Bronchiectasis


Article Author:
Kim Bird


Article Editor:
Jawedulhadi Memon


Editors In Chief:
Jessica Snowden
Asif Noor
H Davies


Managing Editors:
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Frank Smeeks
Kristina Soman-Faulkner
Benjamin Eovaldi
Radia Jamil
Sobhan Daneshfar
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Hajira Basit
Phillip Hynes


Updated:
3/9/2019 8:21:02 PM

Introduction

Initially, bronchiectasis was described in the early 19th century by Laennec. Bronchiectasis is a chronic condition characterized by permanent and irreversible dilatation of the bronchial airways and impairment of mucociliary transport mechanism due to repeated infection leading to colonization of organism and pooling of the mucus in the bronchial tree. [1][2][3]Bronchiectasis is responsible for the significant loss of lung function and one that can result in considerable morbidity and even early mortality.

Etiology

Historically, the most common cause of bronchiectasis was thought to be an antecedent respiratory infection, often during childhood. The causes are idiopathic, acquired, or infection-related.

Bacterial Infections

  • Mycobacterium: Tuberculosis and atypical
  • Haemophilus influenzae
  • Pseudomonas aeruginosa
  • Staphylococcus aureus
  • Mycoplasma and HIV

Viral Infections

  • Respiratory syncytial virus and measles

Fungal Infections

Bronchial obstruction

  • Foreign body
  • Mucus plug
  • Tumors
  • Hilar lymphadenopathy (right middle lobe syndrome: extrinsic compression from postinfectious adenopathy)

Postinflammatory pneumonitis

  • Chronic aspiration/gastroesophageal reflux disorder
  • Chronic sinusitis
  • Inhalational injury

Congenital/Genetic

  • Cystic fibrosis
  • Young syndrome
  • PCD: primary ciliary dyskinesia (Kartenger Syndrome)
  • immunodeficiency (hypogammaglobulinemia)
  • Alpha1-antitrypsin deficiency (AAT)
  • Mounier-Kuhn syndrome

Inflammatory diseases

  • Ulcerative colitis
  • Rheumatoid arthritis
  • Sjögren syndrome

Pulmonary Diseases

  • Asthma 
  • Bronchomalacia
  • Cronic-obstructive pulmonary disease (COPD) (reported in up to 50% of patients with moderate-to-severe COPD)
  • Diffuse panbronchiolitis
  • Idiopathic pulmonary fibrosis (traction bronchiectasis)

Altered immune response

  • Allergic Bronchopulmonary Aspergillosis
  • Hypersensitivity pneumonitis

Others

  • Yellow nail syndrome (yellow nails, lymphedema, pleural effusion, bronchiectasis 40% first described in 1964)

Epidemiology

The prevalence of bronchiectasis is not precisely known. International data show an increase in the prevalence of bronchiectasis over recent years. It occurs in every age group and, in the pre-antibiotic era, it most often began in childhood.[4]Recent evidence shows that bronchiectasis disproportionately affects women and older individuals, and may be contributing to an increasing healthcare burden.

Pathophysiology

The three most important mechanisms that contribute to the pathogenesis of bronchiectasis are an infection, airway obstruction, and peribronchial fibrosis.

Neutrophils dominate airway inflammation in bronchiectasis, driven by high concentrations of neutrophil chemo-attractants such as interleukin-8 (CXCL-8), and leukotriene B4. Airway bacterial colonization occurs because of impaired mucociliary clearance and because of failure of neutrophil opsonophagocytic killing. Other mechanisms of immune dysfunction include failure of clearance of apoptotic cells and T-cell infiltration, with recent evidence pointing to an important role of Th17 cells.

Histologic changes in bronchiectasis: Cartilage destruction and fibrosis, mucosal and mucous gland hyperplasia, inflammatory cell infiltration, and increased mucous and exudate.

History and Physical

History of a long-standing cough with purulence is typical of bronchiectasis. Patients may report repetitive pulmonary infections that require antibiotics over several years. Patients can also present with progressive dyspnea, intermittent wheezing, hemoptysis, pleuritic chest pain, and associated fatigue and weight loss. The hemoptysis is mild and manifested by blood flecks in the patient's usual purulent sputum which is occasionally life-threatening. Often patients are diagnosed after many years of symptoms when a chronic cough or hemoptysis become debilitating.

Cough: 98%, sputum: 78% (sputum is typically mucoid and relatively odorless), dyspnea: 62%, haemoptysis: 56% to 92%, and pleuritic chest pain: 20% (secondary to chronic coughing).

Physical: Findings are nonspecific.

General findings may include digital clubbing (2% to 3%), cyanosis, plethora, wasting, and weight loss.

  • Local chest examination:  Most commonly crackles and wheezes on auscultation.
  • Crackles: 75%, usually bi-basal.
  • Wheezing: 22% (wheezing may be due to airflow obstruction from secretions)

Clinical Features of Associated Causative condition: 

  • Connective tissue diseases: Arthritis Sicca syndrome
  • ABPA: Prominent wheezing
  • Bronchial obstruction: localized wheezing
  • PCD, CF, Young Syndrome: Recurrent sinus disease, infertility
  • Features of acute exacerbation of bronchiectasis: Change in sputum production, increased dyspnea, increased cough, fever, increased wheezing, and reduced pulmonary function.

Evaluation

The British Thoracic Society (BTS) guidelines recommend testing for underlying causes including measurement of immunoglobulins (IgA, IgM, IgG and IgE), testing to exclude ABPA (specific IgE to Aspergillus, IgG to Aspergillus and eosinophil count). [5][6][7][8]Sputum culture to exclude nontuberculous mycobacteria (NTM) and measurement of autoantibodies are also suggested. Testing for cystic fibrosis (CF) (sweat test and/or screening for common CF mutations) is recommended for patients aged younger than 40 years or with recurrent Pseudomonas aeruginosa and Staphylococcus aureus isolation, or upper lobe predominant disease irrespective of age.

Alpha-1 Antitrypsin level, Ciliary function analysis and Serology for HIV  if indicated.

Imaging: 

Chest radiography is usually the initial study performed in suspected bronchiectasis.

Signs on chest x-ray include the identification of parallel linear densities, tram-track opacities, or ring shadows reflecting thickened and abnormally dilated bronchial walls.

Signs of complications/exacerbations, such as patchy densities due to mucoid impaction (mucus may become of high density due to chronic inspissation) and consolidation, volume loss secondary to mucoid bronchial obstruction or chronic cicatrization are also seen.

In comparison to chest x-ray, CT is both more sensitive and provides more specific information. In addition to making the diagnosis, the pattern of disease on HRCT may enable one to limit the differential to a single/few specific causative entities.

The CT chest signs of bronchiectasis were first described by NAIDICH et al. in 1982.

Bronchial dilation, the cardinal sign of bronchiectasis, is characterized:

  • On HRCT by a broncho arterial ratio (BAR) of more than 1
  • Lack of bronchial tapering (normal airways diminish in caliber as they extend toward the lung periphery)
  • Visibility of airways within 1 cm of the pleural surface (normal airways should not be visualized this far out in the lung periphery) or abutting the mediastinal pleural surface.

Usual Pattern on High-Resolution CT scan Chest

Cylindrical (tram track sign): Dilated airways seen in a horizontal orientation.

Signet-ring: The dilated airway lies adjacent to a pulmonary artery branch giving the appearance of a ring (internal bronchial diameter greater than that of the adjacent pulmonary artery).

Varicose: Implies non uniform bronchial dilatation. The bronchi resemble like varicose veins.The luminal dilatation is characterised by alternating areas of luminal dilatation and constriction, creating a beaded appearance, and the wall thickening is irregular.This varicose bronchiectasis serves as an intermediate step before the development of grossly dilated, cystic airways.

Cystic or saccular: A cluster of thin-walled cystic spaces.

Mosaic lung attenuation: This term is used to describe heterogeneous lung density due to air trapping in the affected lung segments and as a result has a geographic distribution. This finding can be produced or exaggerated on expiration.

Dilated bronchial arteries: These are best-demonstrated post administration of intravenous contrast. These tortuous vessels extend along the central airways toward the hila. It is these vessels that are often responsible for haemoptysis.

Other Findings:

Lobar collapse

Mycetoma formation (Fungus ball): Aspergillus fumigatus is a fungus that may colonise dilated airways or bullae/cavities. It is an important cause of haemoptysis. 

Lung function

Airflow obstruction: FEV1 decreased

Air trapping: Residual volume increased  

Treatment / Management

Bronchiectasis is treatable but rarely curable.

Treatment Goals:

  1. Identifying and treating the underlying cause
  2. Improve tracheobronchial clearance
  3. Control infection
  4. Reverse airflow obstruction

General Management

Identifying and treating the underlying cause: Immunoglobulin replacement, steroids, and antifungals for ABPA, treatment for NTM, and of CF all represent opportunities to treat the underlying cause specifically, and systematic testing of all patients is recommended in consensus guidelines.[9][10][11]

Improve tracheobronchial clearance: Most physicians recommend mucus clearance as the mainstay of therapy in bronchiectasis, Postural drainage consists of adopting a position in which the lobe to be drained is uppermost, and should be performed for a minimum of 5 to 10 minutes twice a day. Efficiently performed, this is of great value both in reducing the amount of a cough and sputum and in preventing recurrent episodes of bronchopulmonary infection.

Deep breathing followed by forced expiratory maneuvers (the "active cycle of breathing" technique) is of help in allowing secretions in the dilated bronchi to gravitate towards the trachea, from which vigorous coughing can clear them. "Percussion" of the chest wall with cupped hands may help to dislodge sputum, and a number of mechanical devices are available which cause the chest wall to oscillate, thus achieving the same effect.

Control infection: Choice of antibiotic should primarily be based on the results of culture and sensitivity. When no specific pathogen is identified, and the patient is not seriously ill, an oral agent like amoxicillin, co-amoxiclav, or macrolides for 2 weeks is sufficient.

Use a higher dose of oral amoxicillin 1 gm twice per day for 2 weeks, especially if colonized with H. influenza, if pseudomonas-colonized then a 2-week course of ciprofloxacin 750 mg twice per day (with cautious use in the elderly) is reasonable.

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.

Treatment for Pseudomonas isolates 2 weeks of intravenous (IV) antipseudomonal antibiotics, nebulized colistin for 3 months, or nebulized colistin for 3 months with an additional 4 weeks of oral ciprofloxacin.

Maintenance therapy with intermittent antibiotics is not used routinely in patients with non-CF bronchiectasis, and the decision to use long-term antibiotics should be individualized.

Inhaled aminoglycosides can be of benefit in chronic non-CF bronchiectasis; however, the treatment needs to be of a sustained duration.

Reverse airflow obstruction:

  • In patients with airflow obstruction, inhaled bronchodilators and corticosteroids should be used to enhance airway patency.

General managementAs with other respiratory diseases, patients with bronchiectasis should be encouraged to stop smoking. Vaccination against influenza and pneumococcal disease is also recommended.

Adjunctive Surgical Treatment:

  • Surgery is only indicated in a small proportion of cases. These are usually young patients in whom the bronchiectasis is unilateral and confined to a single lobe or segment as demonstrated by CT.

  • Surgery is an important adjunct to therapy in some patients with advanced or complicated disease.

  • Single- or double-lung transplantation has been used as a treatment of severe bronchiectasis, predominantly when related to CF. In general, consider patients with CF and bronchiectasis for lung transplantation when FEV falls below 30% of the predicted value. Female patients and younger patients may need to be considered sooner.
  • Massive hemoptysis: Bronchial artery embolization and/or surgery is first-line therapy for the management of massive hemoptysis.

Pearls and Other Issues

Bronchiectasis complications include pneumonia, lung abscess, empyema, septicemia, cor pulmonale, respiratory failure, secondary amyloidosis with nephrotic syndrome, and recurrent pleurisy.

Prognosis: The disease is progressive when associated with ciliary dysfunction and cystic fibrosis, and eventually causes respiratory failure. In other patients. the prognosis can be relatively good if postural drainage is performed regularly and antibiotics are used judiciously.

Enhancing Healthcare Team Outcomes

Bronchiectasis is progressive disorder with no cure and hence it is best managed by a multidisciplinary team that includes the primary care physician, nurse practitioner, pulmonologist, infectious disease expert, thoracic surgery and an internist. The key is to improve symptoms and prevent relapses. [12][13]These patients often develop respiratory infections that require antibiotics. At some point, most patients develop complications that include pneumonia, lung abscess, empyema, septicemia, cor pulmonale, respiratory failure, secondary amyloidosis with nephrotic syndrome, and recurrent pleurisy. 

The disease is progressive when associated with ciliary dysfunction and cystic fibrosis, and eventually causes respiratory failure. In other patients. the prognosis can be relatively good if postural drainage is performed regularly and antibiotics are used judiciously. [7](Level V)


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Bronchiectasis - Questions

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Which of the following claims about bronchiectasis is FALSE?



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Which is false about the treatment of bronchiectasis?



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Which of the following is not a feature of bronchiectasis?



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Which of the following about bronchiectasis is false?



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A patient presents with a long history of a chronic cough and mucopurulent sputum production for many years. He has also had 3 bouts of hemoptysis over the past 6 months. Over the past year he had lost weight and become dyspneic. He denies smoking but does state that he had a serious lung infection as a child. Physical reveals digital clubbing, crackles and wheezing. while blood work is pending, the CT scan of the chest reveals irregular and beaded bronchi and 'tram track' lines. Which of the folloing is not true of this condition?



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A 17-year-old presents with a 3-month history of chronic cough with purulent sputum. Prior history reveals numerous episodes of pneumonia and hemoptysis. On examination, he has expiratory and inspiratory wheezes, coarse rales, and clubbing. There is a question of bronchiectasis. Which of the following is the best diagnostic test for confirming this diagnosis?



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You have a patient with a long history of repetitive lung infections, wet cough, trace hemoptysis and progressive dyspnea. Physical exam reveals digital clubbing, wasting, and wheezing. You send him for a CT scan of the chest and the radiologist reports presence of a 'signet-rings.' What does this sign mean to you?



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Which of the following is a false statement about bronchiectasis?



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An elderly patient presents with a long history of a chronic cough and mucopurulent sputum production for many years. He has also had 3 bouts of hemoptysis over the past 6 months. Over the past year he had lost weight and become dyspneic. He denies smoking but does state that he had a serious lung infection as a child. Physical reveals digital clubbing, crackles and wheezing. The CT scan of the chest reveals disease process in the upper lobes plus irregular and beaded bronchi and 'tram track' lines evolving from the central bronchi. In such a scenario, what blood work will you order to determine the cause of his symptoms?



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Which of the following is the most prominent features of bronchiectasis?



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What is the primary vessel involved during hemoptysis in patients with bronchiectasis?



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What is the most likely diagnosis in an 17-year-old patient with two years of productive cough, bilateral wheezing, and chest radiographic evidence of dilated bronchi?



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A 71-year old male presents with a persistent wet cough, general malaise, dyspnea, anorexia and weight loss. At times he had noted trace blood when he coughs. He has been an asthmatic for many years but does not smoke. Physical revels wheezing and digital clubbing. The skin test is negative. The CT scan of the chest reveals mucoid impactions of the distal airways and tubular branching opacities extending from the hilar region. You feel that he most likely has?



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Select the true statement about the diagnosis of bronchiectasis.



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If a patient has bronchiectasis they are experiencing:



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What is the most likely diagnosis in a patient with 3 years of a productive cough, crackles on auscultation, and chest imaging which shows thickened and abnormally dilated bronchial walls?



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Which of the following is not diagnosed using an ultrasound in utero?



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A 43-year old presents with a chronic cough and purulent sputum for three months. He has been admitted numerous times for pneumonia and hemoptysis. His past medical history is significant for pneumonia as a child. Since then he has been plagued with recurrent pneumonia and cough. On examination, she has expiratory and inspiratory wheezing, coarse rales, and clubbing. What is the best diagnostic test for confirming this diagnosis?



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Bronchiectasis - References

References

Ho T,Cusack RP,Chaudhary N,Satia I,Kurmi OP, Under- and over-diagnosis of COPD: a global perspective. Breathe (Sheffield, England). 2019 Mar;     [PubMed]
Ferri S,Crimi C,Heffler E,Campisi R,Noto A,Crimi N, Vitamin D and disease severity in bronchiectasis. Respiratory medicine. 2019 Mar;     [PubMed]
Guan WJ,Han XR,de la Rosa-Carrillo D,Martinez-Garcia MA, The significant global economic burden of bronchiectasis: a pending matter. The European respiratory journal. 2019 Feb;     [PubMed]
Goeminne PC,Hernandez F,Diel R,Filonenko A,Hughes R,Juelich F,Solomon GM,Upton A,Wichmann K,Xu W,Chalmers JD, The economic burden of bronchiectasis - known and unknown: a systematic review. BMC pulmonary medicine. 2019 Feb 28;     [PubMed]
Schoovaerts K,Lorent N,Goeminne P,Aliberti S,Dupont L, National Survey on the Management of Adult Bronchiectasis in Belgium. COPD. 2019 Feb 21;     [PubMed]
O'Neill K,O'Donnell AE,Bradley JM, Airway clearance, mucoactive therapies and pulmonary rehabilitation in bronchiectasis. Respirology (Carlton, Vic.). 2019 Mar;     [PubMed]
Patel S,Cole AD,Nolan CM,Barker RE,Jones SE,Kon S,Cairn J,Loebinger M,Wilson R,Man WD, Pulmonary rehabilitation in bronchiectasis: a propensity-matched study. The European respiratory journal. 2019 Jan;     [PubMed]
Kocurek EG,Jagana R, Noncystic fibrosis bronchiectasis management: opportunities and challenges. Current opinion in pulmonary medicine. 2019 Mar;     [PubMed]
Bell SC,Elborn JS,Byrnes CA, Bronchiectasis: Treatment decisions for pulmonary exacerbations and their prevention. Respirology (Carlton, Vic.). 2018 Nov;     [PubMed]
Mitchelmore P,Wilson C,Hettle D, Risk of Bacterial Transmission in Bronchiectasis Outpatient Clinics. Current pulmonology reports. 2018;     [PubMed]
Visser SK,Bye P,Morgan L, Management of bronchiectasis in adults. The Medical journal of Australia. 2018 Aug 20;     [PubMed]
Dalrymple RA,Kenia P, European Respiratory Society guidelines for the diagnosis of primary ciliary dyskinesia: a guideline review. Archives of disease in childhood. Education and practice edition. 2018 Aug 3;     [PubMed]
Polverino E,Dimakou K,Hurst J,Martinez-Garcia MA,Miravitlles M,Paggiaro P,Shteinberg M,Aliberti S,Chalmers JD, The overlap between bronchiectasis and chronic airway diseases: state of the art and future directions. The European respiratory journal. 2018 Sep;     [PubMed]

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