Bronchiectasis
D E FI N I T ION L
ung airway disease characterized by chronic bronchial dilation, impaired
mucuociliary clearance and frequent bacterial infections.
AE T IOLOGY
Severe inflammation in the lung causes fibrosis and dilation of the bronchi.
This is followed by pooling of mucus, predisposing to further cycles of infection, damage and
fibrosis to bronchial walls.
. Causes of bronchiectasis.
. Idiopathic in 50% of cases.
. Post-infectious: After severe pneumonia, whooping cough, tuberculosis.
Host defence defects: e.g. Kartagener’s syndrome,1 cystic fibrosis, immunoglobulin deficiency,
yellow-nail syndrome.2
. Obstruction of bronchi: Foreign body, enlarged lymph nodes.
. Gastric reflux disease.
. Inflammatory disorders: e.g. rheumatoid arthritis.
E P IDEMIOLOGY
Most often arises initially in childhood, incidence has # with use of
antibiotics, approximately 1 in 1000 per year.
H ISTORY
Productive cough with purulent sputum or haemoptysis.
Breathlessness, chest pain, malaise, fever, weight loss.
Symptoms usually begin after an acute respiratory illness.
EXAMINA T I ON
Finger clubbing; Coarse creptitations (usually at the bases) which shift
with coughing; Wheeze.
INVE S T I G A T IONS
Sputum: Culture and sensitivity, common organisms in acute exacerbations: Pseudomonas
aeruginosa, Haemophilus influenzae, Staphylococcus aureus, Streptococcus pneumoniae,
Klebsiella, Moraxella catarrhalis, Mycobacteria.
CXR: Dilated bronchi may be seen as parallel lines radiating from hilum to the diaphragm
(‘tramline shadows’). It may also show fibrosis, atelectasis, pneumonic consolidations, or
it may be normal.
High-resolution CT: Dilated bronchi with thickened walls. Best diagnostic method.
Bronchography (rarely used): To determine extent of disease before surgery (radioopaque
contrast injected through the cricoid ligament or via a bronchoscope).
Other: Sweat electrolytes (see Cystic fibrosis), serum immunoglobulins (10%of adults have
some immune deficiency), sinus X-ray (30% have concomitant rhinosinusitis), mucociliary
clearance study.
MANAGEMENT
Treat acute exacerbations with two IV antibiotics with efficacy for
Pseudomonas. Prophylactic courses of antibiotics (oral or aerosolized) for those with
frequent (3/year) exacerbations.
Inhaled corticosteroids (e.g. fluticasone) have been shown to reduce inflammation and
volume of sputum, although it does not affect the frequency of exacerbations or lung
function.
Bronchodilators may be considered in patients with responsive disease.
Maintain hydration with adequate oral fluid intake.
1 Kartagener’s syndrome is caused by immotile cilia and is characterized by a combination of chronic
sinusitis, infertility and situs inversus.
2 Yellow-nail syndrome is characterized by pleural effusions, lymphoedema and yellow dystrophic nails.
Approximately 40% will also have bronchiectasis.
Bronchiectasis (continued)
Consider flu vaccination.
Physiotherapy: Cornerstone of management is sputum and mucus clearance techniques (e.g.
postural drainage). Patients are taught to position themselves so the lobe to be drained is
uppermost, 20 min twice daily. Some studies show that these techniques reduce
frequency of acute exacerbations and aids recovery.
Bronchial artery embolization: For life-threatening haemoptysis due to bronchiectasis.
Surgical: Various surgical options include localized resection, lung or heart–lung
transplantation.
COMPL I C A T IONS
Life-threatening haemoptysis, persistent infections, empyema, respiratory
failure, cor pulmonale, multi-organ abscesses.
P ROGNOS I S
Most patients continue to have the symptoms after 10 years.
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