosis?
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.
does immunoglobulin replacement treatment therapy improve outcomes in patients with bronchiectasis due to antibody deficiency?
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)
Monitor patients with co-morbid COPD and bronchiectasis as they are at higher risk of death. (D)
Complication of broncheactasis
Haemoptysis IF 10 ml or less treat with ABx
Tt of significant haemoptysis
Is Bronchial artery embolization
