Bronchiectasis

Hu Suping
Pulmonary Department
1st clinical college, Wuhan University
 Definition
an acquired disorder of the major bronchi
and bronchioles characterized by permanent
abnormal dilation and destruction of bronchial
walls
the most common symptoms are chronic
cough with large amounts of purulent sputum
and/or recurrent hemoptysis
 it involves chronic respiratory tract infection
and an up-regulation of the host inflammatory
response
Enhanced cellular and mediator responses
bronchial mucosal biopsies reveal infiltration by
neutrophils and T lymphocytes; expectorated
sputum has increased concentrations of elastase
and the chemoattractants IL-8, TNFa, and
prostanoids
 Pathological changes
Cylindrical or tubular bronchiectasis: dilated
airways alone, sometimes seen as a residual effect of
pneumonia

Varicose bronchiectasis: focal constrictive areas

along the dilated airways that result from defects in the
bronchial wall

Saccular or cystic bronchiectasis: progressive

dilatation of the airways, which end in large cysts,
saccules, or grape-like clusters (the most severe form )
The lumen of the bronchus is dilated and
there is prominent chronic inflammation
in the bronchial wall
Bronchiectasis can present in either of two
forms a local or focal obstructive
process of a lobe or segment of a lung or a
diffuse process involving much of both
lungs and often accompanied by other
sinopulmonary diseases, such as sinusitis
and asthma
Pathophysiology and Etiology
Three types of focal airway obstruction
(1) luminal blockage by a foreign body,
broncholith, or slowly growing benign tumor
(2) extrinsic narrowing due to enlarged lymph
nodes (middle lobe syndrome)
(3) twisting or displacement of the airways after a
lobar resection or chronic infection
 Pathophysiology and Etiology
Infections
Childhood respiratory tract infections (pertussis or
whooping cough)
Chronic infections( chronic lung abscess, TB)

Primary Ciliary Dyskinesia

an autosomal recessive syndrome, estimated frequency
at birth is 1 in 15,000 to 1 in 40,000
half have Kartageners syndrome (bronchiectasis,
sinusitis, and situs inversus viscerum)
Pathophysiology and Etiology
Immunodeficiency
humoral immunodeficiency syndromes
(deficiencies of IgG, IgM, and IgA) at risk for
recurrent suppurative sinopulmonary infections
and bronchiectasis
immune globulin replacement reduces the
frequency of infectious episodes and prevents
further destruction of the airways
 Clinical findings
Symptoms:
daily cough productive of mucopurulent phlegm
intermittent hemoptysis
recurrent lung infections
shortness of breath

Physical findings:
crackles, cyanosis
Chest radiography
High-resolution computed tomographic scanning
(HRCT)
the defining modality for diagnosis of
bronchiectasis
Specific abnormalities found on HRCT include
(1) dilatation of an airway lumen > 1.5 times as wide as a
nearby vessel
(2) lack of tapering of an airway toward the periphery
(3) varicose constrictions along airways
(4) ballooned cysts at the end of a bronchus
 Normal lung Bronchiectasis

Normal Lung and the Lung of a Patient with Bronchiectasis. Bronchiectasis is primarily in the lower lobe,
which is the most common distribution. The saccular dilatations and grapelike clusters with pools of mucus
are signs of severe bronchiectasis.
 Bronchoscopy
an important diagnostic tool to examine for
obstruction ( foreign body, tumor, structural
deformity, or extrinsic compression from
lymph nodes) and to help localize the
bleedingto identify pathogen
 Pulmonary function tests
obstructive impairment ( low FEV1
and/or low FEV1/FVC)
airway hyperresponsiveness ( 40% with
a positive reversibility test result, and
30% to 69% with a positive bronchial
provocative test result)
Diagnostic evaluation
(1) to confirm the diagnosis of bronchiectasis
(2) to identify potentially treatable underlying
causes
(3) to provide functional assessment
Imaging of the chest is always necessary to
confirm the diagnosis
 Differential diagnosis
Chronic bronchitis
Lung abscess
Pulmonary tuberculosis
Congenital bronchocele
Diffuse panbronchiolitis
 Therapy
Control infectionsadministration of antibiotics
Treatment of underlying conditions
Promotion of bronchial hygiene
Control of bronchial hemorrhage
Surgical therapy
 Acute Exacerbations
An exacerbation: including four of the nine
symptoms
change in sputum production; increased dyspnea;
increased cough; fever (>38.0C); increased
wheezing; malaise, fatigue, lethargy, or decreased
exercise tolerance; changes in chest sounds
reduced pulmonary function; radiographic
changes
Early antibiotic therapy: fluoroquinolone as
levofloxacin or ciprofloxacin for at least 7 to 10
days
Sputum culture and sensitivity testing: who fail to
respond to the initial antibiotic or who have
repeated symptomatic attacks in a short interval
 Bronchopulmonary Hygiene
Postural drainage, chest physiotherapy,
thinning and loosening of secretions, the
administration of a bronchodilator and of
inhaled corticosteroids part of maintenance
therapy and treatment for acute exacerbations
 Hemoptysis
life-threatening hemoptysis: > 600 ml/ day
bronchoscopy or CT of the chest is warranted to
help determine which lobe or side is bleeding
interventional radiology: selective bronchial
arteries embolization
surgery may be required to resect an area
suspected of bleeding
 Surgery
Removal of an obstructing tumor or residue of a
foreign body
Elimination of the segments or lobes the most
damaged and suspected of contributing to acute
exacerbations, overwhelming viscous secretions,
mucous impaction, and plugs
Elimination of areas that are subject to
uncontrolled hemorrhage
Removal of damaged lung suspected of
harboring problematic organisms such as
multidrug-resistant M. tuberculosis or M. avium
Double-lung transplantation is now considered
for patients with cystic fibrosis and respiratory
failure (one year survival rate 75% and 48% at
five years)