Bronchiectasis–essentials of diagnosis
- chronic productive cough with dyspnea and wheezing
- Radiograph–dilated, thickened airways and scattered, irregular opacities
General considerations of bronchiectasis
- congenital or acquired disorder of large bronchi
- permanent abnormal dilation, destruction of bronchial walls
- caused by recurrent inflammation or infection of airways and may be localized or diffuse
Causes of bronchiectasis
- CF causes half of all cases
- other causes=lung infection (TB, fungi, abscess, pneumonia), abnormal defense (humoral deficiency, alpha-1 antiprotease with cigarette smoking, mucociliary clearance disorders, rheumatic diseases), and localized airway obstruction (foreign body, tumor, mucoid impaction)
Immunodeficiency states that may lead to bronchiectasis include
- congential or acquired panhypogammaglobulinemia
- common variable immunodeficiency
- selective IgA, IgM and IgG deficiencies
- Acquired immunodeficiencies from cytotoxic therapy, AIDS, lymphoma, multiple myeloma, leukemia, chronic liver diseases
Most patients with bronchiectasis have
-Panhypoglobulinemia reflecting an immune system response to chronic airway infection
Acquired primary bronchiectasis is
-now uncommon in US bc of improved control of bronchopulmonary infections
Symptoms and signs of bronchiectasis
- chronic cough with copious purulent sputum
- hemoptysis
- pleuritic chest pain
- Dyspnea and wheezing
- Weight loss, anemia
- PE nonspecific but crackles common
- Clubbing only seen in severe cases
- Foul smelling purulent sputum is characteristic
- Obstructive pulmonary dysfunction with hypoxemia is seen in moderate or severe disease
Imaging of bronchiectasis
- dilated and thickened bronchi
- appear as “tram tracks” or as ring-like markings
- Scattered irregular opacities, atelectasis and focal consolidations may be present
- HR CT is imaging of choice!!
Microbiology of bronchiectasis
- H. flu is most common organism from non-CF cases
- Pseudomonas, Strep pneumo and staph a. also common
- Nontuberculous mycobacteria seen less commonly
- If pseudomonas, accelerated course with more exacerbations and more rapid decline in lung fnx
Treatment for bronchiectasis
- antibiotics
- 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
Antibiotics for bronchiectasis guided by sputum smears and cultures; if bacterial pathogen not identified, then do what?
- empiric oral antibiotic therapy for 10-14 days
- common=amoxicicillin or amoxicillin-clavulanate (500mg/8 hrs);
- ampicillin or tetracycline (250-500 mg 4x daily)
- TMP-SMX (160/800 mg/12 hrs)
- Cipro (500-750 mg BID)
Important to screen patients for nontuberculous mycobacteria because
-these pathogens may underlie lack of Tx response
Preventative or suppressive treatment sometimes given to stable outpatients who have copious purulent sputum
- Prolonged macrolide Tx (axithromycin 500mg 3x/wk for 6 mo or 250mg daily for 12 mo)–found to decrease frequency of exacerbations
- High dose amoxicillin (3g/day) or alternating cycles of above antibiotics orally for 2-4 wks–not supported by clinical trial data
Role of aerosolized ahminoglycosides in CF
- reduce colonization of pseudomonas
- improve FEV1, reduce hospitalizations
Complications of bronchiectasis include
- hemoptysis
- cor pulmonale
- amyloidosis
- secondary visceral abscess at distant sites (e.g. brain)
Bronchoscopy sometimes necessary to evaluate
- hemoptysis
- remove retained secretions
- 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
