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Year 3: Respiratory > Respiratory: Bronchiectasis > Flashcards

Respiratory: Bronchiectasis Flashcards

1
Q

Define what is meant by bronchiectasis [1]

A

Bronchiectasis is the abnormal 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 risk factors for bronchiectasis? [4]

A
  • Cystic fibrosis
  • Host immunodeficiency
  • Previous infections
  • Primary ciliary dyskinesia
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3
Q

Which infections can cause bronchiectasis? [3]

A
  • Pneumonia
  • Whooping cough (pertusis)
  • TB
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4
Q

Which inherited diseases can cause bronchiectasis? [4]

A
  • (Alpha-1-antitrypsin deficiency)
  • Connective tissue disorders (e.g., rheumatoid arthritis)
  • Cystic fibrosis
  • Yellow nail syndrome
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5
Q

Describe the classic triad of yellow nail syndrome [3]

A
  • Yellow fingernails
  • Bronchiectasis
  • Lymphoedema

TOM TIP: Yellow nail syndrome is characterised by yellow fingernails, bronchiectasis and lymphoedema. Patients are stable and have good clinical signs, making it a good choice for OSCEs. As it is rare, examiners will score high marks if you can combine these features and name the diagnosis.

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6
Q

Describe the pathophysiology of bronchiectasis [7]

A

Cole’s ‘vicious cycle hypothesis:

A deficit in mucociliary clearance +/- immune function
→
Microorganism acquisition, colonisation and infection
→
Chronic inflammation
→
Dilation and thickening of bronchi
→
Bronchial wall oedema and increased mucus production
→
More infections
→
Further inflammation and damage.

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7
Q

Describe the three morphological types of bronchiectasis [3]

A

Tubular/cylindrical:
- most common type
- the morphology is of smooth uniform dilatation of the bronchi with loss of normal tapering. **
- This type is associated with the ‘signet ring sign**’ due to an increased bronchoarterial ratio and the ‘tram-track sign’ due to parallel bronchial walls.

Varicose:
- relatively uncommon, the bronchi are irregular with dilatation interspersed with areas of constriction.

Cystic:
- associated with cystic fibrosis, dilated bronchi that are cyst like and filled with either air or fluid.

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8
Q

What is the name for this sign of tubular bronchiectasis? [1]

A

Signet ring sign

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9
Q

What is the name for this sign of tubular bronchiectasis? [1]

A

Tram track sign

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10
Q

Describe the classical symptoms of bronchiectasis [5]

A
  • Shortness of breath
  • Chronic productive cough: may produce large amounts of purulent sputum and sometimes haemoptysis
  • Recurrent chest infections
  • Weight loss
  • Fever
  • Chest pain
  • GORD
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11
Q

Describe the classical signs of bronchiectasis [5]

A
  • Scattered crackles throughout the chest that change or clear with coughing
  • Scattered wheezes and squeaks
  • Sputum pot by the bedside
  • Oxygen therapy (if needed)
  • Weight loss (cachexia)
  • Finger clubbing
  • Signs of cor pulmonale (e.g., raised JVP and peripheral oedema)
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12
Q

When taking a history and examining the patient, it is also important to consider other systems of the body too, as these may reveal co-morbid conditions associated with the development of bronchiectasis
.
Which do these include? [4]

A

Joints:
- RA

GI:
- IBD
- Cystic fibrosis
- GORD

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13
Q

Sputum culture is used to identify colonising and infective organisms. The most common infective organisms are? [2]

A

Haemophilus influenza

Pseudomonas aeruginosa

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14
Q

Describe what CT [7] and CXR [2] would reveal when investigating for bronchiectasis? [2]

A

High resolution chest CT
- Test of choice
- Thickened & dilated airways
- May show fluid-filled cysts; these represent superimposed infection and warrant a course of systemic antibiotics.
- Tram line or signet ring appearance
- Bronchoarterial ratio > 1: the internal airway lumen is larger than the adjacent pulmonary artery (signet ring sign)
- Lack of tapering: bronchi should taper in diameter as they travel distally from the lung hila to the periphery
- Bronchus visible within 1cm of pleural surface: normal, non-dilated airways cannot usually be seen within 2cm of the pleura

CXR:
- the majority of X-rays will be abnormal in those with bronchiectasis but findings are non-specific and further imaging is required.
- They are also useful for ruling out other possible causes such as TB or malignancy

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15
Q

Asides from imaging investigations, describe what else you would investigate for bronchiestasis [7]

A

Sputum culture
- Most commonly Haemophilus influenzae and Pseudomonas aeruginosa

FBC:
- may reveal high eosinophil count in bronchopulmonary aspergillosis

specific IgE or skin prick test to Aspergillus fumigatus

serum alpha-1 antitrypsin phenotype and level

serum immunoglobulins
- to identify individual immunoglobulin deficiencies as underlying aetiology

Rheumatoid factor

Serum HIV antibody

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16
Q

Describe most common pattern seen on post-bronchodilator spirometry in bronchiectasis

A

Post-bronchodilator spirometry: most commonly an obstructive pattern is seen, although mixed, restrictive, and normal results are also possible.

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17
Q

How would you distinguish between bronchiectasis and:

  • COPD [2]
  • Asthma [2]
A

COPD Differences:
- Sputum more likely to be clear (except during infection)
- Smoking stronger RF

Asthma:
- Dysopnea more associated with triggers

NB: Both diseases can co-exist with bronchiectasis

18
Q

How would you distinguish between bronchiectasis and:

  • Lung cancer [2]
  • TB [2]
A

Lung cancer:
* Similarities: cough, haemoptysis, chest pain
* Differences: weight loss, hoarse voice

Tuberculosis:
* Similarities: cough, haemoptysis
* Differences: weight loss, night sweats

19
Q

TOM TIP: The key features to remember with bronchiectasis are [4]

A

TOM TIP: The key features to remember with bronchiectasis are finger clubbing, diagnosis by HRCT, Pseudomonas colonisation and extended courses of 7-14 days of antibiotics for exacerbations.

20
Q

Describe the treament algorithm for bronchiestasis for the initial presentation? [5]

A

initial presentation
1ST LINE: exercise and improved nutrition.
- Including vitamin D supplementation
- Higher BMI has beneficial outcomes
- Excercise is considered form of airway clearance

PLUS –
airway clearance therapy (ACT):
- maintenance of oral hydration; percussion, breathing, or coughing strategies
- positioning and postural drainage; positive expiratory pressure devices; and oscillatory devices
- recommended for 15 to 30 minutes, 2 or 3 times daily

PLUS –
self-management plan

CONSIDER –
inhaled bronchodilator:
- salbutamol inhaled

CONSIDER –
mucoactive agent
- hypertonic saline

BMJ BP

21
Q

acute exacerbation: mild to moderate underlying disease if is first or new presentation of Pseudomonas aeruginsoa

A

1ST LINE –
short-term oral antibiotic:
- For adults, prescribe amoxicillin 500 mg three times a day for 7–14 days

PLUS –
increased airway clearance

PLUS –
continued maintenance therapy:
- Healthy diet & exercise
- Higher BMI
- Nebulised bronchodilators
- Nebulised hyperosmolar agents, such as hypertonic saline,

22
Q

How many acute exacerbations in a year would indicate treatment to be escalated in a stepwise manner? [1]

A

≥ 3 exacerbations in one year despite following the initial management

23
Q

Describe how treatment for bronchiectasis would be escalated in a stepwise manner if they were suffering ≥ 3 exacerbations in one year despite following the initial management?

A

3 or more exacerbations per year despite maintenance therapy
1ST LINE –
reassess physiotherapy ± mucoactive treatment

PLUS –
continued maintenance therapy
- Azithromycin 500 mg three times a week, or
- Azithromycin 250 mg daily, or
- Offer a minimum of 6 months treatment, but up to 1 year may be required.

CONSIDER –
long-term antibiotic

CONSIDER –
surgery:
- Surgical resection is considered in patients with localised disease whose symptoms are not controlled by optimal medical treatment
- Complete resection of the bronchiectatic area is associated with the best results

CONSIDER –
treatment of respiratory failure

24
Q

When giving long term antibiotic therapy to those with bronchiestasis, if people have concurrent Pseudomonas aeruginosa infection, first-line therapy is []

A

inhaled colistin.

25
Q

BTS sugget what criteria for a lung transplantation for bronchiestasis? [3]

A

BTS specify the following criteria for lung transplantation:
* Aged 65 years or less and
* FEV is < 30% predicted with significant clinical instability
or
* Rapid progressive deterioration despite optimal medical management

26
Q

A patient is diagnosed with bronchiestasis. Subsequent sputum sampling diagnoses them the infective agent as Streptococcus pneumoniae. What is the approriate first line treatment

  • Co-amoxiclav 625 mg three times daily
  • Amoxicillin 500 mg three times daily
  • Flucloxacillin 500 mg four times daily
  • Doxycycline 100 mg twice daily PLUS rifampicin (for adults)
  • Ciprofloxacin 500 or 750 mg twice daily
A

Amoxicillin 500 mg three times daily

27
Q

A patient is diagnosed with bronchiestasis. Subsequent sputum sampling diagnoses them the infective agent as Haemophilus influenzaebeta lactam negative. What is the approriate first line treatment

  • Co-amoxiclav 625 mg three times daily
  • Amoxicillin 500 mg three times daily
  • Flucloxacillin 500 mg four times daily
  • Doxycycline 100 mg twice daily PLUS rifampicin (for adults)
  • Ciprofloxacin 500 or 750 mg twice daily
A

A patient is diagnosed with bronchiestasis. Subsequent sputum sampling diagnoses them the infective agent as Haemophilus influenzae. What is the approriate first line treatment

  • Co-amoxiclav 625 mg three times daily

Amoxicillin 500 mg three times daily

  • Flucloxacillin 500 mg four times daily
  • Doxycycline 100 mg twice daily PLUS rifampicin (for adults)
  • Ciprofloxacin 500 or 750 mg twice daily
28
Q

A patient is diagnosed with bronchiestasis. Subsequent sputum sampling diagnoses them the infective agent as Haemophilus influenzae (beta-lactamase positive). What is the approriate first line treatment

  • Co-amoxiclav 625 mg three times daily
  • Amoxicillin 500 mg three times daily
  • Flucloxacillin 500 mg four times daily
  • Doxycycline 100 mg twice daily PLUS rifampicin (for adults)
  • Ciprofloxacin 500 or 750 mg twice daily
A

Co-amoxiclav 625 mg three times daily

29
Q

A patient is diagnosed with bronchiestasis. Subsequent sputum sampling diagnoses them the infective agent as Pseudomonas aeruginosa. What is the approriate first line treatment

  • Co-amoxiclav 625 mg three times daily
  • Amoxicillin 500 mg three times daily
  • Flucloxacillin 500 mg four times daily
  • Doxycycline 100 mg twice daily PLUS rifampicin (for adults)
  • Ciprofloxacin 500 or 750 mg twice daily
A

A patient is diagnosed with bronchiestasis. Subsequent sputum sampling diagnoses them the infective agent as Pseudomonas aeruginosa. What is the approriate first line treatment

  • Co-amoxiclav 625 mg three times daily
  • Amoxicillin 500 mg three times daily
  • Flucloxacillin 500 mg four times daily
  • Doxycycline 100 mg twice daily PLUS rifampicin (for adults)
  • Ciprofloxacin 500 or 750 mg twice daily
30
Q

A patient is diagnosed with bronchiestasis. Subsequent sputum sampling diagnoses them the infective agent as Klebsiella. What is the approriate first line treatment

  • Co-amoxiclav 625 mg three times daily
  • Amoxicillin 500 mg three times daily
  • Flucloxacillin 500 mg four times daily
  • Doxycycline 100 mg twice daily PLUS rifampicin (for adults)
  • Ciprofloxacin 500 or 750 mg twice daily
A

A patient is diagnosed with bronchiestasis. Subsequent sputum sampling diagnoses them the infective agent as Klebsiella. What is the approriate first line treatment

  • Co-amoxiclav 625 mg three times daily
  • Amoxicillin 500 mg three times daily
  • Flucloxacillin 500 mg four times daily
  • Doxycycline 100 mg twice daily PLUS rifampicin (for adults)
  • Ciprofloxacin 500 or 750 mg twice daily
31
Q

Which vaccines are recommonded for bronchiestasis? [2]

A

Vaccines (e.g., pneumococcal and influenza)

32
Q

[] is the usual choice for infective exacerbations caused by Pseudomonas aeruginosa

A

Ciprofloxacin is the usual choice for exacerbations caused by Pseudomonas aeruginosa

33
Q

How long are the extended course of Abx for infective exacerbations? [1]

A

Extended courses of antibiotics, usually 7–14 days

34
Q

Which immunodeficiency is associated with bronchiectasis? [1]

A

bronchiectasis

35
Q

What type of breathing is associated with bronchiectasis? [1]

A

Wheezing

36
Q

Describe the cough that occurs in bronchiectasis? [1]

A

Foul smelling haemoptysis

37
Q

What is the name for this radiological sign? [1]

What pathology does it indicate? [1]

A

Tram-track sign indicates bronchiestasis

38
Q

Label A & B [2]

What pathology do they indicate? [1]

A

A: signet ring sign
B: tram track sign

Indicates bronchiectasis

39
Q

This CT shows which sign of bronchiectasis? [1]

A

String of pearls

40
Q

What is this radiographic sign? [1]

What pathology does it indicate? [1]

A

Bunch of grapes; bronchiectasis

Year 3: Respiratory (42 decks)

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