Bronchiectasis

 Introduction

 Etiology and Pathogenesis

 Pathology

 Clinical findings

 Radiographic and Laboratory findings

 Diagnosis and Differential diagnosis

 Treatment

 Prognosis and Prevention

 Introduction
 Bronchiectasis is an abnormal and
permanent dilatation of the bronchi
due to the destruction of the muscle
and elastic tissue support around the
medium-sized airways.
 It mainly manifests chronic cough,
copious purulent sputum, and /or
recurrent hemoptysis.
 Most patients can be tracked back
to a severe bacterial infection in
childhood consequent upon
measles or whooping cough.
 In the past, Bronchiectasis is a very
common respiratory disease and only
be second to pulmonary tuberculosis.
 Recently, with the inoculation
against measles and whooping
cough ,and the improved control
of bronchopulmonary infections, it
has reduced apparently .
 Etiology and pathogenesis
 1.Bronchopulmonary parenchyma
infection and bronchial obstruction
could be the initial event.

 2.Rarely, it may be the result of

congenital abnormalities of bronchi or
genetic factors .
Bronchopulmonary Airway mucosa
parenchyma hyperemia ，
infection hydropsia secretions↑

Lumens stenosis，
secretion obstruct
lumens
 Recurrent infection can damage
and weaken the bronchial wall,
especially the destruction of
muscle and elastic tissue could cut
back the support to the bronchial
wall, leading to dilatation.
 After the cure of pulmonary
tuberculosis, fibrous tissue pulling
bronchial wall can result in the
dilatation of bronchia, too.
 Bronchial obstruction could lead
pulmonary closure and induce
infection in the lung distal, which
result in bronchiectasis.
 Inhalation of a toxic gas such as
ammonia could damage bronchial
wall and cause bronchi recurrent
infection, leading bronchiectasis.
 Congenital abnormalities, such as
immotile cilia syndrom, Kartagener’s
syndrome (bronchiectasis, sinusitis
and transportation of the viscera), and
Young’s syndrom has mucociliary
dysfunction, which result in inefficient
clearance of bacteria and secretions
and cause bronchiectasis.
 Some diseases related with genetic
factors such as Congenital
immunoglobulin deficiency can go
with bronchiectasis, too
 Pathology
Location:
 The bronchi dilatation are often at the
level of segmental or subsegmental
bronchi.
 They usually occur in lower lobe,
especially in left lower lobe . But the
dilatation of bronchia by pulmonary
tuberculous are often in upper lobe ,
where drainage are efficient and
sputum are little.
 Pattern
 cylindrical bronchiectasis
 varicose bronchiectasis
 saccular (cystic) bronchiectasis
 Cylindrical bronchiectasis：
The bronchi appear as uniformly
dilated tubes that end abruptly at the
point that smaller airways are
obstructed by secretions.
 Varicose bronchiectasis：
The affected bronchi have an
irregular or beaded pattern of
dilatation resembling varicose veins.
 Saccular (cystic) bronchiectasis
The bronchi have a ballooned
appearance at the periphery, ending
in blind sacs without recognizable
bronchial structures distal to the
sacs.
 Gross inspection :
 The normal structural components of the
bronchial wall (cartilage, muscle, and
elastic tissue) are destroyed and may be
replaced by fibrous tissue.
 The dilated airways frequently
contain pools of thick, purulent
material.
 More peripheral airways are often
occluded by secretions and replaced
by fibrous tissue.
Bronchiectasis versus Normal Lung

Microscopic features
 Bronchial and peribronchial
inflammation
 Fibrosis, ulceration of the bronchial
wall
 Squamous metaplasia

 Mucous gland hyperplasia.

 Vascularity of the bronchial wall
increases
 Enlargement and hypertrophy of
the bronchial arteries
 Anastomoses between the
bronchial and pulmonary arterial
circulations.
 Clinical Findings
Symptoms:
 1.Chronic cough and purulent
sputum.
 2.Recruent hemoptysis .

 3.Recruent pulmonary infection.

 4.The systematic symptoms of chronic

infection
 1.Chronic cough and purulent
sputum
 Copious, foul-smelling, purulent
sputum that separates into three
layers in a cup is characteristic:
the upper is foam, the lower is
necrotisis, and the middle is mucus.
 Degree can be evaluated according to
the amount of sputum:
Mild,<10ml/d; Moderate,10-150ml/d;
Severe,>150ml/d.
 With exacerbations of infection, the
amount of sputum increases, it
becomes more purulent and often
more bloody, and patients may
become febrile.
 2. Recruent hemoptysis
 It occurs in 50 to 70% of cases

 Due to bleeding from friable,

inflamed airway mucosa.
 More significant, even massive
bleeding is often a consequence of
bleeding from hypertrophied
bronchial arteries.
 In some cases, patients are either
asymptomatic or have a
nonproductive cough , and recruent
hempotysis is the only symptom,
which lesion often be in the efficient
drainage upper lobe. These
bronchiectasis are called “dry
bronchiectasis”.
 3.Recruent pulmonary infection
 Recruent pneumonia occur in the
same pulmonary segmental and not be
cured easily.
 4.The systematic symptoms of
chronic infection
 fever

 tedious

 anemia
 lost weight

 lost one’appetite

 the failure to thrive in children

 Physical signs
 Examination may be normal in early
or dry bronchiectasis .
 Persistent crackles over the affected
area are common. Rhonchi and
wheezes may be heard.
 Clubbing is infrequent in mild cases
but is commonly seen in severe disease.
 Patients with severe, diffuse
disease, particularly those with
chronic hypoxemia, may have
associated cor pulmonale and
right ventricular failure.
 Radiographic findings
 Chestradiograph
 Computed tomography (CT)

 Bronchography
 Chest radiograph
 Often normal if not severe
 Too many white lines extending
from the hila = tram-tracks
 Elongated (tubular) opacities
(white)
 Small circles containing air (black)
or fluid and air (air-fluid level)
 Computed tomography (CT) scan
 can provides an excellent view of
dilated airways as seen in cross-
sectional images .
 High-resolution CT scanning can
suggest a specific etiology of the
bronchiectasis
 Signet ring sign
 Tram-tracks
 String of beads
 Circles filled with air or air and
fluid
 Tubular and branching opacities
 Scarring
 Bronchography
 Itcan provide excellent
visualization of bronchiectatic
airways including the
position ,patten, range, and
degree of lesion.
 However, this technique has now
been replaced by computed
tomography (CT) .
 So,it mainly be used as
preparation before surgery .
 Fiberoptic bronchoscopy
 Itis not value in the diagnosis of
bronchiectasis
 But it can reveal the location of
bleeding or the reason of
obstruction in some cases. We
can ues it as hemostasia and
ascertain the etiology of
obstruction.
 Laboratory findings
 Examination of sputum
Appropriate staining and culturing
of sputum often provide a guide to
antibiotic therapy .
 Blood routine test:

The increase of blood white cell

and neutrophil can be seen in
acute infections
 Pulmonary function test
may demonstrate airflow
obstruction in diffuse
bronchiectasis
 Diagnosis
 History :chronic cough, copious
purulent sputum, and /or recurrent
hemoptysis ,excepting lung
abscess, emphysema, chronic
bronchitis.
 Purulent sputum can separates
into three layers in a cup : the
upper is foam, the lower is
necrotisis, and the middle is
mocus.
 Persistent crackles can be heard over
the affected area in serve cases.
 Clubbing is seen in severe disease.

 Computed tomography (CT) scan,

especially high-resolution CT can
determin the diagnosis and suggest a
specific etiology of the bronchiectasis
 Differential diagnosis
 Chronic bronchitis
 Lung abscess

 Congenital pulmonary cyst

 Tuberculousis
 Treatment
Major goals:
(1) elimination of an identifiable
underlying problem;
(2) improved clearance of
tracheobronchial secretions;
(3) control of infection, particularly
during acute exacerbations;
(4) reversal of airflow obstruction
 Measures
 Elimination of an identifiable
underlying problem:
To look for the underlying problem
and eliminate the treatable cause .
Removal of tracheobronchial
secretions
Sputum be removed efficiently can not
only conduce to relieve the symptoms
(cough ，sputum) , control
bronchopulmonary infection and shorten
the days in hospital, but also facilitate to
prevent recurrent episodes of
bronchopulmonary infection ,so it has an
important role in the management.
 1. Apophlegmatisant
They can thin the thick secretions
and allow better clearance.
 Ambroxol Hydrochloride （30 mg
thrice daily）, or Bisolvin （8-16
mg thrice daily） can be adopted.
 Inhaling α-Chymotrypsin by
ultrasonic nebulization may be
used usually.
 2.Postural drainage
 Takingappropriate positioning
acccording to the diseased region
can facilitate drainage in patients
with copious secretions.
 The position in which the lobe to
be drained is uppermost shoud be
adopted, thereby allowing the
secretions in the dilated bronchi
to gravitate towards the trachea,
from which they can readily be
cleared by vigorous caughing .
 The optium duration and
frequency of postrual drainage
depend on the amount of sputum,
but 15-30 minutes once or twice
daily is a minimum for most
patients.
 Chest percussion with cupped
hands aid dislodgement of
sputum.
 Some mechanical devices such as
hand-held flutter valve device are
available which cause the chest
wall to oscillate.
 3.Exsuction sputum by fibre
bronchoscope
 In these patients with
inefficient postural drainage,
exsuction sputum by fibre
bronchoscope and bronchi
lavement with 0.9% Natri-
chloride can be used.
 Inaddition,some antibiotics
such as gentamycin or
Isoniazid (INH ) can be
infuseed directly to the
diseased region.
 Control of infection
 Atibiotics are very important in
eradicating infection.
 Although choice of an antibiotic
may be guided by Gram‘s stain
and culture of sputum, empiric
coverage (e.g., with ampicillin,
amoxicillin, quinolone , or
cephalosporin ) is often given
initially.
 During acute episodes
 In mild or moderate cases ,oral
antibiotic therapy for 10-14 days
with amoxicillin (500mg every 8
hours) or ofloxacin (200 mg every
12 hours) is reasonable.
 In serve cases, two or three these
antibiotics by intravenous
injection for 2-4 weeks may be
appropriate.
 In patients with chronic purulent
sputum
 Oral antibiotic or inhaled
aminoglycosides , or intermittent
but regular courses of single or
rotating antibiotics can beused.
 Oral therapy with erythromycin
(500 mg twice per day) for 8 weeks
can reduce the amount of sputum
and improve the pulmonary
function.
 Broncho-dilators Broncho-
dilators
 Inpatients with airway
hyperreactivity and reversible
airflow obstruction. Broncho-
dilators are particularly useful to
improve obstruction and aid
clearance of secretions.
 Broncho-dilators can be used if
there is not hemoptysis.
 Aminophyllin 0.1g ,orally thrice
daily.
 Inhalation of β2–adrenoceptor
agonists (terbutaline , salbultamol
or fenoterol) or anticholinergic
agents (ipratropium) by
nebulization.
 Recently ,some researches show
that inhalation of fenoterol and
ipratropium by nebulization can
improve pulmonary function
significantly.
 Surgical treatment
 Although surgical therapy was common in
the past, more effective antibiotic and
supportive therapy has largely replaced
surgery.
 However, when bronchiectasis is localized
and the morbidity is substantial despite
adequate medical therapy, surgical
resection of the involved region of lung
should be considered.
 Other measures
 In patients with extensive disease,
chronic hypoxemia and cor pulmonale
may indicate the need for long-term
supplemental oxygen.
 For selected patients who are disabled
despite maximal therapy, lung
transplantation is a therapeutic option
 Hemoptysis treatment
 In small amounts of hemoptysis ,
carbazochrome(10 mg three times
per day) or vitamin K4(4 mg three
times per day) by mouth can be
adopted usually.
 In massive hemoptysis, patients
should be sent to hospital
immediately.
 Usually , conservative therapy,
including rest and antibiotics does
not resolve this massive
hemoptysis, therapeutic options
are either surgical resection or
bronchial arterial embolization.
 Although resection may be
successful if disease is localized,
embolization is preferable with
widespread disease.
 Prognosis
 This disease is progressive when
associated with cillary dysfunction and
cystic fibrosis, and inevitably causes
respiratory failure and right ventricular
failure
 In other patients,the prognosis can be
relatively good if postural drainage is
performed regularly and antibiotics be used
judiciously
 Prevention
 Adequate prophylaxis and treatment measles ,whooping
cough or primary tuberculosis infection.
 Recognition and treatment of bronchial obstruction early .
 Avoiding the inhalation of poisonous gas, smog and dust.
 Using immunoglobulin in patient with immunoglobulin
deficiency .
 Treatment gastrointestinal disease efficiently.