1.1.

Bronchiectasis
a. Definition
Bronchiectasis is a congenital or acquired disorder of the large bronchi
characterized by permanent, abnormal dilation and destruction of bronchial walls. It
may be caused by recurrent inflammation or infection of the airways and maybe
localized or diffuse. Cystic fibrosis causes about half of all cases of bronchiectasis.
However, most patients with bronchiectasis have panhypogammaglobulinemia,
presumably reflecting an immune system response to chronic airway infection.treatmet
Although this definition is based on pathologic changes in the bronchi, diagnosis is
often suggested by the clinical consequences of chronic or recurrent infection in the
dilated airways and the associated secretions that pool within these airways.harrison

b. Clinical Findings
A. Symptoms and Signs
Symptoms of bronchiectasis include chronic cough with production of
copious amounts of purulent sputum, hemoptysis, and pleuritic chest pain. Dyspnea
and wheezing occur in 75% of patients. Weight loss, anemia, and other systemic
manifestations are common. Physical findings are nonspecific, but persistent
crackles at the lung bases are common. Clubbing is infrequent in mild cases but is
common in severe disease. Copious, foul-smelling, purulent sputum is
characteristic.

B. Imaging
Radiographic abnormalities include dilated and thickened bronchi that
may appear as tram-tracks or as ring-like markings. Scattered irregular
opacities, atelectasis, and focal consolidation may be present. High-resolution CT
is the diagnostic study of choice.tree
Although the chest radiograph is important in the evaluation of suspected
bronchiectasis, the findings are often nonspecific. At one extreme, the radiograph
 may be normal with mild disease. Alternatively, patients with saccular
bronchiectasis may have prominent cystic spaces, either with or without air-liquid
levels, corresponding to the dilated airways.

These may be difficult to distinguish from enlarged airspaces due to

bullous emphysema or from regions of honeycombing in patients with severe
interstitial lung disease.

C. Laboratory Finding
Examination of sputum often reveals an abundance of neutrophils and
colonization or infection with a variety of possible organisms. Appropriate
staining and culturing of sputum often provide a guide to
antibiotic therapy.

d. Treatment

Treatment of acute exacerbations consists of antibiotics (selected on the

basis of sputum smears and cultures), daily chest physiotherapy with postural drainage
and chest percussion and inhaled bronchodilators. Hand-held flutter valve devices may
be as effective as chest physiotherapy in clearing secretions. Empiric oral antibiotic
therapy for 1014 days with amoxicillin or amoxicillin-clavulanate (500 mg every 8
hours), ampicillin or tetracycline (250500 mg four times daily), or trimethoprim-
sulfamethoxazole (160/800 mg every 12 hours) is reasonable therapy in an acute
exacerbation if a specific bacterial pathogen cannot be isolated.
Preventive or suppressive treatment is sometimes given to stable outpatients
with bronchiectasis who have copious purulent sputum. Clinical trial data to guide this
practice are scant. Common regimens include macrolides (azithromycin, 500 mg three
times a week; erythromycin,500 mg twice daily), high-dose (3 g/d) amoxicillin or
alternating cycles of the antibiotics listed above given orally for 24 weeks. Inhaled
aerosolized aminoglycosides reduce colonization by Pseudomonas species. In patients
with underlying cystic fibrosis, inhaled antibiotics improve FEV1 and reduce
hospitalizations, but these benefits are not consistently seen in the noncystic fibrosis
population.
Complications of bronchiectasis include hemoptysis, cor pulmonale,
amyloidosis, and secondary visceral abscesses at distant sites (eg, brain).
Bronchoscopy is sometimes necessary to evaluate hemoptysis, remove retained
secretions,and rule out obstructing airway lesions. Massive hemoptysis may require
embolization of bronchial arteries or surgical resection. Surgical resection is otherwise
reserved for the few patients with localized bronchiectasis and adequate pulmonary
function in whom conservative management fails.