BRONCHIECTASIS

Dr B Palani kumar MD
Q1. Define bronchiectasis.

Bronchiectasis is an obstructive respiratory disorder defined as abnormal and permanent

dilation of bronchi and proximal bronchioles due to destruction of smooth muscle and supporting elastic
tissue.

Q2. What is the pathogenesis of bronchiectasis?

Acute necrotizing infection

Recurrent infection Primary immunodeficiency
Viral pneumonia
Secondary immunodeficiency
Tuberculosis

Ciliary dysfunction Destruction of cilia Obstruction

1. Immotile cilia syndrome Destruction of bronchial wall Tumor
2. Cystic fibrosis Foreign body
3. Viral infection Lymph node enlargement
4. smoking

Impaired clearance of secretion

Impaired local defense mechanism

Loss of cilia Colonization of microorganism

Destruction of wall And recurrent infection
Dilation

Chronic inflammation
Neutrophil infiltration and
release of proteases Dr PK

a) Necrotizing and suppurative pneumonia caused by virulent bacteria or virus leads to destruction
of cilia and bronchial wall.
b) Congenital, acquired causes of ciliary dysfunction and immuno deficiency disorders lead to
recurrent infection.
c) Obstruction of bronchial tree by neoplasm, foreign body, and stenosis impede clearance of
infected mucus secretion, an important defense mechanism of lung.
ALL of the above factors lead to same pathology, destruction of cilia, defect in clearance of
secretion and dilation of bronchi which lead to colonization of microorganisms.
 Cole’s vicious cycle hypothesis explains the pathophysiology of bronchiectasis.

Chronic infection and inflammation of the bronchial tree >>> infiltration of neutrophils, ROS, pro
inflammatory cytokines >>> destruction of bronchial wall elastin and cartilage >>> dilation and
replacement with fibrous tissue >>> impaired clearance of secretion and impaired local defense
mechanism >>> chronic infection and inflammation.

Q3. What are the three pathological types of bronchiectasis?

1. Cylindrical bronchiectasis – dilated straight bronchi that ends abruptly

2. Cystic or saccular bronchiectasis – cystic dilation of bronchi with air fluid level
3. Varicose bronchiectasis – bulbous appearance with a dilated bronchus and interspersed
sites of relative constriction

Q4. What are the organisms causing bronchiectasis?

Acute necrotizing pneumonia with destruction of bronchial tree is the most common cause of
bronchiectasis seen in adults. The organism is virulent or the patient is an immuno deficient states.
Untreated or partially treated pneumonia always leads to bronchiectasis.

Bacteria

a) Staphylococcus aureus
b) Klebsiella species
c) Tuberculosis
d) Bordetella pertussis
e) Mycoplasma pneumoniae
f) Mycobacterium avium-intracellulare complex (MAC)
g) PSEUDOMONAS and HAEMOPHILUS are the most common organisms colonizing the dilated
bronchi
 VIRUS

a) Influenza virus
b) Adeno virus
c) Measles virus
d) Herpes simplex virus

Q5. How tuberculous infection causes bronchiectasis?

a) Middle lobe syndrome – either obstruction by lymph node enlargement from outside or
endo bronchial stenosis causes bronchiectasis of middle lobe. Other unknown etiologies
lead to chronic collapse of the middle lobe and bronchiectasis. Mycobacterium avium-
intracellulare complex (MAC) often prefers mid lung field.
b) Endo bronchial tuberculosis (EBTB) leads to bronchial stenosis and obstruction is one of the
important mechanisms of bronchiectasis in tuberculosis.
c) Traction bronchiectasis – fibrosis of lung is a sequela of TB infection. Because of the scarring
of surrounding lung tissue the bronchial lumen becomes dilated (mechanical traction). This
type of bronchiectasis is also seen in interstitial lung diseases.

Q6. What are the other acquired causes of bronchiectasis?

Causes / features Specific investigation

1. Obstruction of 1. Foreign body
bronchial tree 2. Bronchial neoplasm Bronchoscopy
3. Middle lobe syndrome
4. Enlarged lymph node
2. Allergic 1. Involvement of central 1. Skin test - aspergillus
bronchopulmonary airways precipitins
aspergillosis (ABPA) 2. Wheezing – asthma type 2. Increased eosinophils
3. Elevated Ig E levels
3. Auto immune 1. Rheumatoid arthritis 1. Anti CCP antibodies, RA
disorders 2. SLE factor,
3. Sarcoidosis 2. ANA, anti-ds DNA antibodies
3. Chest x ray, tissue biopsy,
elevated ACE
4. Aspiration GERD Esophagogastroduodenoscopy
5. Immuno deficient 1. HIV 1. Ag Ab immune assay
state 2. Diabetes mellitus 2. HbA1C
3. Malnutrition

.
Q7. What is bronchiectasis sicca?

Bronchiectasis sicca is also known as dry bronchiectasis in which the sputum production is absent.
The patient may present with hemoptysis. It is usually associated with tuberculosis.

Q8. What are the causes of upper lobe bronchiectasis?

1. Tuberculosis
2. Post radiation fibrosis
3. ABPA
4. Cystic fibrosis

Q9. What are the major symptoms of bronchiectasis?

1. Chronic cough with large volume of sputum production is the most prominent symptom of
bronchiectasis. The sputum is mucoid or mucopurulent.
2. Blood streaked sputum or frank hemoptysis is another feature. Hemoptysis occurs in 60 to
90% of patients.
3. Dyspnea.
4. Weight loss and fatigue.
5. Wheeze – a prominent symptom in ABPA.
6. Recurrent infective exacerbations are the characteristic feature of bronchiectasis. During
infective exacerbation patient experiences fever, pleuritic chest pain and more production
of mucopurulent sputum.

Q10. What are the signs of bronchiectasis?

1. Clubbing - not seen in all patients

2. Coarse leathery crackles are diagnostic of bronchiectasis.
3. Wheeze may be present.
4. Other features depend upon the complications associated with bronchiectasis. High pitched
bronchial breathing and pleural effusion may be present during infective exacerbation.
Recurrent infection with associated scarring may lead to fibrosis of the lung.
5. Features of cor pulmonale and RV failure like elevated JVP, pedal edema may be present.

Q11. What are the complications of bronchiectasis?

LOCAL COMPLICATIONS

1. Recurrent pneumonia
2. Lung abscess
3. Empyema
4. Fibrosis of the lung
5. Cor pulmonale
6. Massive hemoptysis from eroded bronchial artery
 7. Respiratory failure
8. Central cyanosis

SYSTEMIC COMPLICATIONS

1. Metastatic abscess – brain abscess

2. Hypoproteinemia
3. Systemic amyloidosis
4. Nephrotic syndrome due to amyloidosis

Q12. What is the investigation of choice to diagnose bronchiectasis?

High-Resolution CT (HRCT) is the investigation of choice to diagnose bronchiectasis.

Q11.what is the x ray findings in bronchiectasis?

Chest x ray is diagnostic in few cases only.

1. In cases of cylindrical bronchiectasis tram track appearance is seen.

2. In two or three bronchi involvement gloved fingers appearance is seen
3. In cystic bronchiectasis cystic dilation of bronchi with air fluid level is seen.
4. Diagnosis of pulmonary tuberculosis can be done.

Q13. What are the findings observed in HRCT?

1. Tram track sign – thickened parallel cylindrical bronchi.

2. Signet ring sign – the dilated bronchi and accompanying pulmonary artery branch are seen
in cross section as signet ring.
3. The diameter of the bronchi is 1.5 times greater than the adjacent pulmonary artery branch.
4. Honeycomb appearance is seen in cystic bronchiectasis.
5. Tree-in-bud appearance – bronchial wall thickening in dilated airways with inspissated
secretions.

Q14. What are the investigation done in bronchiectasis?

1. HRCT
2. Chest X ray
3. Sputum gram stain
4. Sputum AFB and NAAT
5. Sputum culture and sensitivity
6. Pulmonary function test
7. Echocardiography
8. ECG
9. Complete blood count
10. HbA1C
 11. HIV test
12. Bronchoscopy – to exclude airway obstruction
13. Investigations to rule out other causes (see above)

Q15. What is the management of bronchiectasis?

1. Management of acute infective exacerbation – the common organisms are pseudomonas

and haemophilus influenza. They are treated with aminoglycoside and an anti pseudomonal
antibiotics like piperacillin/tazobactum, fluoroquinolones, third generation cephalosporin.
They are administrated for 7 days.
2. Bronchial hygiene – clearance of the pooled secretion is important in the management of
bronchiectasis. Adequate hydration, aerosolization with hypertonic saline and mucolytic like
dornase (DNase) may help to lyse the thick sputum.
3. Postural drainage with percussion and vibration is used to loosen and mobilize secretion.
4. Inhaled bronchodilators and corticosteroids may be beneficial.
5. Systemic steroid is the treatment of choice for ABPA and connective tissue disorders.
6. Influenza and pneumococcal vaccines have to be given.
7. After the management of acute infective exacerbation intermittent antibiotic therapy
(suppressive antibiotics) may be given to prevent the recurrent episodes. The choices of
antibiotics are azithromycin given daily or three times a week, ciprofloxacin for daily 1to 2
weeks per month. Azithromycin also has an anti-inflammatory property.
8. Treatment of the primary cause like tuberculosis, GERD, bronchial obstruction.
9. Bronchial artery embolization is done for massive hemoptysis.
10. In refractory cases surgery may be considered like resection of affected lung or lobe.

Q16. What are the congenital causes for bronchiectasis?

1. Immotile cilia syndrome

2. Kartagener syndrome
3. Cystic fibrosis
4. Primary hypogammaglobinemia

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Dr B PALANI KUMAR MD