Chapter 33-7: Bronchiectasis

TEXTBOOK PRESENTATION

Dyspnea and chronic, purulent sputum production are often present in patients with bronchiectasis. There is often a history of a chronic infection that has led to airway damage and dilatation.

DISEASE HIGHLIGHTS

1. Chronic sputum production is the hallmark of bronchiectasis.

2. The disease is caused by the combination of an airway infection and an inability to clear this infection because of impaired immunity or anatomic abnormality (congenital or acquired). Bronchiectasis can be the result of common (viral infection) or rare (Kartagener syndrome) diseases.

   1. Pertussis and tuberculosis were the classic causes of bronchiectasis.

   2. Some of the common causes now are:

      1. Postviral, often with lymphadenopathy causing airway obstruction

      2. Aspergillus fumigatus, mainly in association with allergic bronchopulmonary aspergillosis

      3. Mycobacterium avium complex infection, usually causing middle lobe disease

      4. Cystic fibrosis

      5. HIV

3. The most common bacteria isolated from the sputum of people with bronchiectasis are H influenzae, Pseudomonas aeruginosa, and Streptococcus pneumoniae.

4. Complications of the disease include hemoptysis and rarely amyloidosis due to the chronic inflammation.

EVIDENCE-BASED DIAGNOSIS

1. The diagnosis of bronchiectasis depends on recognizing the clinical symptoms (chronic sputum production) and demonstrating airway damage and dilatation, usually by high-resolution CT scanning.

2. Symptoms and their prevalence

   1. Dyspnea and wheezing, 75%

   2. Pleuritic chest pain, 50%

3. Signs and their prevalence

   1. Crackles, 70%

   2. Wheezing, 34%

4. Differentiation of bronchiectasis from COPD can sometimes be difficult because both may present with cough, sputum production, dyspnea, and airflow limitation. Important points in the differentiation are as follows:

   1. Sputum production is heavy and chronic in bronchiectasis, while it is only truly purulent in COPD during exacerbations.

   2. There is usually a smoking history associated with COPD.

   3. Spirometry is not helpful since bronchiectasis can cause both airflow limitation and airway hyperreactivity.

   4. Imaging (CT scan) will show diagnostic airway changes in bronchiectasis. In COPD, imaging may or may not demonstrate parenchymal destruction.

TREATMENT

1. Antibiotics are used both to treat flares of disease and to suppress chronic infection.

2. Pulmonary hygiene

   1. Chest physiotherapy

   2. Oscillatory positive expiratory pressure (PEP) devices

   3. There may be a role for bronchodilators, mucolytics, and anti-inflammatory medication.

3. Surgery is mainly used to treat airway obstruction, to remove destroyed and chronically infected lung tissue, and to treat life-threatening hemoptysis.