1. Chapter 14 – Des Jardins P. 584-589 – Merck Manual
Bronchiectasis
Chapter 14 – Des Jardins
P – Merck Manual

2. 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.

3. 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.

4. Etiology Usually occurs secondary to: Congenital Defect
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)

5. Etiology (cont.) Idiopathic Immune-related diseases
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 (?)

6. 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

9. Types of Bronchiectasis
Varicose
Saccular
Technically there are 2 other kinds: Follicular and Traction. But….who cares?
Cylindrical

10. Varicose Bronchiectasis
Bronchi are dilated and constricted in an irregular fashion similar to varicose veins.
Varicose bronchiectasis is also called fusiform.

11. 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

12. 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.

13. 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.

14. Pathophysiology
Obstructive Lung Diseases but can have a restrictive component if alveolar lung volumes are reduced.
Obstructive and Restrictive Disease

15. Physical Examination Vital Signs: Inspection:
f: Increased (tachypnea).
HR: Increased
BP: Increased (Increased CO)
Inspection:
Pursed lip breathing.
Cyanosis.
Prolonged expiratory phase.
Increased A-P diameter
Digital clubbing

16. Physical Examination Palpation: Percussion: Auscultation:
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.

17. 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.

18. ABG Mild to Moderate Bronchiectasis Severe Bronchiectasis
Acute alveolar hyperventilation with hypoxemia.
Severe Bronchiectasis
Chronic ventilatory failure with hypoxemia.
Oxygenation Indices
Increased shunting.
Decreased oxygen delivery.

19. 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.

21. Chest X-ray Obstructive Lung Disease Restrictive Process
Translucent (dark) lung fields
Depressed, flattened diaphragms
Long, narrow hearts
Right ventricular enlargement
Restrictive Process
Atelectasis and consolidation
Increased opacity

22. Laboratory Findings Culture and Sensitivity CBC Haemophilus influenzae
Streptococcus pneumoniae
Staphylococcus aureus
Pseudomonas aeruginosa
Anaerobic organisms
Sputum separates into layers
CBC
Polycythemia and increased WBC (infection).

23. Diagnosis Bronchography (Bronchogram) High-Resolution CT Scan
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.

24. Prophylaxis
Awareness and early identification may allow for earlier intervention.
Childhood immunizations.
Reduce exacerbations.

25. Treatment Goals Reduce infections/exacerbations Manage secretions
Reduce airway obstruction
Treat complications
Hemoptysis
Hypoxemia
Respiratory Failure
Cor Pulmonale

26. Treatment Antibiotics to treat pneumonia
Inhaled steroids to reduce inflammation
Oxygen therapy (low FiO2)
Bronchial Hygiene Protocol
CPT/PD
Hydration
Deep breathing/coughing
Humidification

27. Therapy Aerosol Therapy Flu shots/Pneumonia Vaccinations Bronchoscopy
Mucolytics
Bronchodilators
Flu shots/Pneumonia Vaccinations
Bronchoscopy
Avoidance of respiratory irritants
Surgical resection
Saccular is most suitable for surgery

28. 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