BRONCHIECTASISPrepared By:Sharmin Susiwala

Definition:Bronkos + Ectasia = Bronchi +

DilatationLocalized, irreversible dilation of

part of the bronchial tree/bronchi with destruction of their elastic and muscular component, usually due to acute or chronic infection.

 It is classified as an obstructive lung disease.

Etiology:

The induction of bronchiectasis requires two factors: (1) an infectious insult (2) impairment of drainage, airway obstruction.Bronchiectasis is often caused by recurrent

inflammation or infection of the airways.Occur along with - emphysema- bronchitis- asthma- cystic fibrosis. Involved bronchi are dilated, inflamed, and easily

collapsible, resulting in airflow obstruction and impaired clearance of secretions.

If the condition is present at birth, it is called congenital bronchiectasis.

If it develops later in life, it is called acquired bronchiectasis.

Acquired causes Acquired Immune Deficiency Syndrome (AIDS) Tuberculosis  / Endobronchial tuberculosis  Bronchial stenosis Secondary traction from fibrosis. Inflammatory bowel disease, especially ulcerative colitis. Crohn's disease Allergic responses to inhaled fungus spores Hiatal hernia can cause Bronchiectasis when the stomach

acid that is aspirated into the lungs causes tissue damage.

Rheumatoid arthritis Cigarette smoke is a specific primary cause of

bronchiectasis remains unclear.

Bronchiectasis is associated with a wide range of disorders, but it usually results from bacterial infections, such as

Staphylococcus Klebsiella species Bordetella pertussis.Airway obstruction due to foreign body

aspiration.Inhalation and aspiration of ammonia and

other toxic gasesAlcoholismheroin (drug use)Allergic bronchopulmonary aspergillosis

Congenital causesHumoral Immunodeficiency:

Hypogammaglobulinemia (IgG,IgG2)Kartagener syndrome, which affects the

mobility of cilia in the lungs.Another common genetic cause is cystic fibrosisYoung's syndrome, this is due to the occurrence

of chronic, sinopulmonary infectionsAlpha 1-antitrypsin deficiency Primary immunodeficienciesCongenital disorders can also lead to

bronchiectasis, includes:- Williams-Campbell syndrome- Marfan syndrome

Pathology:

The affected areas show a variety of changes including transmural inflammation, mucosal edema, cratering and ulceration with bronchial neovascularization, and distortion due to scarring or obstruction from repeated infection .

The obstruction often leads to postobstructive pneumonitis that may temporarily or permanently damage the lung parenchyma

 Involved bronchi are dilated, inflamed, and easily collapsible, resulting in airflow obstructionand impaired clearance of secretions.

Clinical Features: Cough Daily sputum production green/yellow sputum (patients with

bronchiectasis may produce 240ml (8 oz) of sputum daily).  Dyspnea Wheezing Hemoptysis Bluish skin color Recurrent pleurisy Dry Bronchiectasis Breath odor Clubbing of fingers Fatigue Paleness Weight loss Acute exacerbation Late : hypoxemia and hypercapnia

Diagnosis: ABNORMAL LUNG SOUNDS:

Crackles, wheezes, rhonchi

CHEST RADIOGRAPHY:

Abnormal (>90%), Suspicious but not diagnostic radiographic findings include:

focal pneumonitis, scattered irregular opacities that may represent mucopurulent plugs, linear or plate-like atelectasis , dilated and thickened airways that appear as ring-like shadows (of airways that are seen on end) or tram lines (in the case of airways that are perpendicular to the x-ray beam)

HIGH-RESOLUTION COMPUTED TOMOGRAPHIC SCANNING:

"tree-in-bud" abnormalities 

The major features of bronchiectasis on HRCT include airway dilatation and bronchial wall thickening

BRONCHOSCOPY:

For diagnosis of tumor, foreign body, localize site of hemoptysis.

PULMONARY FUNCTION TESTS BLOOD AND SPUTUM EXAMINATION

Treatment:Goals:1. Controlling infections and bronchial secretions2. Relieving airway obstructions3. Removal of affected portions of lung by surgical

removal or artery embolization 4. Preventing complications.Treatment of bronchiectasis includes: The prolonged usage of antibiotics to prevent

detrimental infections Eliminating accumulated fluid with postural

drainage and chest physiotherapy Surgery may also be used to treat localized

bronchiectasis, removing obstructions that could cause progression of the disease.

Inhaled steroid therapy that is consistently adhered to can: Reduce sputum production Decrease airway constriction over a period of time, and Prevent progression of bronchiectasis. One commonly used therapy is beclometasone dipropionate, which

is also used in asthma treatment. Use o f inhalers such as albuterol (salbutamol), fluticasone

(Flovent/Flixotide) and ipratropium (Atrovent) may help reduce likelihood of infection by clearing the airways and decreasing inflammation.

ACBT (Active Cycle Breathing Techniques) can be useful in the clearance of sputum

These techniques encourage relaxed, diaphragmatic breathing, greater expansion (via collateral inflation) of otherwise consolidated areas of the lungs, and help in mucociliary clearance (MCC).

A useful adjunct to these cycles are manual techniques, wherein the healthcare professional uses percussion, vibrations, and shaking, to dislodge sputum from the chest walls, enabling the patient to expectorate more easily.

Prevention:Immunization against

measles, pertussis and other acute respiratory infections of childhood.

Bronchial HygieneAvoiding URTI, smoking and

pollution

Complications:Cor pulmonaleCoughing up bloodLow oxygen levels (in severe

cases)Recurrent pneumonia

Images: SEVERE BRONCHIECTASIS

Bronchiectasis

Dextrocardia

KARTAGENER’S SYNDROME

CYSTIC FIBROSIS

LUNG ABSCESS

Prepared By:Sharmin Susiwala

DEFINITION:Lung abscess is necrosis of the pulmonary tissue and

formation of cavities (more than 2 cm) containing necrotic debris or fluid caused by microbial infection.

This pus-filled cavity is often caused by aspiration, which may occur during altered consciousness.

TYPES:

Lung abscess is considered Primary (60%): when it results from

existing lung parenchymal process Secondary:  when it complicates

another process e.g. vascular emboli or follows rupture of extrapulmonary abscess into lung.

CAUSES: Conditions contributing to lung abscess: Aspiration of oropharyngeal or gastric secretion Septic emboli Necrotizing pneumonia Vasculitis: Wegener's granulomatosis Necrotizing tumors: 8% to 18% are due to neoplasms across all age

groups, higher in older people; primary squamous carcinoma of the lung is the most common.

Organisms In the post-antibiotic era pattern of frequency is changing. In older

studies anaerobes were found in up to 90% cases but they are much less frequent now.

Anaerobic bacteria: Peptostreptococcus, Bacteroides, Fusobacterium species

Aerobicbacteria: Staphylococcus, Klebsiella, Haemophilus, Pseudomonas, Nocardia, Escherichia coli, Streptococcus, Mycobacteria

Fungi: Candida, Aspergillus Parasites: Entamoeba histolytica

SIGNS AND SYMPTOMS:

Onset of symptoms is often gradua Cough Fever with shivering Night sweats Cough can be productive with foul

smelling purulent sputum(≈70%) or less frequently with blood (i.e. hemoptysis in one third cases).

Chest pain Shortness of breath Lethargy and other features of chronic illness. Patients are generally cachectic at presentation. Finger clubbing is present in one third of patients.  Dental decay is common especially in alcoholics and children. On examination of chest there will be features of consolidation such

as localised dullness on percussion, bronchial breath sound etc.

DIAGNOSIS:

Chest Xray and other imaging studies Abscess is often unilateral and single involving posterior

segments of the upper lobes and the apical segments of the lower lobes as these areas are gravity dependent when lying down.

Presence of air-fluid levels implies rupture into the bronchial tree or rarely growth of gas forming organism.

Laboratory studies Raised inflammatory markers (high ESR, CRP) are usual but not

specific. Examination of sputum is important in any pulmonary infections

and here often reveals mixed flora.  Transtracheal of Transbronchial (via bronchoscopy) aspirates can

also be cultured. Fibre optic bronchoscopy is often performed to exclude

obstructive lesion; it also helps in bronchial drainage of pus.

MANAGEMENT:Broadspectrum antibiotic to

cover mixed flora is the mainstay of treatment.

Pulmonary physiotherapy Postural drainage Surgical procedures are required

in selective patients for drainage or pulmonary resection.

COMPLICATIONS:Rare nowadays but include: Spread of infection to other lung

segmentsBronchiectasisEmpyemaBacteraemia with

Metastatic infection such as brain abscess.