Bronchiectasis

    Cards (16)

    • Bronchiectasis involves permanent dilation of the bronchi
      Initial insult to the bronchi results in recruitment of immune cells that damage the muscle and elastin
    • Dilated bronchi are predisposed to persistent microbial colonisation as mucus is trapped
    • Causes of bronchiectasis:
      • Post infection (most common): recurrent childhood LRTIs, pulmonary TB and allergic bronchopulmonary aspergillosis
      • Pulmonary disease: COPD and asthma
      • Congenital: Cystic fibrosis and alpha-1 antitrypsin deficiency
      • Connective tissue disorders: RA, SLE and sarcoidosis
      • 40% of cases are idiopathic
    • Key presenting symptoms are:
      • Daily cough productive of large amounts of mucopurulent sputum
      • Haemoptysis is present on 50% of patients
      • Exertional dyspnoea which may progress to resting dyspnoea
      • Fatigue
      • Rhinosinusitis symptoms - nasal discharge, nasal obstruction and facial pressure
    • Bronchiectasis on examination:
      • Finger clubbing - increased secretion of growth factors
      • signs of connective tissue disease
      • Course crepitations present on inspiration and expiration that change or clear when coughing
      • Rhonchi - low pitched snoring noise on auscultation
      • High pitched inspiratory speaks and pops
    • Typical pulse oximetry target is 94-98%
    • Investigations:
      • Sputum culture: most commonly pseudomonas aeruginosa or haemophilus influenzae
      • Spirometry - obstructive pattern but may be normal
      • Echo - bronchiectasis may impair ventricular function and lead to pulmonary hypertension
      • FBC - raised white blood cells
      • Autoimmune screen - Anti-CCP, ANA and ANCA
      • IgE
      • Genetic testing - cystic fibrosis
    • Bronchiectasis can cause signs of cor pulmonale such as a raised JVP
    • Advanced bronchiectasis will show tram lines and ring shadows on a chest x-ray
      HRCT is the gold standard imaging test - bronchial dilation with or without airway thickening
    • General management for bronchiectasis:
      • Pulmonary rehab - airways clearance techniques
      • Smoking cessation
      • Vaccinations
    • Medical management of bronchiectasis:
      • Mucoactive agents - nebulised saline and carbocisteine
      • Long term antibiotics if there are frequent exacerbations - azithromycin
      • LABAs such as formoterol for dyspnoea
      • LTOT
      • Lung resection or transplant
    • Risk factors:
      • Age over 70
      • Female gender
      • Smoking history
    • Important areas to cover in the history:
      • History of childhood lower respiratory tract infections
      • Family history - congenital conditions such as cystic fibrosis and autoimmune conditions such as RA
      • Smoking history
    • Disease-related complications of bronchiectasis include:
      • Respiratory failure: due to failure of gas exchange in the lungs
      • Massive haemoptysis (>250ml per day): often due to rupture of a bronchial artery into a bronchus
      • Anxiety and depression: due to impaired quality-of-life
    • Treatment-related complications of bronchiectasis include:
      • Azithromycin - long QT syndrome, tinnitus and hearing loss
      • Lung transplant: immediate complications (e.g. blood loss), early complications (e.g. transplant rejection) and late complications (e.g. post-transplantation lymphoproliferative disorder)
    • Haemophilus influenzae is the most common organism