BRONCHIECTASIS AND LUNG ABSCESS

DEFINITION
Bronchiectasis
refers to an irreversible airway dilation that involves the lung in either a focal or a diffuse manner.

TYPES


cylindrical or tubular - most common form  varicose  cystic.

Indian incidence -3 per 1000.

TYPES
According to macroscopic morphology, three types have been described, which also represent a spectrum of severity 8: cylindrical : bronchi have a uniform calibre, do not taper and have parallel walls (tram track sign and signet ring sign) varicose : relatively uncommon, with a beaded appearances where dilated bronchi have interspersed sites of relative narrowing cystic : severe form with cyst-like bronchi that extend to the pleural surface; air-fluid levels are commonly present

Major Etiologies of Bronchiectasis and Proposed Workup

PATTERN OF LUNG INVOLVEMENT Focal Diffuse ETIOLOGY BY CATEGORIES Obstruction (e.g., aspirated foreign body, tumor mass) Infection (e.g., bacterial, nontuberculous mycobacterial) WORKUP Chest imaging (chest x-ray and/or chest CT); bronchoscopy Gram's stain/culture; stains/cultures for acid-fast bacilli and fungi. If no pathogen is identified, consider bronchoscopy with bronchoalveolar lavage (BAL) Complete blood count with differential; immunoglobulin measurement; HIV testing

Immunodeficiency (e.g., hypogammaglobulinemia, HIV infection, bronchiolitis obliterans after lung transplantation) Genetic causes (e.g., cystic fibrosis, Measurement of chloride levels in Kartagener's syndrome, alpha1 sweat (for cystic fibrosis), 1 antitrypsin deficiency) antitrypsin levels; nasal or respiratory tract brush/biopsy (for dyskinetic/immotile cilia syndrome); genetic testing

Autoimmune or rheumatologic causes (e.g., rheumatoid arthritis, Sjgren's syndrome, inflammatory bowel disease) Recurrent aspiration Miscellaneous (e.g., traction bronchiectasis from postradiation fibrosis or idiopathic pulmonary fibrosis) Idiopathic

Clinical examination with careful joint exam, serologic testing (e.g., for rheumatoid factor). Test of swallowing function and general neuromuscular strength Guided by clinical condition

Exclusion of other causes

Pathophysiology
2 Prerequisites:
Infectious insult Impairment of drainage, airway obstruction, and/or a defect in host defense.

CLINICAL MANIFESTATIONS
Symptoms  Cough (90 %)  Daily sputum production (76%)  Dyspnea (72%)  Hemoptysis (56%)  Recurrent pleurisy Signs  Clubbing of digits.  crackles n wheezing .

DIAGNOSIS
 persistent chronic cough and sputum production.

+
radiographic features - presence of "tram tracks" dilated airways.  Chest CT- choice of investigation. CT findings include airway dilation
(detected as parallel "tram tracks or as "signet-ring sign ).

 bronchial wall thickening in dilated airways, inspissated secretions (e.g., the "tree-in-bud" pattern)  cysts emanating from the bronchial wall (especially pronounced in cystic bronchiectasis

HRCT

Radiol Clin N Am 43(2005) 513-542

4. Diagnosis Chest CT
lack of tapering

cysts

dilated bronchi

bronchial wall thickening tree in bud pattern

TREATMENT
4 Goals:1. Eliminate cause. 2. Improve tracheo bronchial clearance. 3. Control active infection. 4. Reverse airflow obstruction.

No specific medical therapy exists for the treatment of bronchiectasis. Pharmacologic therapy focuses on the treatment of infectious exacerbations that these patients commonly experience. Commonly used medications: antibiotics, beta-agonists, inhaled corticosteroids, and expectorants.

ANTIBIOTIC TREATMENT
 In acute exacerbations >> broad-spectrum antibacterial agents.  Sampling of respiratory secretions allows treatment with antibiotics based on specific species identification. Acceptable choices (mild to moderately ill) : Amoxicillin Tetracycline Trimethoprim-sulfamethoxazole A newer macrolide (eg, azithromycin[83] or clarithromycin[84, 85] ) A second-generation cephalosporin A fluoroquinolone Duration of antibiotic therapy : 7-10 days.  Moderate-to-severe symptoms : parenteral antibiotics, such as an aminoglycoside (gentamicin, tobramycin) and antipseudomonal synthetic penicillin, a third-generation cephalosporin, or a fluoroquinolone, may be indicated.

 Patients with bronchiectasis from CF are often infected with mucoid Pseudomonas species, and, as such, tobramycin is often the drug of choice for acute exacerbation.

 NTM infections > 2 sputum samples +ve > 1 BAL fluid sample +ve > a biopsy sample h/p features(eg. granuloma or a +ve stain- AFB) + 1 +VE sputum culture or a pleural fluid +ve on culture .
Treatment of MAC in the setting of bronchiectasis, the American Thoracic Society recommends a 3- to 4-drug treatment regimen with clarithromycin, rifampin, ethambutol, and possibly streptomycin that is continued until the patient's culture results are negative for 1 year. The typical duration of therapy may be 18-24 months.

 BRONCHIAL HYGIENE to enhance secretion clearance hydration and mucolytic administration, aerosolization of bronchodilators and hyperosmolar agents (e.g., hypertonic saline) chest physiotherapy

ANTI-INFLAMMATORY THERAPYdyspnea, decreased need for inhaled beta-agonists, reduced sputum production with inhaled glucocorticoids.

REFRACTORY CASES
select cases, surgery can be considered, with resection of a focal area of suppuration. In advanced cases, lung transplantation can be considered.

COMPLICATIONS
Pneumonia Recurrent fibrinous pleurisy Pleural effusion/empyema Haemoptysis-fatal Brain abscess Secondary amyloidosis.

PREVENTION
gamma-globulin Ig deficient. Vaccination resp. infection- (influenza n
pnemococcal vaccines). suppressive antibiotic treatments (1) administration of an oral antibiotic- (e.g.ciprofloxacin) daily for 1 2 weeks per month; (2) rotating schedule- oral antibiotics- minimize the risk of drug resistance); (3) macrolide antibiotic daily or three times per week ; (4) inhalation of aerosolized antibiotics - [e.g., tobramycin inhalation solution
(TOBI)] on a rotating schedule (e.g., 30 days on, 30 days off) decreasing the microbial load.

(5) intermittent administration of IV antibiotics (e.g., "clean-outs") for patients with more severe bronchiectasis and/or resistant pathogens.

LUNG ABSCESS lung abscess refers to a microbial infection of the lung that results in
necrosis of the pulmonary parenchyma.

EDA

PM AFC

RB

B A
Necrotizing pneumonia or lung gangrene refers to multiple small pulmonary abscesses in contiguous areas of the lung, usually resulting from a more virulent infection.

CLASSIFICATION
Depending on duration of infection
acute - < 4 wks subacute 4-6 wks chronic - > 6 wks

Depending on presence or absence of underlying pulmonary lesion.

Primary = abscess in previously healthy patient or in a patient at risk for aspiration Secondary = associated bronchogenic neoplasm or immunocompromised patient.

. nonspecific lung abscess refers to cases in which no likely pathogen is recovered from

expectorated sputum. Putrid lung abscess is a term applied to anaerobic bacterial lung abscesses, which are characterized by distinctive foul-smelling breath, sputum, or empyema fluid.

ETIOLOGY
Microbial Pathogens Causing Cavitary Lung Infection

Aspiration-Prone Host Anaerobic bacteria plus microaerophilic and/or anaerobic streptococci, Gemella spp. Embolic (endovascular) lesions: usually Staphylococcus aureus, Pseudomonas aeruginosa, Fusobacterium necrophoruma Endemic fungi: Histoplasma, Blastomyces, Coccidioides spp. Mycobacteria: M. tuberculosis, M. kansasii, M. avium Immunocompromised HostM. tuberculosis, Nocardia asteroides, Rhodococcus equi, Legionella spp., P. aeruginosa, Enterobacteriaceae (especially Klebsiella pneumoniae), Aspergillus spp., Cryptococcus spp. Previously Healthy HostBacteria: S. aureus,bS. milleri, K. pneumoniae, group A Streptococcus; Gemella, Legionella, and Actinomyces spp. Parasites: Entamoeba histolytica, Paragonimus westermani, Strongyloides stercoralis

MECHANISMS OF INFECTION
Commonest cause Aspiration of oropharyngeal contents.  75% abscesses - posterior segment Rt. upper lobe or Apical segments of either lower lobe - aspirated material - gravitate in the supine subject.  The development of lung abscess favoured by conditions that prevent normal clearance of pulmonary secretions lung tumours, bronchiectasis , inhaled foreign bodies.  Secondary infection in cong. abn like bronchopulmonary sequestration & lung cysts .

CLINICAL MANIFESTATION
. Symptoms

   fatigue cough sputum production- putrid-smelling sputum indicative of the presence of anaerobes. while the foul odor - organisms' production of short-chain fatty acids such as butyric or succinic acid.  fever  Chills are uncommon.  pleurisy due to pleural involvement by contiguous spread or by a bronchopleural fistula.

Signs  no signs specific for lung abscess  Digital clubbing within a few wks. d/t inadequate t/t.  Dullness to percussion  Diminished breath sounds - abscess - too large - near the surface of lung.  bronchial breath sounds

DIAGNOSIS
1. 2. IMAGING CXR PA VIEW, CT CHEST. MICROBIOLOGICAL STUDIES stains n cultures.
Difficult to isolate anaerobic bacteria m/c cause. if symptoms and clinical setting right for anaerobic infection, generally treat empirically.    Gram stain: both +ve & -ve, mixed AFB & Anaerobic culture Transtracheal aspirates (TTA), transthoracic needle aspirates (TTNA), BAL, pleural fluid, or blood cultures allow uncontaminated specimens.

3.

Bronchoscopy

RADIOLOGICAL FINDINGS
 Chest radiograph Increased density Cavity formation Cavity with air-fluid levels Fibrosis Pleural effusion

Manifests radiologically as a cavity With air fluid levels.

Figure 16-2. Reactivation tuberculosis with a large cavitary lesion containing an air-fluid level in the right lower 16airlobe. Smaller cavitary lesions are seen in other lobes. (From Armstrong P et al: Imaging of diseases of the chest, ed 2, St. Louis, 1995, Mosby.)

TREATMENT ANTIBIOTIC THERAPY

Depending on presumed or established etiology.

ANAEROBIC BACTERIA
CLINDAMYCIN
initially 600 mg i/v qid followed by 300 mg qid orally.

any beta -lactam/beta-lactamase inhibitor combination; parenteral treatment may be followed by orally administered amoxicillin/clavulanate. Penicillin was previously regarded as a preferred drug for these infections, but many oral anaerobes produce -lactamases and clindamycin proved superior to penicillin G. Metronidazole anaerobes.

FAILURE OF THERAPY
Persistence of fever beyond 5 7 days. progression of the infiltrate .
exclude factors such as - obstruction, complicating empyema and involvement of antibiotic-resistant bacteria. bronchoscopy and/or CT to detect a possible associated anatomic lesion, such as a tumor, or a foreign body.

 S. aureus  vancomycin = trough serum level of 15 20 micro g/mL. alternative linezolid.  Daptomycin should not be used for pulmonary infections
 AEROBIC gram-negative bacteria
 antibiotic senstivity test  common pathogens - K. pneumoniae and P. aeruginosa  prolonged courses of parenteral antibiotics.

Carbapenems or beta -lactams are frequently combined with aminoglycosides; oral fluoroquinolones are often effective initially, but resistance is common with prolonged use. Aerosolized colistin and aminoglycosides .

SURGICAL INTERVENTION
1. 2. 3. Surgery rarely required 10 -12 % cases. Indications: failure of medical management, suspected neoplasm, or hemorrhage. Predictors of poor response to antibiotic therapy alone: abscesses associated-with an obstructed bronchus, large abscess (>6 cm in diameter), relatively resistant organisms such as P. aeruginosa. The usual procedure in such cases is a lobectomy. Alt. intervention percutaneous drainage under CT guidance.

4. 5.

RESPONSE TO THERAPY
 Usually show clinical improvement with 5 days of initiation of antibiotic therapy.   DEFERVESCENCE expected within 5-10 days. Persistent fever beyond this time indicates DELAYED RESPONSE.  such patients should undergo bronchoscopy or further diagnostic tests to define the underlying anatomy and microbiology of the infection. fever within 3-

COMPLICATIONS
1. 2. 3. 4. 5. 6. Empyema Bronchopleural fistula Pneumothorax , pyoneumothorax Metastatic cerebral abscess Sepsis Fibrosis,bronchiectasis,amyloidosis

 THANK YOU

 There are three primary types of bronchiectasis. These types are described by their anatomical appearance. Cylindrical bronchiectasis is the mildest form and reflects the loss of the normal tapering of the airways. The symptoms may be quite mild, like a chronic cough, and usually are discovered on CT scans of the chest. Saccular bronchiectasis is more severe, with further distortion of the airway wall and symptomatically, affected persons produce more sputum. Cystic bronchiectasis is the most severe form of bronchiectasis, and fortunately it is the least common form. This often occurred in the preantibiotic era when an infection would run its course and the patient would survive with residual lung damage. These patients often would have a chronic productive cough, bringing up a cup or more of discolored mucus each day.

Supportive Treatment The following general measures are recommended: Smoking cessation Avoidance of second-hand smoke Adequate nutritional intake with supplementation, if necessary Immunizations for influenza and pneumococcal pneumonia[81, 82] Confirmation of immunizations for measles, rubeola, and pertussis Oxygen therapy is reserved for patients who are hypoxemic with severe disease and end-stage complications, such as cor pulmonale.

Antibiotic Therapy Antibiotics have been the mainstay of treatment for more than 40 years. Oral, parenteral, and aerosolized antibiotics are used, depending on the clinical situation. In acute exacerbations, broad-spectrum antibacterial agents are generally preferred. However, if time and the clinical situation allows, sampling of respiratory secretions during an acute exacerbation may allow treatment with antibiotics based on specific species identification. Acceptable choices for the outpatient who is mild to moderately ill include any of the following: Amoxicillin Tetracycline Trimethoprim-sulfamethoxazole A newer macrolide (eg, azithromycin[83] or clarithromycin[84, 85] ) A second-generation cephalosporin A fluoroquinolone In general, the duration of antibiotic therapy for mild to moderate illness is 7-10 days. For patients with moderate-to-severe symptoms, parenteral antibiotics, such as an aminoglycoside (gentamicin, tobramycin) and an antipseudomonal synthetic penicillin, a third-generation cephalosporin, or a fluoroquinolone, may be indicated. Patients with bronchiectasis from CF are often infected with mucoid Pseudomonas species, and, as such, tobramycin is often the drug of choice for acute exacerbation. Infection with Mycobacterium avium complex (MAC) provides special treatment challenges. For the treatment of MAC in the setting of bronchiectasis, the American Thoracic Society recommends a 3- to 4-drug treatment regimen with clarithromycin, rifampin, ethambutol, and possibly streptomycin that is continued until the patient's culture results are negative for 1 year. The typical duration of therapy may be 18-24 months.

 Regular antibiotic regimens Some patients with chronic bronchial infections may need regular antibiotic treatment to control the infectious process. Some clinicians prefer to prescribe antibiotics on a regular basis or for a set number of weeks each month. The oral antibiotics of choice are the same as those mentioned previously. Potential regimens include daily antibiotics for 7-14 days of each month, alternating antibiotics for 7-10 days with antibiotic-free periods of 7-10 days, or a long-term daily dose of antibiotics. For patients with severe CF and bronchiectasis, intermittent courses of intravenous antibiotics are sometimes used.[86, 87] Aerosolized antibiotics In the past several years, the nebulized route of antibiotic administration has received more attention because it is capable of delivering relatively high concentrations of drugs locally with relatively few systemic adverse effects.[88] This is particularly beneficial in treating patients with chronic infection from P aeruginosa. Currently, inhaled tobramycin is the most widely used nebulized treatment for patients with bronchiectasis from either CF or non-CF causes of bronchiectasis.[89, 90, 91, 92, 93] Gentamicin[94] and colistin[95] have also been used. No significant studies have examined the long-term use of inhaled antibiotics in patients with non-CF bronchiectasis. A study by Govan et al found sustained long-term benefit (12 mo) of inhaled gentamicin in this subgroup, along with an acceptable side effect profile.[96] Optimal dosing regimen of inhaled gentamicin still needs to be elucidated.

 Bronchodilator Therapy Bronchodilators, including beta-agonists and anticholinergics, may help some patients with bronchiectasis, presumably reversing bronchospasm associated with airway hyperreactivity and improving mucociliary clearance.[107, 108, 109] High-quality, large, randomized clinical trials of bronchodilator treatment in bronchiectasis have not been performed, however.

ANTI INFLAMMATORY THERAPY

Azithromycin has known anti-inflammatory properties and longterm use has been studied in patients with both CF and non-CF bronchiectasis. In non-CF patients, azithromycin has been shown to decrease exacerbations and improve spirometry and microbiologic profiles.[115] In CF patients a meta-analysis suggests that it improves lung function, especially in those patients colonized with Pseudomonas.[103] A practical approach is to use tapering oral corticosteroids and antibiotics for acute exacerbations and to consider inhaled corticosteroids for daily use in patients with significant obstructive physiology on pulmonary function testing and evidence of reversibility suggesting airway hyperreactivity. However, Kapur et al reported that the evidence supporting the use of inhaled steroids in adults with stable bronchiectasis is insufficient.[116]

 Medication Summary No specific medical therapy exists for the treatment of bronchiectasis. Pharmacologic therapy focuses on the treatment of infectious exacerbations that these patients commonly experience, most often in the form of an acute bronchitis-type syndrome. The most widely accepted and commonly used medications in the treatment of acute infectious processes associated with bronchiectasis include antibiotics, beta-agonists, inhaled corticosteroids, and expectorants. Other more controversial medications have been previously mentioned in this article for completeness but are not discussed here.

 Antibiotics Class Summary These are the mainstays of treatment of patients with bronchiectasis and infectious exacerbations. The route of antibiotic administration varies with the overall clinical condition, with most patients doing well on outpatient regimens. Some patients benefit from a set regimen of antibiotic therapy, such as therapy for 1 week of every month. The choice of antibiotic is provider dependent, but, in general, the antibiotic chosen should have a reasonable spectrum of coverage, including the most common gram-positive and gram-negative organisms. Treatment of the patient who is more ill or the patient with CF often requires intravenous anti-Pseudomonas species coverage with an aminoglycoside, most often in combination with an antipseudomonal synthetic penicillin or cephalosporin. Aerosolized tobramycin has been found effective in patients with cystic fibrosis (CF).

 Inhaled Beta Agonist Class Summary Although no long-term studies have been performed with inhaled betaagonists, these medications are routinely used in patients with bronchiectasis for multiple reasons. Bronchiectasis may cause an obstructive defect on pulmonary function testing that may respond to inhaled beta-agonists. Many older patients with bronchiectasis often have a concomitant illness, such as chronic obstructive pulmonary disease, that responds to inhaled beta-agonists. Finally, in the acute infectious bronchitic exacerbation that occurs in patients with bronchiectasis, patients may develop transient obstructive airway physiology that may improve with an inhaled beta-agonist. Along these same lines, many patients are started on inhaled steroids for longterm airway stabilization, but the efficacy of these medications in bronchiectasis is questionable, and any effect simply may be secondary to the treatment of other concomitant obstructive airway diseases.

 Inhaled Corticosteroids Class Summary Studies suggest a benefit of inhaled corticosteroids in bronchiectasis, although the optimal dosing remains to be determined. No significant studies of oral steroid therapy in patients with bronchiectasis have been performed.

 Expectorants Class Summary One of the hallmarks of bronchiectasis is a chronic, thick, viscid sputum production. In bronchiectasis, it is extremely difficult for the body's natural mucociliary clearance mechanisms to adequately clear the sputum produced. Although definitive evidence is lacking, expectorants are expected to increase respiratory tract fluid secretions and to help loosen phlegm and bronchial secretions. By reducing the viscosity of secretions, expectorants increase the efficacy of the mucociliary clearance system. Expectorants are often marketed in combination with decongestants, which may provide some patients additional relief. View full drug information Guaifenesin (Mucinex)

4. Diagnosis Chest CT

Cylindrical bronchiectasis

4. Diagnosis Chest CT

Varicose bronchiectasis

4. Diagnosis Chest CT

Cystis / saccular bronchiectasis