Bronchiectasis

• • Defined as abnormal dilation of bronchi

  • Denotes clinical syndrome marked by:

  • -Chronic dilation of bronchi

    -Paroxysmal cough producing mucopurulent sputum

    -Recurrent pulmonary infections

  • 2 main types

  • -Saccular: Follows most infections and bronchial obstruction

    -Cylindric: Associated with post-TB bronchiectasis

  • Mixed or varicose: Third type; alternates saccular and cylindrical areas

  • Involves second to fourth order branches

  • Congenital often bilateral bronchiectasis

  • TB/granulomatous disease more often unilateral, or bilateral but limited to upper lobes

  • Pyogenic/pneumonias result in bronchiectasis of lower lobes, lingula

Epidemiology

• • Congenital disease can cause bronchiectasis

  • -Kartagener syndrome

    -Cystic fibrosis, Williams-Campbell syndrome

    -Mounier-Kuhn syndrome, immunoglobulin deficiency

    -α1-Antitrypsin deficiency

  • Most cases are not congenital but caused by infection and bronchial obstruction

  • -Pertussis

    -Measles

    -Influenza

    -TB

    -Bronchopneumonia

  • Repeated bouts or single severe pneumonia can causes bronchiectasis

  • Foreign bodies, endobronchial neoplasms, hilar lymphadenopathy can lead to bronchiectasis

  • Common pathogens: H influenza, S aureus, K pneumoniae, E coli

Symptoms and Signs

• • Recurrent febrile episodes

  • Chronic or intermittent cough producing foul-smelling sputum (up to 500 mL/d)

  • Hemoptysis (about 50% of patients)

  • Advanced disease indicated by increased sputum production, fever, dyspnea, anorexia, fatigue, and weight loss

  • History of sinus problems, infertility, or family history may indicate inherited disease

Imaging Findings

• • High-resolution chest CT: Documents bronchial dilation

Rule Out

• • Obstruction from neoplasm or foreign body

• • Culture for common pathogens (E coli, Klebsiella, Staph, H influenza)

  • Culture for mycobacteria, fungi, Legionella

  • Chest CT scan: Required preoperatively

  • Bronchoscopy with bronchoalveolar lavage (BAL) for culture

  • Bronchogram may be needed prior to operation

• • In most cases, conservative medical treatment is sufficient

  • Broad-spectrum antibiotics, bronchodilators, humidification, expectorants, mucolytics, and postural drainage

  • Continued infection: Bronchoscopy with BAL for culture

  • Influenza and pneumococcal vaccines may be needed

  • Inhaled antibiotics (gentamicin or tobramycin) may help control infection

Surgery

• • Goals: Remove all active disease, preserve functioning lung as much as possible

  • Maintain clear airway devoid of mucopurulent secretions or blood

Indications

• • Criteria for failure of medical therapy include:

  • -Localized disease and completely resectable

    -Adequate pulmonary reserve

    -Irreversible process

    -Significant symptoms despite medical treatment

Complications

• • Hemoptysis, lung, and brain abscess; empyema; respiratory failure; death

  • All complications decreased since anti-TB medications emerged

Prognosis

• • Local disease: 80% success with surgery

  • Diffuse disease: 36% surgical success

  • Prognostic factors: Unilateral disease in basal segments, young age, absence of sinusitis or rhinitis, history of pneumonia, no airway obstruction

  • Morbidity: 3-5%; mortality < 1%

Prevention

• • Long-term antibiotic therapy may be needed for ...