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Bronchiectasis. Chapter 14 – Des Jardins P. 584-589 – Merck Manual. Objectives. State the clinical definition for Bronchieactasis Describe the anatomic alterations of the lungs in Bronchieactasis Describe the etiology of Bronchieactasis

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bronchiectasis

Bronchiectasis

Chapter 14 – Des Jardins

P. 584-589 – Merck Manual

objectives
Objectives
  • State the clinical definition for Bronchieactasis
  • Describe the anatomic alterations of the lungs in Bronchieactasis
  • Describe the etiology of Bronchieactasis
  • List the clinical manifestations seen in Bronchieactasis. Include findings of the physical examination, laboratory tests, pulmonary function tests, chest x-rays, arterial blood-gas values, and hemodynamic indices.
  • Describe the management of Bronchieactasis.
definition
Definition
  • A chronic dilation and distortion of one or more bronchi due to extensive inflammation and destruction of the bronchial wall cartilage, blood vessels, elastic tissue and smooth muscle.
etiology
Etiology
  • Usually occurs secondary to:
    • Repeated, severe pneumonia
      • Measles, Pertussis, Adenovirus in children
      • Klebsiella
      • Staphylococci
      • Influenza virus
      • Fungal infections
      • Myocbacteria
      • Mycoplasma
    • Bronchial Obstruction
  • Congenital Defect
    • Manifestation of Cystic Fibrosis
    • Kartagener’s Syndrome
    • Primary ciliary dyskinesia (PCD)
etiology cont
Etiology (cont.)
  • Idiopathic
    • Accounts for roughly 50 to 80% of cases
    • Possible immunologic defect or autoimmune abnormality.
  • Immune-related diseases
    • Allergic bronchopulmonary aspergillosis (ABPA)
    • Collagen Vascular diseases
      • Rheumatoid arthritis
      • Sjögren syndrome
    • Ulcerative colitis
    • Crohn’s disease
  • Immune deficiencies (?)
pathophysiology
Pathophysiology
  • Either one or both lungs may be involved.
  • It is commonly limited to a lobe or segment and is frequently found in the lower lobes.
    • Right Middle Lobe and Left Lingula also possible.
  • Extent and character of pathologic changes determines the functional abnormalities.
    • Increased mucus production with impaired mucociliary clearance
    • Changes in lung volumes distal to obstruction
      • Increased due to Ball-Valve effect
      • Decreased due to atelectasis
    • Reduced flow rates
    • / defects with hypoxemia
types of bronchiectasis
Types of Bronchiectasis

Varicose

Saccular

Technically there are 2 other kinds: Follicular and Traction. But….who cares?

Cylindrical

varicose bronchiectasis
Varicose Bronchiectasis
  • Bronchi are dilated and constricted in an irregular fashion similar to varicose veins.
  • Varicose bronchiectasis is also called fusiform.
cylindrical bronchiectasis
Cylindrical Bronchiectasis
  • Bronchi are dilated and have regular outlines similar to a tube. The dilated bronchi fail to taper for 6-10 generations and then in the bronchogram appear to end squarely because of mucous obstruction
saccular bronchiectasis
Saccular Bronchiectasis
  • Bronchi progressively increase in diameter until they end in large, cyst-like sacs in the lung parenchyma.
    • This form causes the greatest damage to the tracheobronchial tree.
    • The bronchial walls become composed of fibrous tissue.
    • Cartilage, elastic tissue and smooth muscle are all absent.
anatomic alterations
Anatomic Alterations
  • Copious amounts of bronchial secretions.
  • Mucociliary clearance mechanism is impaired.
  • Foul smelling mucous from anaerobic organisms.
  • Mucous plugs cause partial or complete obstruction.
  • Hyperinflation of the distal alveoli as a result of an expiratory check valve obstruction.
  • Atelectasis, consolidation, and fibrosis results from complete bronchial obstruction.
pathophysiology1
Pathophysiology
  • Obstructive Lung Diseases but can have a restrictive component if alveolar lung volumes are reduced.
    • Obstructive and Restrictive Disease
physical examination
Physical Examination
  • Vital Signs:
    • f: Increased (tachypnea).
    • HR: Increased
    • BP: Increased (Increased CO)
  • Inspection:
    • Pursed lip breathing.
    • Cyanosis.
    • Prolonged expiratory phase.
    • Increased A-P diameter
    • Digital clubbing
physical examination1
Physical Examination
  • Palpation:
    • Use of accessory muscles during I & E.
  • Percussion:
    • Hyperresonant if obstructive, Dull if restrictive.
  • Auscultation:
    • Inspiratory crackles and/or rhonchi.
    • May be diminished if obstructive, bronchial with restrictive.
physical assessment
Physical Assessment
  • Chief complaint:
    • Cough with large volume of sputum
      • Hemoptysis
      • Sputum settles into distinct layers with streaks of blood often seen
      • Thick, tenacious sputum
  • Chronic sinusitis is a common complaint.
    • Also nasal polyps
    • Kartagener’s Syndrome (Bronchiectasis, dextrocardia & paranasal sinusitis).
      • 20% of Bronchieactasis is as a result of Kartagener’s.
slide18
ABG
  • Mild to Moderate Bronchiectasis
    • Acute alveolar hyperventilation with hypoxemia.
  • Severe Bronchiectasis
    • Chronic ventilatory failure with hypoxemia.
  • Oxygenation Indices
    • Increased shunting.
    • Decreased oxygen delivery.
pulmonary function studies
Pulmonary Function Studies
  • Obstructive Disease
    • Decreased FVC and FEV1.0
    • Decreased Flowrates
    • Increased RV, FRC, TLC, RV/TLC
  • Restrictive Defect
    • Reduced RV, FRC, TLC
      • RV/TLC ratio normal
    • Flows are normal.
chest x ray
Chest X-ray
  • Obstructive Lung Disease
    • Translucent (dark) lung fields
    • Depressed, flattened diaphragms
    • Long, narrow hearts
    • Right ventricular enlargement
  • Restrictive Process
    • Atelectasis and consolidation
    • Increased opacity
laboratory findings
Laboratory Findings
  • Culture and Sensitivity
    • Haemophilus influenzae
    • Streptococcus pneumoniae
    • Staphylococcus aureus
    • Pseudomonas aeruginosa
    • Anaerobic organisms
    • Sputum separates into layers
  • CBC
    • Polycythemia and increased WBC (infection).
diagnosis
Diagnosis
  • Bronchography (Bronchogram)
    • Injection of opaque contrast material into the TB tree
    • Rarely done.
  • High-Resolution CT Scan
    • Bronchial walls appear thick, dilated.
    • Replaced standard CT scan and Bronchography as gold standard.
prophylaxis
Prophylaxis
  • Awareness and early identification may allow for earlier intervention.
  • Childhood immunizations.
  • Reduce exacerbations.
treatment goals
Treatment Goals
  • Reduce infections/exacerbations
  • Manage secretions
  • Reduce airway obstruction
  • Treat complications
    • Hemoptysis
    • Hypoxemia
    • Respiratory Failure
    • Cor Pulmonale
treatment
Treatment
  • Antibiotics to treat pneumonia
  • Inhaled steroids to reduce inflammation
  • Oxygen therapy (low FiO2)
  • Bronchial Hygiene Protocol
    • CPT/PD
    • Hydration
    • Deep breathing/coughing
    • Humidification
therapy
Therapy
  • Aerosol Therapy
    • Mucolytics
    • Bronchodilators
  • Flu shots/Pneumonia Vaccinations
  • Bronchoscopy
  • Avoidance of respiratory irritants
  • Surgical resection
    • Saccular is most suitable for surgery
prognosis
Prognosis
  • Mild Bronchiectasis – may have a normal life span
  • Extensive Bronchiectasis – shorter life span
    • Result of respiratory infection and complications
  • Disease of slow deterioration interspersed by episodes of exacerbation