By Dr.

Eman Arram

Bronchiectasis is an abnormal
permanent dilatation of the medium

sized

cartilagenous

bronchi,

accompanied by variable destruction of muscular and elastic components of the bronchial walls. It may be congenital or acquired. It may be focal

or diffuse.

 It is a syndrome & characterized by cough and expectoration that is usually copious and related to posture and time It includes:
Bronchiectasis

Lung abscess
Empyema with bronchopleural fistula

Infected cystic lung

Dilatation of medium sized subsegmental bronchi from about the 4th to 9th generations and filling with purulent secretions or mucus plugs. Bronchial wall inflammation and destruction and replacement of the all components of the wall by fibrous tissue.

Pathogenesis:
Initiating factors for bronchiectasis:

Infection Bronchial obstruction Fibrosis

 Site:
Bilateral in 30% of patients. Left lower lobe > Rt lower lobe (>3 times). Left LL posterior basal segments is almost always affected then lingula then Rt LL then middle lobe. The particular lobes affected may sometimes bear a relationship to underlying predisposition:
Upper lobe bronchiectasis is often 2ry to TB, lung abscess or cystic fibrosis. Middle lobe bronchiectasis in TB. Central bronchiectasis in ABPA. Bronchiectasis due to FB aspiration is more in the Rt LL or in post segment of UL.

Classification (Reids classification)

Cylindrical (tubular) Cystic (saccular) Varicose Fusiform

Aetiology of Bronchiectasis
A) Congenital and hereditary disorders:
Primary ciliary dyskinesia syndromes (PCD). Cystic fibrosis Alpha1 anti-trypsin deficiency Tracheomalacia Tracheobronchomegally Intralobar bronchopulmonary sequestration Immunodeficiency syndromes Yellow nail syndrome

 Kartagners syndrome:
Bronchiectasis. Sinusitis or absent frontal air sinuses Situs inversus

Youngs syndrome:
Recurrent pulmonary infections predisposing to bronchiectasis Sinusitis Infertility (obstructive azospermia)

B) Acquired bronchiectasis:
1- Post-infection: Bacterial: klebsiela
aureus, B. pertussis. pneumonia, S.

Mycobacteria. Mycoplasma. Viruses as infleunza,

adenoviruses, herpes simplex, measless and HIV.

Fungi eg histoplasmosis.

2- Bronchial obstruction:
Endobronchial: FB, tumor, mucoid impaction. Extrabronchial compression: LN, tumor, aneurysm. Bronchial stenosis.

3- Chronic obstructive pulmonary disease. 4- Inhalation / Aspiration injury:

Inhalation of irritants such as ammonia, NO2, smoke
and toxic fumes.

Heroin use. Aspiration of gastric contents. Recurrent aspiration pneumonias,

neurologic disorders, lipoid pneumonia.

alcoholism,

5- Autoimmune diseases: Inflammatory bowel disease. Coeliac disease. SLE. Rheumatoid arthritis. Cryptogenic fibrosing alveolitis. Primary biliary cirrhosis. Thyroiditis. Pernicious anemia.
.

Clinical presentation of bronchiectasis:

Chronic cough with copious amount
of foul-smelling sputum more in the morning and on leaning forwards with characteristic winter exacerbations.

Dyspnea. Chest pain. Haemoptysis.

 Wheezy chest.

Concomitant sinusitis in some cases.

General manifestations: fever, weight
loss, growth retardation, GIT troubles.

Clubbing of the fingers and may be

HPOA.

Oedema LL.

Complications of bronchiectasis: Recurrent haemoptysis, pneumonia

and pleurisy are common.

Lung abscess and metastatic brain

abscess.

Amyloidosis. Cor pulmonale

failure.

and

respiratory

Investigations
1) Chest radiography:
Tooth past or gloved finger
appearance.

Tramlines appearance.
Honeycoomb or soap bubble
appearance in cystic bronchiectasis.

2) Bronchography: It was the investigation of choice. 3) HRCT chest: Is now the favored investigation of
establishing the diagnosis of bronchiectasis. Cylindrical bronchiectasis appears as uniformly dilated airways. Signet ring sign: dilated bronchi appear as ring structures with internal diameters greater than those of their accompanying pulmonary artery branches.

Bronchogram showing cystic bronchiectasis

4) Fiberoptic bronchoscopy:
Evaluation of patients with recurrent
haemoptysis.

Perform

more bronchography.

selective

segmental

5) Sputum culture and sensitivity:

H.influenza,
S.pneumoniae, moraxella catarrhalis, staphyloccocus aureus, klebsiella pneumonia, pseudomonas aeruginosa, adenovirus and anaerobes.

6) Pulmonary function tests: Obstructive ventilatory defect is the

predominant defect usually mild. Preoperative evaluation of patients.

7) Other investigations: Sweat chloride test in CF. Serum immunoglobulins. ECG evidence of cor pulmonale in
advanced disease. CBC anaemia and leucocytosis.

Treatment
A) Medical treatment:
1) Postural drainage:
Gravitational drainage of accumulated sputum in
the bronchiectatic area facilitated by direct percussion, mechanical percussors and vibrators.

2) Antimicrobial therapy: Amoxycelline 250mg TDS for 2 weeks may be

increased to 3 gm twice daily in severe cases.

Ofloxacin 200 mg twice daily for 10-15 days.

Clarithramycin 250 mg twice daily for 10 days. Tetracyclines. B lactam antibiotics clavulinic acid. e.g. amoxycelline

Antistaph, antipseudomonal antibiotics. Nebulized antibiotics for pseudomonas

aeruginosa.

3) Expectorants and mucolytics.

4) Bronchodilators.

5) Corticosteroids: when there is failure to obtain an adequate response to bronchodilators. 6) Human gamma globulin: IM 25 mg/kg weekly or 2 weekly intervals in patients with immunodeficiency syndromes.
7) Vaccination: by influenza and pneumoccocal vaccine specially in children.

B) Surgical treatment:
Indications:
The diagnosis has been confirmed with
bilateral bronchogram or HRCT.

Localized disease to one lung or part of

the lung.

Significantly

disturbed patient by recurrent infective exacerbation or haemoptysis despite medical treatment over a period of at least 12 months.

 Good pulmonary function.

No systemic causal factor.

Patient is less than 40 years.

Surgical

maneuvers

include

either

segmentectomy, lobectomy or even pneumonectomy.

C) Embolotherapy:
Bronchial artery embolization to control massive or recurrent haemoptysis for patient not candidates for surgery.

Thank you for attention