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Chapter 14 Bronchiectasis
C A B E D Figure 14–1. Bronchiectasis. A, Varicose bronchiectasis. B, Cylindrical bronchiectasis. C, Saccular bronchiectasis. Also illustrated are excessive bronchial secretions (D) and atelectasis (E), which are both common anatomic alterations of the lungs in this disease.
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Three Forms of Bronchiectasis
Varicose bronchiectasis Cylindrical bronchiectasis Saccular bronchiectasis
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Anatomic Alterations of the Lungs
Chronic dilation and distortion of bronchial airways Excessive production of often foul-smelling sputum Smooth muscle constriction of bronchial airways Hyperinflation of alveoli (air-trapping) Atelectasis, consolidation, and parenchymal fibrosis Hemorrhage secondary to bronchial arterial erosion
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Etiology Acquired bronchiectasis Congenital bronchiectasis
Recurrent pulmonary infection Bronchial obstruction Congenital bronchiectasis Kartagener’s syndrome Hypogammaglobulinemia Cystic fibrosis
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Overview of the Cardiopulmonary Clinical Manifestations Associated with BRONCHIECTASIS
The following clinical manifestations result from the pathophysiologic mechanisms caused (or activated) by Atelectasis (see Figure 9-12), Consolidation (see Figure 9-8), Bronchospasm (see Figure 9-10), and Excessive Bronchial Secretions (see Figure 9-11)—the major anatomic alterations of the lungs associated with bronchiectasis (see Figure 14-1).
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Figure 9-7. Atelectasis clinical scenario.
Figure 9-7. Atelectasis clinical scenario.
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Figure 9-8. Alveolar consolidation clinical scenario.
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Figure 9-9. Increased alveolar-capillary membrane thickness clinical scenario.
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Figure 9-10. Bronchospasm clinical scenario (e.g., asthma).
Figure Bronchospasm clinical scenario (e.g., asthma).
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Figure 9-11. Excessive bronchial secretions clinical scenario.
Figure Excessive bronchial secretions clinical scenario.
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Clinical Data Obtained at the Patient’s Bedside
Vital signs Increased respiratory rate Increased heart rate, cardiac output, blood pressure
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Clinical Data Obtained at the Patient’s Bedside
Use of accessory muscles of inspiration Use of accessory muscles of expiration Pursed-lip breathing Increased anteroposterior chest diameter (barrel chest) Cyanosis Digital clubbing
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Figure 2-36. The way a patient may appear when using the pectoralis major muscles for inspiration.
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Figure A, Schematic illustration of alveolar compression of weakened bronchiolar airways during normal expiration in patients with chronic obstructive pulmonary disease (e.g., emphysema). B, Effects of pursed-lip breathing. The weakened bronchiolar airways are kept open by the effects of positive pressure created by pursed lips during expiration.
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Figure 2-46. Digital clubbing.
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Clinical Data Obtained at the Patient’s Bedside
Peripheral edema and venous distention Distended neck veins Pitting edema Enlarged and tender liver
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Figure 2-48. Distended neck veins (arrows).
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Figure Pitting edema. From Bloom A, Ireland J: Color atlas of diabetes, ed 2, London, 1992, Mosby-Wolfe.
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Cough, sputum production, and hemoptysis
A chronic cough with production of large quantities of foul-smelling sputum is a hallmark of bronchiectasis
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Clinical Data Obtained at the Patient’s Bedside
Chest assessment findings (primarily obstructive) Decreased tactile and vocal fremitus Hyperresonant percussion note Diminished breath sounds Rhonchi and Wheezing
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Clinical Data Obtained at the Patient’s Bedside
Chest assessment findings (primarily restrictive) Increased tactile and vocal fremitus Bronchial breath sounds Crackles Whispered pectoriloquy Dull percussion note
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Figure 2-12. Percussion becomes more hyperresonant with alveolar hyperinflation.
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Figure As air trapping and alveolar hyperinflation develop in obstructive lung diseases, breath sounds progressively diminish.
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Clinical Data Obtained from Laboratory Tests and Special Procedures
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Pulmonary Function Study: Expiratory Maneuver Findings Primarily Obstructive
FVC FEVT FEF25%-75% FEF PEFR MVV FEF50% FEV1%
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Pulmonary Function Study: Lung Volume and Capacity Findings Primarily Obstructive
VT RV FRC TLC N or N or VC IC ERV RV/TLC ratio N or N or
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Pulmonary Function Study: Expiratory Maneuver Findings Primarily Restrictive
FVC FEVT FEF25%-75% FEF N or N or N PEFR MVV FEF50% FEV1% N N or N N or
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Pulmonary Function Study: Lung Volume and Capacity Findings Primarily Restrictive
VT RV FRC TLC N or VC IC ERV RV/TLC ratio N
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Arterial Blood Gases Mild to Moderate Bronchiectasis
Acute alveolar hyperventilation with hypoxemia pH PaCO HCO PaO2 (Slightly)
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Alveolar Hyperventilation
Time and Progression of Disease Disease Onset Alveolar Hyperventilation 100 90 Point at which PaO2 declines enough to stimulate peripheral oxygen receptors 80 70 60 PaO2 PaO2 or PaCO2 50 40 30 PaCO2 20 10 Figure 4-2. PaO2 and PaC02 trends during acute alveolar hyperventilation.
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Arterial Blood Gases Severe Bronchiectasis
Chronic ventilatory failure with hypoxemia pH PaCO HCO PaO2 Normal (Significantly)
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Alveolar Hyperventilation Chronic Ventilatory Failure
Time and Progression of Disease Disease Onset Alveolar Hyperventilation Chronic Ventilatory Failure 100 Point at which disease becomes severe and patient begins to become fatigued 90 Point at which PaO2 declines enough to stimulate peripheral oxygen receptors 80 70 PaCO2 Pa02 or PaC02 60 50 40 30 PaO2 20 10 Figure PaO2 and PaCO2 trends during acute or chronic ventilatory failure.
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Acute Ventilatory Changes on Chronic Ventilatory Failure
Acute alveolar hyperventilation on chronic ventilatory failure Acute ventilatory failure on chronic ventilatory failure
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Oxygenation Indices QS/QT DO2 VO2 C(a-v)O2 Normal Normal
O2ER SvO
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Hemodynamic Indices (Severe Chronic Bronchiectasis)
CVP RAP PA PCWP Normal CO SV SVI CI Normal Normal Normal Normal RVSWI LVSWI PVR SVR Normal Normal
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Abnormal Laboratory Tests and Procedures
Hematology (Increased hematocrit and hemoglobin) Sputum examination Streptococcus pneumoniae Haemophilus influenzae Pseudomonas aeruginosa Anaerobic organisms
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Radiologic Findings Chest radiograph Bronchogram CT scan
Translucent (dark) lung fields Depressed or flattened diaphragm Long and narrow heart Enlarged heart Bronchogram CT scan
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Figure 14-2. Cylindrical bronchiectasis
Figure Cylindrical bronchiectasis. Left posterior oblique projection of a left bronchogram showing cylindrical bronchiectasis affecting the whole of the lower lobe except for the superior segment. Few side branches fill. Basal airways are crowded together, indicating volume loss of the lower lobe, a common finding in bronchiectasis. (From Armstrong P et al: Imaging of diseases of the chest, ed 2, St. Louis, 1995, Mosby.)
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Figure 14-3. Saccular bronchiectasis
Figure Saccular bronchiectasis. Right lateral bronchogram showing saccular bronchiectasis affecting mainly the lower lobe and posterior segment of the upper lobe. (From Armstrong P et al: Imaging of diseases of the chest, ed 2, St. Louis, 1995, Mosby.)
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Figure 14-4. Varicose bronchiectasis
Figure Varicose bronchiectasis. Left posterior oblique projection of left bronchogram in a patient with the ciliary dyskinesia syndrome. All basal bronchi are affected by varicose bronchiectasis. (From Armstrong P et al: Imaging of diseases of the chest, ed 2, St. Louis, 1995, Mosby.)
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Figure 14-5. Bronchiectasis. High-resolution thin-section (1
Figure Bronchiectasis. High-resolution thin-section (1.5-mm) computed tomographic (HRCT) scan showing numerous oval and rounded ring opacities in the left lower lobe. The right lung appears normal. The fact that the airways tend to be arranged in a linear fashion and have walls of more than hairline thickness helps distinguish these bronchiectatic airways from cysts or bullae. (From Armstrong P, Wilson AG, Dee P: Imaging of diseases of the chest, St. Louis, 1990, Mosby.)
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General Management of Bronchiectasis
General treatment includes: Controlling pulmonary infections Controlling airway secretions Preventing complications
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General Management of Bronchiectasis
Respiratory care treatment protocols Oxygen therapy protocol Bronchopulmonary hygiene therapy protocol Hyperinflation therapy protocol Aerosolized medication protocol Mechanical ventilation protocol
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General Management of Bronchiectasis
Other medications commonly prescribed by the physician Xanthines Expectorants Antibiotics
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Classroom Discussion Case Study: Bronchiectasis
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